Excerpts from Must Read Books & Articles on Mental Health Topics
Articles- Part XIII

Shock and Disbelief
Daniel Smith, The Atlantic Monthly, February 2001

On the cover of a pamphlet I was sent recently appears a photograph of an elderly man with bright bolts of electricity shooting outward from his temples. His teeth are clenched. His eyes are squeezed shut. His hair is standing on end. Holding the man's head secure is a leather strap that resembles the restraint on a prisoner in the electric chair.
    This is electroconvulsive therapy ( ECT) -- the psychiatric use of an electric current to stimulate a grand mal seizure--as seen through the eyes of the Citizens Commission on Human Rights, a lobbying group founded by the Church of Scientology and the most active and well organized anti-ECT group in existence. It is a grim view, invoking coercion, barbarity, anguish--everything negative that has ever been associated with psychiatry. It is also the common view.
    Last fall I saw a patient receive ECT at McLean Hospital, a private psychiatric facility in Belmont, Massachusetts. There, in a well-lit treatment room, attended by a nurse, a psychiatrist, and an anesthesiologist, a middle-aged man suffering from hallucinations and depression lay unconscious on his back while two electrode paddles were placed on his head. A button was pressed, and the patient's right foot twitched lightly. Shortly afterward the patient awoke and was given a snack before being escorted back to his room.
    The contrast between image and reality is surprising. The procedure I saw at McLean reflects the way ECT has been administered for years, as cautiously and as formally as any other medical procedure--perhaps even more so, because of the awareness psychiatrists have of ECT's reputation as savage. Yet the popular image of ECT has persisted, sustained almost single-handedly, it sometimes seems, by the 1975 movie One Flew Over the Cuckoo's Nest, the release of which coincided with a decline in the use of ECT. In 1980 less than three percent of all psychiatric inpatients were being treated with the procedure, and by 1983, thirty-three states were in some way regulating it.
    Although the public seemed willing to let ECT fall into obsolescence, many psychiatrists felt that they were losing a valuable and irreplaceable treatment. In 1985 the National Institutes of Health, in Bethesda, Maryland, called a three-day conference on electroconvulsive therapy. The first day of the conference passed without incident, as experts delivered lectures. On the second day, however, during an open discussion period, anger erupted on the floor of the conference hall. Former patients and even a few clinicians began protesting loudly. One of those present was Max Fink, then a professor of psychiatry at the State University of New York at Stony Brook and a pioneer in modern ECT research. As Fink remembers it, "They were shouting, 'How dare you even consider electroshock as a possibility! It has no place in the world! Everybody who does electroshock should be in jail!"' When the conference resumed, a panel of "nonadvocate" experts forged a consensus statement in which they observed, with standoffish delicacy,
    Electroconvulsive therapy is the most controversial treatment in psychiatry. The nature of the treatment itself, its history of abuse, unfavorable media presentations, compelling testimony of former patients, special attention by the legal system, uneven distribution of ECT use among practitioners and facilities, and uneven access by patients all contribute to the controversial context in which the consensus panel has approached its task.
    Today ECT has strengthened its position in the profession. Many psychiatrists, whether or not they actively administer the treatment, have come to appreciate its ability to ameliorate a range of mental illnesses, from depression to some forms of schizophrenia and catatonia. A 1993 commentary in The New England Journal of Medicine stated, "Electroconvulsive therapy is more firmly established than ever as an important method of treating certain severe forms of depression." The first phase of a National Institute of Mental Health supported study, to be published this spring, found that ECT produced a greater than 95 percent remission rate in psychotically depressed patients--vastly higher than the rate for any drug on the market. When I talked with Fink recently, he told me, "ECT is the most effective antidepressant, antipsychotic, anticatatonic we have today." Other psychiatrists have been even more enthusiastic. One, T. George Bidder, has written that ECT is "one of the most effective treatments in all of medicine--with a therapeutic efficacy, in properly selected cases, comparable to some of the most potent and specific treatments available, such as penicillin in pneumonococcal pneumonia." Such endorsements have led to what looks like a renaissance for ECT; it is estimated that 100,000 patients are treated with it each year--nearly triple the number cited for 1980 by the NIMH.
    Yet the attacks on the treatment are as virulent as ever. Activists continue to push for prohibitive legislation. In 1997 a bill that would effectively have made administering ECT a criminal act, punishable by a fine of up to $10,000 and/or up to six months in jail, was narrowly defeated in Texas. ECT has virtually disappeared from state-run psychiatric facilities, owing in large part to government regulation. To be treated, patients must almost always gain access to a private or academic hospital. This means that ECT is very rarely an option for poor patients--those without adequate insurance or access to information, or without the means to travel, for example, to a distant, well-equipped university hospital. A 1995 article in the American Journal of Psychiatry found that ECT was unavailable in more than a third of the 317 metropolitan areas nationwide that it surveyed. "The situation has reversed itself from where it was decades ago," says Richard Weiner, a professor of psychiatry at Duke University and the head of the American Psychiatric Association's Committee on ECT. "Many ECT patients used to be asylum patients. Now it's very hard to get ECT in such places, and its use has shifted to general hospitals and private psychiatric hospitals."
    The stigma attached to ECT is in some ways a holdover from less scrupulous days of psychiatry. But one of the main reasons many people still consider ECT to be archaic and even destructive is that it continues to be painted as such by an unlikely trio of activist groups: a handful of former ECT patients, some dissenting psychiatrists, and the Church of Scientology. These groups have agitated for the complete elimination of ECT. They have pushed legislative attempts to limit or ban ECT. They have initiated and supported lawsuits against psychiatrists, hospitals, and ECT device manufacturers. They claim that ECT is authoritarian, violent, and representative of everything that is wrong with the profession of psychiatry. And despite all medical evidence to the contrary, people are listening to them.

"A CRACK OF ELECTRICITY"
Electroconvulsive therapy emerged during a bleak period for psychiatry. In the first third of the twentieth century not much could be done for the mentally ill. Psychoanalysis, the dominant method of treatment, proved helpful to some wealthy patients complaining of the so-called "minor illnesses": melancholy and neurosis. But it didn't do much for patients with more systemic afflictions, such as schizophrenia and manic-depressive illness. These patients were merely warehoused in vast state asylums, where conditions were appalling. Patients were abused, shackled, even surgically sterilized. Psychiatry's job seemed to be no more than brutal custodianship; psychiatrists could do no more than hope that their patients would recover spontaneously from their illnesses. Under these desperate circumstances some psychiatrists began experimenting with radical treatments: insulin coma, transorbital lobotomy, malarial fever. One of these "somatic therapies --Metrazol shock--seemed particularly promising, given the theory (now known to be untrue) that a "biological antagonism" existed between epilepsy and schizophrenia. A schizophrenic patient was injected with Metrazol, a drug similar to camphor. After a few minutes the patient would undergo a full-blown seizure: all the muscles in his body would convulse violently, his back would arch, his limbs would flail, his breathing would become shallow. Often he would vomit. It was a gruesome ordeal. The historian Edward Shorter, in A History (1997), reported that a Swiss psychiatrist stopped using the treatment because it caused "agonizing fears of dying and crumbling away," and that a British doctor spoke of "the unseemly and tragic farce of an unwilling patient being pursued by a posse of nurses with me, a fully charged syringe in my hand, bringing up the rear." And yet, strangely, Metrazol shock worked pretty well "Convulsive therapy," as it came to be called, opened wide vistas of possibility.
    But no one really understood why inducing seizures made patients better. Even today there are only educated guesses. Some subscribe to the neuroendocrine hypothesis, which states that seizures cause a shift in the body's hormonal system. Others subscribe to what has been called the anticonvulsant view, which holds that, paradoxically, the whole purpose of causing a seizure is to tap into the brain's ability to stop that seizure naturally. In other words, the brain's anticonvulsant mechanism may alter the brain's neurochemistry, acting as a built-in antidepressant. Still others believe that it is the seizures themselves that change the level of chemicals in the brain. In 1990 a group of articles in the journal Neuropsy examined all three possibilities without drawing any conclusions.
    Regardless, from the beginning convulsive therapy proved promising. Ugo Cerletti, in the 1930s the chief of the Clinic for Nervous and Mental Diseases at the University of Rome, was among those who were impressed. But he considered that electricity might cause seizures more quickly, and thus in a less harrowing manner, than Metrazol. Earlier Cerletti had tested the neurological effects of electricity by conducting experiments on dogs. His first attempts were inauspicious: because he put one electrode in the dog's mouth and one in its anus, the bulk of the current passed through the dog's heart; half the dogs died of cardiac arrest. Lucio Bini, one of Cerletti's assistants, solved this problem by transferring the electrodes to the dogs' temples. Cerletti and his staff worked tirelessly, experimenting on animals that were brought to them each week by dogcatchers. The results supported their hopes: it seemed that using electricity was an effective way to produce an epileptic fit. Before applying it to a human being, Cerletti's assistants visited a Rome slaughterhouse to observe an electrical device that was being used to incapacitate pigs prior to slaughter. They discovered that there was a wide margin between the amount of electricity that would create a seizure and the amount that would kill.
    In the spring of 1938 "electroshock" as Cerletti called it, was ready to be tested on a human being. The subject was a Milanese man the Roman police had found wandering in the train station without a ticket, mumbling gibberish to himself. Shorter described the inaugural treatment>

The patient, his head shaved, seemed quite indifferent to what was going on. A nurse placed the electrodes on his temples while an orderly put a rubber tube between his teeth to prevent him from biting his tongue ... There was a crack of electricity. The patient's muscles jolted once ... "Let's step it up to 90." said Cerletti. Another electrical crack. Another spasm. The patient lay motionless for a minute, then began to sing. "We'll try it one last time at a higher voltage," said Cerletti, "poi basta [and then enough]." At this point, the patient said, in a perfectly calm and reasonable voice, as though answering an exam question. "Look out! The first is pestiferous, the second mortiferous." The residents looked at each other puzzled.

