Beyond the metaphor of the pendulum: Electroconvulsive therapy, psychoanalysis, and the styles of American psychiatry

Journal of the History of Medicine and Allied Sciences

Volumn 61, Issue 1, 2006, Pages 1-25

  Sadowsky, Jonathan ^a  

^a NONE

Author keywords

Electroconvulsive therapy; Metaphor; Psychiatry; Psychoanalysis; Somatic treatments

Indexed keywords

ELECTROCONVULSIVE THERAPY; HISTORY; HUMAN; LITERATURE; PSYCHIATRY; PSYCHOANALYSIS; PSYCHOANALYTIC THEORY; REVIEW; UNITED STATES;

ELECTROCONVULSIVE THERAPY; HISTORY, 20TH CENTURY; HUMANS; METAPHOR; PSYCHIATRY; PSYCHOANALYSIS; PSYCHOANALYTIC THEORY; UNITED STATES;

EID: 29144489067     PISSN: 00225045     EISSN: 14684373     Source Type: Journal    
DOI: 10.1093/jhmas/jrj001     Document Type: Review

References (112)

1. Ralph Ellison, Invisible Man (1947; New York: Vintage, 1990), p. 236.1 am grateful to Susan Reverby for conversations and correspondence that deepened my understanding of Ellison's work.
2. Ellison, Invisible Man, pp. 232-33.
3. Ellison, Invisible Man, p. 236. This depiction of ECT fits a pattern set in other episodes of Invisible Man. Much of the novel is about the shallow benevolence the protagonist encounters from white society, from liberal paternalists and white Marxists, among others, and this seems to be embodied in this medical encounter, too.
4. Helen Swick Perry, Psychiatrist of America: The Life of Harry Stack Sullivan (Cambridge, Mass.: The Belknap Press of Harvard University Press, 1982), pp. 348-49. Sullivan shared his work with Ellison, seeking help with his writing.
5. Examples of the explicit use of the pendulum metaphor to describe the history of psychiatry include J. Allan Hobson and Jonathan A. Leonard, Out of Its Mind: Psychiatry in Crisis (Cambridge, Mass.: Perseus Publishing, 2001), p. 220;
6. Don R. Lipsitt, "Psyche and Soma: Struggles to Close the Gap," in American Psychiatry after World War II, ed. Roy W. Menninger and John C. Nemiah (Washington, D.C.: American Psychiatric Press, 2000), p. 154;
7. Glen Gabbard, The Psychology of the Sopranos: Love, Death, Desire and Betrayal in America's Favorite Gangster Family (New York: Basic Books, 2002), p. 21.
8. Lipsitt's chapter points out that amid every swing of the pendulum, there have been contrary currents. Using the word "cycle" instead of "pendulum," Mark S. Micale also represents psychiatry's history as an alternation between extremes, in "The Psychiatric Body," in Companion to Medicine in the Twentieth Century, ed. Roger Cooter and John Pickstone (London: Routledge, 2003), p. 344.
9. See Edward Shorter, A History of Psychiatry: From the Era of the Asylum to the Age of Q Prozac (New York: John Wiley and Sons, 1997),
10. a general history of psychiatry that expresses an unabashed preference for the somatic style; Joel Braslow, Mental Ills and Bodily Cures: Psychiatric Treatment in the First Half of the Twentieth Century (Berkeley: University of California Press, 1997);
11. David Healy, The Anti-Depressant Era (Cambridge, Mass.: Harvard University Press, 1997);
12. David Healy, The Creation of Psychopharmacology (Cambridge: Cambridge University Press, 2002);
13. Jack Pressman, Last Resort: Psychosurgery and the Limits of Medicine (Cambridge: Cambridge University Press, 1998);
14. Elliott Valenstein, Blaming the Brain: The Truth About Drugs and Mental Health (New York: The Free Press, 1998);
15. Sheldon Gelman, Medicating Schizophrenia: A History (New Brunswick, N.J.: Rutgers University Press, 1999);
16. and Jonathan Metzl, Prozac on the Couch: Prescribing Gender in the Era of Wonder Drugs (Durham, N.C.: Duke University Press, 2003).
17. See especially Pressman on lobotomy in Last Resort and Braslow on a range of therapies in Mental Ills. The Thompson quote is from The Making of the English Working Class (1963; New York: Vintage Books, 1966), p. 12: "I am seeking to rescue the poor stockinger, the Luddite cropper, the 'obsolete' hand-loom weaver, the 'utopian' artisan, and even the deluded follower of Joanna Southcott, from the enormous condescension of posterity."
18. See especially Healy's work on psychopharmacology in The Anti-Depressant Era and The Creation of Psychopharmacology.
