Milieu reactions to ECT

Electroconvulsive therapy (ECT) evokes strong emotional reactions and disagreements among mental health professionals, patients, and families. The indications for ECT, its efficacy and sequelae, theories of its mechanism of action, social and political debate, and the technique itself have all been sources of controversy. In the forty years since its advent, knowledge of these issues has evolved. The efficacy of ECT in major depressive illness is now well established, but at the same time we can eliminate most of the fifty theories that Gordon listed in 1948 to explain how ECT works. While the mechanism of action appears likely to be a neurochemical one, it is far from being clearly understood. But is is not just uncertainty about how ECT works that remains. Not only are there arguments among the lay public, but even knowledgeable mental health workers are sharply divided in their opinions of ECT (Frankel et el. 1978). We believe that even when ECT is administered in a humane manner with informed consent to appropriately selected patients who derived lasting benefit without major sequelae, it will continue to evoke strong emotional reactions in therapists, patients, and ward staff. In this paper, some of the continuing controversy surrounding ECT is examined through reactions to it in the therapeutic milieu among therapists, staff, and patients. We hypothesize that ECT can be especially upsetting because it often produces rapid improvement in patients who had previously not responded to treatment. This tends to create an inflated estimation of ECT. Devaluation of other therapeutic modalities, staff splitting, and disruptions in the therapeutic alliance may follow. We present two cases to exemplify aspects of how the milieu reacts to ECT, and conclude with recommendations to improve the delivery of treatment.