Shock Therapy Controversy

BETWEEN CHARYBDIS & SCYLLA

Along with Edward Shorter, I recently authored a book on the history of electro- convulsive therapy (ECT) called Shock Therapy. ECT polarises people more than any other treatment in medicine. A history of ECT was therefore almost certain to polarise and hostile reviews were to be expected. Having never responded to a hostile review before, I hadn’t expected to start now until following a review on Amazon.com, Arthur Schafer and Aubrey Blumsohn argued I had little option but to respond.

The reason a response to this intensely ad hominem piece was called for was that it made several claims that pharmaceutical companies are all too likely to exploit. These claims were first that I had undeclared conflicts of interest and second that material appearing under my name had been ghost-written. These specific issues feed into larger aspects of the conflict of interest issue that an AHRP review of the book raised that this response will also deal with.

The apparent author of the amazon.com review is a Jerome Franklin “PhD”. The quotation marks and a subsequent review suggest this is not the true name of the reviewer.

I first became aware of the claims the review contains regarding conflict of interest and ghost authorship in early 2006 when Linda Andre made these claims in emails. This correspondence raised these questions and answered them, although Ms Andre was not inclined to believe the answers she got.

If not the actual author of the review, Ms Andre in this sense seems likely to be the originator of these claims in the review. She has also made significant contributions to the AHRP review. There are furthermore details in the review not present in the email correspondence that it seems to me cannot have come from anyone other than Ms Andre. Finally there are good reasons why Ms Andre would not wish to author a review under her name, which may become clear from the email correspondence.

It occurred to me that the review might stem from a PR agency working for one of the pharmaceutical companies such as Manning Selvage & Lee. It seems unlikely however that Ms Andre or others linked to her would consummate a relationship with a group like MS&L. And MS&L or other PR agencies are unlikely to adopt such a bitter tone toward Max Fink, whereas if Jerome Franklin had been inclined to full disclosure s/he might have disclosed that Max Fink has stood in the way of several of those who have become engaged with the issues, as the key expert witness for a series of defendants in ECT cases.

The problem is that agencies like MS&L are unlikely to have any compunctions about liaising with Ms Andre’s Committee for Truth in Psychiatry (CTIP) or using her claims.

First a piece of housekeeping. I am the author of chapters 9, 11 and the postscript. Chapter 9 outlines the interaction between the practice of ECT and the issue of informed consent. Chapter 11 charts the development of a series of other physical treatments, such as transcranial magnetic stimulation (rTMS), vagus nerve stimulation (VNS), and deep brain stimulation (DBS). The postscript deals in ways of seeing things - mentalities.

Ned Shorter authored the remainder of the book. The ground rules between us were that he would not interfere with my sections and I would not interfere with his. When it comes to issues raised in reviews, Ned has a policy of not responding.

While it can be argued that an author has responsibility for all the material that appears under their name, this responsibility lies with matters of fact. The claims made have much more to do with motives rather than facts, and I cannot readily answer for Ned Shorter’s motives, or his strategy for presenting the material in particular ways.

This response therefore at present only touches on issues covered in the material regarding which I am can answer for both the motives and strategy involved. As it happens the Andre/Franklin claims focus primarily on chapter 9, the pre copyedited version of which is attached here, along with the postscript. Given the heat chapter 9 has generated I wondered if some of the critics were reading it as ironical. There is nothing ironical about it - it is intended as a celebration of patient resistance to the medical machine and what that can achieve.

Conflicts Personal

First, let me declare a conflict that has not come up yet. A number of people in my personal circle have received ECT. In these cases it has seemed helpful and it does not appear to have caused problems.

A related conflict stems back some 12 years when I had a young patient who I believe lost her life owing to the marginalisation of ECT. It was not just that she would be alive if she had been treated with ECT, but rather that the way of seeing psychosyndromes that stems from the current dominance of psychopharmacology meant that I and others involved in her care were blinkered. There were things to see right in front of our nose that we missed, and this blindspot led to her needless death. Her undeclared case underpins the postscript to the book.

