The Checkered Career of Electroconvulsive Therapy
BEFORE AND FOR SOME YEARS AFTER the introduction of the first drugs to treat mental illness in the early 1950s, electroconvulsive therapy (ECT) was widely used in American mental hospitals. It was administered almost regardless of a patient’s diagnosis and, though no systematic records were kept, was unquestionably the most frequently employed active treatment in most of these establishments, public and private alike. Most psychoanalysts disliked ECT and counseled their patients against it, but inside mental hospitals it had an unchallenged place in the psychiatric armamentarium.1
Then things changed dramatically. The antipsychiatry movement that emerged in the 1960s saw ECT as a symbol of psychiatric oppression. Hollywood, novelists, and journalists increasingly dismissed it as a barbaric intervention that broke bones and destroyed memories. In an era when mental hospitals began to empty, those running them increasingly relied on drugs, not ECT. Psychoanalysts, the dominant fraction among outpatient psychiatrists, renewed their own criticisms of the procedure. Medical schools stopped teaching how to perform ECT, and psychiatry for the most part abandoned it. Like the other somatic treatments developed in the 1920s and 1930s, it appeared to be moribund.2
But that was not the end of the story. Those convinced that shock therapy had a role to play in the treatment of depression had found ways to head off the fractures and upsetting scenes that accompanied the administration of unmodified ECT. Administering muscle relaxants and performing the procedure under general anesthetic avoided broken bones and rendered the whole process less fraught. Yet those developments did not suffice to rescue the procedure.
Decades on, however, as we shall see later in this book, while some patients described how undergoing ECT had destroyed their lives, a number of prominent figures published memoirs testifying that it had saved them from killing themselves and alleviated the miseries of their depressive state. In the early twenty-first century, with the side effects of medication more evident, interest in ECT began to revive, new claims were made about its efficacy, and, though stigma still clung to its administration, it reentered the realm of acceptable psychiatric practice.
AS WITH INSULIN AND METRAZOL, there was no generally accepted account of why ECT worked.3 Metrazol had been launched on the basis of the fallacious claim that schizophrenia and epilepsy were mutually exclusive conditions, and ECT’s rationale was initially similar. In both forms of treatment there was growing skepticism about their value in treating schizophrenia, and more and more clinicians were suggesting that their primary utility lay in their impact on affective disorders, particularly depression. This meant that biological antagonism played no role in whatever therapeutic gains ECT brought in its train; its administration was purely empirical, bereft of any clear foundation.
Despite an emerging consensus that ECT worked best in cases of depression, during the 1940s and 1950s it was deployed extensively across the board. To some extent, this reflected how unreliable and labile psychiatric diagnoses were in this era, and the fact that ECT acted to modify patients’ behavior, quieting them, and rendering them more tractable, particularly when several shocks were given in rapid succession. Ugo Cerletti’s assistant, Lucio Bini, had given this approach the unfortunate name of “annihilation therapy,” and there is abundant if necessarily anecdotal evidence that this kind of “therapeutic discipline,” as Joel Braslow calls it, was a routine feature of mental hospital life.4
Braslow’s examination of the clinical records at Stockton State Hospital in California provides some systematic data about how widely ECT was used across diagnostic labels and how frequently patients were singled out for this treatment as a means of controlling those who acted out. Even the hopeless diagnosis of senile psychosis or general paresis (tertiary syphilis) did not preclude treatment with ECT. What kind of psychiatric “disease” one was held to have seems to have exercised little or no effect on the choice of treatment. Disordered behavior was, for these psychiatrists, symptomatic of disordered bodies, and by whatever mysterious alchemical process electroshock worked, it demonstrably acted to change the disordered behavior and thus was, as Braslow puts it, “unassailably therapeutic: the control of bodies was the control of disease.”5
Doctors clearly hoped that in at least some cases, the therapeutic effects would result in patients being cured. In the immediate aftermath of ECT, patients were often confused and cloudy, but these effects gradually wore off, and they then seemed to be less distressed and more amenable to ward discipline.6 All too often, these benefits proved transient, but then most patients were being shocked three times a week for several weeks, and the working assumption (or hope) was that the intervals of lessened distress and improved behavior would grow longer with time.
