DON'T DARE TELL THEM YOU'RE DEPRESSED! A Review of Pushbutton Psychiatry

Timothy Kneeland and Carol A.B. Warren's Pushbutton Psychiatry: A Cultural History of Electroshock in America, is a useful source whose value is disguised by the ideology they authors impose on their subject. In focusing on patriarchy and sexism they are harping on the irrelevant, for ECT is not a gender issue. That is quite obvious from the fact that the most famous (although hardly the best) negative depiction of ECT, Ken Kesey's One Flew Over the Cuckoo's Nest, is emphatically sexist. And perhaps the most eminent victim of ECT, Ernest Hemingway, was a "macho man" who would not please most feminists. To judge by the CIA's decades of experiments with the procedure, including experiments in the field during the Vietnam War, it is likely that the most pitiable victims of ECT today are terrorist suspects, all of whom are men who adhere to beliefs of which no feminist could approve. Finally, as I know from personal experience, it is perfectly possible for a divorced woman to be the head of a household and to decide of her own volition, without any influence from men, to place her child in a mental hospital where he or she may be forced to endure ECT, drugging with neuroleptics, or other horrors. When women were decidedly second-class citizens, they were more often the victims of ECT because as with any type of abuse, it is the most helpless who are the most victimized. Today, when women have achieved an equal place with men, they are more likely to be victimizers, like for instance Kitty Dukakis whom I wrote about in my last blog, and Joan Prudic, M.D., a co-author of Harold Sackeim's now-famous article promoting unilateral ECT, who teaches a course in that subject at The New York State Psychiatric Institute. This should not surprise us, because there is no fundamental difference between males and females, and no reason why women should not be attracted to power and wealth as much as men-- ECT is an issue upon which some will take a stand from moral courage and others will use to further their own self-interest, regardless of whether they are male or female.

Under the spell of their obsession with gender, the authors waste many pages discussing the quasi-erotic and quackish use of electricity and "animal magnetism" in eighteenth and nineteenth century medical performances (and performances they were, in many cases before an audience) involving male doctors and female patients. Thus they miss the opportunity to discuss a much more relevant use of electricity in so-called "therapy". The practice of aversive conditioning derived from the theories of psychologist B.F. Skinner often makes use of painful electric shocks. Although these are not directed at the brain and therefore do not cause the massive physical damage that ECT does, they can cause psychological trauma when inflicted upon the helpless, such as children at the Judge Rotenberg School for Autistic Children. More importantly, they are similar to ECT in that they are in actuality punishment masquerading as therapy. Indeed, the closest relative of the ECT machine today is the Graduated Electronic Decelerator (GED) developed by Mathew Israel, director of the aforementioned school. The reader would do well to simply skip the first two chapters of this book entirely and read only chapters 3 through 5, which follow ECT from its birth in fascist Italy and enthusiastic reception in the what those countries which we used to call the "Western democracies", through its challenge by the social reform movements of the nineteen-sixties and seventies, to the ultimate and tragic triumph of ECT in the era of incipient totalitarianism, 1981 to the present day.

There are three excellent contributions which the authors make in these chapters. First, they discuss the struggle between the psychodynamic and somatic, or biological approach to mental illness. They establish quite accurately, although it rather undercuts their thesis of ECT as being an expression of patriarchy, that the psychodynamic model is the traditional one, the somatic a brazen usurper of recent vintage. Freud and his followers, whatever their defects (and some, such as Adler and Jung, were relatively free from the sexism which marred Freud's thinking), put the emphasis upon understanding the patient through prolonged discourse. Genuine psychotherapy is a time-consuming and expensive process, which does not appeal to the technocrats of today, obsessed as they are with the search for a "quick fix". But the their substitutes-- whether chemical or electrical-- not only do profound damage to the patient, they do not cure them. Even Kitty Dukakis admits that she has to go back to have more ECT treatments every few months, when her symptoms re-appear. So in a sense, ECT is like an addictive drug, and far more damaging to the user than cocaine or heroin. Similarly, people who are given neuroleptics are subject to the inner tortures of tardive dyskinisea or akathisia (a bit like delirium tremens) when they attempt to withdraw from them, even after a short period of time, with the result that they end up "hooked". The psychodynamic approach to mental illness may or may not cure it-- it is hard to say, for human beings are complex and any approach which takes account of these complexities is not easily subjected to statistical analysis. But the somatic approach is demonstrably a dismal failure. Indeed, psychiatrists who use it do not even claim that they are aiming to cure the patient, generally describing the individual upon whom they have inflicted their techniques as "in remission", implying that they are not and never will be "cured", but will have to come back again and again to pay for ever more expensive and damaging treatments. They are the legal equivalent of drug pushers. And what Kneeland and Warren fail to point out is that the place where the somatic concept of mental illness triumphed first and most completely, to the point of becoming official dogma, is the Soviet Union. Is there not something inherently totalitarian in an approach which had such appeal to the doctors working under Stalin?