There is a reason for mentioning this. The debates about ECT stereotypically feed into a dynamic which pits powerful professionals against victimised patients. In this case, such a dynamic risks being deeply misleading. Giving a voice only to those who claim to have been harmed and not to those who have been helped by a treatment self-evidently introduces a bias to any history of that treatment. Many people who have done well on ECT are going to be reluctant to reveal their illness and, also owing to its stigmatisation, their treatment. Some have done so and these are mentioned in chapter 9.

The critics regularly invoke a conspiracy on the part of organised psychiatry to defend ECT. But as chapter 9 makes clear, more medical professionals are opposed to ECT than to any other technique in medicine. On this issue psychiatry simply has not been involved in a plot to foist this treatment on people. The proponents of ECT are not a powerful lobby group within psychiatry. For example in the course of the last five years ECT has been reviewed by a number of bodies in the UK including NICE. These have invited inputs from all major groups with an interest in the area and have had extensive input from patient groups. At such meetings there has been minimal or no representation from the Royal College of Psychiatrists. Neither the College nor the profession has felt bothered to defend ECT. Where ECT has been defended in the UK, Europe, the US, or elsewhere this defence has come from committed individuals such as Max Fink rather than from professional organisations.

Coming to the Andre/Franklin claims that a foundation, the Scion Foundation, linked to Max Fink, in some way supported me. It didn’t. I was first informed of the Scion Foundation by Ms Andre – see correspondence. The answer I gave her then is the same as now. A payment appears to have been made by the Scion Foundation to the University of Toronto and in line with University policy on funding Ned Shorter declared this. It appears that this payment was to cover travel expenses for Dr Shorter who visited a series of archives, obtained a large amount of material for the purposes of research on his areas of the book, and travelled to interview several of the older pioneers in the field.

I am not aware of a single cent being paid to me from the Scion Foundation or Max Fink or the University of Toronto or anyone else for my contributions to the book or anything connected with my involvement with the book. As far as I know, this grant from the Scion Foundation had no strings attached to it, so the University may have disbursed it to mental health service users for all I know.

On the question of conflict of interests, I have never claimed to have no conflicts of interest. I have also never claimed that anyone else came to their point of view because of a conflict of interest. I repeatedly take the opportunity to lay out all possible conflicts of interest including personal animosities or difficulties with individuals with whom I am engaged in a debate. I have always indicated that I am as corruptible as others by money and other factors. I have made this point clear in many publications and presentations and am not aware of ever having said anything to the contrary.

I do not believe however that a declaration of a conflict of interest helps move issues of science forward. No-one should have to depend on a scientist to be a saint or even to be ethical. Transparency in science does not involve scientists making clear where their conflicts of interest lie. It hinges on the data that science generates. Where this data, such as the data from drug trials, is kept concealed, this is the point at which the norms of science are breached.

When science emerged in the 17 th century, its distinctive feature when compared with other forms of discourse lay in a novel appeal to evidence. It became clear where debates were centred on evidence or the possibility of generating evidence that the conflicting interests of Catholics, Protestants, Jews, Muslims, atheists and others could be overcome. All of these people who could be regarded as having close to delusional beliefs and significant competing interests, and who maintained their committed positions and significant competing interests, could nevertheless participate together in science.

Ultimately as I have argued elsewhere the group with most to gain from the current debate about conflicts of interest are the pharmaceutical industry for whom it is infinitely preferable to have the field think all problems stem from a few rotten apples in the barrel who fail to declare conflicts of industry than have journals ban company articles and academic meetings ban company presentations on the basis that these do not conform to the norms of science ( Healy D. One Flew over the Conflict of Interest Nest. World Psychiatry 2007, 6, 26-27).