Despite the primitive application, the patient responded quite well. He had ten more treatments and was released, "in good condition and well-oriented." After a year he had not relapsed significantly. This was no small feat; no one could remember any experiment that had shown nearly such promising results. Thereafter ECT spread quickly to European hospitals. By 1940 it had appeared in the United States. Psychiatrists were enthusiastic One whom Shorter quoted wrote in the British Journal of Psychiatry, "Without ECT I would not have lasted out in psychiatry, as I would not have been able to tolerate the sadness and hopelessness of most mental illnesses."
    ECT was a great step up. Patients did not vomit, as they did in the course of Metrazol shock, and they did not experience as much psychological trauma. But they did still have to suffer the effects of muscular convulsions, which were frequently excruciating, and which have contributed to the persistent image of ECT as a brutal form of treatment. Thrashing around on the treatment table, many patients bit their tongues and cheeks. Many suffered broken bones or serious spinal injuries. Sometimes a gang of orderlies and nurses was needed to prevent the patient from tossing himself off the table altogether. In addition, patients suffered memory loss. They would awake confused, unsure of where they were or what had happened, often forgetting events of the preceding weeks or months.
    ECT was also drastically overused. Doctors in some hospitals would treat dozens of patients in one giant room, wheeling the device on a cart from bed to bed; patients were forced to watch the ordeal of those who came before them. One doctor in England treated some of his patients more than a thousand times each. In the 1950s Ewen Cameron, a psychiatrist at McGill University, in Montreal, "depatterned" his patients by giving them twelve treatments daily. Milledgeville State Hospital, in Georgia, for a time the largest asylum in the United States, had perhaps the worst history of abuse: it used what was known as the Georgia Power Cocktail to punish uncooperative patients.
    The publicized experiences of famous patients treated privately with ECT bolstered the evidence against the treatment. The poet Sylvia Plath was subjected to ECT and wrote about it in her autobiographical novel, The Bell Jar : "Then something bent down and took hold of me and shook me like the end of the world. Whee-ee-ee-ee-ee, it shrilled, through an air crackling with blue light, and with each flash a great jolt drubbed me till I thought my bones would break and the sap fly out of me like a split plant." (Later in the novel the narrator had a less unpleasant ECT experience.) Ernest Hemingway underwent a course of ECT at the Mayo Clinic, in Rochester, Minnesota, and wrote to his biographer, A. E. Hotchner: "What is the sense of ruining my head and erasing my memory, which is my capital, and putting me out of business? It was a brilliant cure, but we lost the patient." Soon afterward Hemingway shot himself. In 1972 Senator Thomas Eagleton had to withdraw as the presidential candidate George McGovern's running mate after it was revealed that he had been treated with ECT. And, of course, One Flew Over the Cuckoo's Nest bundled all the public's negative associations into the disturbing image of Jack Nicholson, mocking and playful one moment, writhing on a table the next, and finally catatonic--the result, in actuality, not of the ECT he received but of an off-camera lobotomy.
    ECT all but disappeared in the 1970s, eclipsed by psychiatric drugs, which brought about, as Shorter called it, the "triumph of the biological." More and more drugs came on the market, offering a sophisticated biochemical arsenal for treating mental illness. In the 1980s, owing to more advanced neuro-imaging techniques, physiological sources were found for schizophrenia and manic-depressive illness. As is by now well known, psychiatry and neurology edged toward a permanent intimacy. Electroconvulsive therapy seemed more than a little outmoded.
    But drugs have not been the complete answer to mental illness. They were and still are a frustratingly inexact method of treatment with a long wait between the first pill and any sign of relief. Often they don't work at all. This can be fatal for a patient who is suicidally depressed. Moreover, some patients prove resistant to medication.
    The psychiatric community set out to modernize ECT and improve its image. Researchers worked with manufacturers to modernize ECT devices, outfitting them with equipment to monitor heart rate and brain activity and upgrading the electricity used. The 1985 NIH conference was followed by a 1990 report by the American Psychiatric Association committee charged with introducing better standards for treatment. The problem of physical injuries had been solved by the administration of fast-acting anesthesia and muscle relaxants, which confine the effects of a seizure to the brain. Clinicians implemented an informed-consent procedure that detailed every aspect of ECT along with its benefits and risks--including the (slim) possibility of death. (According to the most recent report of the APA Committee on ECT, published this year, one death occurs for every 80,000 treatments.) ECT became safer and more exact, and psychiatrists used it more selectively. Today ECT is frequently used to treat the elderly, a population highly susceptible to mental illness and sensitive to the side effects of medication. Because drugs can cause birth defects, ECT is also often the preferred psychiatric treatment for women during the early stages of pregnancy.
     Some side effects do remain. Memory loss is the most prevalent and is the primary reason that ECT is not used more often. Patients may have gaps in their memory affecting several months preceding treatment, and may also have trouble "laying down" new memories for a couple of weeks following treatment. in a small number of patients these problems can persist for a much longer period of time. But to some people, the fact that ECT causes any memory loss at all is unacceptable. ECT's detractors focus their objections on this side effect.

A PATIENT'S COMPLAINT
Linda Andre, a tall, attractive woman in her early forties, is the director of the Committee for Truth in Psychiatry, a loose-knit organization of 500 former ECT patients. I was directed to CTIP by Max Fink, who has had numerous run-ins with Andre. At a talk Fink gave some years ago in New York, Andre stood up in the audience and loudly protested his association with Somatics, one of the two largest U.S. manufacturers of ECT devices. (Fink says he has no financial links with any ECT device manufacturer.) Andre has been to many psychiatric conferences. She is hardly ever afforded official time to speak. More often she simply rises from the crowd.
    When Andre and I met recently, I mentioned Fink, and she shook her head. "Ah, Max Fink, my dear friend. Oh, that man. That man. Not an honest and ethical individual, shall we say? I cannot believe that the scientific press lets the stuff he says get through. I'm sure he told you that no one ever had memory loss from ECT, except maybe around the time of ECT itself, and that they don't want to remember. He probably told you that we're just exaggerating. And everybody has some memory loss. He keeps these positions because he can. Shock is his baby. He's been associated with it longer than anyone." Fink, it became clear, represents for Andre the epitome of psychiatric deception. In an unpublished article on ECT, Andre has written,

After 50 years of giving electroshock, I can't believe Fink knows any less about the extent of permanent memory loss and disability than I do. I believe he and his fellow apologists are making a value judgment about the worth of their patients' memories and lives. and deciding on that basis to essentially trade brain damage for temporary relief of depression.

