Book Review: Shock Therapy by David Healy, Edward Shorter (and Max Fink)
“When science has a commercial basis, those who make a living out of one point of view seem much less likely to tolerate dissent than is normal in the rest of science.”
(David Healy, from his 2004 book Let Them Eat Prozac)
Once, just once, it would be nice to see doctors who use ECT make an argument for their product based on facts and science, without lies and omission, without making stereotypical errors of reasoning, and without lowering themselves to the level of libel by disparaging the sanity and veracity of their former patients.
If any shock doctor is capable of doing this, it ought to be David Healy (director of the ECT service at a Welsh clinic). But Healy’s chosen not to do so.
The first clue that that this book is nothing more than the industry party line on ECT comes on the very first page, but you might not pick up on it. Funding for the book, the authors admit, came from the Scion Natural Science Association. What they don’t tell you is that Scion is Max Fink’s private family foundation, one he started decades ago to fund research favorable to ECT from his personal money. Fink, age 84—often called the grandfather of shock—has been promoting ECT for half a century. He makes promotional videos for shock machine company Somatics, publishes books and articles denying any adverse effects of ECT, and has helped many younger men and women build careers as shock doctors. No one alive has a greater investment in shock. Public records show Fink’s foundation paid the authors $34,000 to write this book. Fink also co-wrote the book, according to sources like Wikipedia and the State University of New York website.
And then there’s this on page three:
“So clear are the benefits from ECT for patients who might otherwise commit suicide, or otherwise languish for years in the blackness of depression, that there should be little controversy over whether it is safe or effective.”
The 382-page book can be pretty well reduced to the above statement. Whether you accept its very loaded assumptions (ECT has great benefits, ECT prevents suicide, ECT cures depression) and agree with it or not, there is nothing in the remaining 379 pages that will change your mind. Even if you don’t know much about shock therapy before picking up the book, you might well stop right there and ask yourself how the second part of that sentence follows logically from the first: can any treatment be so effective we needn’t ask whether it’s safe, and can disregard evidence that it’s not? If you read the rest of the book, you’ll realize that this is indeed the authors’ position. That should be on page three is the alarm bell warning you that this book is full of value judgments by supposed authorities substituting for evidence and reasoned arguments. It is history rewritten as the authors, all unabashed proponents of ECT, think it should be.
To an informed reader, that any supposed history of ECT can leave out so much of what is known about it is somewhat puzzling. It makes a kind of sense only when the book is understood as a long love letter to its invisible third author. Here Fink’s opinions on the treatment he has zealously spearheaded for his entire career have finally been set down in one place for prosperity. It was decided to take his name off the book, most likely for public relations purposes; Fink’s partisanship of ECT is so extreme and so well-known that many would dismiss a book by him as self-serving propaganda. Shock Therapy is no less that for the thinly veiled attempt to erase his fingerprints, such as not revealing that the Scion Foundation is Fink’s own private family foundation.
It’s not a surprise that Shorter, the author of a history of psychiatry which dismisses all nonbiological approaches to mental illness, supports Fink’s position. But those who know Healy’s work are likely to be astonished that he has been willing to put his name to an adulatory book on electroshock. Healy is internationally known for his criticism of the influence of psychopharmaceutical companies on medicine, in particular their skewing of research and their marketing tactics. He has also, through all this, accepted money from more than a dozen such companies.
He’s become widely esteemed in some circles, especially ex-patient circles, as a whistleblower, upholding high standards of scientific evidence and honesty in research. That reputation is the capital he has now invested in this new book, and it’s all been squandered away in a work of audacious, breathtaking dishonesty. That Healy has perhaps engaged in as much self-deception as other-deception in order to write this hardly matters. In either case he has willfully disabled his intelligence and critical thinking skills, his scientific knowledge and scruples, and even reason and logic.
The book takes the position that adverse permanent effects of the treatment don’t occur. Ever. “The charge of brain damage is an urban myth,” the authors say, and dismiss permanent memory loss at every turn as entirely fanciful, not real. It’s a position that is too extreme for even many of ECT’s most rabid proponents, but it is the position maintained by Fink, and so it must be upheld no matter what the cost.
