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Hollywood has had a long-standing love affair with psychiatry and its portrayals of electroconvulsive therapy reflect and influence public attitudes toward the treatment. One-third of medical students decreased their support for the treatment after being shown ECT scenes from movies, and the proportion of students who would dissuade a family member or friend from having ECT rose from less than 10% prior to viewing to almost 25% afterward. So what is the legacy of portrayals that have been so abhorrent, and are there any exceptions to the rule?
Hollywood has had a long-standing love affair with psychiatry (Gabbard and Gabbard, 1999; Schneider, 1987, 1977). Dating from the first psychiatric film, Dr. Dippy's Sanitarium (1906), almost 500 movies dealing with the specialty have been made. While the film industry has demonstrated a particular fascination for depicting psychotherapy, physical treatments including electroconvulsive therapy have also been featured (McDonald and Walter, 2001; Walter, 1998). Indeed, some of the major psychiatric films--The Snake Pit (1948), One Flew Over the Cuckoo's Nest (1975), Frances (1982) and Shine (1996)--have prominent convulsive therapy scenes. (See the Table for a selected chronology of films depicting ECT.)
Portrayals of ECT reflect and influence public attitudes toward the treatment. For example, in a survey of lay attitudes toward convulsive therapy, the majority of respondents who had seen One Flew Over the Cuckoo's Nest were "put off ECT" by the film (O'Shea and McGennis, 1983). In another study, one-third of medical students decreased their support for the treatment after being shown ECT scenes from movies, and the proportion of students who would dissuade a family member or friend from having ECT rose from less than 10% prior to viewing to almost 25% afterward (Walter et al., 2002). So what is the legacy of portrayals that have been so abhorrent, and are there any exceptions to the rule?
Electroconvulsive therapy made its film debut in 1948 in Anatole Litvak's Academy Award-winning The Snake Pit, a movie set at Juniper Hill State Hospital. The film follows the path to recovery of Virginia Cunningham (Olivia de Havilland), a young writer who develops a psychosis shortly after marriage. Taken to the ECT room for treatment, a perplexed Virginia sees the previous patient being wheeled out, mouth guard still protruding. Fully conscious, Virginia asks before receiving the treatment, "Why are you electrocuting me?" Trumpets and flutes loudly announce the delivery of the electrical current. After three further treatments, mild improvement is noted and Virginia's psychiatrist terminates the course, much to the annoyance of the officious head nurse. Psychotherapy could then begin.
The second celluloid appearance is in Fear Strikes Out (1957), a recounting of the true story of Jim Piersall, a baseball player who suffered a catatonic breakdown shortly after joining the Boston Red Sox. Soon after his admission to hospital, the psychiatrist seeks consent for "electroshock" from Jim's wife. "I can't promise anything, and I won't minimize the risk," he declares, without elaborating upon the latter. After several treatments, Jim emerges from catatonia and can engage in psychotherapy. Electroconvulsive therapy was again a helpful adjunct to the psychotherapist's treatment.
After such a promising start, ECT is progressively depicted more negatively. In Shock Corridor (1963), a reporter becomes psychotic and receives convulsive therapy. The portrayed treatment is barbaric. The reporter is strapped to a table with leather bands on his arms and legs, as a rolled-up bandage wad is shoved into his mouth. His recovery is short-lived and, by the movie's end, he is frozen and mute.
Subsequent films during the heyday of the antipsychiatry movement portrayed ECT as an agent of social control, a protector of the status quo, a weapon against individual freedom. In A Woman Under the Influence (1974), Mabel, the overburdened matriarch of a wild young family, cannot cope with her unruly children and her frenzied husband; she has a "nervous breakdown" and is taken to a psychiatric hospital. The underlying theme is that the real problem is the family (society), and her reaction is entirely appropriate. When she returns home, Mabel announces that she received shock treatment every day in hospital. Nothing has changed and, shortly afterward, she attempts to cut her wrists.
