Excerpts from Must Read Books & Articles on Mental Health Topics
Articles- Part XIII

Shock and Disbelief
Daniel Smith, The Atlantic Monthly, February 2001

On the cover of a pamphlet I was sent recently appears a photograph of an elderly man with bright bolts of electricity shooting outward from his temples. His teeth are clenched. His eyes are squeezed shut. His hair is standing on end. Holding the man's head secure is a leather strap that resembles the restraint on a prisoner in the electric chair.
    This is electroconvulsive therapy ( ECT) -- the psychiatric use of an electric current to stimulate a grand mal seizure--as seen through the eyes of the Citizens Commission on Human Rights, a lobbying group founded by the Church of Scientology and the most active and well organized anti-ECT group in existence. It is a grim view, invoking coercion, barbarity, anguish--everything negative that has ever been associated with psychiatry. It is also the common view.
    Last fall I saw a patient receive ECT at McLean Hospital, a private psychiatric facility in Belmont, Massachusetts. There, in a well-lit treatment room, attended by a nurse, a psychiatrist, and an anesthesiologist, a middle-aged man suffering from hallucinations and depression lay unconscious on his back while two electrode paddles were placed on his head. A button was pressed, and the patient's right foot twitched lightly. Shortly afterward the patient awoke and was given a snack before being escorted back to his room.
    The contrast between image and reality is surprising. The procedure I saw at McLean reflects the way ECT has been administered for years, as cautiously and as formally as any other medical procedure--perhaps even more so, because of the awareness psychiatrists have of ECT's reputation as savage. Yet the popular image of ECT has persisted, sustained almost single-handedly, it sometimes seems, by the 1975 movie One Flew Over the Cuckoo's Nest, the release of which coincided with a decline in the use of ECT. In 1980 less than three percent of all psychiatric inpatients were being treated with the procedure, and by 1983, thirty-three states were in some way regulating it.
    Although the public seemed willing to let ECT fall into obsolescence, many psychiatrists felt that they were losing a valuable and irreplaceable treatment. In 1985 the National Institutes of Health, in Bethesda, Maryland, called a three-day conference on electroconvulsive therapy. The first day of the conference passed without incident, as experts delivered lectures. On the second day, however, during an open discussion period, anger erupted on the floor of the conference hall. Former patients and even a few clinicians began protesting loudly. One of those present was Max Fink, then a professor of psychiatry at the State University of New York at Stony Brook and a pioneer in modern ECT research. As Fink remembers it, "They were shouting, 'How dare you even consider electroshock as a possibility! It has no place in the world! Everybody who does electroshock should be in jail!"' When the conference resumed, a panel of "nonadvocate" experts forged a consensus statement in which they observed, with standoffish delicacy,
    Electroconvulsive therapy is the most controversial treatment in psychiatry. The nature of the treatment itself, its history of abuse, unfavorable media presentations, compelling testimony of former patients, special attention by the legal system, uneven distribution of ECT use among practitioners and facilities, and uneven access by patients all contribute to the controversial context in which the consensus panel has approached its task.
    Today ECT has strengthened its position in the profession. Many psychiatrists, whether or not they actively administer the treatment, have come to appreciate its ability to ameliorate a range of mental illnesses, from depression to some forms of schizophrenia and catatonia. A 1993 commentary in The New England Journal of Medicine stated, "Electroconvulsive therapy is more firmly established than ever as an important method of treating certain severe forms of depression." The first phase of a National Institute of Mental Health supported study, to be published this spring, found that ECT produced a greater than 95 percent remission rate in psychotically depressed patients--vastly higher than the rate for any drug on the market. When I talked with Fink recently, he told me, "ECT is the most effective antidepressant, antipsychotic, anticatatonic we have today." Other psychiatrists have been even more enthusiastic. One, T. George Bidder, has written that ECT is "one of the most effective treatments in all of medicine--with a therapeutic efficacy, in properly selected cases, comparable to some of the most potent and specific treatments available, such as penicillin in pneumonococcal pneumonia." Such endorsements have led to what looks like a renaissance for ECT; it is estimated that 100,000 patients are treated with it each year--nearly triple the number cited for 1980 by the NIMH.
    Yet the attacks on the treatment are as virulent as ever. Activists continue to push for prohibitive legislation. In 1997 a bill that would effectively have made administering ECT a criminal act, punishable by a fine of up to $10,000 and/or up to six months in jail, was narrowly defeated in Texas. ECT has virtually disappeared from state-run psychiatric facilities, owing in large part to government regulation. To be treated, patients must almost always gain access to a private or academic hospital. This means that ECT is very rarely an option for poor patients--those without adequate insurance or access to information, or without the means to travel, for example, to a distant, well-equipped university hospital. A 1995 article in the American Journal of Psychiatry found that ECT was unavailable in more than a third of the 317 metropolitan areas nationwide that it surveyed. "The situation has reversed itself from where it was decades ago," says Richard Weiner, a professor of psychiatry at Duke University and the head of the American Psychiatric Association's Committee on ECT. "Many ECT patients used to be asylum patients. Now it's very hard to get ECT in such places, and its use has shifted to general hospitals and private psychiatric hospitals."
    The stigma attached to ECT is in some ways a holdover from less scrupulous days of psychiatry. But one of the main reasons many people still consider ECT to be archaic and even destructive is that it continues to be painted as such by an unlikely trio of activist groups: a handful of former ECT patients, some dissenting psychiatrists, and the Church of Scientology. These groups have agitated for the complete elimination of ECT. They have pushed legislative attempts to limit or ban ECT. They have initiated and supported lawsuits against psychiatrists, hospitals, and ECT device manufacturers. They claim that ECT is authoritarian, violent, and representative of everything that is wrong with the profession of psychiatry. And despite all medical evidence to the contrary, people are listening to them.