    Andre has been the director of CTIP since 1992. She told me she first became involved in the organization in 1985, several months after she received fifteen "shock" treatments at the Payne Whitney Psychiatric Clinic in New York City. Andre takes exception to the term ECT, dismissing "electroconvulsive therapy" as "the elegant new PR-conscious name for `electroshock.'" She says that she doesn't remember anything about her treatments, and that she was committed to the clinic against her will.
    "Everything I know about getting electroshock is what I've been told." she says. "I don't remember anything about it. From what I understand, my brother basically tricked me into going into the hospital at a time when I was going through a lot of problems and had become a pain in the ass to him." Andre says she escaped from the hospital several times before her treatment began, and that each time her brother recommitted her. When she was finally released, she says, she had both retrograde and anterograde amnesia: she couldn't remember much of the previous four years, and she had difficulty creating memories of new events. One day, at home, she heard a woman named Marilyn Rice talking on the radio about ECT.
    Rice is something of a legend in the world of ECT. In 1974 the distinguished medical writer Berton Roueche published an article about her in The New Yorker, disguising Rice, who had received ECT to treat a serious bout of depression, as "Natalie Parker." The article, titled `As Empty as Eve,' depicted Rice's experience as a nightmarish erasure of memory. "There is a harrowing sense of confusion," Roueche wrote, "and then a full awakening in the midnight dark of total amnesia." Her sense of purpose bolstered by the article, Rice formed CTIP and began accumulating documentation that ECT causes, as she put it, "psychiatrically induced brain damage." She wrote letters to psychiatrists, government officials, newspapers and magazines, and other potential allies, and created a small network of ECT "survivors," as she called them. To one doctor she wrote, "I could easily set up a psychiatric hospital as good as yours. I would just put the patients down on the sidewalk and interfere with their cerebral function by dropping flower pots on their heads." Andre got Rice's phone number from the radio station and called her. The two became very close, and when Rice died, of heart failure, in 1992; Andre took over as director.
    Can ECT cause a complete erasure of memory, as Andre claims? Most psychiatrists insist that it can't, and that side effects are usually slight. Roland Kohloff, the principal tympanist for the New York Philharmonic, was treated several times with ECT after slipping into severe depression. Each time he quickly rebounded and went back to work. "After you get a series," he told me recently, "there will be for a while some short-term memory problems. I might not remember something I had done a couple of weeks before, or somebody called and I don't remember that they called. But nothing major; and then, as time goes on, it gets better. Look at Vladimir Horowitz, the concert pianist, who has also been treated with ECT. "He was able to play billions of notes: Chopin, Tchaikovsky. The worst for me was that I'd forget something and my wife would say, `Oh, I told you a couple of weeks ago but you didn't remember: you had the ECT."'
    What patients like Andre are complaining about is something more serious. They argue that ECT can result in wholesale amnesia, along with a steep decline in IQ. At the age of twenty, Andre says, her IQ was 156. Three years after her ECT, it was around 112 and it does not appear to have increased since. Whether or not this is a result of ECT is hard to determine. Norman Endler, a psychologist who was himself treated with ECT, and Emmanuel Persad, a psychiatrist, wrote in their book Electroconvulsive Therapy: The Myths and the Realities (1988), "There is no conclusive proof that ECT causes permanent brain damage." What muddies the issue is that mental illness itself can cause cognitive defects, including a drop in IQ and in the ability to retain new memories. The informed-consent document for ECT used by Charles Kellner, a professor of psychiatry at the Medical University of South Carolina and the editor of The Journal of ECT, although scrupulous in its delineation of even the most severe side effects, states, "In part because psychiatric conditions themselves produce impairments in learning and memory, many patients actually report that their learning and memory functioning is improved after ECT."
    In some cases a profound deterioration of cognitive ability is clearly the result of mental illness. Harold Sackeim, the chief of biological psychiatry at the New York State Psychiatric Institute, in New York City, and probably the most prolific ECT researcher in the world, told me about a colleague whose son had a psychotic break while a student at Harvard and now can't hold down a job at a fast-food restaurant. Andre, Sackeim says, has shown him her medical records; he says that she may have experienced a similar breakdown. But there is no way to know for sure whether ECT was the culprit in Andre's loss of IQ and memory. "In very rare cases," Sackeim acknowledges, "there will be profound memory loss. People can lose years of their lives."
    Jeremy Coplan, a professor of psychiatry at SUNY Downstate Medical Center, in Brooklyn, who, like many other psychiatrists, doesn't actively treat with ECT but does refer patients for it, told me that the issue of memory loss is, unfortunately, often downplayed by psychiatrists. "For instance, someone may forget where the bathroom is in their house at least temporarily," he said. "There can be a profound disruption of memory--not a minor thing if you put yourself in the patient's shoes." But, he said, it's a matter of risk versus benefit "It's better that the patient is temporarily disoriented than seriously depressed for years."
    The effect that ECT has on memory has been notoriously hard for ECT practitioners to concede. "The field has been under attack for such a long period of time," Sackeim says, "that a defensive posture was developed where limitations of the treatment were not acknowledged. So people complained of profound cognitive effects, and those effects were attributed to an ongoing psychopathology and essentially dismissed. I think that hurt the field of ECT. Lately, doctors have been taking special pains to spell out the risks that patients face. "I tell all my patients that they are going to have memory loss," Sackeirn says. "In the vast, vast majority of patients that will be limited to a few months surrounding the course of treatment. There will not be a blank slate. But there will be gaps in memory. And the vast majority of patients say that's a small price to pay for getting well. It's not really a big deal to them. But I also tell them that in very rare instances it can be more extensive, and that no one can tell for certain who is going to experience that and who is not."
    It has taken some time for a full disclosure to seep into the official literature. The report published this year by the APA Committee on ECT contains that organization's first substantial discussion of the possibility of serious memory problems.

A DOCTOR'S COMPLAINT
There was a moment at the 1985 NIH conference, Peter Breggin recalls, when patients who had had positive experiences with ECT were asked to step up to the lectern and tell about their illness and recovery. Breggin, who is the director of the International Center for the Study of Psychiatry and Psychology, in Bethesda, Maryland, had already delivered a lecture titled "Neuropathology and Cognitive Dysfunction From ECT," and he listened intently as the patients spoke. Afterward one of them pressed a note into his hand, thanking him for speaking out about the side effects of ECT. "This was one of the pro-ECT people," Breggin told me when we spoke recently. "They were up there to tell people that ECT works, and here this person was thanking me for providing a dissenting opinion."
    For Breggin, the experience epitomized ECT's ability to reduce patients to docility--to the point where they are willing to praise a treatment they feel has done them harm. In his view, ECT is a purposeful assault on the brain. He has been publicizing this opinion since 1979, when his first book, Electroshock: Its Brain-Disabling Effects, was published. Since then Breggin, a psychiatrist by training, has made a career out of attacking psychiatry and its methods. He has written several books arguing against the use of medication to treat mental illness, and he claims to be responsible for quashing the resurgence of lobotomy. His most recent efforts have been directed at establishing a link between antidepressants and the Columbine massacre. When Breggin discusses psychiatry, it is in the brusque manner of an aggressive debater.
    Though Breggin has waged many campaigns, he has attacked ECT particularly vehemently, arguing that it causes "severe brain dysfunction" and that it creates in patients profound feelings of apathy or delirium. Psychiatrists welcome either outcome, he told me, because they can note with satisfaction on their charts that the patient is "complaining less" or has "an elevated mood." In this way, he says, psychiatrists fool themselves into believing that they are helping a patient when they are really doing harm. In his book Toxic Psychiatry (1991), Breggin wrote,

If a woman received an accidental shock in her kitchen, perhaps from touching her forehead against a short-circuited refrigerator, and fell to the floor convulsing, she'd be rushed to the local ER and treated as an acute medical emergency. If she awoke the way a shock patient does--dazed, confused, disoriented, and suffering from a headache, stiff neck, and nausea--she'd be hospitalized for careful observation and probably put on anticonvulsants for months to prevent another convulsion. But on a psychiatric ward she'd be told she was doing fine and "not to worry," while the electrical closed-head injury was inflicted again and again.

    Breggin first encountered ECT in the 1950s, when, as an undergraduate at Harvard, he volunteered at a state psychiatric hospital. He was horrified, he recalls, at the conditions on the hospital's "back wards." Schizophrenic patients were left mumbling and rocking back and forth, without any human contact. They were led, zombie-like, to be treated with insulin coma or ECT. Breggin believed that if the patients were exposed to a more empathic environment and one that provided for their basic needs, they would get better, so he persuaded the hospital administration to start a program of "love and care." He contends that plain old kindness worked. Later, as a resident in psychiatry and a teaching fellow at Harvard Medical School, Breggin observed firsthand the trend in psychiatry away from psychotherapy and toward physiological treatment, and he found it very disturbing.
    "Mental illness," he says, "is a metaphor. It's not reality. When patients come into my office and say that they're depressed, I don't give them medication. I ask questions: What is their life like? What is their story? Where are they from? How did they get depressed? Why do they call it depression? Depression isn't caused by some mythical biochemical imbalance. It's another word for hopelessness."
    This is a philosophy that Breggin absorbed from his training under Thomas Szasz, one of the forerunners of the "anti-psychiatry" movement In the 1960s--along with Erving Goffman, R. D. Laing, and Michel Foucault. Szasz, a refugee from Nazi-era Hungary and a psychiatrist, promoted the view that mental illness is a social construct. Breggin's language is taken straight from his teacher. In the revised edition of his 1961 book, The Myth of Mental lllness, Szasz wrote, "`Mental illness' is a metaphor. Minds can be `sick' only in the sense that jokes are `sick' or economies are `sick."'
    Breggin is scorned by mainstream psychiatrists for his links to Szasz and for his contemptuous attitude toward physiological psychiatry. "Lots of fields have splinter groups," Harold Sackeim says. "Increasingly the dominant perspective in psychiatry is a biochemical one. There are people who, on ideological grounds, feel that this shouldn't be the case. They think psychotherapy should be the first line of treatment." But, he says, this opinion isn't necessarily benign. "Breggin will argue that a cup of tea, chicken soup, and a lot of hugging will get a psychotically depressed patient well. And he'll kill a lot of patients that way. That's why he doesn't have hospital privileges."
    Still, Breggin has hit a nerve. Patients who have had negative experiences with ECT restate his arguments almost verbatim. By demonizing psychiatrists, by "exposing" their claims, Breggin has suggested answers to patients seeking to understand why they continue to suffer.