When clinicians chose whom to treat, clinical records suggest that disciplinary considerations were the primary driver of the interventions. Psychiatrists did not seem inclined to differentiate sharply between improvements in mental status and improvements in behavior, repeatedly conflating the two. Stockton psychiatrists described the patients they selected for treatment as “fighting,” “restless,” “noisy,” “quarrelsome,” “resistive,” “combative,” “stubborn,” “aggressive,” “obstinate,” “uncooperative,” “hyperactive,” and “disrobes.” Physicians saw incorrigible behavior as a signifier of treatable disease. Its elimination measured therapeutic success. “Quieter,” “manageable,” “calm,” “more cheerful,” “cooperative,” and “not so aggressive” all described effective therapeutic outcomes.7
In the 1940s and 1950s, the expansive use of ECT that Braslow documented at Stockton State Hospital was clearly the norm, and the psychiatric literature is replete with evidence of its widespread employment to manage the problems posed by schizophrenics and other troublesome inmates. The magic phrase was “maintenance therapy.” Active treatment offered demonstrable results, producing calmer wards valued by psychiatrists, ward attendants, and perhaps patients themselves.8 If disorder threatened to return, that provided a rationale for a new round of interventions.
At Pilgrim State Hospital, where Lothar Kalinowsky had set up shop in October 1940, the superintendent, Harry Worthing, quickly grasped that treated patients became “quieter and more manageable. It was therefore decided to treat chronic, disturbed patients in the disturbed buildings … with the sole intention of making them less disturbed, less assaultive, and less destructive.” Worthing made no attempt to disguise what counted as success here: “We feel that results from a purely symptomatic standpoint are worthwhile considering the little effort involved in giving three or four treatments, if the patients become more manageable even for several weeks.”9
There were no checks on how many shocks individual patients might receive, and the numbers reported were often remarkably high. There was one published reference, for example, to a patient receiving more than 800 shocks.10 Two British psychiatrists, Kino and Thorpe, reported on 500 patients to whom they had administered ECT. “Most” were female (this was the norm), and if they were melancholic, they might receive sixty or seventy treatments. Cases of mania and schizophrenia, they reported, required longer and more intensive treatment.11 Thorpe separately provided an example of what this more intensive treatment could involve. In cases of mania, he recommended “several shocks daily until the excited state is suppressed” and then “frequent spacing of shocks to prevent relapse.” Making use of such a regimen would ensure that “the most maniacal patient can be rapidly and dramatically be brought under control”—and, thereafter, “the quiet cooperation of the patient will be appreciated by the nursing staff.”12
Early on, there were occasional experiments with the subconvulsive use of electricity. In 1946 at Rockland State Hospital in New York, for example, Walter Thompson and his colleagues, following earlier trials along these lines by Nathaniel Berkwitz, tried connecting one electrode to the patient’s head and the other to a leg. (They had earlier tried putting both electrodes on the head and using a nonconvulsive dose of electricity but dismissed this approach since “the transmission of the current through the brain only was comparatively painless and innocuous.”)13 All 213 patients they experimented on (one as young as thirteen) were female. Turning on the current produced a tetanuslike convulsion with forcible contraction of the face and eye muscles and obvious signs of pain. During the contractions, patients stopped breathing temporarily but remained fully conscious.
Initially, the women were given thirty of these subconvulsive shocks, which “had no beneficial effects as far as the psychosis was concerned.” In other respects, the treatment seemed useful, proving “of definite help in improving antisocial behavior.” For some odd reason, both patients and attendants considered this to be “a form of punishment … but every attempt was made to prevent this attitude.” Metrazol, Thompson noted, elicited similar responses. By contrast, subconvulsive shocks carried fewer risks of fractures or other untoward effects, and they were a useful means of reducing “destructiveness, combativeness, untidiness, self-mutilation and at times, although rarely, hallucinations and delusions.” All these “beneficial effects appear to be on a reality basis and due to the associated discomfort.”14
Overt reliance on aversive therapy of this sort was uncommon, though the use of ECT to achieve similar results was widespread.15 Kalinowsky and Paul Hoch’s 1946 textbook on shock treatment advised that “maintenance treatment should be available on every chronic ward” and lauded “the great satisfaction that active treatment gives to the personnel of a chronic ward.” Repeated shocks produced docile patients and instead of inmates being left to rot on “continuous treatment wards,” the staff could see themselves as dispensing therapy. Such interventions thus served multiple goals, and their use “inevitably improves morale and, consequently, the interest of the nursing and medical staff in the individual patient.” Some patients might even become suitable for discharge, returning for repeat ECT if and when their condition deteriorated.16 The authors of the major textbook on shock therapy assured their colleagues that “such treatment can be continued for years without damage.”17