The second contribution the authors make is in tracing the history of the legal battles over ECT, especially in California, where they raged most fiercely, probably because the juxtapositioning of some of the most wealthy electronics firms in Silicon Valley next to some of the most enlightened politically progressive communities in the nation in San Francisco and Berkeley. The attempts to restrict ECT in Berkeley and California at large which were made in the nineteen-seventies gave rise to a powerful backlash, led by the Association for Convulsive Therapy (ACT), which has completely eliminated free debate over the issue from the American Psychiatric Association and the psychiatric profession at large. Acceptance of the efficacy of some form of ECT is now required dogma for the aspiring psychiatrist and he or she can no more challenge it than a Soviet doctor could have challenged the questionable tenets which underlay Soviet medicine. But the most important factor in the triumph of ECT seems to have been money. Indeed, greed looms obscenely large in Kneeland and Warren's account. Contrary to Dukakis' assertion that there are only "two small companies manufacturing ECT devices, and they lack the means to do studies of it", there appear to be five major corporations-- Somatics, MECTA, Medcraft, Hittman and Eliot. These companies played a major role in the rehabilitation of ECT after its decline in the seventies, lobbying the FDA not to force them to pre-market test their machines because doing so would increase their costs by more than three million dollars (pp. 88-89). Thus a decision which could adversely affect the lives of millions of potential patients was made purely on the basis of the economic well-being of the corporations which manufactured the devices.

The ties between the "shock doctors" and the companies which make the machines they use and the videos to sell them to the consumer are close: MECTA was the invention of Dr. Paul Blachly, one of the founders of ACT; ECT proponents Drs. Richard Abrams and Conrad Swartz began Somatics in 1985; and Richard Abrams, who wrote the leading text on ECT, derives more than fifty per cent of his income from that company (pp. 91-92). Max Fink, the leading proponent of ECT in America today, shock proponents Harold Sackeim and Richard Weiner all contributed to the making of $350 videos to advertise ECT: Fink received $18,000 for his work and an 8% royalty on the them. One critic of of this overlap of professional and economic interest remarked that the APA Task force on ECT ought to be called "The Manufacturers Task force on ECT" (pp. 91-92). Here one must note the profits to be made from both private and taxpayer supported insurance: one study showed that 65-year-olds receive 360 per cent more shock therapy than 64-year-olds in Texas. The difference? Medicare pays for the latter. (p. 93). Reductions in the length of hospital stays reimbursed by private insurance during the 1980s set time limits on trials of psychoactive drugs (and even more so on traditional psychotherapy, which has always been undersupported by insurance). "Cynical observers noted that the advent of Diagnostic Related Groups (DRGs) for hosptial reimbursement may make ECT more cost-effective than drugs, for it works [sic] 30 to 40 times faster." (p. 93-- of course this means in practice that the patient gets the "high" associated with brain damage much faster than he would if given drugs). Thus insurance companies do not have to pay so much for the procedure, while shock is "very advantageous economically to hospitals". p. 83) Psychiatrists' fees are anywhere from $125 to $250 for the 5- 15 minute procedure; a study published in 1998 found that Medicare paid $97.73 and Medicaid $36 for psychiatrists attending ECT, the anaesthesiologist's fee fanged drom $75 to $160, while the nurse and treatment room added another $500 per treatment." (p. 92) Given the profitability of ECT, it is not surprising that the number of recipients in California doubled between 1994 and 2004, from 2,356 to 4,553.