The authors are 10,000% behind shock, and that goes for the types of ECT that even zealous proponents can’t quite stomach. Unmodified ECT (without anesthesia), ECT outside of hospitals, outpatient ECT in doctors’ offices without anesthesia, regressive ECT of the sort that reduced patients to incontinent and spoon-fed infants, multiple ECT, involuntary ECT, sine wave ECT—the book hasn’t an unkind word to say about any of them. The treatment works, the book says smugly, as if that were all that mattered (and with little evidence in support besides the repeated assertions of psychiatrists).
For example, the authors say of regressive ECT, “The circumstances of the entire thing were ghastly, yet the treatment seemed to work…beating chemotherapy soundly in terms of the ultimate result of getting off therapy entirely.” The use of involuntary ECT without anesthesia to punish inmates at a large state hospital in Milledgeville, Georgia has become the stuff of legend, and the nickname the staff and patients had for shock, the “Georgia power cocktail,” a kind of shorthand for the worst that can be done to mental patients. To my knowledge, before Shock Therapy no contemporary psychiatrist has ever defended the use of the Georgia power cocktail. Yet these authors approvingly quote a Milledgeville psychiatrist who said, “I have seen some remarkable recoveries here.” They conclude the two-page section addressing past abuse of ECT by saying that even under the worst circumstances it led to “remarkably effective results in terms of successful discharges.”
While any history of ECT is obliged to acknowledge allegations of abuse, this is the first to brush them off: ECT “does not lend itself well to abuse because it is painless: the patient is immediately unconscious.” International human rights advocates, who consider ECT without anesthesia torture, would disagree. Those who know Healy by reputation as a critic of psychiatry, and those in the mental patients’ movement who considered him an ally, will simply be astonished, and then feel betrayed, to see his name on such a work.
His name is in fact essential to the book’s claim to be a credible history. Healy is a historian of psychiatry and the author of well respected books like The AntiDepressant Era. However, having Healy’s name on this book does not make it a history; not in the sense of his other works, not in any sense at all. True historians don’t leave out a huge swath of what they know because it doesn’t fit into an agenda determined in advance. In other words, they write history, even if always from their own perspective and with a particular focus, but they do not rewrite it.
A work of scholarship does not make categorical statements like “There is no known occurrence of brain damage associated with ECT” that are not backed up with any references, only the presumed credibility of the authors and the publisher, and which the authors and publisher know are easily proven to be false. Any serious scholar looking into the history of ECT would acknowledge evidence of brain damage from the get-go—for instance, in the earliest studies done by the inventors of the treatment—and on up to the present day.
Permanent amnesia has also been documented since the 1940s. Even one instance of the presumed impossible occurrence—even one former ECT patient interviewed by Healy who lives on Social Security disability due to brain damage caused by ECT and documented by her physicians, even one scientific study—makes such statements untrue. Rather than engaging and weighing the evidence for permanent brain damage and permanent memory loss, even if only to tell us they find it unconvincing, the authors have chosen to simply omit it. When they can’t get away with that, they resort to lies. Healy felt constrained to mention the case of Marilyn Rice, a prominent former ECT patient. Rather than revealing that her brain scan, which she made public, documented permanent structural damage, he says only that she “believed” she experienced permanent memory loss. He then goes on to try to discredit her by telling readers she was an “anti-ECT,” “anti-psychiatry” activist. While the authors and publisher well know these statements about Rice to be false, readers will accept them at face value because of the trust they place in the authors and the Press. But if Rice were alive, she could sue the authors and the publisher for libel. Leonard Frank, a former ECT patient very much alive, is libeled as well. Healy interviewed him, plus much of Frank’s story is public record, so he well knew that Frank never engaged in the illegal act (smoking marijuana) he’s accused of in the book. Healy made this claim up, smug in the knowledge that even living former psychiatric patients don’t have the means to pursue libel lawsuits against doctors. But it is shameful (and far beneath anyone who calls himself a scholar) that he used his immunity this way.