The quintessential antipsychiatry movie is One Flew Over the Cuckoo's Nest (1975), in which the misguided and malevolent role of psychiatry is explicitly made. The movie follows the fate of Randle Patrick McMurphy (Jack Nicholson) as the renegade individualist clashing with society. McMurphy, a small-time criminal feigning psychiatric illness to dodge jail, is sent for an inpatient assessment. He becomes locked in a battle of wills with the staff, who soon call on ever stronger weapons: first medicines, then ECT seizures and finally bilateral frontal lobotomy. Near the beginning of the film, McMurphy stimulates a patient revolt on the ward. After a scuffle with the staff, he and two others are led to the ECT suite. We see the first patient being dragged into the room kicking and screaming, soon emerging unconscious on a trolley. McMurphy is led into the suite in restraints. He is met by three wardsmen, a nurse and a doctor, who smilingly declares, "This won't hurt a bit and it will be over in just a minute." His forehead is swabbed, a mouth guard inserted, a pincer set of electrodes is placed on his temples and, as he lies fully conscious, a switch is flicked on the ECT machine. McMurphy immediately begins a clonic seizure as the camera zooms in on his face, full of tension and pain. Unlike the frenzied musical accompaniment of previous ECT scenes, the only sounds are his laboured grunts and heavy breathing. When the seizure ends, the scene cuts to a group therapy session in the old ward, presided over by the manipulative Nurse Ratched (Louise Fletcher). McMurphy stumbles in like a zombie, much to the distress of the other patients, but he winks at one of them and we are soon aware that he is faking it. He suddenly bursts into life and teases his gullible mates, memorably declaring, "Perfect. They was giving me 10,000 watts a day, you know, and I'm hot to trot. Next woman takes me on's gonna light up like a pinball machine and pay off in silver dollars." Electroconvulsive therapy is presented as a barbaric and unjustified tool for social control, but also as impotent and ineffective.
Electroconvulsive therapy is misused in Frances (1982), a movie based on the life of free-spirited actress Frances Farmer (Jessica Lange). Her defiant and unconventional behavior lands her in a county hospital, where she is given ECT. We witness Farmer struggling in a straitjacket, being dragged down a corridor to the ECT suite. Soon after, Farmer is at the review tribunal declaring her recovery and decision to return to Hollywood. The chief psychiatrist proclaims, "I think this case demonstrates just how successfully antisocial behavior can be modified ... a significant victory for the mental hygiene program here in the state of Washington." Alas, Farmer's hygiene lapses, she ends up having the new "icepick lobotomy" and, by the film's end, she has been drained of all vivacity. She is an emotionless, socially compliant being. We are left to conclude that there was nothing ever wrong with her, and whatever problems existed were those of her mother and a society that insisted on conformity. Psychiatry had conspired with the establishment to crush this carefree spirit, and ECT had been used as weapon of social control.
Ordinary People (1980), portraying a compassionate, personable and ever-available psychiatrist, is sometimes championed as one of the motion picture industry's more sympathetic representations of psychiatry. Yet even in this movie, ECT is devalued. On being reminded that young Conrad (Timothy Hutton) had ECT, Conrad's swim coach berates him, "You know, Conrad, I'm no doctor, but I would never've let them put electricity through my head." It is only when Conrad's case is taken on by an understanding therapist who absolves him of his guilt that he can be cured.
Death Wish II (1982) takes the stand that psychiatry is ineffectual and insufficiently punitive. The film follows the revenge odyssey of an average American tough guy, Paul Kersey (Charles Bronson), whose daughter is kidnapped and raped by idle bad guys. Kersey tracks down one of the killers, who has evaded prison and has been remanded to a state hospital after convincing authorities that the crime occurred while he was under the influence of the hallucinogen PCP (phencyclidine). Kersey smuggles himself into the hospital disguised in a white coat, sporting a fake name badge and carrying a clipboard. He is led to a room containing what looks like a mainframe computer. He asks the aide what it is and is told it is the shock therapy equipment. The aide adds, "Since you guys turned up, we don't use it. It's all done with kindness now, isn't that right, Doctor?" His prey is led into the room and immediately recognizes Kersey. A bout of fisticuffs ensues, and with a misdirected right hook, the villain finds himself stuck in the shock therapy equipment. Quick-thinking Kersey sees his chance and throws a large switch on the machine. Sparks fly, and the villain mortally convulses as the machine makes a grinding, whirring sound. The villain drops dead--the first ECT fatality in cinema--as the machine is switched to standby. Kersey's use of the machinery is clearly unorthodox, but apparently condoned by the filmmaker.