Maintenance treatment on the wards of understaffed state hospitals was more extreme than this sanitized account suggests. At Milledgeville in Georgia, for example, one of the largest state hospitals in the country, “maintenance therapy” had a different name: “the Georgia Power Cocktail.”18 By 1942, the hospital census had reached 10,000 patients whom a staff of fifteen physicians were charged with treating. ECT proved to be an essential tool for managing the massively overcrowded wards. One of the staff psychologists described the routine:
The matter of who was to receive electric shock treatment on the various wards was largely based on the reports of nurses and attendants. The words “punish” and “shock treatment” were often synonymous to the disturbed. Which electric shocks were given for treatment, which for punishment, and which for both presented confusing problems to the patients, many of whom were paranoid to begin with and felt they were being punished for their “guilty” deeds prior to their illness.… The attendant himself was confused when he was criticized for using force to subdue a patient who might have attacked him when he had heard a physician say that force was unnecessary “because shock treatment left no marks.” The physician could have added that the patient would not even be able to remember the circumstances surrounding the behavior leading to the punitive shock treatment.19
Edward Shorter and David Healy imply that this abusive and “vengeful” use of ECT at Milledgeville was exceptional.20 But considerable evidence casts doubt on this contention. At Traverse City State Hospital in Michigan, Paul Wilcox reported on 500 chronic patients who had been given an extensive series of electroshocks. “Many were selected,” he noted, “because they were extremely difficult ward problems.” Wilcox stressed that others had failed to achieve results with patients like these because they had not treated them adequately. “Adequate treatment means intensive treatment until the expected improvement has occurred.” Diagnosis was irrelevant. Patients drawn from thirty-six different diagnostic categories were treated, and women on the average were given twice as many shocks as the men. No justification was offered for this discrepancy. As for what all this was intended to accomplish: “No attempt was made to judge basic improvement in the psychosis other than in the ward behavior.” Perhaps that was just as well, since “only a small number of these chronic patients improved enough to leave the hospital, even with the help of the treatments.” But the patients were no longer so difficult to manage.21
The role of ECT in enforcing order on mental hospital wards and punishing patients whom the staff deemed troublesome was likewise a central theme of Ivan Belknap’s ethnography of a Texas state hospital in the early 1950s.22 Lists of patients to be given ECT were compiled daily by the ward attendants, singling out those who were violent, had proved uncooperative or troublesome, or had annoyed the staff: hallucinatory and delusional “worry warts” were particularly likely to be put on the shock lists.
Sometimes the mere threat of being referred for ECT was sufficient to rein in the patients. They had witnessed the effects firsthand, since they were often called on to hold down a fellow patient while the shock was administered. The procedure occurred in front of them, with no attempt to hide the results: “The patient’s convulsions often resemble those of an accident victim in death agony and are accompanied by choking gasps and at times by foaming overflow of saliva from the mouth.… Moreover, in the early disorientation and vacuity of his recovery he is obviously upsetting to the other patients.” For those who refused to be deterred, or were too disturbed to respond to these sights, “the amnesia and disorientation produced … by the shock treatment keeps them quiet and prevents their disturbing or hurting the other patients and upsetting the ward routine.”23
THE WORKING ASSUMPTION of many of those advocating ECT was that failure to improve was either the result of the patient suffering from a particularly malignant psychosis, or because the patient’s treatment had not proceeded far enough.24 There were no markers to indicate when the limits of treatment had been reached, and there were complaints that “the vital question remains unanswered at what number of treatment should one stop.”25 There was always the hope that additional shocks would produce the improvement psychiatrists sought. Quite early on, however, there were suggestions that patients who failed to respond to the conventional sequence of three or four shocks a week might need a more drastic approach.
In 1941 at St. James Hospital in Portsmouth, England, the superintendent, Thomas Beaton, and his assistant, Liddell Milligan, began giving as many as four shocks a day to a series of “psychoneurotic” patients, an approach that deliberately served “to reduce the patient to the infantile level, in which he is completely helpless and doubly incontinent” and to create “confusion, amnesia, and complete disorientation.” Milligan did not report the results of the hundred patients they treated in this fashion till after the war.26 In 1944, Bini tried a similar approach, one he dubbed metodo dell’annichilimento, or “annihilation therapy.” Soon others followed, some calling it BLITZ ECT.