19. Psychiatry is international, and of course American psychiatry was influenced by international developments and ideas. Many of the psychiatrists discussed in this paper were immigrants from Europe. My focus here, however, is on how psychiatric debate proceeded in the United States.
20. On the difference between living and dead metaphors, see Paul Ricoeur, Time and Narrative, trans. Kathleen McLaughlin and David Pellauer (Chicago: University of Chicago Press, 1984), p. ix: "The metaphor is alive as long as we can perceive, through the new semantic pertinence . . . the resistance of the words in their ordinary sense and therefore their incompatibility at the level of a literal interpretation of the sentence." On historical metaphors,
21. see also Robert Nisbet, Social Change and History: Aspects of the Western Theory of Development (London: Oxford University Press, 1969).
22. Nathan Hale, Freud and the Americans: The Beginnings of Psychoanalysis in the United States, 1876-1917 (New York: Oxford University Press, 1971), p. 50.
23. For an introduction to the historiographical issues raised by this tension, see AndrewScull, "Somatic Treatments and the Historiography of Psychiatry," Hist. Psychiatry, 1994, 5,1-12;
24. H. Mersky, "Somatic Treatments, Ignorance, and the Historiography of Psychiatry," Hist. Psychiatry, 1994, 5, 387-91;
25. Andrew Scull, "Psychiatrists and Historical 'Facts,' Part One: The Historiography of Somatic Treatments," Hist. Psychiatry, 1995, 6, 225-41.
26. Roy R. Grinker and Helen V. McLean, "The Course of a Depression Treated By Psychotherapy and Metrazol," Psychosom. Med., 1940, 2, 119-38.
27. Norman Levy and Roy Grinker, "Psychological Observations in Affective Psychoses Treated with Combined Convulsive Shock and Psychotherapy,"J. Nerv. Ment. Dis., 1943, 97:6, 623.
28. Harry Stack Sullivan, Conceptions of Modern Psychiatry (Washington, D.C.: The William Alanson White Psychiatric Foundation, 1947), p. 73.
29. Cited as a personal communication in L. Bryce Boyer, "Fantasies Concerning Convulsive Therapy," Psychoan. Rev., 1952, 39, 252-70.
30. Boyer was a psychoanalyst who championed the idea that countertransference could be used positively in therapeutic settings. He also advocated the use of psychoanalytic techniques for severe mental illness and not simply for mild neurosis. Wolfgang Saxon, "L. Bryce Boyer," New York Times, 26 August 2000.
31. T. M. Luhrmann, Of Two Minds: The Growing Disorder in American Psychiatry (New York: Alfred A. Knopf, 2000).
32. Sullivan's comments on somatic treatments have been cited more frequently than he likely expected, a point I return to below. Boyer used the quote as an example of a vitriolic and irrational response to somatic therapy in his "Fantasies Concerning Convulsive Therapy." The quote is taken up as a prime exhibit of psychoanalytic hostility to ECT in Shorter, A History of Psychiatry, p. 222.
33. Historical study of ECT remains undeveloped. Braslow has provided the best account, in chapter 5 of Mental Ills, by carefully reconstructing ECT's clinical justifications and usages in its early years and moving beyond the one-dimensional descriptions of shock therapy as a form of social control. His study stops short in 1950, though, and ECT's clinical, social, and cultural manifestations have changed dramatically, and often, since then. More recently, Carole Warren and Timothy Kneeland have provided the first book-length account of ECT in America in Pushbutton Psychiatry, which reasserts the claim that ECT has been a tool for enforcing gender norms. Whatever merit there may be to Kneeland and Warren's argument, it is marred by their explicit refusal to engage (whether to support or criticize) with the evidence for ECT's efficacy as a treatment for illness. See Pushbutton Psychiatry, p. xiii.
34. Other historical accounts of ECT include G. E. Burns, "The Scientific Origins of Electroconvulsive Therapy: A Conceptual History," Hist. Psychiatry, 1997, 5, 105-19;
35. Norman S. Endler, "The Origins of Electroconvulsive Therapy (ECT)," Convulsive Therapy, 1988, 4:1, 5-23;
36. and Luca Alverno, "The Origins of Electroconvulsive Therapy," Wisconsin Med. J., 1990, 89, 54-56.
37. For two recent reviews of the literature on ECT's efficacy, see Richard Abrams, Electroconvulsive Therapy, 4th ed. (Oxford: Oxford University Press, 2002), ch. 2;