"A CRACK OF ELECTRICITY"
Electroconvulsive therapy emerged during a bleak period for psychiatry. In the first third of the twentieth century not much could be done for the mentally ill. Psychoanalysis, the dominant method of treatment, proved helpful to some wealthy patients complaining of the so-called "minor illnesses": melancholy and neurosis. But it didn't do much for patients with more systemic afflictions, such as schizophrenia and manic-depressive illness. These patients were merely warehoused in vast state asylums, where conditions were appalling. Patients were abused, shackled, even surgically sterilized. Psychiatry's job seemed to be no more than brutal custodianship; psychiatrists could do no more than hope that their patients would recover spontaneously from their illnesses. Under these desperate circumstances some psychiatrists began experimenting with radical treatments: insulin coma, transorbital lobotomy, malarial fever. One of these "somatic therapies --Metrazol shock--seemed particularly promising, given the theory (now known to be untrue) that a "biological antagonism" existed between epilepsy and schizophrenia. A schizophrenic patient was injected with Metrazol, a drug similar to camphor. After a few minutes the patient would undergo a full-blown seizure: all the muscles in his body would convulse violently, his back would arch, his limbs would flail, his breathing would become shallow. Often he would vomit. It was a gruesome ordeal. The historian Edward Shorter, in A History (1997), reported that a Swiss psychiatrist stopped using the treatment because it caused "agonizing fears of dying and crumbling away," and that a British doctor spoke of "the unseemly and tragic farce of an unwilling patient being pursued by a posse of nurses with me, a fully charged syringe in my hand, bringing up the rear." And yet, strangely, Metrazol shock worked pretty well "Convulsive therapy," as it came to be called, opened wide vistas of possibility.
    But no one really understood why inducing seizures made patients better. Even today there are only educated guesses. Some subscribe to the neuroendocrine hypothesis, which states that seizures cause a shift in the body's hormonal system. Others subscribe to what has been called the anticonvulsant view, which holds that, paradoxically, the whole purpose of causing a seizure is to tap into the brain's ability to stop that seizure naturally. In other words, the brain's anticonvulsant mechanism may alter the brain's neurochemistry, acting as a built-in antidepressant. Still others believe that it is the seizures themselves that change the level of chemicals in the brain. In 1990 a group of articles in the journal Neuropsy examined all three possibilities without drawing any conclusions.
    Regardless, from the beginning convulsive therapy proved promising. Ugo Cerletti, in the 1930s the chief of the Clinic for Nervous and Mental Diseases at the University of Rome, was among those who were impressed. But he considered that electricity might cause seizures more quickly, and thus in a less harrowing manner, than Metrazol. Earlier Cerletti had tested the neurological effects of electricity by conducting experiments on dogs. His first attempts were inauspicious: because he put one electrode in the dog's mouth and one in its anus, the bulk of the current passed through the dog's heart; half the dogs died of cardiac arrest. Lucio Bini, one of Cerletti's assistants, solved this problem by transferring the electrodes to the dogs' temples. Cerletti and his staff worked tirelessly, experimenting on animals that were brought to them each week by dogcatchers. The results supported their hopes: it seemed that using electricity was an effective way to produce an epileptic fit. Before applying it to a human being, Cerletti's assistants visited a Rome slaughterhouse to observe an electrical device that was being used to incapacitate pigs prior to slaughter. They discovered that there was a wide margin between the amount of electricity that would create a seizure and the amount that would kill.
    In the spring of 1938 "electroshock" as Cerletti called it, was ready to be tested on a human being. The subject was a Milanese man the Roman police had found wandering in the train station without a ticket, mumbling gibberish to himself. Shorter described the inaugural treatment>

