Confessions of an Ambivalent Psychiatrist
Susan Mahler, MS, MD, is a writer and psychiatrist who practices in North Adams, MA. Her work has appeared in STAT, The American Scholar, and other publications.
“She told our class that there were really only two reasons to write: desperation and revenge.”
Darryl Pinckney, “My Literary Education with Elizabeth Hardwick,” The New Yorker
After 25 years as a psychiatrist, I find myself in the throes of what might be a professionally fatal identity crisis.
I’ve been seeing a patient, I’ll call him Daniel. Daniel has battled depression for decades and found that periodically his meds stop working. For over a year, we’ve been trying things with no success; he’s exhausted, I’m exhausted. Recently I told a group of colleagues in a Zoom meeting that I was considering a referral for ECT—Electroconvulsive Therapy.
“Of course!” My peers gushed, almost in unison, their concerned faces brightening. It’s very safe now. Standard of care. Extremely effective. Of course, I learned this in Residency. Of course, I’ve referred people for ECT. At least a few times. Why am I so ambivalent now?
Per the American Psychiatric Association:
“Like any medical procedure, ECT has some risks… Some people have trouble remembering events that occurred in the weeks before the treatment or earlier. In most cases, memory problems improve within a couple of months. Some patients may experience longer lasting problems, including permanent gaps in memory.”
So, for example, you might forget that you had fish for supper the night before your treatment. You might not recall a conversation with your spouse the next day. You might even find that a memory of a trip to Portugal was completely erased. Disturbing, this last, but still reassuringly acceptable, given that you’ve been hideously depressed and now have decent odds of feeling better.
Except that I am not reassured.
I became depressed in medical school. I had been a rock-climber, and the crash felt like a long rappel, with no belay. Like Daniel, I could not manage to stay well, no matter how many medications or therapists I tried. By the time I transitioned into practice, I had plenty of experience juggling the dual identities of doctor and patient.
I knew that I could not use myself as a guide when prescribing medication, though it was of course tempting to prescribe the few drugs that had helped me. Lithium always provided me a lift after three days, even though the research says nothing works that quickly. Naturally, I always counsel patients that nothing works that quickly—while sometimes softly observing that occasionally, something does.
The first time I took lithium was in the spring of my first year of psychiatry residency. A bitter, aptly-metallic-tasting white pill, unimpressive, like all the others. Shortly after starting it, my class met for a retreat in Jamaica Plain, outside of Boston. All day, I had felt alienated, inferior and hopeless. As evening set in, people made plans to go for dinner—I declined. I was trudging wearily down the sidewalk to my car when something made me stop abruptly, look up at the late afternoon sky. That hyacinth canvas was neatly split with streaks of rose and tangerine, adorning it like ribbon candy. The shock of beauty. Suddenly, I wanted company. I turned around and raced back to where my friends were lingering.
Score one point for psychiatric medication.
But lithium eventually stopped working; I would take a break, try it again. Each time, the glory of equanimity, but for shorter and shorter periods of time, until there was no space, at all.
I’ve prescribed SSRIs, of course, although they never worked for me. I’ve prescribed antipsychotics, even though these eventually caused me to develop tardive dyskinesia, an often-permanent movement disorder associated with long-term use of these drugs. This fortunately disappeared after I got off psychiatric meds entirely.
I still prescribed them. I didn’t see many of my patients developing TD; in fact, outside of hospitals, I wasn’t seeing it at all. But I knew it could happen. I remember the grimace on my face captured in a photo at a family reunion, as though I were looking in a fun-house mirror, the tongue thrusting with exertion on the elliptical. I get a shiver of disgust now, thinking about it. And I still prescribed them.
But it wasn’t the meds, really. After all, the TD had gone away. They didn’t shatter my patient-doctor amalgam.
Composite metals such as steel or brass are many times stronger than elemental metals, yet less flexible. The atoms in pure substances, like gold, are so neatly packed that they glide easily over one another; they lend themselves to malleability and art. We rely on steel, not gold, to hold up our buildings, but creativity resides in substances that give. As a composite—both patient and doctor—I thought of my identity as elemental, responsive, but also sturdy.
Why, now, do I find myself neither sturdy nor flexible?
“This is only oxygen.” So says the nurse who places a mask over my mouth and nose.
I had ECT for the first time in 2001, toward the end of my last year of residency. I was 35, a bit old to still be in training. My previous career had been in journalism. The decision to apply to medical school had taken every amount of self-salesmanship I possessed. But medicine was the family business, and, in the end, would not be denied. I made a bargain with myself to keep writing, though. I published a couple of essays. I even started a low-residency MFA program, and fell in with a brilliant group of writers.