So are there missing data in the ECT story? Not as far as I’m aware. What there is, however, is great difficulty in generating good data. The neuropsychological test data that some think must exist somewhere to prove the reality of cognitive problems with ECT, for reasons that will become more clear below, almost in principle cannot exist. Neuropsychology has hitherto simply not been up to the task. If things are to move forward in this domain, there almost must be a collaborative approach between service users and professionals – but this collaboration is made less likely by loose allegations of conflict of interest.

The Franklin/Andre claims point to another series of possible conflicts of interest. It claims that Max Fink was my mentor, and that he salvaged my career, implying that my involvement in the book has to do with this.

All of the above statements are untrue. They appear to be conjured out of thin air. I first met Max Fink when I interviewed him for a series of interviews on the history of psychopharmacology in 1999. He was never my mentor. He did not salvage my career. My involvement with the book has nothing to do with any of the above.

Conflicts Global

The AHRP and Andre/Franklin claims argue that ECT only continues because there is a cohort of people who make a substantial amount of money out of it. It is only for this reason supposedly that a clearly damaging treatment continues to be inflicted on people who are not being informed as to the true reasons it is being given. Estimates are offered that ECT is worth up to $5 billion a year, significant amounts of which go to a small coterie of its pushers.

The $5 billion figure a year is a guestimate. It is not clear what the basis for this guess is. The AHRP review indicates that in part it depends on there being 100,000 patients getting ECT in the United States per annum. If the rate of ECT being delivered in the US (which is unknown) is close to the current rate in the UK then the true figure is probably in the order of 30,000 people a year, or slightly over 10,000 new patients per year – it is quite possible that the US rate is a lower than this as a third of teaching hospitals do not have an ECT service, a situation that would not be possible in the UK.

But even if ECT services cost $1-2 billion per year does this prove that all that is involved is conflict of interest? Every treatment, from cardioversion for patients with fibrillating hearts to cancer surgery, costs money. There would seem to be a problem if we have arrived at a culture where it is automatically assumed that things only get done because people earn money out of them. Orthopaedic surgeons are not going to do hip replacements for free but to say that the only reason hip replacements get done is because orthopaedic surgeons earn a living out of them is valueless.

There is a further reason to wonder about whether conflict of interest is the right term in this instance. ECT is not only administered in the USA. Indeed it is not primarily administered in the USA. In countries such as the UK and many other European countries any payments there are for ECT services are likely to be salaried so that those charged with delivering the service get paid whether they deliver any treatments or none. They don’t earn a living out of ensuring as many people as possible get given ECT.

The issues are quite different when it comes to treatments such as the antidepressants, lipid lowering agents or other agents in which there are issues about treating people who do not need to be treated, but who end up on treatment even in systems like the British one where doctors – until recently - would have been paid whether or not they put people on treatment. Most people would seem more likely to classify the patients who get ECT as severely ill than they would patients who have mild degrees of hypertension, mild elevations of their lipids and relatively minor nervous problems.

In contrast to the use of ECT, in Britain the treatment of patients with illnesses that don’t exist by treatments that don’t work (to borrow a phrase from Ned Shorter) is associated with Harley Street. The controversies that this kind of medicine gives rise to are quite different to the controversies that the treatment of breast cancer gives rise to, which parallel the difficulties surrounding the ECT debates that were picked up by Baron Lerner in his review of the book in Slate (January 3 rd 2008). There are yet other treatments like surgery for lung cancer where the outcomes are quite dismal and coronary artery bypass surgery where the adverse effects are so much more clear than with ECT in both of which there is a striking lack of controversy.

To move things forward, it seems to me we need a taxonomy of difficulties with some specification of terms so that terms which arise in one domain are not indiscriminately used in another. Indiscriminately putting everything down to conflict of interest does not seem helpful.

Ghostwriting the History of ECT

The Franklin/Andre claims include one that Max Fink was an author on the book and his involvement has been concealed, as it would kill the credibility of the volume.