38. UK ECT Review Group, "Efficacy and Safety of Electroconvulsive Therapy in Depressive Disorders: A Systematic Review and Meta-Analysis," Lancet, 2003, 361, 799-808. Abrams's study and the Lancet article differ on the extent of the safety of ECT, with the Lancet authors claiming greater risks of side effects, but both strongly support the effectiveness of ECT in relieving symptoms of severe mental illness.
39. Psychiatrists now avoid the terms "shock treatment" and "electroshock treatment" partly because of the pejorative connotations they have come to have, but also because it is now known that the efficacy of ECT is related to the induced convulsions, not to any "shock" the treatment causes.
40. There are a number of technical variations in how ECT can be performed. Clinical research has investigated the relative benefits of unilateral ECT (an electrode placed on one side of the head) versus bilateral, and have compared the use of brief-pulse stimulus versus sine wave in the application of the current. For an introduction to the clinical science, see C. Edward Coffey, ed., The Clinical Science of Electro-Convulsive Therapy (Washington, D.C.: American Psychiatric Press, Inc., 1993).
41. For theories regarding the mechanism by which ECT produces a therapeutic effect, see Max Fink, Electroshock: Restoring the Mind (New York: Oxford University Press, 1999), ch. 9,
42. and Fink's "Who Should Get ECT?" in Coffey, The Clinical Science of Electro-Convulsive Therapy. Fink, who is among the leading American advocates of ECT now, concedes that all theories accounting for ECT's efficacy are still speculative.
43. See Peter Roger Breggin, Electroshock: Its Brain-Disabling Effects (New York: Springer Publishing Company, 1979). There is also a flourishing anti-ECT literature produced by former and current mental patients; type the letters ECT into any Internet search engine and you will find some of this literature quickly.
44. The patient is quoted in Fink, Electroshock, p. 4.
45. The standard account is Margaret Rowbottom and Charles Susskind, Electricity and Medicine: History of Their Interaction (San Francisco: San Francisco Press, 1984).
46. See the epigram by eighteenth-century author William Battie, reproduced at the beginning of Max Fink, "Induced Seizures and Human Behavior," in Psychobiology of Convulsive Therapy, ed. Fink (New York: V. H. Winston & Sons, 1974), p. 1.
47. See Shorter, A History of Psychiatry, pp. 214-17.
48. Valenstein, Great and Desperate Cures, pp. 50-51.
49. Braslow, Mental Ills, p. 100.
50. Healy, The Anti-Depressant Era, p. 46.
51. Pressman, Last Resort, p. 10.
52. Braslow, Mental Ills, pp. 101-4.
53. The antipsychiatry movement has not been adequately addressed by historians. The final chapter of Elaine Showalter's The Female Malady (New York: Viking, 1985)
54. is a compelling feminist critique of antipsychiatry as practiced by R. D. Laing. Norman Dain has examined antipsychiatry in "Psychiatry and Anti-Psychiatry in the United States" in Discovering the History of Psychiatry, ed. Mark S. Micale and Roy Porter (Oxford: Oxford University Press, 1994),
55. and "Antipsychiatry," in American Psychiatry After World War II, ed. Menninger and Nemaha. Healy, The Creation of Psychopharmacology, is notable for showing some of the impact antipsychiatry has had on mainstream biopsychiatry.
56. Gelman, Medicating Schizophrenia, p. 12.
57. See also Elliot S. Valenstein, Great and Desperate Cures: The Rise and Decline of Psychosurgery and Other Radical Treatments for Mental Illness (New York: Basic Books, 1986).
58. Most practitioners who use ECT acknowledge that some short-term memory loss, mostly concerning events connected with the treatment, is a side effect of ECT. This is quite different from the more severe losses of long-term memory that critics claim is common but that much clinical research has asserted is rare. For a review of the literature on memory loss, see Abrams, Electroconvulsive Therapy, ch. 10.
59. For one patient's account, see Anne B. Donahue, "Electroconvulsive Therapy and Memory Loss: A Personal Journey," J. ECT, 2000, 16:2, 133-43.
60. See, for example, Donahue, "Electroconvulsive Therapy and Memory Loss: A Personal Journey;"
61. and Andy Behrman, Electroboy: A Memoir of Mania (New York: Random House, 2002).
