ADVERSE PSYCHOLOGICAL EFFECTS OF E.C.T.

Lucy Johnstone,
Senior Lecturer in Clinical Psychology and Counselling,
University of the West of England

 
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.

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 and Krystal (1994.) The ECT handbook contains a single paragraph referring briefly to pre-treatment 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 twenty-three 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 self-punishment 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 and 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, Fisher and Hilkevitch (1953) investigated the conscious and unconscious attitudes towards ECT in 30 psychotic patients, and con-cluded 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-oriented accounts is Warren's (1988) description of the implications of ECT for the self and for family re-lationships. 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 and Kendall, 1980; Hughes et al., 1981; Kerr et al., 1982) were reviewed in Freeman and Cheshire (1986.) Subsequent studies by Malcolm (1989), Szuba et al. (1991), Riordan, Barron and Bowden (1993), and Pettinati et al.(1994) used essentially the same format of asking patients to respond to questions or complete check-lists about their attitudes to and experience of ECT. The conclusions from this series of investigations can be summarised as follows:

*Most people appear to find ECT helpful (varying from 83% in Hughes et al to 56% in Riordan et al.)

*Most people also report side-effects,(around 80% in all studies), with memory impairment complained of most frequently, and headaches and confusion mentioned less frequently.

*Most people do not seem to find ECT particularly frightening to receive (Freeman and Kendall; 50% less so than a visit to the dentist.) However, a majority does experience some level of anxiety (74% in Gomez, 69% in Riordan et al.), and a significant minority reports much stronger reactions; (13.1% said it was so upsetting that they would not want it again, Freeman and Kendall; 14.3% say it was more upsetting than surgery, Pettinati et al; 23.7% agreed with the statement that ECT is a barbaric,inhumane treatment, Kerr et al.).

*Most people do not report other anxieties about ECT, although a minority does mention worries about brain damage. Death, personality change and being anaesthetised are also feared by some.

*Most people who have had ECT are profoundly ignorant about the whole procedure, and say that they were given no or inadequate explanations. (69% did not know that ECT involved a convulsion, Hughes et al.. Only 21% said they were given a good explanation of the procedure, Freeman and Kendall.) It is not clear how much these findings were influenced by memory loss.

(Two other studies produced broadly similar results, but are not directly comparable to those described above because scores for each item were averaged across all responses. See Calev et al., 1991, and Baxter et al., 1986.)

In summary, these studies would seem to justify Freeman and Kendall's (1980) often-quoted conclusion that patients find ECT "a helpful treatment and not particularly frightening." However, there are reasons for believing that the picture may be more complicated than this.

Firstly, there are the limitations acknowledged by Freeman and Kendall, which may apply to some extent to all these psychiatrist-led investigations: "It is obviously going to be difficult to come back to a hospital where you have been treated and criticise the treatment that you were given in a face-to-face meeting with a doctor." Earlier researchers certainly found such factors to be relevant: "The majority of the patients seemed to be motivated by the idea that any criticism that they might make of shock would in an indirect sense be a criticism of the psychiatric staff... patients expressed themselves sincerely only after the interviewers spent considerable time in establishing a relationship." (Fisher et al., 1953.)

Secondly, there is the unusual degree of compliance noted by several investigators, who were puzzled by patients' willingness to agree to ECT despite being anxious and ill-informed: "We were left with the clear impression that patients would agree to almost anything a doctor suggested" (Freeman and Kendall, 1980.) Referring to the same phenomenon, Riordan et al (1993) suggested, "This may reflect a high level of trust, or a resigned lethargy, in part reflecting mental state, but also a feeling of lack of involvement in their own management". Freeman and Kendall (1980) quote a particularly striking example: "Two patients who misunderstood the initial appointment letter .... came fully prepared to have a course of ECT. Neither had been near the hospital for nine months and both were quite symptom-free." Little attempt was made to explore the meaning of this kind of behaviour, but it does raise the question of whether the absence of criticism reflects satisfaction, or merely learned helplessness and passivity.

Thirdly, there is the fact that a minority of people in all the studies did express very strong negative feelings about ECT, although this has been obscured by focussing on the majority view. In the only paper that acknowledges this as a problem, Fox (1993) describes how a "difficult-to-elicit, etiologically obscure, and currently under-recognised 'pathological' fear of treatment develops in some proportion of patients undergoing ECT....Fear of E.C.T. merits further study."

Fourthly, there are several recent surveys carried out by investigators from outside the hospital setting which paint a much less reassuring picture. In the first one, UKAN (United Kingdom Advocacy Network) received 306 replies to a questionnaire distributed through UKAN- affiliated groups, Mindlink and Survivors Speak Out (both the last being service-user run organisations.) Overall, 35.1% described ECT as "damaging" with another 16.5% saying it was "not helpful." Although 30.1% found that it was helpful or very helpful, those who did not were likely to express very strong views against it, using words like "brutal", "barbaric" and "degrading." Psychological after-effects included loss of confidence, dignity and self-esteem; fear of hospitals and psychiatry; anger and aggression; loss of self; and nightmares. Similar themes emerged from a series of semi-structured interviews with 516 psychiatric patients contacted through MIND (Rogers, Pilgrim and Lacey, 1993.) While 43% found ECT helpful or very helpful, a large minority (37.1%) said it was unhelpful or very unhelpful, with a high proportion of the latter group strongly condemning it. Psychological effects included fear, flashbacks and nightmares. The same themes emerged from two smaller surveys by two researchers who had had ECT themselves, (Wallcraft 1987, Lawrence 1997) and from MIND's (1995) survey on "Older Women and ECT." In addition, the recently-formed organisation ECT Anonymous has collected several hundred reports from people who say that ECT has had a variety of disabling physical and psychological effects on them. However, respondents from all these sources were self-selected and might show a bias towards greater dissatisfaction.

In summary, all of the more recent research acknowledges that a proportion of people have very strong reactions against ECT, although very little is known about the nature of, and reasons for, these adverse psychological effects. The differences between the reported rates of adverse reactions (varying from 13.1% in the hospital-based surveys to 35.1% in the others) also remain puzzling.

While some of the earlier accounts may seem far-fetched, they do make an important point that has been overlooked in most subsequent surveys, that "there are crucial psychodynamic events involved in...organic therapy" (Abse and Ewing, 1956) and that attitudes can influence the outcome of the treatment.( Fisher et al 1953, Hillard and Folger 1977). Clearly, we need to know more about the meanings that ECT carries for a certain number of recipients, and which make it such a traumatic event for them. This may also throw some light on issues such as compliance and its possible effects on participants' responses. In order to investigate these areas, the existing questionnaires and pre-structured checklists of possible reactions need to be complemented by an approach that allows a detailed, in-depth exploration of the experiences of those people who find ECT a distressing event, entirely separate from the hospital setting. For these reasons a qualitative design was used in the present study.

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