Clarence Neymann of Northwestern University, mostly famous for his efforts to develop artificial fever therapy, had suggested in 1945 that if a psychotic patient became “violent and unmanageable,” ECT should be employed to the point of “disorientation.… Even beyond this, his psychic state or mentality should be reduced to a merely vegetative level.… No matter how great the excitement, this, of necessity, will cease under continued electric shock therapy.”27 Two years later, the New York State Psychiatric Institute, regarded as one of the foremost centers of therapeutic research in the country, began experimenting with using ECT four times a day, as Neymann had recommended, but soon found that it required too much nursing care and abandoned it.
At the same time, at the nearby Kings Park State Hospital, Cyril Kennedy and David Anchel began their own trial with intensive electroshock and gave the procedure the name most generally used thereafter, REST (for regressive electroshock therapy). Their patients were a group of twenty-five schizophrenics who had previously received “adequate” courses of treatment with insulin coma, metrazol, or conventional ECT, with little or no sign of improvement. A number of these patients had been recommended for another drastic therapy—prefrontal lobotomy—and Kennedy and Anchel, citing Milligan’s paper, preferred to try a more aggressive form of electroshock. Each patient was shocked two to four times a day, “until the desired degree of regression was obtained.… We considered a patient sufficiently regressed when he wet and soiled, or acted and talked like a child of four.” At that point, patients were thoroughly confused and unable to care for themselves, and “liable to fall and injure themselves,” but “their minds seem like clean slates upon which we can write. They are usually cooperative and very suggestible, and thus amenable to psychotherapy.” There were, they claimed, no lasting ill effects from the shocks, and within ten days to two weeks after treatment, in all but one case, the patients improved—though whether the improvement would last, they cautioned, “time alone will tell.” What improvement meant was ambiguous, since they simultaneously conceded that, of the twenty-five patients, “15 regressed to wetting and soiling.”28
Others soon were reporting their own experiments with regressive electroshock.29 In 1950, at Stockton State Hospital, Mervyn Shoor and Freeman Adams, claiming that “intensive electric shock therapy … has become a validated procedure in acute excitement states,” decided to try the approach, once again selecting 123 female patients in “the most disturbed of the chronic women’s wards,” selecting their patients “on the basis of their ward behavior.” The goal was quite explicitly “not curative; they were limited to the level of improved ward behavior.” And this they claimed to have achieved: “Within two weeks from the beginning of our intensive electric shock treatment the character of the ward changed radically from that of a chronic disturbed ward to that of a quiet chronic ward.” With some patients, they were forced to give as many as a hundred shocks before they achieved their goal, though others started to conform much sooner. They were struck, they reported, by the close resemblance those “who receive large numbers of electric shock treatments daily for many weeks bear to the lobotomized patients.” The treatment, they concluded, had promise.30
A decade later, Sylvia Cheng and Sinclair Tait of the Weston State Hospital in West Virginia reported that “electroshock therapy has been used almost universally in the control of disturbed psychotic patients.”31 With chronic patients, by the end of the 1940s, the use of the regressive form of ECT was “not uncommon.”32 Still the hoped-for cure rarely materialized. Koenig and Feldman lamented that despite “insulin, electric shock, metrazol, or combinations of these[,] great numbers of patients remain within the walls of our state hospitals permanently.… [W]ith the passing of time, their regression and deterioration come more and more to the surface.” These patients become great behavior problems. They could be kept in isolation, or immobilized in wet packs, but then they tended to “develop decubitus ulcers and secondary infections.”33 What was to be done?
At Arkansas State Hospital, Feldman had experimented as early as 1942 with giving such patients up to four ECTs a day twice a week, something he dubbed the “block method.” But “though marked improvements were achieved, these were only of short duration.”34 In December 1949, now relocated to Manhattan State Hospital, he and a colleague implemented a similar program. All the patients they chose were assaultive and destructive, and the shocks were used “purely as a palliative treatment and the main aim was to improve the condition of the disturbed wards.” The thirty-one patients they reported on had all previously received insulin comas and metrazol or ECT but had remained hard to manage. All patients received an ECT at 9 a.m. and then a second shock an hour and a half later, with sandbags placed under their backs to minimize the chances of fractured vertebrae. Each received ten to fifteen double treatments, and, thereafter, “the patients quieted down to a point where restraint and sedation were done away with practically altogether.”35 Staff morale improved, the hospital realized considerable savings, and even patients’ relatives commented on how much calmer the patients were.