This kind of intentional deception is very different from framing history. Certainly, the history of any topic can be written from different perspectives; medical, political, social, legal, moral, economic. No one book can include all of these. In fact, Rutgers has in the pipeline another history of electroshock; a social history, in large part the story of those who have experienced and survived it. Those voices have never been heard together in print and that book, due out in January 2009, truly will break new ground. It is possible to leave out some aspects of history in order to focus on others, without being dishonest. But this is not what Healy et al have done. They don’t leave out the question of ECT’s adverse effects. They take it as one of their central topics, only to pretend that most of the evidence of the past seventy years does not exist. They then must try to knit together a case for their position that there are no permanent adverse effects out of—in the case of brain damage— a few very old studies culled from dozens, and—-in the case of memory loss and cognitive disability—thin air. (There are no studies supporting unfootnoted claims like “In the vast majority of patients, memory is restored within weeks after the last treatment,” nor have there ever been any studies undertaken on Healy’s uniquely bizarre claims like the one that anesthesia itself, or maybe even valium, causes the extent of permanent amnesia seen with ECT. Who else would dare to claim that people put under anesthesia for routine surgeries experience years of memory erasure? Where is even one such documented case?)
Simply put, Healy and the other authors know so much about electroshock that it is impossible for them to maintain their position that it is harmless without deceiving their readers. On every page, they seem to be looking over their shoulders to see if anyone will catch them. In several cases, the hubris of these authors is such that they actually cite parts of studies or reports that resoundingly disprove their claims when read in full, but they must have been confident that no one would do so.
Here are some examples.
The authors maintain that “Critics claim ECT produces significant and severe memory loss and brain damage, yet in fact such side effects are either completely unfounded or are short-lived and less profound than stated.” It’s right on page two, but no reference follows the statement.
Yet they are aware that all the available data to date on memory loss was systematically reviewed in a study commissioned by the British government and published in the British Medical Journal in 2003, because they cite to that study elsewhere for some other point, without revealing the main purpose or findings of the study: that at least one-third of ECT patients suffer permanent amnesia and that ECT commonly erases five or more years of their lives.
They cite a 1985 National Institute of Mental Health Report on ECT for its recommendation that questions about shock be included on psychiatry licensing exams. But what they don’t say is that in this same report NIMH found, based on work done by memory expert Larry Squire, that ECT causes an average eight-month period of permanent amnesia. Squire showed that the majority of ECT patients had impaired memories when they were studied three years after treatment—meaning Healy et al have neatly inverted the scientific evidence.
In a discussion of a 1977 American Psychiatric Association survey of psychiatrists, they mention some of the results (about how many do shock, and so on) but leave out the one finding that doesn’t fit their script: the fact that 41% of the surveyed psychiatrists said that ECT causes brain damage.
The book repeatedly flatly denies any “neurologic sequelae” of ECT. In order to do so, the authors simply ignore decades of evidence for such sequelae, from the earliest animal and human autopsy studies (of which dozens show damage) up to the present-day controversy over mossy-fiber sprouting (an abnormal finding seen in epileptics and ECT patients). When the authors try to make their case by citing, rather than omitting, evidence, they have a rough time. They cannot cite one single brain scan study designed to investigate whether ECT causes brain damage by comparing ECT patients to controls who have not been shocked, for there has never been such a study (a fact about the history of ECT that itself speaks volumes).
The authors cite to the famous Irving Janis study of 1951, which used extensive before-and-after testing to document that all patients studied had permanent extensive amnesia after routine ECT (and followed them up long enough to be sure). The Janis study is beyond reproach methodologically and there have been many calls for its replication. But Healy et al do not mention what this study was, or what it found—instead they cite it only to claim it says something it does not!