SCIENTOLOGY VERSUS PSYCHIATRY
If practitioners of ECT tolerate "survivor" groups and disdain dissenting psychiatrists, they actively loathe the Citizens Commission on Human Rights. The inside of the pamphlet I have--one of many published and disseminated by CCHR--is an indication of why. A quick sampling of chapter headings: "Perpetuating Cruelty," "Therapy or Torture?," "The Nazi Heritage" ("electroshock's development .. traces back to a dark alliance between psychiatry and the Nazi concentration camps"), "Apartheid and ECT," "ECT Promotes Breast Cancer," "Shock From Birth to Grave." Bolts of electricity in vivid neon colors provide visual unity here, emanating from the heads of pregnant women, fetuses, piglets. CCHR does not believe in subtlety.
    The commission maintains offices in forty states and chapters in thirty other countries. It has used its branches in part to lobby for legislation against ECT. In 1974 it worked to get the California legislature to prohibit ECT for patients under the age of twelve. It has several times been instrumental in introducing legislation in Texas to ban ECT altogether. Although the legislation has failed, Texas is now, owing in large part to CCHR's efforts, the state in which it is the most difficult to get the treatment. Recently CCHR supported a bill in the Italian region of Piedmont which succeeded in banning ECT for children, the elderly, and, in most cases, pregnant women. That CCHR has effectively and perhaps permanently damaged the public image of ECT is one of the few things about which the commission and psychiatrists agree.
    CCHR was founded in 1969 by the Church of Scientology, which by now has a fashionable Hollywood aura--John Travolta, Tom Cruise, and Nicole Kidman are all members. Scientology, "an applied religious philpsophy," seeks to change the world through a system known as Dianetics, a term made familiar by a series of TV commercials for a book of the same name by the late L. Ron Hubbard, Scientology's founder and a science-fiction writer. Through
    Dianetics, Scientologists hope, according to the church's Web site, to create a utopia "without insanity, without criminals and without war, where the able can prosper and honest beings can have rights, and where man is free to rise to greater heights." In CCHR's view, one of the greatest threats to this vision is abuses inherent in psychiatry, which damages the mind instead of soothing the soul. "For more than 115 years, psychiatrists have treated man as an animal," CCHR's Web site states. "They have assaulted, sexually abused, irreversibly damaged, drugged or killed, all under the guise of `mental healing"'
    CCHR was co-founded by Thomas Szasz, and its members take pains to emphasize this fact. Their connection to "the Church," as they call it, is spoken of less frequently. CCHR is separately incorporated, and although virtually every CCHR member worldwide also happens to be a member of the Church of Scientology, this is by choice, the organization says, not by compulsion. Rather than promote Scientology, CCHR seeks to lay out the evidence of psychiatry's misdeeds through the use of statistics, anecdotes, journal articles, news accounts, and hospital records.
    The most voluminous resource for anti-ECT information within CCHR is Jerry Boswell, the director of the commission's Texas branch and the man most responsible for the state's stringent ECT laws. Boswell is patient and even-tempered, and his voice--soft and deep, with a heavy drawl--conjures the image of a large man in boots and a cowboy hat. At one point in a recent phone conversation with him, I mentioned the TV personality Dick Cavett, who has very publicly and very positively spoken about how ECT helped him out of a terrible depression. "With ECT you have to ask the question of how much electricity was used," Boswell said. "Let's say you have Dick Cavett on your couch. Are you going to shock him at three hundred percent above the seizure threshold, or are you going to give him less electricity? You're going to give him less, because he's a public figure:"
    CCHR continually alleges that ECT uses "too high" a level of electricity. This has been difficult for psychiatrists to counter, because the very concept of "too high" leads immediately into contentious terrain. Dozens of studies have been done to determine how much electricity produces the most-therapeutic seizures. On the basis of these studies some researchers have recommended that ECT devices be equipped to deliver more electricity. A 1991 paper by Harold Sackeim, "Are ECT Devices Underpowered?" published in The Journal of ECT (then called Convulsive Therapy) questioned the ability of contemporary devices to stimulate an ideally therapeutic seizure.
    Whatever damage CCHR may have done to ECT, the organization has unquestionably improved the gathering of statistics regarding the treatment. The results, however, have not been advantageous to CCHR's cause. Several years ago CCHR lobbied successfully for compulsory reporting of ECT cases in Texas. William Reid, a clinical professor of psychiatry at the University of Texas Health Science Center, in San Antonio, and three other authors recently published in the Journal of Clinical Psychiatry all of the Center's available data from September of 1993 to April of 1995. The article reported that 97.5 percent of all admissions were wholly voluntary; that the percentage of patients exhibiting "severe" symptoms was reduced from 70.7 prior to ECT to 2.4 afterward; that the percentage of patients with "moderate," "severe," or "extreme" memory dysfunction decreased after ECT: and that no bone fractures, heart attacks. or deaths occurred during treatment. Of the 2,583 patients described by the data, eight died within two weeks of their last treatment, but only two of these deaths may have been related in any way to ECT. The authors write,
    We are aware that anti-ECT groups have used the publicly available ... data to support their contentions that ECT is dangerous and unnecessary and to campaign in the Texas legislature to ban the treatment altogether. We believe that those groups have often misinterpreted and/or misused the .. data. We hope that this paper promotes objective discussion among clinicians, patients, families, and those who influence patients' access to this important treatment modality.

KEEPING IT BORING
McLean Hospital has the sprawling lawns and architectural mien of a small New England college. Its forty-two buildings, almost all made of brick, are spread out over 242 acres. Adirondack chairs grace the lawns. Even early in the morning people are strolling about, and it is impossible to tell which are patients and which are staff members.
     As at most hospitals, ECT at McLean is administered early on Monday, Wednesday, and Friday mornings--a cycle that allows patients to spend at least two days resting between treatments. In a typical year doctors at McLean give about 2,000 ECT treatments to about 200 patients. The diagnosis for almost all of them is some form of acute depression. Most have experienced what psychiatrists gently call "suicidal ideation." On the April morning that I visited to watch a treatment, Michael Henry, the head of McLean's ECT programs, was scheduled to treat sixteen patients, all of whom fit into those two categories. Henry seems to display all the qualities one hopes for in a psychiatrist. He has soft, comforting features; indomitable patience; and a voice that remains calm even when the situation calls for some emotion.
    I arrived at the hospital before 8:00 A.M. and was met in the reception area by a staff member in the hospital's public affairs office. (This was the first time that a reporter was to be allowed to watch an ECT procedure at McLean.) A few minutes later I was shown into the treatment room, which looked like a small operating room but was less intimidating. With the middle of the room dominated by the table on which the patient lay, there was little space for the small crowd that had assembled: Henry, the anesthesiologist, a nurse, a third-year medical student, another staff member, and me.
    The patient appeared to be in his late fifties, with gray hair and a touch of stubble. He was wearing jeans; a purple long-sleeved shirt, and white tennis shoes. He seemed unalarmed by the treatment that was to come, but his countenance betrayed the anguish of what Henry had told me was a depression whose manifestations included somatic hallucinations--illusions of movement and disease in different parts of the man's body. A year earlier the patient had gone through a course of ECT for similar episodes. That course had shown positive results, but the patient had recently relapsed and opted for more ECT. The treatment he was receiving that morning was his sixth in this course. I later asked Henry how many the man was to have. "That depends on him." he said. "We let the patient decide. We are very reluctant to push ECT"
    The treatment began when the anesthesiologist injected a muscle relaxant and a general anesthetic into the patient's arm. The nurse inflated a blood-pressure cuff around his right ankle, which would prevent the relaxant from reaching his right foot and thus would provide a place where Henry could observe muscle contractions. She gently rubbed his hand as he went under. The anesthesiologist fit a plastic mask attached to a turnip-shaped bag over the patient's mouth and proceeded to squeeze oxygen into his lungs. Manually aided respiration has become standard procedure in ECT; it helps the patient not only to breathe once the muscle relaxants have paralyzed his diaphragm but also to rise from the anesthesia with a minimum of discomfort and memory loss.
    Henry rubbed conductive jelly on two electrodes and placed both on the left side of the patient's head. Unilateral ECT, as this is called, is now the most common form. For years researchers debated whether this method was less effective than bilateral ECT, which involves placing one electrode on either side of the head, thus causing the seizure to affect both hemispheres of the brain. It has recently become dear that the difference in effectiveness is negligible but that unilateral ECT causes much less serious aftereffects.
    Henry walked over to the ECT device, which looks like a large stereo receiver, and pressed a button. The patient's right foot seized, as though experiencing a sudden itch or a slight muscle spasm, and after ten seconds that was it. The procedure was gracefully mundane--anticlimactic, I couldn't help thinking. As we walked out, Henry said, "We try to keep it as absolutely boring as possible. "The less interesting the better." He could have been speaking for nearly all his fellow practitioners of ECT. Henry understands full well that the treatment's reputation is more complicated. Despite all the improvements in patient care, despite all the subtle tweaks and the impressive monitors affixed to the devices, ECT, Henry says, is still fundamentally the same treatment it was sixty years ago. The theory has remained fixed: shock a patient with enough electricity so that he'll have a seizure, and he'll probably get better. It's a blunt idea, medically speaking, and when pills that silently alter neurochemistry are the frame of reference, it is tough to warm up to something so primitively straightforward--even if for some reason it seems to work.
    A number of ECT's most dedicated practitioners express a distaste for engaging in public efforts to bolster its reputation. One reason they give is that such undertakings would require pressing patients into service as witnesses. "We are here to do good by patients," Henry told me, "not to create poster children." In any event, among ECT practitioners there is considerable apprehensiveness about the media. In 1995 USA Today ran a three-part story about ECT that began with the death of a seventy-two-year-old woman during treatment; understandably, the article's publication had serious repercussions for patients' willingness to undergo ECT. In 1980 The Atlantic Monthly ran an article titled "Electroshock: The Unkindest Therapy of All," which Max Fink likened to Mein Kampf.
    A skeptical press is symptomatic of a larger phenomenon. Psychiatrists assume that anti-ECT activists represent a fringe viewpoint on mental illness, whereas the evidence suggests that the anti-ECT outlook is actually close to the public's. In 1999 the Office of the Surgeon General released its first ever report on mental health. The report cited estimates that two thirds of all cases of mental illness in this country go unreported. One of the main reasons the report gave for this is a widespread disbelief in the biological origin of psychiatric disorders. Despite the fact that major depression ranks second only to heart disease in the nation's "disease burden" (a measure that takes both mortality and morbidity into account), and despite the great scientific leaps that psychiatry has made, the report found the stigma associated with mental illness to be overwhelming: many people do not even accept that mental function is the work of a physical organ--a basic tenet of psychiatry. This suggests that the main obstacle ECT proponents face may be not proving its inherent usefulness but proving that the brain is an organ like any other, capable of breakdown.
    When the Surgeon General's report came out, it included a statement about ECT: "First-line treatment for most people with depression today consists of antidepressant medication, psychotherapy, or the combination ... In situations where these options are not effective or too slow ... electroconvulsive therapy (ECT) may be considered." This wasn't the original wording. Two months earlier a consumer rights activist had leaked the section dealing with ECT, which had called it a `safe and effective treatment for depression." A torrent of protests flooded the Surgeon General's office. CCHR sent a sixteen-page document denouncing what it saw as a categorical endorsement of ECT. Linda Andre held meetings with an administrator working on the report. In the end the statement was softened.
    However, the central message of the report--that there exists an enduring, peculiar, and unfortunate double standard involving the "physical" and the "mental" illnesses was not mitigated. The predominant belief in the United States, the report indicated, is that it is all right to be subject to infection, degeneration, and microscopic revolts from the neck down. But a moral culpability is attached to whatever afflicts our minds. The double standard extends to treatment. We concede that coping with diseases of the body may of necessity bring about painful, even dangerous, side effects. We concede that we must weigh risks and benefits. But with psychiatric treatments, especially ECT, any possibility of harm is deemed wanton and intolerable. The discrepancy in attitudes is a strange one. According to Joseph Coyle, the chairman of the Department of Psychiatry at Harvard University, 15 percent of severely depressed patients commit suicide. It is a lethal disease. ECT doctors often draw a parallel with cancer: the treatments for cancer can be as damaging as the disease itself, they point out, yet there are no anti-chemotherapy lobbyists.
    More important than questioning why anti-ECT lobbyists persist is asking what psychiatrists might do to counter the criticism The answer from some is that they are already doing all they need to do. ECT use seems to be on the rise, even if slowly, and psychiatry's professional organizations are continually refining treatment guidelines. Greater advocacy efforts seem not to be on anyone's agenda, perhaps for fear of luring ECT's detractors into even louder denunciations.
    There is still the possibility that a more benign method will be found to produce therapeutic seizures in the brain. Clinical trials are under way at hospitals worldwide for a treatment known as transcranial magnetic stimulation, which in one of its forms uses a strong magnetic field to create a seizure that is much more precise in intensity and placement than an ECT seizure. Convulsive TMS could drastically reduce memory loss, and thus could be an advance in convulsive therapy as marked as the move from Metrazol to electricity, sixty years ago. But it is likely to be years before TMS is fully developed and finds its way into treatment rooms around the country. In the meantime, patients must continue to seek out hospitals that offer ECT. And ECT will continue to offer benefits that other treatments do not.
    As for Michael Henry's patient, he underwent six more treatments and was released, in good condition and well oriented.