My recollections of the origins of the book are that Ned Shorter and I had the idea of writing a history of ECT at much the same time. We decided it would be more expeditious to write jointly rather than independently and competitively. Because I knew Max Fink and had interviewed him in 1999, I introduced Ned Shorter to him. This made sense as Max is an unrivalled repository of information on the early history of ECT and this was the area of the book that Ned was focusing on. Ned subsequently spent time liaising with Max on access to archival sources and tracking down early pioneers in the field to interview.

At one point I believe that Max had been thinking about writing his own history of ECT with Jan Otto Ottosson, to complement a book on the ethics of ECT they had jointly written. In the end they decided not to undertake this further venture. My impression of what happened therefore is that we recruited Max to our efforts rather than he recruited us.

As regards the actual writing of the book, I cannot speak for Ned Shorter. We were separated by over 4,000 miles when our respective sections of the book were written. I have no idea who might have been in the room with him at the time he wrote his sections of the book. But Ned’s style is so distinctive that any deviations from form would be readily recognisable. I made minimal comments on early drafts of Ned’s chapters and he made essentially none on mine.

I can say that Max had no input into the material that I wrote. He answered a number of questions on detail when I had questions – but so did Linda Andre. I came to understand through a third party after the book was in press that he was unhappy about some of the material I had included in the sections that I wrote, but there was not a hint of that from him to me and no effort to get me to change a single word.

Essentially the only input into my part of the book was standard copy editing done by Doreen Valentine at Rutger’s University Press, who removed a considerable amount of material that I would have preferred to have left there. Some of this material was aimed at drawing parallels between the controversies surrounding the treatment of breast cancer and those surrounding ECT. This remains present in the pre copyedited text attached here. Doreen will have to answer for herself whether she was subverted by financial or emotional pressure from third parties when copy-editing my sections.

Ghosting History

One of the interesting features of this book has been the failure of those hostile to the book to accept history as history. They appear only prepared to admit texts that condemn ECT.

The role of history however is usually one of illustrating mentalities rather than advocacy one way or the other. In 1937, for instance, Adolf Hitler was proposed for a Nobel Peace Prize. This now seems unbelievable. The role of history is to help people understand how the world looked then so that someone like Hitler might plausibly have been nominated for Nobel Peace Prize. In order to help people understand this, the world of 1937 has to be reconstructed with understanding for its participants. An understanding that appreciates that it is quite likely that, had most of us been there at the time, we would have reacted in much the same way as people did then. Such a history will not explicitly condemn anyone who thought proposing Adolf Hitler for the Nobel Peace Prize in 1937 was an acceptable thing to do. The condemnation may be brought in more subtly. In the course of history, one of the things that can be done is to ensure that some of the historical actors offer the apposite points of view.

In the case of the history of ECT therefore a great deal of the text will aim at helping the reader understand how it could seem at the time that a treatment like this was worthwhile, how it could seem after it was invented that it really did have an important role to play and how the medical world at the time was one where doctors inflicted all sorts of treatments from radical mastectomy through to ECT on patients without seeking their consent.

In the midst of this an author can let the historical actors speak for him or her. For example, in the AHRP review of the book, it is said that the book condones giving to ECT to children on an indiscriminate basis. In fact the book makes it clear that one of the stimuli that led to the first efforts to reform the practice of ECT in Massachusetts and to the adoption of informed consent came from concern on the part of senior clinicians in the state at the fact that ECT was being given to children and that these children were being damaged by it.

The book also goes on to bring home the key historical message which is that many readers faced with the fact that ECT had been given to children during the 1960s will be horrified and wonder how this could have been done but they are then confronted with a question - how different is this to the mass and indiscriminate drugging not just of children but infants with stimulants and antipsychotics today?

In this brief section, far from condoning the use of ECT for children, my reading as the author of this part of the text is that a very clear message is being given that the authors do not think that ECT should have been given to children other than in extraordinary circumstances and that we are at risk of recreating entirely comparable problems for children today with pharmacotherapies because we have not learned the lessons of the past. Having put registers for ECT in place, why not also have a register of antipsychotic use in minors?

