Shock and flaws; Will ECT therapy ever recover from its treatment by Hollywood?
by Robert Fulford

(The National Post, 5 February 2008)

It may have been the most destructive and irresponsible movie ever made, but in 1975, One Flew Over the Cuckoo's Nest won five major Academy Awards, the first film to accomplish that since 1934.

Audiences loved it. Roger Ebert claimed that he never heard a more tumultuous reception than the one it received at its world premiere in Chicago. As Ebert said, sophomoric cheers greeted even the scenes intended to be sobering, like the attempt of Randle P. McMurphy (Jack Nicholson) to strangle the hateful Nurse Ratched (Louise Fletcher). For the young, this was an antiestablishment parable, the statement of a generation. But today many psychiatrists (and many patients) believe this movie about mental patients resisting a nurse's tyranny was a calamity in the history of medicine. It may have helped kill many depressives whose suicides could have been prevented had the film not grossly prejudiced them against ECT, or electroconvulsive treatment.

Psychiatry once again swims to the top of media concern this season, for two reasons. One is the appearance of Shock Therapy: The History of Electroconvulsive Treatment in Mental Illness (University of Toronto Press), by Edward Shorter of the University of Toronto and David Healy of Cardiff University. The other is the debut on The Movie Channel last week of In Treatment, an ambitious nine-week series starring Gabriel Byrne as a sympathetic but flawed practitioner of talk therapy.

Shorter and Healy tell an appalling story. The medical profession now widely accepts hundreds of evidence-based studies demonstrating the value of ECT in treating severe depression. But it still horrifies many people. And careful inquiry usually reveals that their aversion to it originated in watching ECT's use as an instrument of punishment and control in One Flew Over the Cuckoo's Nest.

In its most primitive stages, long ago, ECT could be terrifying and even physically harmful -- the bones of patients might be broken during convulsions. It didn't help that no one could say (or can say now) how it works. Doctors guess it somehow reboots the nerve cells in the brain; it's like aspirin, another famous medical enigma.

Muscle relaxants and better anaesthetics have made ECT safe and bearable. Still, the primitive version haunts our collective imagination. Sylvia Plath's The Bell Jar depicted early ECT as a nightmare. (People later connected it to her suicide, though she killed herself a week after starting to take an antidepressant drug.) Doris Lessing denigrated ECT in Briefing for a Descent into Hell.

Phyllis Chesler, in Women and Madness, made it sound like another male plot against women.

The spirit of the 1960s welcomed these views. In their generational struggle against authority, young people saw psychiatry as a perfect enemy, with its mysterious ideology and its connections to power and patriarchy. And within psychiatry, what (aside from lobotomy) could be more threatening than ECT?

After decades of positive clinical results, Dr. Tom Bolwig of the University of Copenhagen recently called it "one of the most efficacious and safe treatments in the whole of medicine." But Shorter and Healy suggest that opposition almost drove it out of existence. It became the prize in a struggle between culture and science -- and culture, in the short term, won. Today it's making a comeback, but it still struggles to overcome the notoriety inadvertently created by mass media.

An entirely different kind of psychotherapy dominates In Treatment, a five-nights-a-week drama based on an Israeli hit, BeTipul. It shows the psychiatry we expect to see on TV, the kind practiced by Dr. Jennifer Melfi, who may or may not have done the right thing when she helped Tony Soprano handle his bouts of crippling hysteria.

In Treatment takes place mainly in the office of Dr. Paul Weston (Gabriel Byrne), who charges $150 a session. We see much of the drama through his eyes, and share his troubles. His patients are annoying, aggressive, loudmouthed, or defiantly untruthful. The scripts give us every opportunity to observe their self-delusions. They recall Rule No. 1 of Dr. Gregory House, on the TV show House: Everybody lies about the important things. Later, when Paul admits he's losing patience with his patients, we sympathize.

On Monday night we meet Laura, a sexy young anaesthesiologist, Paul's patient for a year, who announces to his apparent dismay that she's in love with him. On Tuesday it's Alex, a supremely self-confident Navy bomber pilot who killed 17 Arab schoolchildren through an administrative error but claims it doesn't really bother him: "I don't have a guilty conscience." Next comes Sophie, a young gymnast with obvious suicidal tendencies who insists she's not suicidal. Jake and Amy, a married couple, come on Thursday to fight about the abortion she wants to have, making it plain they can't say a civil word to each other. We'll see all of them, on the same nights, for eight more weeks.

By Friday we are not surprised that Paul has been so disturbed by this squad of determinedly wrong-headed patients that he consults his former professional supervisor, Gina (Dianne Wiest), with whom he had a complicated relationship that broke off abruptly 10 years earlier.

He confesses that he's troubled by his feelings, including anger, toward his patients. But as the conversation turns to his wife we realize he's managed his own life badly and we wonder whether he's one of those therapists who understand everyone except themselves. As for the therapist's therapist, Gina, we see that her feelings toward Paul are more complicated than she cares to acknowledge. She's more interested in Paul's sex life, and his reactions to his infatuated patient, than she needs to be -- and why does she keep confusing that sexy young woman's name?

In Treatment can't duplicate the feeling of a psychiatric session. For one thing, the code of TV forbids boredom, which is omnipresent in real talk therapy. But the format (the first one American TV has ever borrowed from Israel) provides an unusual chance to take the audience relatively close to the real thing. And the attitude of the writers, combining curiosity with skepticism and compassion, suggests we may well end this therapeutic journey with more understanding of the process than we had when we began. If that's the case, its effect will be the reverse of what One Flew Over the Cuckoo's Nest left behind.

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