The Limits of Talk
Mary Sykes Wylie, The Psychotherapy Networker-
January/February 2004

Bessel Van Der Kolk likes to introduce his workshops on PostTraumatic Stress Disorder (PTSD) with medical film clips from World War I showing veterans diagnosed with what was then called "shell shock." In these dramatic and riveting clips, one soldier sits hunched over on his hospital cot, staring blankly ahead, responding to nothing and nobody until the single word "bomb" is said, whereupon he dives for cover underneath the small bed. Another man lies almost naked on the bare floor, his back rigidly arched, his arms and hands clawing the air as he tries, spasmodically and without success, to clamber onto his side and stand up. Yet another, who once bayoneted an enemy in the face, now opens his mouth wide into a gaping yaw and then closes it, and opens it and closes it, over and over and over again.
     The images are disturbing, heartbreaking, and all the stranger because these particular men, technically speaking. are physically unharmed. Their physical symptoms -- paralysis, violent trembling, spasmodic movements, repetitive facial grimaces, zombielike demeanor -- look exotic to our eyes because PTSD generally doesn't show up like this anymore in most clinicians' offices. Time and Western cultural evolution have changed the way traumatized people express their distress in a therapist's office. Now, trauma patients may look fine on the surface, but complain of nightmares, flashbacks, feelings of numbness, generalized fearfulness, dissociative symptoms, and other problems that aren't as visible to the world at large. But to van der Kolk, these old images still represent what he calls the "pure form" of PTSD. The appearance in these World War I film clips that the veterans are possessed, mind and body, by invisible demons still captures the fundamental truth about PTSD -- that it can reduce its victims to mute, almost animal-like, creatures, utterly isolated in their fear and horror from the human community.
     Van der Kolk first became aware of the world of trauma in 1978, when he decided to go work for the Veterans Administration, not to study PTSD (it hadn't been recognized yet as a formal diagnosis), but to get the government benefits to pay for his own psychoanalysis. While there, he discovered the reality of PTSD and the beginnings of a stunning, nationwide phenomenon. "At that time, tens of thousands of men who'd served in Vietnam suddenly seemed to come out of the woodwork, suffering from flashbacks, beating their wives, drinking and drugging to suppress their feelings, closing down emotionally," recalls van der Kolk. "It was a phenomenon that spawned a whole generation of researchers and clinicians fascinated by what had happened to these guys."
Van der Kolk himself soon became intrigued by the mysterious mental and emotional paralysis that seemed to afflict these traumatized veterans. Why, he wondered, did many of his patients seem so stuck emotionally in their horror that they relived it over and over in flashbacks and nightmares? What kept these men circling round and round on an endless treadmill of memory, unable to step off and resume life? In spite of their obvious suffering, why did they seem so obsessively attached to their traumatic experiences?
     In the 25 years since then, the trauma field has gone from obscurity, if not disreputability, to become one of the most clinically innovative and scientifically supported specialties in mental health. Trauma researchers have led the pack in setting off an explosion of knowledge about psychobiology and the interaction of body and mind. And van der Kolk, as much as anyone else in the field, has defined the current framework for understanding trauma. He's the author of more than a hundred peer-reviewed scientific papers on subjects such as self-mutilation, dissociation, the therapeutic efficacy of Eye Movement Desensitization and Reprocessing (EMDR), the developmental impact of trauma, and the nature of traumatic memories. He's also been a featured contributor in most of the standard textbooks in the trauma field. In addition to teaching at Boston University, Tufts, and Harvard, he directs the Trauma Center in Boston, possibly the largest trauma specialty center in the country, with 40 clinicians working with clients who range from infants to geriatrics, from incest survivors to international torture victims. Inhabiting both the world of the clinician and the researcher, he also runs a major research laboratory at the Trauma Center, staffed by 15 researchers who investigate everything from neuroimaging of treatment effects on the brain to the effects of theater groups on violent, traumatized teenagers.
     Glowing testimonials about his contributions aren't hard to come by from the field's leading lights. "Very early on, more than anybody else, he introduced neurobiology to the trauma field, and helped us see the interaction between mind and body in trauma," says Charles Figley, professor at the School of Social Work at Florida State University and Vietnam vet, whose early work on war trauma is often credited with prompting the inclusion of PTSD as a diagnosis in the DSM. "He's one of the most generative and creative minds in the trauma field, and his influence has been pervasive," says psychiatrist Judith Herman, renowned trauma expert at Harvard Medical School.
     At the same time, van der Kolk is also one of the trauma field's most controversial figures. Often prickly, rarely shy about offering his own opinions, and unafraid of a good fight, he's scandalized a number of cognitive-behavioral therapists and academic researchers by openly embracing EMDR, demonstrating an interest in such truly outre techniques as Thought Field Therapy, enthusiastically taking up nonstandard somatic therapies, and even sending his patients off to participate in theater groups and martial arts training. Van der Kolk's bold criticism of the orthodoxies of psychotherapy and public advocacy of somatic approaches have, in particular, outraged many. "Advocating unproven body psychotherapies is professionally irresponsible," says Edna Foa, professor of psychology in the psychiatry department at the University of Pennsylvania. "He's marginalized himself as a scientific thinker -- he's no longer in the mainstream," adds Richard Bryant, noted trauma researcher and psychology professor at the University of New South Wales in Australia. "Until he provides data in support of his new somatic approach, the field isn't obligated to pay any attention to what he's doing," sniffs psychologist Richard McNally, author of the widely cited Remembering Trauma, a critique of recovered-memory theory.
     The intensity of response van der Kolk kicks up is an indication of the crusader's fervor underlying his work and his determination to make the field viscerally understand that trauma isn't simply a neutral mental health issue, but a profoundly moral concern. Spicing his talks with earthy, Dutch-accented American slang, van der Kolk regularly reminds his audience in a tone of subdued indignation that trauma forces the reality of human evil into our consciousness, often the evil of presumably good and upright people -- our neighbors, our leaders, our families, and ourselves. It's not a perspective people always welcome because, as he writes in his book Traumatic Stress, most of us like to believe "that the world is essentially just, that `good' people are in charge of their lives, and that bad things only happen to `bad' people.... Victims are the members of society whose problems represent the memory of suffering, rage and pain in a world that longs to forget."