Recent slapstick comedies also depict or refer to ECT. The treatment that had been portrayed with horror and social outrage now has become a cheap source of laughs. In The Beverly Hillbillies (1993), feisty and feral Granny is wrongly institutionalized for strange behaviors including eating raccoon. She is examined by an unconventional psychiatrist who declares her to be a perfect candidate for electroshock therapy. She is eventually rescued, but not before receiving electroshock treatment. After the treatment, we see her standing dazed in a straitjacket, muttering unintelligibly, her hair standing on end, sparks flying from her head. A quick sip of her home-brewed elixir restores her strength and sanity, allowing her to escape.
The horror potential of ECT is rejuvenated in House on Haunted Hill (1999). Set in a refurbished psychiatric hospital supposedly abandoned seven years before the Italians actually performed the first ECT in 1938, it is equipped with no less than 18 ECT suites! It is possessed by the spirits of its many victims, who manage to lure the descendants of five former staff members to a party. By the end of a night of horror, three are dead. Early in the film, a ruthless couple fabricate a murder using high-voltage electricity in one of the ECT suites. The scene opens with a woman convulsing wildly, apparently conscious, strapped to a table with ECT leads attached. All attempts to kill the power are futile and she convulses for 30 seconds. Eventually, the master switch is pulled, and she comes to rest, blood gushing from her mouth. She is pronounced dead by her accomplice lover, an unscrupulous doctor.
The portrayal of insulin coma treatment in A Beautiful Mind (2001), culminating in a violent seizure of the Nobel Prize-winning mathematician John Nash (Russell Crowe), confuses insulin coma therapy and ECT. So distressing was the seizure for Nash's wife, who is shown observing the treatment, that she tearfully turns away and asks the treating psychiatrist, "How often?" He replies, "Five times a week for 10 weeks." Clearly, even one treatment was one too many.
The portrayals of ECT in non-American films are also glum. In An Angel at My Table (1990), a New Zealand film about the novelist Janet Frame, Frame screams during the treatment. In the next scene, sitting alone in the laundry, she sounds defeated as she tells us, "Over the next eight years, I received 200 applications of electric shock treatment, each one equivalent in fear to an execution." More subtle in its criticism of ECT is the Academy Award-winning movie Shine (1996), a film about the pianist David Helfgott. While he is in the ECT suite, a phone is heard ringing. In the next scene, the phone is still ringing. David's father answers it but puts the receiver down after David identifies himself. The meaning is clear--David's plea to be rescued from the fate of having ECT has fallen on deaf ears.
How true-to-life is the practice of ECT in film? In every domain that we examine--diagnostic indications, consent, administration, outcome and side effects--ECT is not portrayed with authenticity. It is most commonly prescribed to overcome antisocial behavior rather than as a treatment for depression or psychosis. Despite the routine use of anesthesia since the 1950s, the films show patients fully awake and in terror. The most frequent outcomes are the change to a mute and confused zombie state or the treatment has no effect (clearly at odds with clinical experience). The electrotherapist is depicted as cruel, the embodiment of evil, in contrast to more avuncular presentations of the psychotherapist, for example in Ordinary People.
Despite a promising start, the portrayal of ECT in film has been deplorable and with little resemblance to modern practice. The audience is left with the impression of a brutal, harmful and abusive treatment with no therapeutic benefit. It encourages stigmatization and discourages patients from its use. Proponents of ECT will need to rely on tools other than movie portrayal to convince those with mental illness about the merits of this treatment.
References 1. Gabbard GO, Gabbard K (1999), Psychiatry and the Cinema, 2nd ed. Washington, D.C.: American Psychiatric Press.
2. McDonald A, Walter G (2001), The portrayal of ECT in American movies. J ECT 17(4):264-274.
3. O'Shea B, McGennis A (1983), ECT: lay attitudes and experiences--a pilot study. Ir Med J 76(1):40-43.
4. Schneider I (1977), Images of the mind: psychiatry in the commercial film. Am J Psychiatry 134(6):613-620.
5. Schneider I (1987), The theory and practice of movie psychiatry. Am J Psychiatry 144(8):996-1002.
6. Walter G (1998), Portrayal of ECT in movies from Australia and New Zealand. J ECT 14:56-60.
7. Walter G, McDonald A, Rey JM, Rosen A (2002), Medical student knowledge and attitudes regarding ECT prior to and after viewing ECT scenes from movies. J ECT 18(1):43-46 [see comment].