At the Chillicothe Veterans Hospital in Ohio in 1952, thirty of the most disturbed and hopeless patients, this time men, were chosen for regressive ECT. All of the patients had received at least twenty prior ECT treatments and fifty or more insulin comas. They were now given three shocks a day five days a week, till they had received a total of sixty to seventy-two ECTs each. “No permanent ill-effects have been observed,” E. S. Garrett and G. W. Mockbee informed their colleagues. Unfortunately, there had also been no positive effects so far as the psychosis was concerned: “The present psychotic pattern of each patient follows that of his preshock picture.” This was “disappointing.” On the other hand, twenty-seven of the thirty were better behaved on the ward, so there was “a definite place [for regressive electroshock] where all other methods of treatment have failed.”36
WORCESTER STATE HOSPITAL in Massachusetts had long been regarded as one of the best in the country. It was where Adolf Meyer had trained his cadre of young psychiatrists, and its programs for treating schizophrenia had garnered both approval and substantial subventions from the Rockefeller Foundation, then the leading source of support for psychiatric and medical research. Here, too, were experiments with regressive ECT. In 1951, fifty-two patients (all young and in good physical condition) who had shown no lasting improvement with other physical therapies were given four shocks a day for seven days: “By the end of this intensive course of treatment practically all patients showed profound disturbances.… [They were] dazed, out of contact and for the most part helpless … prostrated and apathetic.… [M]ost of them whined, whimpered, and cried readily, and some were resistant and petulant in a childish way.” D. Rothschild and his colleagues commented that “regressive” was an appropriate term to apply, as these patients, while they could walk only with assistance and had to be spoon fed, would happily suck on a baby’s bottle. The procedure might appear “drastic” but “clinical psychiatric observations did not reveal any [brain damage].” Five of the fifty-two patients were said to be “much improved,” and “the fact that this improvement may be only temporary should stimulate further research in the field of therapy for such patients.”37
Others were eagerly experimenting along similar lines. At the Willard State Hospital in New York, J. A. Brussel and J. Schneider asked the ward attendants on the most disturbed female ward, where “the problem of the chronically disturbed patient … reached its zenith,” to select their most troublesome fifty patients, all of whom had already received full courses of regular ECT and were currently on “maintenance shock.” The problem was urgent, they claimed, because no one on the ward was improving, and “new admissions were constantly arriving.”38
A series of intensive shocks produced remissions that lasted from six to forty-two days, and “so uniformly gratifying have been the results that it has been most difficult to restrain enthusiasm.” The short duration of improved behavior might at first sight be of concern, but close observation could pave the way for another course of shocks, “enabling patients to enjoy unbroken remissions and maintain improvement.” There was even the prospect that some might be released, returning every two or three weeks for a series of shocks to “maintain improvement.” Not incidentally, employee morale had soared, and the “monetary savings on otherwise smashed windows, destroyed clothing, blankets and bed linen, destroyed furniture and supplies, and the savings in outlay for sedatives and restraint apparatus is an important budgetary benefit.”39
WHEN ECT WAS INTRODUCED, there was considerable concern about whether it was safe. The research on this question was unsatisfactory and usually poorly designed. It was obvious, in the immediate aftermath of regular ECT, let alone its regressive variant, that patients’ memories were severely affected. There were bland assurances in the literature that this amnesia was of limited duration. There was, however, little systematic attention to this issue, and where extended memory loss ensued, there was a propensity to blame it on the depression or schizophrenia the patient was suffering from.40 Follow-up studies were infrequent and as carelessly conducted as the original decision to administer ECT, but concerns about the degree and extent of memory loss and anecdotal complaints from patients cast a long shadow.41 Those dispensing ECT in the 1940s and early 1950s fiercely objected to these criticisms. Kalinowsky spoke dismissively of those who complained as the “hysterical” and “neurotic.”42 He insisted ECT was safe and that memory problems “disappear within the one or two weeks after the last treatment.”43
Many feared that the passage of electricity through the brain might produce brain damage. Those promoting it emphatically declared that there was none, or that the changes involved were temporary.44 Critics professed doubts, pointing to animal studies and autopsy reports that found brain hemorrhages and other signs of damage. Most but not all of the animal experiments “did not closely enough duplicate the conditions pertaining in human electroshock to be important in answering the question.” The better studies of this sort did seem to document damage, but the clinical significance was unclear.45 Thus the position psychiatrists ending up adopting on the question of brain damage depended on their existing view of the treatment, and both sides ended up drawing opposite conclusions from anecdotal evidence and from essentially the same data.