Here’s the book’s case that ECT does not cause brain damage:
—A 1940 Italian dog autopsy study by the inventors of ECT. The authors found grave pathology in the brains of shocked dogs and assumed the pathology was reversible but only in one case did that seem to have happened. They could claim only “the possibility of a relatively good recovery” from brain damage, not that there was no brain damage;
—The speculation that the inventor of a rival therapy started the myth of ECT brain damage in 1942 to promote his own treatment;
— The statement that in 1950 a major shock proponent believed that there had been a number of studies showing ECT did not cause brain damage;
—-A 1942 EEG study which Shock Therapy claims showed that abnormal EEGs eventually return to normal but which actually showed that even after six months a third of ECT patients still had abnormal EEGs;
—A 1942 monkey autopsy study in which the authors found “physiological evidence of dysfunction…as clear and definite as it is in the human patient”;
—A 1944 study of four cats;
—A 1991 uncontrolled MRI study in which the lead author was a longtime consultant to the companies that make the devices, which found that patients’ brains were more abnormal post-ECT (dismissed as “cerebrovascular disease” with the caveat that this was only speculation);
—And finally, a quote from a psychiatrist who said in 1945 that “there cannot be any serious impairment to the brain.”
There. Now are you convinced that brain damage is only an “urban myth?”
The book mentions, in passing, two other contemporary ECT patients besides Rice who have publicly revealed the results of their own neurological testing documenting permanent brain damage (without, in fact, mentioning this fact about them). Healy in particular well knows that ECT disability has ruined the lives of former patients, because he admits interviewing people who’ve painted him pictures in great detail of what ECT memory disability is like and how it differs in extent and kind from any normal memory fallibility. They are credited in the acknowledgments.
Healy is certainly the only one of the three authors who would have deigned to sit down with ECT survivors; Fink, judging by colorful comments he’s made over the years, would as soon carry out an interview with monkeys. It is the pretense of listening, only to dismiss and discard everything he heard and even to print the opposite of what he heard or to libel those who trusted him, that makes Healy morally culpable in a way the other two, despite all their lies, are not.
It was left to Healy to carry out the thankless task of crafting the section of the book that is intended to support its denial of decades of evidence of permanent memory loss. By his own account he seems to have agonized over it for years. To say that it is poorly written is beside the point; it is the thinking behind it that is so bad. Healy had to twist common sense and logic into pretzels, and the section titled “But Why Memory?” is a sad spectacle. Knowing that Healy has in the recent past been capable of critical thinking and scientific reasoning in the case of psychiatric drugs, reading this section is like watching a train wreck. Instead of citing, proposing, or even conducting a single scientific study on the topic of whether ECT causes permanent memory loss—the way he has famously approached the question of whether psychiatric drugs can cause suicides—Healy engages in bizarre and nonsensical rationalizations of what he has already decided to believe: shock cannot cause memory loss. Rather, he says, amnesia after ECT is a kind of mass delusion, and comes about for the following reasons:
—Our culture places too much value on memory.
Healy has made the strange, and easily disproven, claim that ECT amnesia has only become an important issue within the last forty years, and that there was no concern about it for the first thirty. What he says, or tries to say, about why humanity has placed value on intact memory only since the 1960s is too sketchy and incomprehensible to reproduce here. Suffice it to say that no editor ought to have allowed it into print.
—Benzodiazepines such as valium cause sudden permanent extensive amnesia of the type which is seen after, and mistakenly attributed to, ECT. (Not one study is cited to prove this point, probably because no one before Healy has ever postulated such a theory, let alone designed a study to investigate it.)
—General anesthesia in and of itself routinely causes permanent extensive amnesia which is mistakenly attributed to ECT. (No citation, for the same reason.)
—People who undergo coronary artery bypass surgery experience cognitive impairment. (This is supposed to prove that ECT patients don’t, apparently…at least that seems to be the only reason it’s included in this book.)
—ECT patients are “psychoneurotics” who “cling to claims of abolished memories.”
—ECT patients are responding to clinicians’ suggestions that they have memory loss.
—Even psychiatrists forget things that happened 20 to 40 years ago.
—A man in Germany once forgot about an affair he had with a woman.
—”Psychologists may have used memory loss as a wedge in battering down the citadel of medical authority.”