The patient, his head shaved, seemed quite indifferent to what was going on. A nurse placed the electrodes on his temples while an orderly put a rubber tube between his teeth to prevent him from biting his tongue ... There was a crack of electricity. The patient's muscles jolted once ... "Let's step it up to 90." said Cerletti. Another electrical crack. Another spasm. The patient lay motionless for a minute, then began to sing. "We'll try it one last time at a higher voltage," said Cerletti, "poi basta [and then enough]." At this point, the patient said, in a perfectly calm and reasonable voice, as though answering an exam question. "Look out! The first is pestiferous, the second mortiferous." The residents looked at each other puzzled.

Despite the primitive application, the patient responded quite well. He had ten more treatments and was released, "in good condition and well-oriented." After a year he had not relapsed significantly. This was no small feat; no one could remember any experiment that had shown nearly such promising results. Thereafter ECT spread quickly to European hospitals. By 1940 it had appeared in the United States. Psychiatrists were enthusiastic One whom Shorter quoted wrote in the British Journal of Psychiatry, "Without ECT I would not have lasted out in psychiatry, as I would not have been able to tolerate the sadness and hopelessness of most mental illnesses."
    ECT was a great step up. Patients did not vomit, as they did in the course of Metrazol shock, and they did not experience as much psychological trauma. But they did still have to suffer the effects of muscular convulsions, which were frequently excruciating, and which have contributed to the persistent image of ECT as a brutal form of treatment. Thrashing around on the treatment table, many patients bit their tongues and cheeks. Many suffered broken bones or serious spinal injuries. Sometimes a gang of orderlies and nurses was needed to prevent the patient from tossing himself off the table altogether. In addition, patients suffered memory loss. They would awake confused, unsure of where they were or what had happened, often forgetting events of the preceding weeks or months.
    ECT was also drastically overused. Doctors in some hospitals would treat dozens of patients in one giant room, wheeling the device on a cart from bed to bed; patients were forced to watch the ordeal of those who came before them. One doctor in England treated some of his patients more than a thousand times each. In the 1950s Ewen Cameron, a psychiatrist at McGill University, in Montreal, "depatterned" his patients by giving them twelve treatments daily. Milledgeville State Hospital, in Georgia, for a time the largest asylum in the United States, had perhaps the worst history of abuse: it used what was known as the Georgia Power Cocktail to punish uncooperative patients.
    The publicized experiences of famous patients treated privately with ECT bolstered the evidence against the treatment. The poet Sylvia Plath was subjected to ECT and wrote about it in her autobiographical novel, The Bell Jar : "Then something bent down and took hold of me and shook me like the end of the world. Whee-ee-ee-ee-ee, it shrilled, through an air crackling with blue light, and with each flash a great jolt drubbed me till I thought my bones would break and the sap fly out of me like a split plant." (Later in the novel the narrator had a less unpleasant ECT experience.) Ernest Hemingway underwent a course of ECT at the Mayo Clinic, in Rochester, Minnesota, and wrote to his biographer, A. E. Hotchner: "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." Soon afterward Hemingway shot himself. In 1972 Senator Thomas Eagleton had to withdraw as the presidential candidate George McGovern's running mate after it was revealed that he had been treated with ECT. And, of course, One Flew Over the Cuckoo's Nest bundled all the public's negative associations into the disturbing image of Jack Nicholson, mocking and playful one moment, writhing on a table the next, and finally catatonic--the result, in actuality, not of the ECT he received but of an off-camera lobotomy.

The above text covers the first three pages of this eleven page article. For the remainder, visit the archives of the Atlantic Monthly at www.theatlantic.com.