Then there was the question of broken bones. The emphasis in many quarters on repeated convulsions immediately raised questions about whether ECT shared with metrazol a tendency to cause fractured spines and femurs. Once again, Kalinowsky sought to minimize the problem, arguing that X-ray studies that showed evidence of fractures “have limited or no clinical significance at all.”46
His efforts, and those of other enthusiasts for ECT, to devise ways to avoid or limit fractures suggest that behind the scenes they were more concerned than these public protestations would indicate. In his 1946 textbook, Kalinowsky acknowledged that “it is difficult to describe any special holding techniques because none has proven to be absolutely safe.”47 Even four or five nurses holding the patient down did not always suffice.48 He advocated placing sandbags under the middle of the back. “The shoulders and hips are then manually applied to the table with some force.”49 The procedure “looked terrible.”50 Worse still, it was apparently ineffectual. In 1950, I. Meschan and his colleagues conducted a careful study of 212 successive cases treated at a veterans hospital in Arkansas. Despite using a specially designed hyperextension table, pre- and posttreatment X-rays showed vertebral fractures in 35.4 percent of the patients, with, on average, 2.56 vertebrae broken per patient, and they concluded that “the incidence of electric shock convulsive fractures and metrazol fractures is approximately the same.”51
Others, less complacent, sought a better way to perform ECT. Abram Bennett experimented with using curare as a muscle relaxant as early as 1940, in an attempt to mitigate the explosive force of metrazol seizures. Since curare temporarily paralyzed respiratory muscles, its use introduced an additional source of terror unless it was combined with anesthesia, which added still another element to the cocktail.52 The margin between a therapeutic and a fatal dose was slight and uncertain, as the potency of curare, a natural substance, varied considerably.53 Bennett was soon campaigning to extend the use of curare to ECT, but there was fierce resistance among advocates of ECT, Kalinowsky prominent among them.
Discussing the question in his widely used textbook, Kalinowsky wrongly asserted that “fractures in ECT are rare.” “Curarization,” he complained, “adds to the possibility of complications which are more dangerous than those it is designed to prevent.” While ECT rarely led to patient death, curare all too easily could do so. “Another disadvantage of curarization is that most patients dislike the feeling of being paralyzed,” with the result that “the number of our patients who refuse to continue treatment is unduly high among those treated with curare.” One of the great advantages of ECT over metrazol was that it dispensed with the need for injections and minimized the terror metrazol brought in its train. The use of curare with ECT squandered that advantage.54
Bennett attempted to dismiss these objections, attributing deaths among curarized patients to clumsiness or inexperience on the part of the practitioner. Only an effective muscle relaxant could adequately protect patients from fractures, and this, he claimed, was a far more serious problem than Kalinowsky and Hoch were willing to acknowledge. He cited one recent study by Lingley and Roberts that had systematically underestimated the problem by only X-raying patients who complained of severe pain, and yet had found a 23 percent fracture rate.55 Bennett attracted some followers, especially among those practicing in private hospitals.56 But most shied away from the risks, and state mental hospitals, grossly unstaffed and overcrowded, could in any event scarcely afford the extra expense of the drugs and an anesthesiologist.