If these authors were being honest with their readers, they might say that all the chicanery they have engaged in is necessary and justified because electroshock is a procedure worth defending at any cost. They might even say the ends justify the means, as do the many psychiatrists who force shock upon unwilling patients for their own good. The authors repeat over and over that electroshock “works.” (What’s meant by that, for whom, for what, for how long…all questions they don’t ask.) This is assumed to overrule everything: risks of permanent damage, patients’ rights to be informed and to refuse. But that electroshock works, like their other claims, is asserted, not proven. Max Fink is quoted as saying that ECT is the most effective treatment of the 20th century. Data is scarce, mostly consisting of three studies from the 1940s. Their main argument is a 1988 Danish study comparing ECT to the now rarely-used tricyclics, which they claim shows that shock reduces Hamilton scores by ten more points than the drugs. Even one of the adulatory reviews of the book—written, it turns out, by a psychiatrist who’s a colleague of Fink’s and was interviewed for the book—muses that there have been only two randomized controlled trials that even looked at the question of whether ECT is effective compared to drugs. No wonder the authors have to keep repeating over and over “It works.” They haven’t got any evidence.
Two large, 21st century studies comparing contemporary ECT to the type of drugs used today for depression and mania found the procedure to have only about a 30-50% efficacy rate in the short term. In the long term, at six months, patients who’d had ECT did only marginally better than those who hadn’t. Though the author of these studies was interviewed extensively for this book, the studies aren’t mentioned.
And although the claim that ECT is “lifesaving” made it onto the dust jacket copy and is a central selling point for both the procedure and the book, once again the reader is being sold a public relations line, not science. The authors appear to have culled through all the evidence that ECT either has no effect on, or is associated with higher rates of, suicide and mortality to select out two studies from the 1940s (again, why the 1940s?) as their best and only evidence that the procedure has ever saved lives. One was a comparison of ECT and metrazol (the original convulsive shock treatment induced by chemicals) and the other a study of outcome in manic-depressives which only incidentally considered suicide.
In an era of information proliferation, how can the authors get away with this? After all, you can’t get to page three of this book without coming upon a categorical assertion with no reference. It’s not so much that no one will know; it’s that the ECT industry, which has always thrived on deceiving patients, stands solidly behind the book and, holding prominent posts in medicine and academia, they can and will make sure no criticism gets through. The glowing blurbs on the back cover are from prominent shock doctors. The book has gotten loving reviews in the media and the medical journals. Meanwhile, professionals from outside the industry and, most importantly, the survivors of ECT who have been left out of this history, are not able to be heard. In fact, a critical review on amazon.com which infuriated Healy was taken down, presumably by him, soon after it appeared. This, more than anything else, explains why an author and publisher can knowingly and without fear of negative repercussion, one might even say arrogantly, put out a book filled with errors and lies of omission. That is true, at least, when the subject is electroshock, where there is such an imbalance of power between those who champion it and those who have been subjected to it or otherwise know better..
ECT practitioners will be able to cite this book in support of what they already believe, without any need to read it. Who might be interested in actually reading the book? Well, if you like biographical minutiae about the men who championed convulsive treatment—gossip about the mental health of Manfred Sakel or the financial motivations of Lothar Kalinowsky, for instance—you’ll find it here and nowhere else.
As well, you’ll find a story of the invention of shock treatment that is different from the universally accepted version. It may or may not be true; there’s no way to check it out because it’s based on private papers the authors claim to have seen. Whether it reveals anything about the invention of shock or simply about the authors of this book, it’s more revealing than Fink, Shorter, and Healy probably realize.
According to them, the first shock treatment was not the success it has been said to be in all previous histories. In fact, it wasn’t until the third shock treatment that the inventors got an outcome they wanted to reveal publicly. The first was a failure. The second is said to have been given to a different patient, a woman, and nothing more is said, not even whether she lived or died. After the third treatment was judged a success, its inventor, Ugo Cerletti, conflated the first three attempts into one, and that false account has survived until now.
“The creators of electroshock had been so eager to give the public a perfect story,” the authors conclude, “that they concealed a few weaknesses in their claims present in the record.” The same can be said for these authors. Yet today the record is so extensive that Shock Therapy not only fails as history, but will fail to deceive anyone but the procedure’s most devoted enthusiasts.