How then to explain the hypocritical argument, made by many spokesmen for ECT, that it is a "benefit" denied by an unjust society to the poor? (p. 86) To understand this one must recognize that human beings are motivated by the quest for power and prestige as well as profit. And power and prestige can be collective. The struggle to replace the psychodynamic concept of mental illness with a soomatic one emanated from the struggle of psychiatry to gain equality with other medical specialties, and avoid sarcastic comments such as, "We are dissecting a cadaver-- would you be so kind to come and show us the location of the id?" (quoted in Don Gillmor, I Swear by Apollo) To maintain their own self-esteem, psychiatrists had to compete, to come up with results which could be quantified, which presents great difficulty for those who take a humane and compassionate approach to their patients. The increasing public perception of psychiatrists as "scientific" professionals swelled their own pride as it damaged their patients. And of course nothing could compare to the thrill of having the power to destroy a person's identity and rebuild it according to one's own wishes. Faced with the imperatives of modern technological society, traditional psychotherapy was to go the way of the U.S. Constitution and traditional concepts of freedom and dignity, dismissed as a mere relic of an irrelevant past. What was done by government fiat in the Communist countries was done by general agreement in the Western nations. Reading of the tragic acceleration of the rate of administration of ECT, one cannot help but be struck by the harm done by Ken Kesey's One Flew Over the Cuckoo's Nest. The real dangers of ECT are long-term. By emphasizing only the sight of the grand mal convulsion produced by ECT on an unanaesthetized patient, Kesey created a prejudice which was easily overcome by the slick advertising of ECT manufacturers (who were often one and the same as the doctors who administered the treatment). Those of us who formed our opinions of ECT long before we read Kesey's book or saw the film find it maddening to hear people say "Well it's not like that any longer," as if this had any relevance to the debate.

When I think of the ascendancy of the ECT lobby today, I am reminded of a Japanese Noh play, entitled The Valley Rite. I will not go into the entire historical background, which concerns the struggle between the native religion Shintoism and the imported one Buddhism, except to say that the play takes as its starting point an ancient belief that sick people pollute holy places and must not be allowed into them and then exaggerates this in order to make a point. In the play, a young boy, Matsuwaka, accompanies his religious master on a pilgrimage to a holy mountain. On the way, the boy is taken ill. Learning of this, his master says, "Hush! You mustn't say such a thing on this pilgimage. You are only tired because you are not accustomed to traveling. All you need is a good rest." But the leader of the pilgrimage finds out the truth, and says, "The boy is seriously ill. You must inform [his master] that it is our duty to hurl the boy into the valley, as our rule requires." Accordingly the boy is killed (Donald Keene, Editor, 20 Plays of the No Theatre, pp. 323-4). The mentally ill or troubled person is in exactly the same situation today. My advice to them is to find a good friend. If one is agitated, a psychiarist can be of use only if one does not place too much trust in him and knows what to ask for. If one is agitated, demand a minor tranquilizer-- the Benzodiazpepines (such as Valium and Ativan) are the most unjustly maligned of all psychiatric medications and so mild and harmless that in my opinion they should be sold over the counter. If you take an anti-depressant you are getting into heavier stuff-- it may help to pull you out of a depression but it has very bad side effects and should not be taken for long. But the major tranquilizers or neuroleptics will maim you for life and should be avoided. So too, it goes without saying, should ECT. Above all, for God's sake, don't tell anyone that you are severely depressed! Tragically, the "cry for help" does not stimulate compassion any longer but rather the desire to exploit in order to enhance the psychiatrist's own power, prestige and income. I you threaten or attempt to commit suicide, what the psychiatric profession will do to you will make you wish you had.