A Diagnosis Non Grata
While trauma is always clinically described as a horrifically abnormal event, for any casual student of the human condition, it's actually a perfectly normal feature of history, one that has emotionally scarred billions of men, women, and children since before the beginning of recorded time. And yet, while philosophers, writers, and ordinary people have always known that terrible events can cause a lifetime of psychological pain, until the latter part of the 20th century, mental health professionals were oddly blind to this fact of life. "Psychiatry itself has periodically suffered from marked amnesias in which well-established knowledge has been abruptly forgotten," writes van der Kolk in Traumatic Stress, "and the psychological impact of overwhelming experiences has been ascribed to constitutional or intrapsychic factors alone." In other words, a failure to "get over" a trauma was often ascribed to personal weakness or an unconscious desire not to recover.
     Even the official nosology of the psychiatric profession reflected this peculiar obtuseness. The 1952 edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-1) had included combat-related stress under the diagnosis of "gross stress reaction," but this was dropped from the DSM-II in 1968 -- the same year that troop strength reached its peak in Vietnam. All that was left of trauma in DSM-II was the pallid diagnosis "adjustment reaction to adult life," under the general heading of "transient situational disturbance." Adjustment reaction was a grab-bag diagnosis, including "fear associated with military combat and manifested by trembling, running and hiding" and "unwanted pregnancy." It wasn't until 1980, after years of lobbying and wrangling, that PTSD was included in DSMIII. So when van der Kolk first went to the VA in 1978, not only was there no official traumatic stress diagnosis, but the VA assumed that any psychiatric problems occurring more than one year after discharge couldn't be related to military service. Besides denying veterans any compensation for delayed traumatic reactions probably the overriding consideration in the VA's longstanding lack of interest in the enduring impact of "combat stress" -- this rule effectively scotched any research or clinical treatment directly focused on trauma. "When I went to work for the Boston VA," remembers van der Kolk, "there wasn't a single book in the library on war neurosis."
     Unable to do research on war trauma because the VA wouldn't fund studies on a diagnosis that didn't exist, van der Kolk and his colleagues did the first study ever on the real nightmares the vets had and, in another first, used the Rorschach inkblot test to reveal the twin pattern of hyperarousal and dissociation that traumatized vets showed. For van der Kolk, this research pointed to the paradoxical conundrum at the heart of trauma. "This is still the issue with traumatized people -- they see and feel only their trauma, or they see and feel nothing at all; they're fixated on their traumas or they're somehow psychically absent." In either case, traumatic memories from the past have utterly usurped the present.
     By the late-1980s, van der Kolk had had extensive experience working with vets and was becoming a well-known figure among PTSD researchers. He'd been responsible for several important studies, including, besides the Rorschach and nightmare papers, research into psychopharmacology and trauma, and had published the book Post-Traumatic Stress Disorder: Ps ychological and Biological Sequelae, the first book published specifically about PTSD. But in spite of his impressive resume, he felt deeply discouraged. He'd learned a lot, but he didn't think he was fundamentally helping his patients. Even after months or years of work, his patients still suffered from flashbacks, nightmares, depression, aggressive rage, anxiety. They still either couldn't talk about their trauma at all or when he pushed them to talk about it -- as he and many therapists often did, and still do -- they began hyperventilating, shaking, yelling, crying, physically agitated, or just collapsed in a state of helpless fear and dread. "I'd become a reputable PTSD researcher and clinician, but I felt I'd utterly failed my patients," van der Kolk remembers. "I guess they thought I was a good guy, they felt understood by me, but that didn't necessarily help them to get back into their lives."
     And what was the treatment that he felt was not really helping his patients to move on? It was standard talk therapy 101 -- helping them explore their thoughts and feelings -- supplemented with group therapy and medications. During individual sessions with clients, he often focused intensely on patients' past traumas, in the interest of getting them to process and integrate their memories. "I very quickly went to people's trauma, and many of my patients actually got worse rather than better," he says. "There was an increase in suicide attempts. Some of my colleagues even told me that they didn't trust me as a therapist."

The Neurobiology of Trauma
The fundamental conundrum of how trauma affects the mind and body that still plays out in treating trauma survivors was already crystallizing in van der Kolk's mind 20 years ago. "When people get close to reexperiencing their trauma, they get so upset that they can no longer speak," he says. "It seemed to me then that we needed to find some way to access their trauma, but help them stay physiologically quiet enough to tolerate it, so they didn't freak out or shut down in treatment. It was pretty obvious that as long as people just sat and moved their tongues around, there wasn't enough real change."
     Back in the early 1980s, believing that future progress lay in a better understanding of the biology -- particularly the neurobiology -- of trauma, van der Kolk had applied for a VA research grant on the subject. Even though PTSD was now "official," his proposal was turned down flat. The opening sentence of the rejection letter still vividly resonates in his mind. "It's never been shown that PTSD is relevant to the mission of the Veterans Administration." Since then, the VA has grown up and become a leading supporter and funder of trauma research, but in the early '80s, it was clearly a diagnosis non grata to the establishment. Both dumbfounded and enraged by the VA's response, van der Kolk says he never read past that first sentence, and decided right then to seek greener pastures and put in his notice.
     He moved back to the Massachusetts Mental Health Center, a state hospital and psychiatric teaching institution associated with Harvard Medical School, where he'd received his psychiatric training and, before that, had spent a year as a mental health worker on a research ward for unmedicated schizophrenic patients. Here he discovered how easy it is for the best-intentioned therapist to inadvertently make traumatized patients worse. He was struck how some female patients fell apart during personal contacts with him and other male staff, becoming agitated and assaultive. Why would they so suddenly switch from being pleasant and sensible, to losing their minds when a man would pay attention to them? he wondered. Looking into the histories of the women, most of whom had been diagnosed as borderlines or schizophrenics, he found that they'd all been severely and chronically sexually abused as children and adults.
     Van der Kolk began to realize that, for these women, being in a room alone with a man who directed questions at them emotionally hurled them back into their traumas. He noted that their entire bodies responded as if they were being molested again -- heart pounding, muscles tensing -- they seemed, literally, to take leave of their senses -- unable to distinguish now from then. "It seemed that their traumatic memories, like those of Vietnam veterans, prevented them from being able to modulate their autonomic arousal," he observes. "Their physiological housekeeping systems had been messed up by trauma."
     It now seemed to him that chronic trauma explained a great deal about how borderline patients acquired their deep impairments, and why they were so hard for therapists to treat. "Borderlines have a terrible reputation because they often are simply impossible," says van der Kolk. "They cling to you and then hate you, and, either way, they won't leave you alone. But if you look at their behavior through their traumatic background, it makes perfect sense. If you've been raped and abused for years as a child and adult, your entire organism and personality has been organized around your trauma. If they have PTSD, the way they act is understandable -- they're not just people trying to make your life miserable, but people trying to survive."
     Van der Kolk's experience with borderlines reinforced his belief that talk therapy by itself, even in the context of a warm, supportive therapeutic encounter, wasn't enough to reverse the profound physical and emotional changes wrought in his patients by pervasive trauma. But he credits Hurricane Hugo with showing him see just how physical helplessness contributes to the development of serious post-traumatic symptoms, and making him wonder if physical movement might not contribute to healing. In 1989, directly after Hurricane Hugo had ravaged Puerto Rico, van der Kolk accompanied FEMA officials to lend his expertise to dealing with the traumatic aftermath of the devastating storm. "I arrived in the middle of this devastation, and what I saw were lots and lots of people working with each other, actively putting their lives back together -- carrying lumber, rebuilding houses and shops, cleaning up, repairing things."
     But the FEMA officials immediately told everybody to cease and desist until assorted bureaucracies could formally assess the damage, establish reimbursement formulas, and organize financial aid and loans. Everything came to a halt. "People were suddenly forced to sit still in the middle of their disaster and do nothing," van der Kolk remembers. "Very quickly, an enormous amount of violence broke out -- rioting, looting, assault. All this energy mobilized by the disaster, which had gone into a flurry of rebuilding and recovery activity, now was turned on everybody else. It was one of the first times I saw very vividly how important it is for people to overcome their sense of helplessness after a trauma by actively doing something. Preventing people from moving when something terrible happens, that's one of the things that makes trauma a trauma."
     Pondering this striking lesson, van der Kolk wondered if perhaps the most damaging aspect of trauma wasn't necessarily the awfulness of it, but the feeling of powerlessness in the face of it, the experience of being unable to escape or fight or have any impact on what was happening. "The brain is an action organ," he says, "and as it matures, it's increasingly characterized by the formation of patterns and schemas geared to promoting action. People are physically organized to respond to things that happen to them with actions that change the situation." But when people are traumatized, and can't do anything to stop it or reverse it or correct it, "they freeze, explode, or engage in irrelevant actions," he adds. Then, to tame their disorganized, chaotic physiological systems, they start drinking, taking drugs, and engaging in violence -- like the looting and assault that took place after Hurricane Hugo. If they can't reestablish their physical efficacy as a biological organism and recreate a sense of safety, they often develop PTSD.