Succinylcholine, commonly known as “sux,” or by its trade name, Anectine, was a synthetic and much safer and more predictable muscle relaxant that began to be marketed in the early 1950s by Burroughs Wellcome. In May 1952, two Swedish psychiatrists suggested that it could eliminate both the problem of fractures and the brutal sight of patients thrashing about as if in their death throes. If patients were first given a dose of a barbiturate as an anesthetic and were given oxygen to support respiration, ECT could be administered without provoking a grand mal seizure.57 In time, this modified ECT would become the standard way of administering shock, but the parlous situation of the state hospitals drastically slowed its adoption in the institutions where hundreds of thousands of patients still languished. Thus, even in the late 1950s, many psychiatrists continued to administer unmodified ECT. No one challenged their professional authority to do so, and ECT remained in their eyes a valuable means of securing patient compliance. Patients, their minds disordered, had no rights over their bodies and perforce submitted to the orders of those who controlled their fate. Though Anectine, anesthesia, and oxygen made ECT visually and physically a much less taxing procedure, not long after modified ECT became standard, shock treatment fell into disrepute.58
THE ARRIVAL OF A NEW CLASS of psychiatric drugs, the phenothiazines, in 1954, had dramatic effects on the practice of psychiatry. At first this did not dampen enthusiasm for ECT, which was often given alongside the new drug therapy. At the private Stony Lodge Hospital in Ossining, New York, and in the psychiatric unit at the nearby Sing Sing Prison where he was on staff, Bernard Glueck, Jr. continued to experiment with regressive ECT, lamenting in 1957 that others seemed to have abandoned a potentially powerful therapy.59
Not everyone had, however. At the Allan Memorial Institute in Montreal, the psychiatrist in charge, D. Ewen Cameron, remained convinced that regressive ECT had promise, not just as a means of controlling and disciplining the most disturbed of patients, but as a form of therapy. Cameron was no marginal figure. He had trained under Adolf Meyer and Eugen Bleuler and served as president of the American Psychiatric Association, Canadian Psychiatric Association, and the Society of Biological Psychiatry and, for five years in the 1960s, as the first president of the World Psychiatric Association. Ironically, given what many regard as his criminal abuse of his patients, Cameron had also been an expert at the Nuremberg trials of Nazi war criminals.
As chair of the department of psychiatry at McGill University, Cameron had been showered with money from the Rockefeller Foundation and also (secretly) from the CIA.60 The CIA involvement was conducted under the code name MKUltra, or Project Artichoke, and involved other prominent psychiatrists, including Jolyon West, chair of the psychiatry department at UCLA. Cameron (and the CIA) saw in regressive ECT the possibility of erasing patients’ existing memories and then reprogramming them. He experimented with prolonged sleep for up to two months, massive doses of neuroleptic drugs, and what he called “psychic driving” to his program of “de-patterning.” Where others had used regressive ECT primarily on chronic schizophrenics, Cameron embraced few such limits. Even patients who arrived at the Allan Memorial Institute with relatively minor psychiatric diagnoses might find themselves part of his experiments.
Though Cameron’s CIA funding was hidden, what was happening to his patients was not. In 1957, at the Second World Congress of Psychiatry, he announced that his intervention was designed to produce temporary disturbance of brain function. Five of the patients in the series he was reporting on were men, and twenty-one were women; ten had been “ill” for fewer than two years. They were kept asleep for twenty to twenty-two hours a day using barbiturates and chlorpromazine and then subjected to four or five electric shocks in the space of two or three minutes. This combination, Cameron concluded, generally sufficed to de-pattern the patients “somewhere between the 30th and 60th day of sleep and after about 30 electroshocks,” leaving them—allegedly temporarily—with “severe recent memory deficit, disorientation and impairment of judgment.” The patient during this phase was “smiling and unconcerned … does not recognize anyone, had no idea where he [sic] is and is not troubled by that fact …, incontinen[t] and has difficulty performing quite simple physical skills.” The upshot, by his account, was “some blunting of affect, some loss of drive” compared to that shown in earlier years, but this was probably the result of “schizophrenic damage.” Most of the women, he claimed, were then able to resume their careers as housewives, though “some have had relapses … [which] we are always able to terminate within two or three days and often within 24 hours by intensive electroshock therapy.”61
In two later papers, published in 1960 and 1962, Cameron elaborated on aspects of his de-patterning therapy. He freely admitted that the treatment produced massive amnesia. Total amnesia sometimes extended to five years, while “the longest period of differential amnesia has been for ten years prior to treatment.” Where patients relapsed, more de-patterning was in order, and “in rare instances, we have had to repeat this procedure several times for a given patient.”62 By now, the treatment had been extended from schizophrenics to psychoneurotics, some of whom were treated only three months after the onset of symptoms. In 1962, he reported that six ECTs in rapid succession were being given twice a day, with some patients receiving up to sixty such clusters.63 Once again, the patients were disproportionately female: twenty-one out of the thirty reported cases. De-patterning therapy constituted, Cameron claimed, “a noteworthy advance” over insulin comas, chemical therapies, and even earlier forms of regressive electroshock.64