62. Shorter, History of Psychiatry, p. 222.
63. Frank Sulloway has thoroughly discussed what he calls Freud's "crypto-biologism" in Freud: Biologist of the Mind (New York: Basic Books, 1979).
64. Sigmund Freud, "Psychoanalysis and the War Neuroses," in The Standard Edition of the Complete Psychological Works of Sigmund Freud, trans. James Strachey (London: Hogarth Press, 1953-1974), pp. 211-15. Psychoanalytic authors who wrote about ECT did not cite Freud's discussion of electrical therapies. This may reflect their recognition that convulsive therapy had a different clinical rationale, but in some cases, their interpretation of ECT's efficacy was similar to Freud's understanding of non-convulsive electrical treatment.
65. Freud, "Psychoanalysis and the War Neuroses."
66. Freud doubted that the same level of cruelty was evident in Austria.
67. On non-convulsive use of electrical stimulation in military psychiatry, see Ben Shephard, A War of Nerves: Soldiers and Psychiatrists in the Twentieth Century (Cambridge, Mass.: Harvard University Press, 2001), pp. 12, 76, 100-3.
68. One sign of this conflation may be in Shephard's index, which lists all psychiatric uses of electricity under the heading "Electric Shock Treatment," and does not differentiate convulsive therapy - though the text of the book does. See A War of Nerves, pp. 206, 477.
69. Joseph Berke, I Haven't Had to Go Mad Here (1977; Harmondsworth: Penguin Books, 1979, originally published as Butterfly Man), pp. 71-72.
70. Elaine Showalter cited Berke's interpretation as an explanation for the success of Sylvia Plath's ECT. Writing in 1985, during the dawn of the resurgence of biological psychiatry, Showalter assumed that if ECT worked, it would be due to a psychological process, not a physiological one. Showalter, The Female Malady, p. 217.
71. Pressman, Last Resort, pp. 83-84.
72. See Otto Fenichel, The Psychoanalytic Theory of Neurosis (New York: W. W. Norton, 1945), P. 569.
73. Braslow, Mental Ills, p. 96.
74. Valenstein, Great and Desperate Cures, pp. 180-84.
75. Gregory Zilboorg, "The Fundamental Conflict with Psychoanalysis," International J. Psychoan., 1939, 20, 480-92. This article was cited by Boyer as an example of analytic prejudice opposed to ECT, but Zilboorg does not mention ECT in the article, only chemically induced convulsion therapies.
76. Braslow, Mental Ills, p. 100.
77. Edith Vowinckel Weigert, "Psychoanalytical Notes on Sleep and Convulsion Treatment in Functional Psychoses," Psychiatry, 1940, 3, 189-209. Like many of the psychiatrists discussed here, both analysts and "somaticists," Weigert was an immigrant who left Europe during the rise of fascism in Germany and Italy. She settled and practiced in the Baltimore area. Her article on chemical convulsive therapy was cited by several later psychoanalytic authors on related somatic treatments.
78. Weigert, "Psychoanalytical Notes," p. 189.
79. Eric P. Mosse, "Electroshock and Personality Structure,"J. Nerv. Ment. Dis., 1946, 104, 296-302.
80. Mosse was bom and educated in Germany, came to the United States in 1933, and was the author of a book about psychiatry for the lay public, The Conquest of Loneliness (New York: Random House, 1957).
81. John A. P. Millet, and Eric P. Mosse, "On Certain Psychological Aspects of Electroshock Therapy," Psychosom. Med., 1944, 6:3, 226-36, esp. p. 232.
82. Mosse, "Electroshock and Personality Structure," p. 297.
83. Mosse, "Electroshock and Personality Structure," p. 298.
84. Mosse, "Electroshock and Personality Structure," p. 298, emphasis in original.
85. Mosse, "Electroshock and Personality Structure," p. 298.
86. Mosse, "Electroshock and Personality Structure," p. 300.
87. Commentary by Dr. Foster Kennedy, J. Nov. Ment. Dis., 1946, 104, 320. Kennedy wrote that Mosse has "made an effort to combine, willy-nilly, something with which we have been familiar during the last 30 years in psychological mechanism as described by Freud, with an entirely new instrument of treatment, and tried to belittle the latter in terms of the former." Kennedy had been using ECT almost daily since 1940 and asserted confidently that the death threat played no part in the cure of his patients.
88. Millet and Mosse, "On Certain Psychological Aspects of Electroshock Therapy," p. 231.