The Monopoly of Talk
Van der Kolk was now sure that, just as the experience of physical helplessness was at the core of trauma, there was something about frustrated action to repair the situation that played a role in developing long-term PTSD. And he began to wonder if helping traumatized people engage in meaningful, physical action would allow them to recover from PTSD. His growing sense that the body, as much as the mind, might hold the key to recovering from trauma ran up against the sacrosanct tradition of the talking cure as the alpha and omega of all psychotherapy. It was about this virtual monopoly of mainstream therapy by institutionalized talk that van der Kolk was becoming increasingly skeptical.
     Talk is relevant -- even vitally important -- he says, for traumatized patients who don't yet really know what's happened to them, who were too young to understand what was happening, who weren't listened to or believed, or who still can't make sense of what happened. His own therapy is still "very talky," he adds. But, van der Kolk continues, "fundamentally, words can't integrate the disorganized sensations and action patterns that form the core imprint of the trauma." Treatment needs to integrate the sensations and actions that have become stuck, so that people can regain a sense of familiarity and efficacy in their "organism."
     Van der Kolk is also very tough on the old shibboleth of 'psychotherapy as restorative relationship.' Too often, he insists, trauma patients and therapists both move into a quasi-relationship because, that way, they can both evade the real pain of focusing on and dealing with the physical trauma imprints. "Clients may look for `relationship' in therapy because they can't stand what they feel in their own bodies -- as long as the therapist is with them, they can distract themselves from their inner experience. The `felt sense' has become a minefield, and clinging to others is one way of avoiding the intolerable sensations within," says van der Kolk. But what patients really need, he believes, is the "therapist's attuned attention to the moods, physical sensations, and physical impulses within. The therapist must be the patient's servant, helping him or her explore, befriend, and trust their inner felt experience." Relationship therapy can seem like a kind of ersatz friendship, but "it doesn't make you better friends with yourself."
     To underscore the shocking possibility that neither talk nor relationship may be necessary in trauma treatment, van der Kolk likes to tell the story of his training in Eye Movement Desensitization and Reprocessing (EMDR), an approach held in very low esteem by many of his research colleagues. Although he initially considered EMDR a fad, like est or transcendental meditation, he went for the training after seeing the dramatic effects it had on some of his own trauma patients. "They came back and told me how supportive our therapy relationship had been, but that EMDR had done more for them in a few sessions than therapy with me had done in four years," he recalls. Van der Kolk decided to go see for himself what this weird new thing was all about, and took the training.
     He didn't like the training at all: "It felt too packaged, too much like a Billy Graham revival-type thing." He was, however, amazed at what happened to him when he subjected himself to EMDR as part of the training. The Trauma Clinic he'd established at Massachusetts General Hospital in 1991 had recently been closed -- ostensibly for budgetary reasons, but most likely, he suspected, because of his high-profile advocacy of clergy-abuse victims, while his then department chair, a Jesuit priest, was serving as the principal advisor to Cardinal Law, who's since resigned after being accused of covering up incidents of pedophilia among more than one hundred priests in the Archdiocese of Boston. The sudden closing of the Trauma Clinic was the focus for his EMDR session. "During the session, I was fascinated by all the different images from my early childhood that made their way very rapidly through my consciousness, and which seemed somehow related to the loss of my clinic. It was like the kind of hynopompic experience you have when you first begin to wake in the morning, with ideas coming and going and being forgotten before you really wake up." Afterward, he felt as if "something had been processed and left behind," and his distress about the clinic's closing had significantly lessened.
     His own EMDR practice student during the training was another clinician, who refused to tell van der Kolk anything about what he wanted to work on, except that it was "some very tough stuff between me and my dad when I was little." Overtly hostile and uncommunicative throughout the session, the clinician kept saying that he didn't really want to share what he was upset about. As a result, van der Kolk was totally in the dark about what was going on inside the person he was trying to "help" with the EMDR. At the end of the session, the man looked relieved of much of his distress. "How was that?" van der Kolk asked. "I'd never refer a patient to you," the man barked at him. van der Kolk replied, "Oh, why is that?" The man replied, "I really hated the way you dropped your fingers at the end of each movement!" "But what about your original problem?" van der Kolk asked. "Oh, I feel I completely resolved the issue with my dad."
     This episode engaged van der Kolk's curiosity about the role of the therapeutic relationship. "This guy didn't trust me. We didn't have a warm relationship. I never knew anything about what was bothering him. Yet he seemed to have processed whatever it was he needed to take care of. It drove home to me the possibility that maybe people can do excellent therapeutic work, even if they don't like and trust you (as happens, of course, in many victims of interpersonal trauma), as long as the therapist knows how to help them "digest" the imprint of the trauma."

Bottom Up, Not Top Down
In 1994, van der Kolk published a paper called "The Body Keeps the Score," in which he reviewed the existing research about the neurobiological underpinnings of traumatic reactions. The paper described how trauma disrupts the stress-hormone system, plays havoc with the entire nervous system, and keeps people from processing and integrating trauma memories into conscious mental frameworks. Because of these complex physiological processes, van der Kolk explained in the paper, traumatic memories, in effect, stay "stuck" in the brain's nether regions -- the nonverbal, nonconscious. subcortical regions (amygdala, thalaunis. hippocampus, hypothalamus, and brain stem), where they're not accessible to the frontal lobes -- the understanding, thinking, reasoning parts of the brain. In short, he demonstrated with four-part scientific harmony that it was our bodies, not our much-vaunted minds that control how we respond to trauma, what we do and don't consciously remember, and whether we recover from it or live in thrall to it. "We're much less controlled by our conscious cognitive appraisal than our psychological theories give us credit for being," van der Kolk remarks dryly.
     For a densely written article on psychobiology, "The Body Keeps the Score" had a far-reaching impact that brought van der Kolk into much wider circles of therapists than his previous books had done. For this, he credits the article's catchy title. "If you want to write something that gets people's interest, give it a great title. People wanted to know what the hell that article was all about." The paper attracted the interest of Scott Rauch, director of the neuroimaging lab at Massachusetts General, who asked van der Kolk if he'd like to take a look inside the brains of some of his trauma patients -- something that would have been unthinkable before the '90s. The neuroimaging team scanned the brains of eight trauma-patient volunteers. The first scan was while they remembered neutral events in their lives, and the second scan was when they were exposed to scripted versions of their traumatic memories.
     During the scanning, the images actually showed dissociation happen in the brains of these PTSD patients. When they remembered a traumatic event, the left frontal cortex shut down -- particularly Broca's area, the center of speech. But areas of the right hemisphere associated with emotional states and autonomic arousal lit up, particularly the area around the amygdala, which might be called the "smoke detector" center of the brain. According to van der Kolk, what this suggested is that "when people relive their traumatic experiences, the frontal lobes become impaired and, as result, they have trouble thinking and speaking. They no longer are capable of communicating to either themselves or to others precisely what's going on."
     Other neuroimaging studies Van der Kolk has collaborated on since also showed that the executive functions of the brain become impaired when traumatized people try to access their trauma. "The imprint of trauma doesn't "sit" in the verbal, understanding part of the brain, but in much deeper regions -- amygdala, hippocampus, hypothalamus, brain stem -- which are only marginally affected by thinking and cognition. These studies showed that people process their trauma from the bottom up -- body to mind -- not top down." But if trauma is situated in these subcortical areas, "then to do effective therapy, we need to do things that change the way people regulate these core functions, which probably can't be done by words and language alone."
     So what could trauma therapists do to help people "regulate their core functions"? Perhaps because of its title, van der Kolk's article caught the immediate and excited attention of many body psychotherapists, who'd worked with trauma patients for years, but had generally been dismissed -- if noticed at all -- by the psychiatric establishment as New Age flakes. To them, "The Body Keeps the Score" was something like an unexpected benediction from on high. "For the first time, a traditional, mainstream psychiatrist and neurobiology researcher was legitimizing the importance of understanding the effects of psychological disturbance on the body," says Babette Rothschild, a private practitioner in Los Angeles and author of The Body Remembers: The Psychophysiology of Trauma and Trauma Treatment. "It was very exciting to have him confirm what many practitioners had believed for a long time -- that there's something called somatic memory."
     If the body people were entranced with van der Kolk, the feeling was mutual. As he looked out into the audience before delivering an address to them at this time, he remembers thinking, "How well put together these people all look compared to a typical audience of psychotherapists." But while they appreciated his presence and what it stood for -- his recognition that understanding the body was key to understanding the mind -- he seemed to think they had more to teach him than he had to teach them. "I gave my talk, and a bunch of the people there shook their heads and said, `this poor fellow -- he knows a little bit about the body, but he really doesn't understand it.' Several took pity on me and offered to teach me what I needed to learn."
     The body therapists made him see how much of the work of healing from trauma is, he says, "really about rearranging your relationship to your physical self. If you really want to help a traumatized person, you have to work with core physiological states and, then, the mind will start changing." He adds, "if clinicians can help people not become so aroused that they shut down physiologically, they'll be able to process the trauma themselves. Therapists must help people regulate their affective states. That's what we do. We do it so a person can find the strength to face her own inner horrors and begin to move and regain a life for herself."
     One body therapist whose work especially impressed van der Kolk was Peter Levine, the developer of an approach to trauma treatment called Somatic Experiencing. Trauma, argues Levine, is "`locked' in the body, and it's in the body that it must be accessed and healed." PTSD, he argues, is "fundamentally a highly activated, incomplete, biological response to threat, frozen in time." All animals, including humans, are physically programmed by evolution to flee, fight, or freeze in the face of grave threats to life and limb. But in humans, when these natural responses to danger are thwarted and people are helpless to prevent their own rape, or beating, or car accident, the unfinished defensive actions become blocked as undischarged energy in their nervous systems. They remain physiologically frozen in an "unfinished" state of high biological readiness to react to the traumatic event, even long after the event has passed. The undischarged energy of the blocked response to the trauma eventually metastasizes into the full-fledged panoply of PTSD symptoms. Levine believes that psychological trauma is very much about action interruptus, which the traumatized human organism still needs to complete.
     Levine believes that trauma victims, having been totally helpless and unable to move -- physically and psychologically -- must regain in therapy that lost capacity to move, to fight back, to live fully in their bodies as much as in their minds. Instead of curling up into scared little balls when threatened, these patients need to learn in the very cells of their bodies that they can stand up and kick butt.
Just how to help numbed and terrified trauma clients acquire a little more of the Rambo spirit is demonstrated in another video van der Kolk likes to show at workshops. It features a body therapist named Pat Ogden, originator of a treatment method called Sensorimotor Psychotherapy. In it, the client -- a young woman sexually abused as a child -- says very faintly early in the session, "I'm not feeling my body" and "I'm just about gone," indicating that the memory of the abuse causes her to shut herself down -- go numb, blank, and frozen -- in order not to feel anything. "At this point," comments van der Kolk, "she's basically not there. The moment you're not feeling your body, you're gone, because the body really is the engine of aliveness, of thought. As long as people don't feel their bodies, we're wasting our time and theirs trying to do talking psychotherapy." With great emphasis, he adds, "Becoming comfortable in their bodies is, for our patients, the number one, paramount issue, and if we can't help them do that, then we can't help them at all."
     In the video, Ogden tracks the woman's growing physical discomfort in the early stages of the session, helping her to focus on her feelings, rather than flee them. Says van der Kolk, "Asking her, `Where do you feel that? How does that feel? What happens in your body when you say this?' helps her stay grounded in her body and in touch with a core part of herself; it allows her to keep her wits about her."
     Later in the session, when she's standing, the woman says she feels "mushy" in her midsection, defenseless- "like, if you do anything to me I don't want, I wouldn't have the right to stop you." Gradually, without getting into the content of her trauma at all, Ogden helps the woman "fight back"
first by letting her fulfill an urge she has to push by having her push hard against her (Ogden's) shoulder. The woman looks more alive, stronger. When Ogden asks her what's happened, her hands come together in fists and this woman, who earlier said she didn't even have the right to stop someone from hurting her, now begins to release some pent-up fury: "I want to say to you that if you fuck with me, I'll kill you!" she almost hisses at an invisible attacker. Ogden encourages her to engage in a kind of mock combat -- both of her hands pushing both of Ogden's hands, while Ogden braces herself on the floor. It's, in its way, a real struggle, with both women really getting into it, pushing and grunting and ending with both out of breath.
     The effects are remarkable. The client, who's been almost palpably rigid and shrunken into herself, now is laughing, at ease, confident, even exultant. "I feel totally energized and strong," she says breathlessly. "That was really good!" A week later, she returns -- a different woman -- alive, open-faced, smiling. "I feel great," she says, telling Ogden that she's bought some new clothes and gone to a party. "Every day, I see a brighter face in the mirror." As for the trauma, she half shrugs and says, "What was done was done."
     Van der Kolk emphasizes that at no point during this session does Ogden ask the woman to describe what happend to her. "Her problem isn't that she hasn't told the story, but that her body continues to collapse in the face of reminders of her trauma. Pat helps her stay embodied, so that she doesn't lose control of herself. "Once you can do what you couldn't do during the trauma," adds van der Kolk, "once you can take the action you need to protect yourself, and once you're able to recenter and refocus yourself on a deep, organismic basis, you'll move on. The trauma is no longer interesting."