The AHRP review also suggests that its authors state that everything would be well with ECT but for critics, and in particular the Church of Scientology, who have stirred up trouble for a wonderful treatment. This claim may stem from a superficial reading, or misunderstanding of history, or may just be an example of downright mischief-making. Far from this being the suggestion in the book, the only place essentially where the Church of Scientology is mentioned is in a context which views their efforts in a particular case as quite laudable. Just to shake up preconceptions, this is a history of ECT that casts Scientology in a relatively good light.

The book makes it clear that the greatest difficulties for ECT have come not from Scientology but from the emergence of psychopharmacology and ironically a new generation of biological psychiatrists. Are Scientologists likely to be in league with psychopharmacology? Unlikely. Are the public relations companies linked to drug companies likely to use the spectre of Scientology? All too likely.

Misreadings on this scale suggest indiscriminate criticism of the book by people with a preconceived view as to what the book had said, who deprived of the signposts of explicit condemnation give free rein to their preconceptions.

History & Evidence

A criticism flung at the book is that it has skirted past all the evidence showing the harm of ECT and indeed skirted past evidence in general.

A history of a treatment like ECT or a disease like mania does not work by amassing all the evidence, coming down in terms of the truth or otherwise of a particular point based on the weight of evidence on one side or the other of an issue. History aims at trying to indicate to readers how events unfolded and what kind of sense a particular approach made to its proponents at the time.

My book on the history of the antidepressants mentions no evidence of the randomised controlled trial variety at all. Where controlled trials are mentioned it is in the context of indicating how they developed but the material used in outlining a history of the antidepressants is not material that stems from controlled trials.

Where once it might have seemed that only the evidence from controlled trials is worth having, it should be increasingly clear now that actually evidence from controlled trials, certainly as conducted by pharmaceutical companies within the mental health domain, is as limited as any other kind of evidence.

It can also be noted that far from The Antidepressant Era being hostile to the treatments or to the pharmaceutical companies that made them it is a book that was quite sympathetic to all the principal actors and companies in the field. Sometimes a sympathetic approach can bring out problems more effectively than a committed or partisan approach can do. Sympathetic though it is The Antidepressant Era is widely regarded as a critique of the use of antidepressants.

Let Them Eat Prozac is a much more committed book but this does not bill itself as a history of the Prozac group of antidepressants. This signposts itself clearly as a case study of one person’s efforts to grapple with an issue.

At this point, it should be noted that none of my books, not even in Let Them Eat Prozac, calls for the elimination of antidepressants or antipsychotics or any other treatments. In this sense the Healy leopard has not changed its spots. To expect that I would call for the abolition of ECT is to bring into the frame the critics perceptions of my previous work rather than a perception of that work which is based on actually reading what has been written.

Now it has to be said that history written from this point of view has many drawbacks. It leaves out a great deal of evidence. These drawbacks come through in the case of the history of ECT more clearly than they might come through in any other possible instance, except perhaps the history of breast cancer. Writing history and attempting to give a reader an insight into the mentalities that led to particular developments can be done provided the focus is relatively narrow. In the case of a medical treatment this may mean focussing on a relatively small number of key players and events. This biases the historical record toward doctors and away from patients.

In the case of ECT, this bias raises very acute issues in that there is a real issue as to what the patient’s voice might be in the case of this treatment. There are a very large number of people who would feel disenfranchised were a history written from a patient’s point of view that was hostile or antagonistic to ECT or called for its abolition. Many credit their life and their sanity to the treatment. Equally a history written only from the point of view of patients who were helped by the treatment risks missing out huge swathes of patient experience to do with both the treatment and its mode of delivery and the authoritarian manner in which it was delivered from the 40s, through to the 80s.

Given the particular problems in this area, I made efforts to support the publication of an account of ECT that is likely to be hostile to ECT, written by Linda Andre. I have gone into bat for Miss Andre with Rutger’s University Press. I have tried to iron out problems when they have occurred to keep the project on the road. The attached email correspondence gives some feel for my role in this.