89. Millet and Mosse, "On Certain Psychological Aspects of Electroshock Therapy," p. 231.
90. Ben H. Gottesfeld and Calvin Barker, "An Interpretive Study of Subjective Response to Electric Shock Therapy," Dig. Neural. Psychiatry, 1946, 14, 642-48.
91. Sylvia Plath, The Bell Jar (New York: Bantam Books, 1971), p. 118.
92. Shorter claims, as evidence, that the Group for the Advancement of Psychiatry - a psychiatric organization associated with the Menninger Clinic - first opposed ECT, "while not condemning it outright," and later "backtracked" to oppose only its "indiscriminate" use. Shorter, A History of Psychiatry, p. 222.
93. In fact, the group's first statement on the subject opposes only indiscriminate use, and this statement condemns both extravagant claims made on ECT's behalf, as well as uninformed denunciation of ECT from other quarters. Group for the Advancement of Psychiatry, Shock Therapy, report no. 1, 15 September 1947.
94. Perry, Psychiatrist of America, p. 197. It is also not clear that Sullivan should really be considered an analyst. Although he was sympathetic to many psychoanalytic tenets (as many psychiatrists of the time were), and underwent a psychoanalysis, Sullivan was very critical of aspects of psychoanalysis;
95. see Perry, p. 259. According to Perry, Sullivan only called himself as a psychoanalyst "after politics with words had become a big and dangerous game in psychoanalytic/psychiatric circles, particularly along the eastern seaboard." Perry, pp. 362-63.
96. Charles H. Kellner, John T. Pritchett, Mark D. Beale, and Edward C. Coffey, Handbook of ECT (Washington, D.C.: American Psychiatric Press, 1997), P. 3.
97. Lothar B. Kalinowsky and Paul H. Hoch, Shock Treatments and Other Somatic Procedures in Psychiatry (New York: Grune and Stratton, 1946).
98. In the early days of ECT, Kalinowsky was probably its leading American practitioner. Kalinowsky was born in Germany, and fled from the Nazi regime to Italy, where he worked in Cerletti's lab, in 1933. He came to the United States in 1940. See Kneeland and Warren, Pushbutton Psychiatry, p. 50.
99. Hoch was born in Hungary, was educated in Germany, and came to the United States in 1933; he was an important proponent of a number of somatic treatments in psychiatry, such as the use of chlorpromazine for schizophrenia. See Sidney Malitz, "Paul Hoch," Am. J. Psychiatry, 1996, 153:10, 1339.
100. Kalinowsky and Hoch, Shock Treatments, p. v.
101. Kalinowsky and Hoch, Shock Treatments, pp. 237-40.
102. Kalinowsky and Hoch, Shock Treatments, pp. 241-42.
103. "Regulation of Electroconvulsive Therapy," Mich. Law Rev., 1976-1977, 75, 363-412.
104. In Kellner, et al., Handbook of ECT,
105. the authors mark the turning point as the "classic research" by J. O. Ottoson in the early 19605 that established that the convulsion was crucial to efficacy. See J. O. Ottoson, "Experimental Studies of the Mode of Action of Electroconvulsive Therapy," Acta Psychiatr. Neural. Scand. Suppl., 1960, 145, 1-141;
106. and J. O. Ottoson, "Seizure Characteristics and Therapeutic Efficiency in Electroconvulsive Therapy: An Analysis of the Antidepressive Efficiency of Grand Mal and Lidocaine-Modified Seizures," J. Nerv. Ment. Dis., 1962, 133, 239-51.
107. But Kalinowsky and Hoch had already proposed that convulsions were necessary for therapeutic effect; see Shock Treatments, pp. 238-39.
108. See UK ECT Review Group, "Efficacy and Safety of Electroconvulsive Therapy."
109. Healy, The Creation of Psychopharmcology, p. 343.
110. Millet and Mosse, "On Certain Psychological Aspects of Electroshock Therapy," p. 227.
111. Metzl, Prozac on the Couch. Metzl's account is compelling in many respects, but is weakened by a tendency to treat any sexist practices and assumptions as "psychoanalytic" rather than showing how they are sexist in specifically psychoanalytic ways; while there is no doubt a rich history of sexism within psychoanalysis, sexism is far too diverse in its origins, and psychoanalysis too diverse in its manifestations, for the two to be so strongly equated.
112. For example, Pressman relates that Roy Grinker criticized proponents of lobotomy in the early 19405, charging them with an agenda of hoping to swing the therapeutic pendulum from psychological to somatic methods. Pressman, Last Resort, p. 132.