Pushbutton Psychiatry: A History of Electroshock in America (review)

In Pushbutton Psychiatry, Timothy Kneeland and Carol Warren set out to "explore the relationship between electricity and psychiatry from the eighteenth to the late twentieth century in America, against the background of ancient and modern electrotherapeutics." In particular, they are interested in the "intersection of electricity and the body with gender hierarchies" (p. vii). It is an ambitious task they have set themselves, but also an overwhelming task to tackle in 135 pages. The result is a book that makes many insightful, almost tantalizing, observations but does not follow them up with the sustained analysis they deserve.

For instance, in the last two chapters the authors argue that there is a connection between changing systems of payment for psychiatric treatment and the revival of electroshock, or electroconvulsive therapy (ECT), within private (but not public) institutions. It appears that ECT became an appealing treatment to HMOs because it is cheaper for them than paying for a multiyear course of antidepressant drugs, and it became appealing to psychiatrists because a psychiatrist/physician must be present—and therefore paid—for every ECT treatment. This intriguing hypothesis is not explored in detail, however, nor are potentially contradictory facts reconciled with it, such as the higher malpractice premiums for psychiatrists that use ECT. In the end, the reader is left interested but unconvinced.

Much the same can be said for the authors' repeated efforts to link ECT to the patriarchal values of the West in general and of psychiatry in particular. The authors quite rightly point out that while the ailments that ECT has been used to treat have changed over time, the type of patient has not: the typical person receiving ECT today, just as in the 1950s, is a middle- to upper-class woman. Clearly, something about ECT is strongly gendered. But what? And why? Today, ECT is primarily used as a treatment for depression, which is most commonly diagnosed among middle- to upper-class women. Is the gender bias in the diagnosis, then, or in the selection of the mode of treatment? Is the relationship even more complex, with the gendering of ECT affecting how psychiatrists think about their female versus their male patients? Or is this a case of spurious correlation, with some unknown third variable explaining the higher (but not exclusive) use of ECT in treating women?

The first two chapters and parts of the last three chapters argue that the career of ECT has been shaped primarily by cultural factors, such as a widespread fascination with electricity, the deep-seated patriarchal values of American society, and a broad reaction against the institutionalization of the mentally ill in the wake of popular exposés, such as One Flew over the Cuckoo's Nest. The last three chapters, however, are mainly structured around the ongoing debates between "somatikers" and "psychikers." The argument here is that ECT appealed to those who saw a physical basis for mental illness (somatikers), even though they never have been able to agree on why ECT works. Those who believed in the psychological origins of mental illness (psychikers), on the other hand, have been wary of ECT, seeing it as unnecessarily dangerous. As the fortunes of the somatikers rise and fall, so too does the popularity of ECT. One interesting result of this dynamic is that a revival in the use of ECT accompanied the development of new drugs for treating mental illness in the 1980s and 1990s. Even though some of those drugs provide alternatives to ECT, the success of drug therapy bolstered the somatic view, thus restoring ECT's popularity.

The authors' arguments are set out in language that is usually clear, direct, and jargon-free, but the book often reads as though an overzealous editor had cut out every other sentence...