One of the issues that the controversy surrounding ECT throws up is the issue of romance. A dislike of ECT is entirely reasonable. It is a physically confronting treatment that runs counter to 50 or 100 years worth of expectations as to how psychotherapy should look. It has been delivered in an authoritarian and insensitive fashion and has almost unquestionably in many cases been delivered punitively and has caused damage.

But efforts to ban ECT seem to involve a denial of reality to any psychiatric illnesses. A great many people can agree that a great amount of what gets called mental health problems or psychiatric illness these days either is not an illness or if it is an illness does not need treatment either with a physical treatment or a psychotherapy and that many people would be much healthier if they never had anything to do with mental health services.

Many will probably also agree that there are a number of conditions that can look very severe but again are not physical illnesses and would do much better with a behavioural management approach. Some of these states can lead to people being treated inappropriately with ECT and such people stand exposed to all the risks of ECT while being unlikely to gain any benefits. In the current state of psychiatry where no diagnostic tests are available to establish the presence of a disorder or its degree of biological abnormality mistakes of this kind are almost inevitable.

But there is a third group of conditions and it is this group of conditions on which arguments tend to founder. This is a group of conditions on which there are two points of view. One is the point of view that says these conditions are real and the other is the point of view that denies the reality of these conditions. These conditions include schizophrenia, psychotic depression, catatonic states and other severe states that led to people being hospitalised 100 or 150 years ago with conditions that are recognisably the same as present to mental health services today. These are the kinds of states where despite the risks of treatment there may be a harm-benefit trade off that warrants interventions with treatments like ECT.

If such conditions do exist, they legitimately underpin a discerning use of treatments like ECT. Calls to ban ECT fundamentally deny there are such conditions.

There is an area of common ground between these two camps, provided the positions held are not too extreme. This is in the area of attempting to minimise to the greatest possible extent the degree of forced or involuntary treatment. Even if the conditions are real it is not necessarily the case that people who are quite unwilling to have treatment should be forced to have that treatment. There is a fine line to tread between advocating rights to refuse treatment in the case of serious illnesses, and ensuring the rights to those who may wish to refuse by denying the treatment to all.

Denying access to treatment may be institutionalised or may come about by promulgating unfounded scares about the treatment. This soft form of denying access has its mirror image in pharmaceutical company propaganda that creates a climate that ensures drug treatments are given. While campaigns to mitigate the problems of involuntary treatment have been one of the great achievements of the mental health field in the period starting in the 1960s, and these campaigns have benefited greatly from the paradigmatic use of ECT as villain, soft coercion has almost certainly led far more people to receive treatment they would not freely have wished to have than involuntary treatment has done.

These soft forms of coercion and denial of access, in which pharmaceutical companies specialise, interest me even more than the issue of involuntary coercion. I have been writing on this for 15 years now, as evidenced by the attached chapters on pharmaceutical abuse from Psychiatric Drugs Explained (Consent, Pharmacological abuse).

Some of the most intriguing exchanges have occurred around the issue of memory problems with ECT. The book does not claim there are no memory problems; it makes clear there are memory problems. But it also makes clear that it has been terribly difficult to show enduring memory problems specific to ECT. It makes clear that it is not hard to find people who complain of enduring memory problems but also clear that it is difficult to demonstrate what these problems actually are.

If it were simple to test for brain damage or enduring memory problems after ECT such tests would be in common use. I am repeatedly told that it is surely possible to organize some simple before and after research that should be able to nail this one down. Well, after 20 years worth of research in this area with millions of dollars of NIMH funding Harold Sackeim and the resources of Columbia Psychiatric Institute has not been able to nail this one down. There is no good instrument that can be used to pick up problems. If there were, ECT has so many opponents and critics within the psychiatric and mental health professions generally that studies would have been done to demonstrate conclusively what should apparently be so easy to demonstrate.