The Limits of Talk
Mary Sykes Wylie, The Psychotherapy Networker-
January/February 2004

Bessel Van Der Kolk likes to introduce his workshops on PostTraumatic Stress Disorder (PTSD) with medical film clips from World War I showing veterans diagnosed with what was then called "shell shock." In these dramatic and riveting clips, one soldier sits hunched over on his hospital cot, staring blankly ahead, responding to nothing and nobody until the single word "bomb" is said, whereupon he dives for cover underneath the small bed. Another man lies almost naked on the bare floor, his back rigidly arched, his arms and hands clawing the air as he tries, spasmodically and without success, to clamber onto his side and stand up. Yet another, who once bayoneted an enemy in the face, now opens his mouth wide into a gaping yaw and then closes it, and opens it and closes it, over and over and over again.
     The images are disturbing, heartbreaking, and all the stranger because these particular men, technically speaking. are physically unharmed. Their physical symptoms -- paralysis, violent trembling, spasmodic movements, repetitive facial grimaces, zombielike demeanor -- look exotic to our eyes because PTSD generally doesn't show up like this anymore in most clinicians' offices. Time and Western cultural evolution have changed the way traumatized people express their distress in a therapist's office. Now, trauma patients may look fine on the surface, but complain of nightmares, flashbacks, feelings of numbness, generalized fearfulness, dissociative symptoms, and other problems that aren't as visible to the world at large. But to van der Kolk, these old images still represent what he calls the "pure form" of PTSD. The appearance in these World War I film clips that the veterans are possessed, mind and body, by invisible demons still captures the fundamental truth about PTSD -- that it can reduce its victims to mute, almost animal-like, creatures, utterly isolated in their fear and horror from the human community.
     Van der Kolk first became aware of the world of trauma in 1978, when he decided to go work for the Veterans Administration, not to study PTSD (it hadn't been recognized yet as a formal diagnosis), but to get the government benefits to pay for his own psychoanalysis. While there, he discovered the reality of PTSD and the beginnings of a stunning, nationwide phenomenon. "At that time, tens of thousands of men who'd served in Vietnam suddenly seemed to come out of the woodwork, suffering from flashbacks, beating their wives, drinking and drugging to suppress their feelings, closing down emotionally," recalls van der Kolk. "It was a phenomenon that spawned a whole generation of researchers and clinicians fascinated by what had happened to these guys."
Van der Kolk himself soon became intrigued by the mysterious mental and emotional paralysis that seemed to afflict these traumatized veterans. Why, he wondered, did many of his patients seem so stuck emotionally in their horror that they relived it over and over in flashbacks and nightmares? What kept these men circling round and round on an endless treadmill of memory, unable to step off and resume life? In spite of their obvious suffering, why did they seem so obsessively attached to their traumatic experiences?
     In the 25 years since then, the trauma field has gone from obscurity, if not disreputability, to become one of the most clinically innovative and scientifically supported specialties in mental health. Trauma researchers have led the pack in setting off an explosion of knowledge about psychobiology and the interaction of body and mind. And van der Kolk, as much as anyone else in the field, has defined the current framework for understanding trauma. He's the author of more than a hundred peer-reviewed scientific papers on subjects such as self-mutilation, dissociation, the therapeutic efficacy of Eye Movement Desensitization and Reprocessing (EMDR), the developmental impact of trauma, and the nature of traumatic memories. He's also been a featured contributor in most of the standard textbooks in the trauma field. In addition to teaching at Boston University, Tufts, and Harvard, he directs the Trauma Center in Boston, possibly the largest trauma specialty center in the country, with 40 clinicians working with clients who range from infants to geriatrics, from incest survivors to international torture victims. Inhabiting both the world of the clinician and the researcher, he also runs a major research laboratory at the Trauma Center, staffed by 15 researchers who investigate everything from neuroimaging of treatment effects on the brain to the effects of theater groups on violent, traumatized teenagers.
     Glowing testimonials about his contributions aren't hard to come by from the field's leading lights. "Very early on, more than anybody else, he introduced neurobiology to the trauma field, and helped us see the interaction between mind and body in trauma," says Charles Figley, professor at the School of Social Work at Florida State University and Vietnam vet, whose early work on war trauma is often credited with prompting the inclusion of PTSD as a diagnosis in the DSM. "He's one of the most generative and creative minds in the trauma field, and his influence has been pervasive," says psychiatrist Judith Herman, renowned trauma expert at Harvard Medical School.
     At the same time, van der Kolk is also one of the trauma field's most controversial figures. Often prickly, rarely shy about offering his own opinions, and unafraid of a good fight, he's scandalized a number of cognitive-behavioral therapists and academic researchers by openly embracing EMDR, demonstrating an interest in such truly outre techniques as Thought Field Therapy, enthusiastically taking up nonstandard somatic therapies, and even sending his patients off to participate in theater groups and martial arts training. Van der Kolk's bold criticism of the orthodoxies of psychotherapy and public advocacy of somatic approaches have, in particular, outraged many. "Advocating unproven body psychotherapies is professionally irresponsible," says Edna Foa, professor of psychology in the psychiatry department at the University of Pennsylvania. "He's marginalized himself as a scientific thinker -- he's no longer in the mainstream," adds Richard Bryant, noted trauma researcher and psychology professor at the University of New South Wales in Australia. "Until he provides data in support of his new somatic approach, the field isn't obligated to pay any attention to what he's doing," sniffs psychologist Richard McNally, author of the widely cited Remembering Trauma, a critique of recovered-memory theory.
     The intensity of response van der Kolk kicks up is an indication of the crusader's fervor underlying his work and his determination to make the field viscerally understand that trauma isn't simply a neutral mental health issue, but a profoundly moral concern. Spicing his talks with earthy, Dutch-accented American slang, van der Kolk regularly reminds his audience in a tone of subdued indignation that trauma forces the reality of human evil into our consciousness, often the evil of presumably good and upright people -- our neighbors, our leaders, our families, and ourselves. It's not a perspective people always welcome because, as he writes in his book Traumatic Stress, most of us like to believe "that the world is essentially just, that `good' people are in charge of their lives, and that bad things only happen to `bad' people.... Victims are the members of society whose problems represent the memory of suffering, rage and pain in a world that longs to forget."