We gathered on Thursday evenings, late, in a purple house in Somerville. A shopping cart sat in the living room, I have no idea why. We talked, ate chocolate, and read our work. L had written an award-winning breakout book. P combined the sounds of words in ways that were shockingly, thrillingly unexpected. I used to close my eyes when they read, as though I was listening to a symphony. Language had always had the quality of music for me, more so than most music.
It is confusing for me to recall that, at a time when I’d been gaining ground with my writing, I should have remained so depressed. Perhaps I need not have. That writers’ group was like a low-hanging branch, fortuitously slung across the raging river of my despair. I might have grabbed on.
I was referred for ECT at a medical center in Boston. I was, in fact, hideously depressed. I dreamed that my toes were black, gangrenous. Speech was difficult; the flesh in my face felt sunken, stretched over something cadaverous. “There’s no energy in my face,” I would tell doctors. They looked at me quizzically.
At the time I was referred, I was, despite the benign information I’d swallowed during my training, terrified of ECT. It still seemed barbaric, a relic of psychiatry’s morbid past, along with lobotomies and insulin shock treatments. I worried about the impact of applying such a blunt instrument as an electrode to such a sensitive piece of equipment as the human brain.
ECT clinics are busy places. I recall walking in that spring day, to see blue-garbed nurses moving swiftly about. The psychiatrist, Dr. B., was a tall man with a mist of gray in his hair, nattily dressed in a pin-stripe suit and yellow tie. As I sat hunched on plastic chair and hugged the ragged edges of a johnnie, he calmly explained the procedure.
Unilateral ECT involves the application of 70-120 volts of electrical current, for up to 6 seconds, to the non-dominant cerebral hemisphere, inducing a controlled seizure. He told me ECT might “reset” my brain, an inexact phrase that did not inspire confidence.
Suddenly, gone was the marigold tie, obscured by the mask and sea of blue-scrubbed nurses. My cot had become the center of a hive of activity.
Anesthesia is unlike sleep; the light does not fade, unconsciousness does not accrue slowly but rather descends in a rush, like the snap of a shutter at high speed. There is no pre-figuring pause, no drifting lofty weightlessness, no measured distension of unreality to denote the passage from wakefulness to slumber. There is before—click—and there is after.
I awoke to a battery of questions: Where are you? What’s your name? What’s the date? The answers came readily, but I knew not from where. It was as though that click of a shutter had spliced the narrative of my life, and a blank frame had been inserted. I reached for clothes I only vaguely recognized.
The usual course of ECT is 8-10 treatments. That spring, I stopped after three. I felt better, but there was also the fact that I could not seem to comply with the “rules”: one is not supposed to drive, work, or stay alone. A friend of mine observed that I was breaking all the rules on a pretty much daily basis—a fact to which my supervisor at work had just been alerted. And, not insignificantly, there was the odd sense of disconnection from my life, which persisted between treatments.
When I felt well, in those days, I wrote. Sentences and paragraphs crowded into my brain; the necessity to catheterize them being often quite inconvenient. I scribbled notes in class, bolted home to capture a page which had materialized during a run.
I wrote an essay, several months after my last ECT treatment, which was published in a literary journal, The Threepenny Review. I strove to capture the dimensions of memory with which I had recently become acquainted:
“Memory, I know, is a non-unitary concept. There are memories that are explicit, that can be produced and formulated, verbally expressed, set down neatly in ink in a honeycomb of black-and-white squares. This we call declarative memory. There is the body’s memory, instinct, the intuitive flash which enables us to perch atop a bicycle, skitter across a keyboard, engage the clutch, shift gears. This is named procedural memory. And then, subtler still, there are the undercurrents, the consciousless implicit threads, the fleeting construction of self that eludes neuroanatomical localization but rather floats free and wireless, synapse to synapse, axon to axon, shifting yet unitary, like a glass of water heated to evaporation and then condensed, molecules re-convened, reconstituted, flawlessly and inexplicably restored to an integrated whole.”
I always liked that last line.
Upon receiving my essay, the editor of the Review called me and left a message on my answering machine (quaint, I know). I still recall her exact words: “My husband says it’s going to win prizes, and he NEVER says that.” I’d sent the essay simultaneously to The American Scholar, which also accepted it. Apologetically, I gave the Scholar another essay I’d written about depression, and they acquiesced because it worked well with Sherwin Nuland’s piece in that issue. My essay cheek-to-cheek with Sherwin Nuland’s!
I saved that voice message, possibly for the life of the answering machine.