In 1964, Cameron abruptly left Montreal under mysterious circumstances. Despite his professional prominence and twenty years as head of McGill’s psychiatry department, he departed for a new post in Albany, New York, without notice and without any ceremony to mark his exit.65 De-patterning continued for some months at the Allan Memorial Institute after he left, and then, without fanfare, was abolished.66 Three years after his departure, he suffered a heart attack while mountain climbing and died, eulogized as a giant of twentieth-century psychiatry. The Canadian Medical Association Journal mourned the passing of “a man who was vitally concerned with the well-being of men everywhere”—someone whose extraordinary abilities had transformed Montreal into “one of the leading psychiatric centres in the world.”67
Years later, the CIA and the Canadian government were sued for the human damage Cameron had left in his wake: patients depressed and crippled, tortured by what had happened to them, who never recovered their memories and in some cases control over bodily functions. Many despaired, and there were a number of suicides. Several hundred patients belatedly secured a small measure of financial compensation.68
As with virtually all published research on ECT through the 1960s, Cameron’s findings rested upon research conducted without control groups against whom to compare the treated population. Assessments of “improvement” were unsystematic and anecdotal. The body of research on ECT consisted of little more than strings of case reports and judgments about outcomes with no provisions to guard against observer bias or independent yardsticks to measure changes in patients’ mental states. In many instances, follow-up data were missing altogether, or so brief as to be worthless. In the 1940s, these methodological shortcomings were characteristic of medicine as a whole. Most historians regard the trial of streptomycin in the treatment of tuberculosis, published in 1948, as the research that led to the establishment of the double-blind randomized trial as the gold standard in medical research.69 Even in medicine, the new approach was not adopted overnight, but psychiatry’s status as the poor relation of the profession allowed such unreliable research to pass muster for still longer.
THE HORRORS ASSOCIATED with Ewen Cameron’s “psychic driving” were not exposed until 1975. Tales of the destruction he had inflicted on the lives of the patients he experimented on provided critics with a dramatic illustration of just how damaging ECT could be. But the attacks on the procedure had begun many years earlier and had built to a crescendo by the 1970s. Much of the criticism came from nonscientific sources. Writers as different as Ernest Hemingway and Sylvia Plath, one almost a caricature of the macho man and the other (at least after her suicide) a feminist icon, were both seen as victims of a failed treatment. Before Hemingway blew his brains out with a shotgun, he denounced his doctors at the Mayo Clinic: “What these shock doctors don’t know is about writers … and what they do to them.… What is the sense of ruining my head and erasing my memory, which is my capital, and putting me out of business? It was a brilliant cure but we lost the patient.”70
Ken Kesey’s novel One Flew over the Cuckoo’s Nest and Janet Frame’s Faces in the Water were both based on personal experience—Kesey worked as an attendant in a mental hospital in Menlo Park, California, in 1960, and Frame was a patient who underwent hundreds of ECTs. (Frame’s psychiatrists judged those treatments a failure and were about to lobotomize her when news that she had won a major literary prize led them to abort the surgery.) Both novels portrayed ECT in harsh terms, and both were subsequently made into highly influential films. Jack Nicholson’s scene in the movie One Flew over the Cuckoo’s Nest seems to have been particularly effective in demonizing ECT. But it fed into a narrative already launched by renegade psychiatrists like Thomas Szasz and R. D. Laing that portrayed psychiatrists as little more than agents of social control, and ECT as one of the tools used to secure conformity.
Symptomatic of the changed attitudes toward ECT was the passage of legislation in California (soon followed by other states) that sharply constrained the use of ECT, virtually abolishing its use except on patients who volunteered for it.71 ECT’s sharply diminished profile was reflected in the fact that the National Institute of Mental Health awarded $9.9 million in research grants on somatic therapies in psychiatry in 1972 and 1973, less than $5,000 of which was for research on ECT.72 More subtly, ECT simply disappeared from the psychiatric journals and the academic conference circuit.
The advent of the first modern drug therapies for schizophrenia in the early 1950s had proved an unexpected bonanza for the pharmaceutical industry, and as the companies realized the massive profits that lay within reach, the volume of drug advertising in the psychiatric journals exploded. In the 1950s, these advertisements often included references to ECT. After 1965, such references simply vanished. The upshot was that “ECT disappeared from the awareness of most doctors, except insofar as they read negative and stereotyped references to it in the popular press.”73 A contemporary survey of ECT practice, completed in 1976, confirmed that “public and professional opinion of ECT was generally unaccepting, negative, and somewhat hostile.”74 It appeared to be on its deathbed.