A Diagnosis Non Grata
While trauma is always clinically described as a horrifically abnormal event, for any casual student of the human condition, it's actually a perfectly normal feature of history, one that has emotionally scarred billions of men, women, and children since before the beginning of recorded time. And yet, while philosophers, writers, and ordinary people have always known that terrible events can cause a lifetime of psychological pain, until the latter part of the 20th century, mental health professionals were oddly blind to this fact of life. "Psychiatry itself has periodically suffered from marked amnesias in which well-established knowledge has been abruptly forgotten," writes van der Kolk in Traumatic Stress, "and the psychological impact of overwhelming experiences has been ascribed to constitutional or intrapsychic factors alone." In other words, a failure to "get over" a trauma was often ascribed to personal weakness or an unconscious desire not to recover.
     Even the official nosology of the psychiatric profession reflected this peculiar obtuseness. The 1952 edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-1) had included combat-related stress under the diagnosis of "gross stress reaction," but this was dropped from the DSM-II in 1968 -- the same year that troop strength reached its peak in Vietnam. All that was left of trauma in DSM-II was the pallid diagnosis "adjustment reaction to adult life," under the general heading of "transient situational disturbance." Adjustment reaction was a grab-bag diagnosis, including "fear associated with military combat and manifested by trembling, running and hiding" and "unwanted pregnancy." It wasn't until 1980, after years of lobbying and wrangling, that PTSD was included in DSMIII. So when van der Kolk first went to the VA in 1978, not only was there no official traumatic stress diagnosis, but the VA assumed that any psychiatric problems occurring more than one year after discharge couldn't be related to military service. Besides denying veterans any compensation for delayed traumatic reactions probably the overriding consideration in the VA's longstanding lack of interest in the enduring impact of "combat stress" -- this rule effectively scotched any research or clinical treatment directly focused on trauma. "When I went to work for the Boston VA," remembers van der Kolk, "there wasn't a single book in the library on war neurosis."
     Unable to do research on war trauma because the VA wouldn't fund studies on a diagnosis that didn't exist, van der Kolk and his colleagues did the first study ever on the real nightmares the vets had and, in another first, used the Rorschach inkblot test to reveal the twin pattern of hyperarousal and dissociation that traumatized vets showed. For van der Kolk, this research pointed to the paradoxical conundrum at the heart of trauma. "This is still the issue with traumatized people -- they see and feel only their trauma, or they see and feel nothing at all; they're fixated on their traumas or they're somehow psychically absent." In either case, traumatic memories from the past have utterly usurped the present.

The above text covers the first two pages of this nine page article. For the remainder, visit the archives of the Psychotherapist Networker at www.psychotherapynetworker.org.