Within six months, my mood was faltering again.
I had by this time completed my training and had taken a job at McLean Hospital, on the Trauma Unit. By spring, things were bad enough that I was encouraged to return for another round of ECT.
This time, there was no lift. I experienced the sense of displacement, of being a stranger in my own life. I went again, and again, and again. Nine, ten treatments.
They said I needed to have a bilateral treatment. Current would be applied to both hemispheres of the brain.
The brain, of course, is not uniform and has areas of specialized function. Unilateral treatments are applied to the non-dominant hemisphere, avoiding the primary language centers. If the brain refuses to comply, the profession responds with a firmer and more resolute hand.
I do not recall waking up from that treatment. I must have answered “the questions,” or they would not have released me. Since I lived alone and was of course still breaking rules, I must have driven myself around. I showed up at my psychiatrist’s office; he thought something was off and sent me to the ER. They sent me home.
Procedural memory is powerful stuff. We drive preoccupied, but automatically stop at a red light. In old age, we remember how to play a song on the piano we learned as a child. A few years ago, a video of a former ballerina went viral. Now severely demented, wheelchair-bound, upon listening to a recording of Swan Lake, the woman moved her arms and upper body with the precise, exquisite motions of a professional dancer. Deeply engrained procedural memory is extraordinary. But is it this extraordinary?
How is it possible to navigate the streets of Boston, return home, place the key in the lock, fetch food, go to bed, get up, shower, get dressed, all without consciousness, without awareness? Or are those two different things?
The second time I showed up at my psychiatrist’s office, he again sent me to the hospital; this time, they admitted me, to the very same hospital where I’d received ECT. I “came to” after three days. I was holding a book in my hands but recall not being able to read it.
I remember nothing after the placement of the oxygen mask until the moment I opened a book in a locked unit three days later. The sequence of events was related to me by my psychiatrist.
It was a deemed a delirium.
And yet, I must have at least appeared not to be confused or unaware. I was driving, I was conversing. I was never pulled over by a police officer, I arrived at the right house, the right doctor’s office. I was not naked or disheveled.
I was still depressed, but since more ECT did not seem to be a good idea, I went back to work. I was asked to interview a new patient and found I could not recall the parts of a psychiatric interview, a rubric that had been imprinted in my brain for years (longer than had the geographical layout of Boston).
On the third day, my boss took me aside and told me she had to let me go. I’d written for a dose of Ritalin that didn’t exist.
I think it had not hit me until then that I was having a devilish time with letters and numbers. They didn’t cooperate. They had become a school of silverfish that slipped and slithered over one another, virtually indistinguishable.
My boss was, I think, as kind as she could be. I, of course, felt deeply humiliated.
I sat at home for the next three months, struggling to write cover letters for jobs. I found the letters of the alphabet so cumbersome; how did one put them together into words, and then words into sentences? How to connect these clumps of words together in paragraphs?
I would finally complete a letter, read it over, find one mistake; read it again and find a different mistake, read it a third time and find yet another error which had previously been invisible to me. It was like my mistakes were stars, twinkling on and off, eluding my detection.
I did eventually get another job, and my capacity to use letters and numbers mostly returned—but not entirely.
Language no longer formed spontaneously in my head; when I sat down to write, there were no words stored there, at all. I had to eke them out, one by one. There was no flow, and there was no music.
I went one evening to writers’ group. L told me my essay had been nominated for Best American Essays. She showed me the volume: There was my name, among the glitterati of writing: Oliver Sacks, Jamaica Kincaid, and L herself.
I didn’t publish again for 20 years.
The inability to understand or utilize language is called aphasia; it seems clear that I suffered from some form of this for a period of many months.
There are a total of five case reports of aphasia associated with ECT. All involved impairment with spoken language, as well as written, which was not true in my case.
About two years ago, a colleague and friend referred a patient to me. The young woman had severe OCD and was crippled by intrusive thoughts and compulsions. She had trouble leaving the house in the morning because she was terrified her cat might get into poisons under the sink, though she had placed child locks everywhere.
The woman, whom I’ll call Kristin, belonged to a family who did not support the use of psychiatric medication. She loved and depended on her parents. My colleague referred Kristin to me to see if there was any wiggle room in terms of a medication her family might accept.
Kristin clutched her hands together as we discussed the options. I recall the fear in her pale face but mostly the sense that she felt utterly trapped. I suggested meds from a few different classes. She did not think her family would be convinced. I offered to speak with them, she declined.
A few days later, Kristin was hospitalized locally for suicidal thoughts. The doctors on the unit were recommending ECT.