A Huge Debate
While some of the mainstream trauma field's leaders are intrigued by the potential in this treatment, many prominent figures are dismissive, when not positively horrified. In fact, the only issue that's generated as much heat in the trauma community has been the recovered-memory debate. Van der Kolk now finds himself in the thick of a battle that, once again, pits people of passionate convictions, high-minded purpose, and not a little professional ambition against each other.
     This particular clash over the place of body psychotherapy in trauma treatment exploded at the 2000 World Congress meeting of the International Society for Traumatic Stress Studies in Melbourne, Australia. Van der Kolk himself inadvertently lit the fuse when he was asked to chair a plenary session on body psychotherapy, which featured the work and videos of several somatic therapists. One video (which van der Kolk hadn't seen) showed a practitioner sitting astride a rape victim. Although van der Kolk later repudiated this particular work, saying it exhibited serious boundary violations, the film caused an uproar. "It had a remarkable fallout," says Australian psychology professor and trauma specialist Richard Bryant. "Nearly all the major players in the trauma field were appalled by the fact that he'd used a leading trauma meeting to demonstrate a therapy like this, which was both ethically marginal and had no empirical support whatsoever. A huge debate emerged about the role of evidence in science versus the belief of many therapists that if they `know' something works, they don't have to wait for the science to prove them right."
     The "huge debate" continues to churn on. While this particular skirmish involves somatic therapy, the overall conflict is an old one, which basically reflects the division between two subcultures in the profession -- practitioners and scientists. This is certainly not a "pure" division (clinicians do research; researchers do clinical work), but the world views of each differ substantially. Clinicians are immersed in the messy reality of daily clinical practice with multiply-diagnosed patients, and are often glad to try out innovations on the say-so of colleagues and on their own personal experiences that almost none would care to subject to a controlled, double-blind study. To researchers, "innovative" is often just another term for "outlandish." From their perspective, the only safe and dependable treatments are those that have been empirically proven in carefully controlled studies with homogeneous populations, that are easily put in the form of a "treatment protocol." These differences lead to "enormous tension" between practitioners and scientists, says Bryant, a tension he believes therapists tend to use to their own advantage when they accuse scientists, as the, regularly do, of being more interested in their dry paradigms than in real-life patients. "Therapists often put forward the view that the process of validating new treatments is too difficult and takes too long, in the meantime depriving suffering patients of treatment they know from experience works, just because scientists want them to do randomized trials. But, we researchers would argue the opposite -- that because we're treating people who are in such pain, we have an ethical responsibility to make sure we aren't making them worse."
     Edna Foa, one of the foremost authorities on prolonged-exposure therapy -- in which traumatized patients repeatedly recount their trauma until it loses its disturbing power -- is also not enchanted by van der Kolk's expedition into somatic therapy. Indeed, she suggests that the whole clinical practice of psychotherapy needs to be renovated along more scientific lines. "I think we've come to the point in the scientific research of therapy that clinicians shouldn't be allowed to practice and disseminate treatments without solid evidence that they work. Doctors can lose their licenses if they use unproven treatments. Why shouldn't we be the same way? Why allow practitioners to go wild with unvalidated therapies that may not help and can even make people worse?" Van der Kolk counters that scientific funding organizations virtually never support research in unproven treatments, thus promoting an Orwellian cycle of only advancing the exploration and practice of what is already known and closing the door on true exploration. In essence, such strictures would not only eliminate the practical insights and experience of therapists who actually see the real-life complexity of human suffering, but would put the kibosh on any original and potentially useful ideas emerging from clinical practice.
     Living both in the laboratory and in the clinical office, van der Kolk has first-hand experience with the different paradigms that rule these worlds: Laboratory researchers pose a particular question they want answered, choose the subjects and methodology that will provide the best test of that question, and ruthlessly screen out any confounding variables. But "confounding variables" are the stuff of ordinary therapy. "As a clinician, you always have to listen to what your patients are bringing in, listen to what they're telling you that doesn't necessarily fit DSM categories," van der Kolk says. "It's the raw data of daily clinical practice and the variations in clinical experience that generate new research protocols."
     More than just about any other field, the town-gown split between scientists and practitioners in psychotherapy reflects sharp differences in fundamental ways of taking in the world. "Skepticism is the core of scientific enquiry," says trauma expert Alexander McFarlane of the University of Adelaide. "Science is based on statistical comparisons between groups -- it's not a science of the individual subject. And it's supposed to be critical -- scientists make their money out of criticizing ideas. Therapy, on the other hand, happens in the realm of the individual stories people tell, and the variety of ways they do it." The therapeutic endeavor is built on a framework of reasonable trust and belief in what the patient says, not criticism. "You can't treat patients if you don't believe in what you're treating," says McFarlane. In a moment of candor not calculated to endear him to his researcher colleagues, van der Kolk says simply, "It's an issue of temperament: Therapists seem to enjoy living with the uncertainty, unpredictability, and complexity that comes with the intimacy of the relationship, whereas most laboratory scientists are most committed to establishing `facts,' which, by virtue of the dictates of the scientific method, can only encompass a small slice of the total complexity of human beings."
     But van der Kolk is nothing less than an equal-opportunity provocateur. He seems determined to make clinicians fundamentally reconsider their usual responses to the suffering souls who visit their offices, down to the furnishings they choose. With his characteristic wryness, he insists that "As long as people sit on their tochas and simply move their tongues around, they may not be able to make enough of a difference to affect internal sensations and motor actions. People need to learn to regulate their physical states in order to get their minds to work. Once they shift their physiological patterns, their thinking can change."
     It's been an implicit premise of psychological science and clinical practice both, as it is of our entire culture, that our singular human identity resides in our disembodied minds. The West's infatuation with Cartesian dualism has made our bodies somehow strange to us, a self-alienation reinforced by clinical psychology. It's hard even to conceive of the lofty mind -- our own, anyway -- as an indisputably physical, material organ, a wrinkled, ovoid mass of blood and tissue. PTSD -- or any deeply painful emotional state -- is experienced as a foreign intrusion that smothers our "true self," our mind's self. Most of psychotherapy is geared to getting this mind-self back, and most of it is conducted as a mental exchange between two people sitting quietly in chairs. Even psychopharmacology seems intended more to quell the rebellious body -- quiet and soothe it, get it out of the way and under wraps than acknowledge and welcome its living presence in the therapy room.
     For all the ferment he's helped create, van der Kolk admits that he doesn't have any easy answers about how to unravel the tangled web of trauma, much less reconcile our culturally enshrined mind-body split. During a presentation last year, he confessed his discomfort to several hundred therapists. "I always wonder how I can continue to do workshops like this and ask you to sit on your rear ends all day listening to me talk, knowing that people really only learn when they move and act," he says. "I feel increasingly bothered by the real contradiction between what I practice and what I preach." With his penchant for stirring things up and raising questions that can't be ignored, it's a safe bet that as long as van der Kolk feels uncomfortable with therapy's conventional wisdom, the rest of us will, too.