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Page 1 of 10 Journal of Mental Health
Feb 1999
Authors: Lucy Johnstone
Volume: 8
Issue: 1
Pagination: 69-85
Abstract: Do something, please! I need my freedom. I have all the rights of a respectable human being and all his duties."
Although it is known that a proportion of people find ECT distressing to receive, these adverse psychological reactions are little understood. Twenty people who reported having found ECT upsetting were interviewed about their experiences in detail. Copyright Carfax Publishing Company Feb 1999
Full Text:
Abstract:
Although it is known that a proportion of people find ECT distressing to receive, these adverse psychological reactions are little understood. Twenty people who reported having found ECT upsetting were interviewed about their experiences in detail. A variety of themes emerged, including feelings of fear, shame and humiliation, worthlessness and helplessness, and a sense of having been abused and assaulted. This had reinforced existing problems and led to distrust of psychiatric staff. Few had felt able to tell professionals of the strength of their reactions, implying a possible hidden pool of trauma. Implications for the practice of ECT are discussed.
Introduction
Although ECT (electroconvulsive therapy) is widely used in depression and some other conditions, it continues to attract controversy. Disagreement mainly centres around the possibility of memory loss and intellectual impairment, with the generally accepted official view being that `As far as we know, ECT does not have any long-term effects on your memory or your intelligence' (Royal College of Psychiatrists, 1997). Although the debate about cognitive impairment has received much attention (Breggin,1991; Frank, 1990; Friedberg, 1976), the question of possible unwanted psychological effects has, until recently, been almost totally neglected. No mention is made of them in most summaries of adverse effects, such as that in Weiner & Krystal (1994). The ECT handbook contains a single paragraph referring briefly to pretreatment anxiety (Royal College of Psychiatrists, 1995). This omission has been commented on both by psychiatrists: `Doctors who give ECT have shown remarkably little interest in their patients' views of the procedure and its effects on them and only recently has this topic received any consideration in the literature' (Abrams, 1997) and by service users: `What is never discussed in the literature is the profoundly damaging psychological effects ECT can have' (Lindow, 1992).
This is in contrast to earlier, mainly psychoanalytic, theorising about the psychological impact of ECT. Psychogenic theories of ECT's action were summarised in a review article by Cook (1944). Earlier belief in the therapeutic effects of fear had been largely replaced by theories about the healing nature of this symbolic death and re-birth. There was speculation along Freudian lines that the fit `by its severe motor manifestations "discharges" large amounts of energy inherent in the destructive and death drives and unloads them in a...harmless manner'. Gordon (1948) listed 23 possible psychological explanations of ECT's effects, such as the destruction of narcissistic protective patterns and the eroticising of the body. Some clinicians believed that these and other hypothesised reactions, such as the relief from guilt and selfpunishment following the experience of 'a sadistic, real attack', made the conjunction of ECT with psychoanalysis a particularly fruitful one (Weigart, 1940 in Boyer, 1952). Boyer includes a lengthy case history in which the young female client equates ECT in fantasy not only with death and re-birth, but also with intercourse, castration and impregnation, with ultimately favourable results in her therapy.
On a less positive note, Abse & Ewing (1956) noted that conscious attitudes towards ECT are 'time and again', in long-term therapy, succeeded by feelings that it was cruel and destructive. There is 'a revival of threatening and punitive parental figures' who are often, like the physician, initially credited with good intentions. The ECT appears to arouse anxiety and fear, while at the same time holding out hope of forgiveness and a fresh start. Wayne (1955) noted that certain aspects of the procedure may evoke unconscious meanings in both doctor and patient; for example, `It has all the characteristics of an overwhelming assault...and this can be documented by the reactions of some patients who have had this treatment'. Fisher et al. (1953) investigated the conscious and unconscious attitudes towards ECT in 30 psychotic patients, and concluded that `the majority of patients found electric shock to be a traumatic experience'. D.W. Winnicott ( 1947) argued that psychological reactions to ECT often compounded patients' difficulties and defences; for example, obsessional people might need to become even more controlled.
An exception to these analytically-orientated accounts is Warren's (1988) description of the implications of ECT for the self and for family relationships. In her interviews with ten women admitted to a state hospital in California between 1957 and 1961 and their relatives, there was uniform confusion and bewilderment at the loss of memory in everyday life. Sometimes this forgetfulness, for example of previous hostile outbursts, was welcome to their husbands. Fear of future ECT stopped some women from confiding emotional upsets, and family relationships were subtly altered all round.
With the general decline of psychoanalytic influences on psychiatry, theorising and research in this area appears to have been abandoned until Gomez's survey (1975) of side-effects in 96 ECT patients. Findings from this and other attitude studies (for example, Freeman & Kendall,1980; Hughes et al., 1981; Kerr et al., 1982) were reviewed in Freeman & Cheshire (1986). Subsequent studies by Malcolm (1989), Szuba et al. (1991), Riordan et al. ( 1993) and Pettinati et al. (1994) used essentially the same format of asking patients to respond to questions or complete checklists about their attitudes to and experience of ECT. The conclusions from this series of investigations can be summarised as follows:
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