Kristin called me and asked if I thought she should do it. I hesitated. I finally said, yes, I thought she should have the treatment, but I recommended that she go to a different hospital. That hospital, I knew, performed ultra-brief pulse ECT, which has a lower risk of cognitive and memory effects. I knew this from experience, because, even after my traumatic experience, I later had ultra-brief pulse ECT. No greater force than desperation.
Kristin thanked me, her voice tight, and hung up.
She was discharged from the hospital. The next day, I got a call from the director of the inpatient unit. Kristin had unlocked her brother’s shotgun and put a bullet through her head.
I hesitated. My hesitation. What if I had just said, Hell, yes! Yes, have the ECT! Go for it! My colleagues would have said this. It’s very safe, not like it used to be. Transient memory loss. Totally acceptable. I felt the metals in me groan and shift. I had gone with gold rather than steel, had allowed myself to be informed by my own experience—she was, after all, so young. Younger even than I had been. Steel might have saved her life, would have served her better.
You would have thought that having had this experience with Kristin, I would now be more disposed to recommend ECT. It would only make sense. ECT saves lives. It might have saved Kristin’s. It didn’t save mine, not with repeated rounds. Other things did. But I have learned not to use myself as a guide.
I’m at a loss with Daniel—but not just with him. I no longer trust my instincts, but nor do I want to blindly follow blithe directives. The truth is, I find myself disillusioned with my profession. There is more and more evidence that antidepressants, while sometimes helpful, are nowhere near as effective as they were once touted to be. The serotonin deficit model of depression has been rendered obsolete. We psychiatrists find ourselves scrambling to pull more and more esoteric rabbits out of our illusory hats. Both lived and professional experience seem to be failing me.
On the other hand, how do I practice psychiatry, given my own reluctance to recommend ECT? Does this make me an irresponsible clinician? Did Kristin pay for my own aggrievement?
I discussed ECT with my current patient at length. He was anxious about having electric current applied to his brain which, APA assurances aside, I had to take as a sign of psychological health. A colleague had offered a medication suggestion; it seems to be helping somewhat.
My ECT story does not exist in the medical canon. I should long ago have reconciled myself to this fact, and to my loss. But I apparently have not.
A few months ago, I looked up the doctor who had performed the ECT. He was still at the same hospital. The phone number rang through to his personal voicemail. He’d always had a warm voice, I thought, a bit scratchy, liked frayed wires, but with a pulse underneath. I left a broken message.
“Hi, I don’t know if you’ll remember me… I was a patient, also a psychiatrist… and I wrote about ECT.”
I never thought it was his fault. ECT is extremely safe, risks include transient amnesia, at worst forgetting a trip to Portugal. I was a low-risk case, physically healthy, young, no complicating factors. I was certain, am still certain, that he did everything according to protocol.
I was at the optometrist with my daughter when he called. He was headed on vacation; we made a time to speak when he returned. Of course, he said, he remembered me.
At the appointed time, my cell phone rang. I asked how he was. He did not sound like someone who had been rejuvenated by a week’s vacation. Nevertheless, it was now or never. I plunged in with my story.
He sounded shocked, outraged even, when I told him about the delirium, the hospital admission. No one had told him. No one in his own hospital had told him. Didn’t you wonder? I thought maybe you felt better.
I told him about the silverfish words, the nonexistent dose of Ritalin, the empty shelves in my brain which had been stocked with language. I stopped.
Do you believe me? I asked. Have you ever seen this?
I knew he had read my essay, over twenty years ago.
He spoke slowly: He had not seen this exactly, but things close enough. He believed me. He sounded exhausted.
I told him about my kids, 13 and 15, brain cells still branching and vital, dendrites weaving those fine, fractal webs of connection. My daughter with her art—I imagined intricate spider-webs of color, iridescent; my son, with his profound understanding of the world and technology—I pictured dark branches, laid evenly out in a complex geometric pattern, like the London Underground. All so perfect, so perfect and intact.
The offering I laid at his feet was a lot—it was all I had—but I had the acute sensation that it fell short of compensating for the blow I’d dealt him. That he, like me, had come to some place of existential pain with his work or his life, or both, and I had tipped the scales.
That maybe he would not see his work the same way again. That he was now straining under the unique pressure of composite meeting pure knowledge.
I never meant to hurt him. But had he not experienced disquiet or unease, I would have hung up feeling empty, a November tree whose leaves like words had silently fallen.
This, I realize, is what I want: to create unease.
I want to shake the forest of my profession until more leaves fall, but I will stop short of striking a match and setting it ablaze. I’ll be content if we can sit together in the autumnal carpet, contemplating the remains of our good intentions.