One of the problems as outlined in the book is there are almost no patients who get ECT and there have been no patients since the 1940s and 50s who have had ECT without also getting drugs like the barbiturates then, the benzodiazepines now, as well as the antipsychotics now. All of these drugs cause cognitive problems.

What the critics miss is that in the 1980s when dependence on the benzodiazepines was a prominent issue in the media, there were many stories of people claiming they had lost years of their lives as a result of dependence on these pills. They attributed their inability to remember the salient events of their children’s childhood to their benzodiazepines in stories that were almost identical to those from patients who attribute their loss to ECT.

There is another narrative found following ECT – namely that the individual has difficulties remembering phone numbers, or names or other organisational details. I have emails on file from patients claiming such difficulties following ECT, and emails from the same individuals indicating they are taking antipsychotic agents, and emails from other individuals taking antipsychotics who have never had ECT who outline in almost exactly the same words comparable difficulties.

There is no reason to doubt that mental health treatment can cause problems, but there can be very real difficulties pinpointing just what leads to what. In the case of ECT it is not at all surprising that very clear cognitive problems that no one denies occur might after time be conflated with subtle problems stemming from other sources.

Andre/Franklin point to the one third of patients surveyed in the UK who had enduring cognitive problems after ECT. There is a misreading here. One third of patients claim problems rather than have problems. Ms Andre herself claims enduring cognitive problems and that ECT knocked 10-15 points off her IQ. For those trying to defend the treatment who see stuporose people the day before treatment doing crossword problems the day after, Ms Andre’s ability to put together a university press book raises questions about her claims. But the key word here is claim.

Mismatches between what people claim and what can be recorded arise in the domains of sleep and health awareness. Insomnia is a complaint. The sleep of insomniacs is commonly indistinguishable from non-insomniacs. Similarly the actual health of those who don’t complain about physical ailments overlaps heavily with the health of those who do.

Mismatches like these have often somewhat unhelpfully led to designations that someone is neurotic. The study of memory has thrown up another possibility with some discussion recently of the concept of metamemory. Following very clear brain injury, a person may complain bitterly about their memory even though cognitive testing reveals little or no problem.

What is going on? Well one possibility is that the answers may lie in the hitherto unexplored domain of metamemory. Another is that they are neurotic. Yet another is that even sophisticated neuropsychological testing is pretty limited in what it can detect. Such testing rarely detects subtle problems. It is not possible for instance to detect the differences between an antipsychotic and a tranquilizer reliably using the standard tests we have available.

A much more reliable method to detect the effects of a treatment on the brain was quantitative electro-encephalography. But, this was a branch of science that was eclipsed in the late 1960s. Were it still flourishing we would be in a much better position today to talk about what ECT and other treatments do to the brain. In another twist of history though, Jerome Franklin or anyone else interested to find out what the evidence from this source might have to say would have to revisit the work of one of its leading exponents – Max Fink.

In attempting to explore these issues, two points came up. One is the clear cognitive problems that for instance patients with coronary artery bypass surgery have. My experience has been that critics do not want to engage with the evidence that other disorders produce cognitive problems that have been clearly delineated.

It has also been my experience that when the issue of clear brain damage caused by antipsychotic drugs is brought into the frame, brain damage that is visible in the form of tardive dyskinesia in a significant number of patients who take these drugs where no comparable visible brain damage is apparent after ECT, again such observations cause consternation to those hostile to ECT.

While on the one hand they may appeal to the horrors of these drugs, when it comes to ECT this it would appear is a uniquely awful treatment and they simply do not want it put in a context in which all treatments are viewed as being risky, potentially brain damaging and where as a result treatments should be used with caution.

What gives claims about easily visible brain damage on ECT traction is the fact as outlined in the book that, compared with treatments like Prozac or Aspirin or other treatments in daily use, ECT is now used so rarely it has become a stranger. We think we know our neighbours and the risks they pose but we regard strangers warily, where in fact the greatest risk of child abuse, sexual assault and a number of other problems comes from our neighbours and not from strangers.