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This is an extraordinary post -- can you call it a post? Incredible Susan - thank you for sharing so deeply, writing so beautifully, being so searingly honest and demonstrating power of reflection in the face of complexity ... So much worth quoting..✨
Dr. Mahler, I’m so impressed with your post. I especially appreciate your willingness and ability to expose your vulnerabilities to an audience. I thought I would write about the ‘adverse events’ I experienced during ECT treatment.
I have treatment-resistant depression and have been through the usual gamut of treatments-SSRIs, SNRIs, adjunct stimulants and anti-psychotics, inpatient care, IOPs, individual and group therapy. I heard about TMS and had high hopes, which quickly crashed. At that point, like you, I felt desperate enough to try ECT. Since this was a short time before the interest in psychedelics for treatment of depression, I felt this was the ‘last stop’ before pursuing the more invasive Vagus Nerve Stimulation. I understand statistics and methodology and so I was confident that ECT was an effective treatment for depression. But I was still anxious about the method.
After having my vitals checked by a nurse, along with administering a PHQ-9 (really? I was fairly sure I had it memorized), I walked across the hall and laid on a gurney. I was introduced to the Respiratory Therapist, standing above my head, taping electrodes on my forehead; the anesthesiologist at my left elbow, preparing his various potions to knock me out very briefly; a nurse at my feet, who smiled encouragingly at me; and finally, the psychiatrist at my right elbow, who explained the function of the dials on the black box behind him. The box that would send a current of electricity to one side of my brain sufficient to induce a seizure. Then it was over and all was well for the first 7-8 treatments.
Then I woke up from a session and multiple nurses were scurrying around me, instead of the usual calm monitoring of a single nurse. I was asked if I had eaten or drunk anything before the treatment? Of course not, I answered indignantly. But my blood oxygen level was stubbornly staying at an insufficient 85, unless I was on a high level of oxygen. They called EMS to deliver me to the ‘medical’ hospital a mere 4/10s mile away (that’s the distance we were billed for). I spent 3 days in the hospital with aspiration pneumonia being infused with antibiotics as they slowly stepped down the oxygen levels I was receiving. I had to delay ECT a couple of weeks until my cough cleared.
A month later I had finished with the acute treatment phase and was having the first of six monthly maintenance treatments. Afterwards, there was once again much scurrying about me. I became aware that my chest was hurting. I was also aware of doctors and nurses whispering to my husband in the hall. But they put me in the wheelchair as usual and walked me down to the elevator with my husband and the nurse and I waited for our car. The slip of paper I was given that had always stated the date and time of my next treatment just said “No More Treatments.” I was so confused.
It was left to my husband when I got in the car to explain it all. He said my heart had stopped for two minutes following the seizure. A brief pause was expected, and apparently protocol dictated that they observe me for 30 seconds, and then the anesthesiologist gave me chest compressions for 90 seconds, at which point my heart started. No wonder my chest hurt.
They just told my husband to take me home. Instead, he called our PCP, who was alarmed by the story and told us to go straight to his office. The ECG he administered was normal. But he called my cardiologist to see if she could check me and decide if I should be observed on a telemetry unit. She said to come straight to her office. She also administered an ECG, which was also normal. After some thought, she sent me home with a Holter monitor and I was monitored remotely. I had no more incidents.
My ribs continued to hurt for four months. I had X-rays taken but, as my PCP and the radiology tech told me, micro fractures sometimes don’t show up without more advanced imaging. The pain interfered with my job of working with students with severe disabilities but I kept at it because I was in shock about the whole thing. The final chapter of my ECT experience (I hope) came about 18 months later. At that point, I sat in a nephrologist’s office as she questioned me about how my blood work had, a year before, started showing that my kidneys were no longer up to par. In fact, they were operating at about 45% of normal functioning. She asked if I had any issues with my heart. I told her I had a cardiac arrest during an ECT treatment. Chest compressions?, she asked. I answered affirmatively. She nodded and said that would have been enough to damage my kidneys.
Psychiatrists have told me that each of my ‘adverse events’ were one in a thousand to ten-thousand events. But they and their aftermath were traumatic to me. They have also made me angry, particularly because the kidney damage prevents me from taking some types of medication that would help me with other issues.
I am not ambivalent about ECT. Despite the persuasive statistics, I would be very upfront about my experiences with anyone who asked my opinion. Fortunately, five years later, I am doing well with Spravato treatments.
Thank you again for the article, and if you’ve read to this point, thank you for reading my ECT story.