Folk appropriation of ECT among South Indian patients

on self­treatment with electricity, we wish to reportits use by a patient with obsessive compulsivedisorder.Mr A, aged 24, was admitted to the ward afteranattemptedoverdose. He gave a three monthhistory of obsessive thoughts characterised bya wish to stareatthe"privatepartsof women".During his in-patientstay, he began frequent­ing the ECT clinic and talking to relatives ofpatients receiving ECT. This led to his demandthat he be given ECT to get rid of his painfulobsessions. Unsuccessful attempts to dis­suade him led to anger and resentment. Oneday he was found to have in his possession acardboard box containing batteries, wires andclips. He explained that, since we were unwill­ing to give

Sir: In response to the case report by Hosty (Psychiatric Bulletin, 1993, 17, 630), on selftreatment with electricity, we wish to report its use by a patient with obsessive compulsive disorder.
Mr A, aged 24, was admitted to the ward after an attempted overdose. He gave a three month history of obsessive thoughts characterised by a wish to stare at the "private parts of women". During his in-patient stay, he began frequent ing the ECT clinic and talking to relatives of patients receiving ECT. This led to his demand that he be given ECT to get rid of his painful obsessions. Unsuccessful attempts to dis suade him led to anger and resentment. One day he was found to have in his possession a cardboard box containing batteries, wires and clips. He explained that, since we were unwill ing to give him ECT, he had constructed his own ECT machine and was giving 'shocks' to his forehead to burn his obsessions. His notion of brain functioning revealed an electrical or gan which was wired up to produce thoughts that were an end-product of electrical activity. The knowledge gained from the ECT clinic and aversion therapy at the behaviour therapy unit were proof to him that doctors used a similar model for treating mental illness.
Metaphors often diffuse out and reshape to fit prevailing folk notions in popular culture. In our experience of working with patients in South India, ECT is a popular and often highly desired form of treatment. Patients consider the ECT room a sacred place, symbolically associating it with a temple (photographs of deities, bells at the entrance with incense sticks and prayers that are frequently offered).
Nurses in uniform along with apron-clad doc tors using stethoscopes and ophthalmoscopes, complete a picture that reveals a fascinating co-existence of secular and sacred symbols of healing. We have encountered many patients requesting 'current treatment' and this parallels a similar pattern of disappointment when doc tors refuse to prescribe 'pills' or 'injections'. Apart from isolated research (Nichter, 1980) we know little about how biomÃ©dical ideas are appropriated by any culture to make sense of such notions (Jadhav, 1993

Attitudes to ECT
Sir: Riordan, Barron & Bowden (Psychiatric Bulletin, 1993, 17, 531-533) describe a reexamination of patients' attitudes towards and experience of electroconvulsive therapy (ECT). Such studies are important in keeping psy chiatrists aware of consumer opinion and help ing us to continually update and review our procedures. Perhaps consumer views ought to be routinely sought by consultants with responsibility for ECT clinics.
I would, however, take issue with their state ment that ECT is "widely seen by the public as a barbaric and outmoded form of treatment". Freeman & Cheshire (1986) reviewed 11 studies of patient and/or public attitudes to ECT and found generally positive views, but with consid erable ignorance concerning the nature and pur pose of the treatment. The possible influence of the misrepresentation of ECT in the media is a concern, but various authors disagree about the effect of publicity on attitudes towards ECT and the relative influence of different sources of infor mation such as personal experience of the treat ment, explanation from a doctor, and written information.
The authors conclude that there is a need for more explanation of ECT, more particularly for repeated explanations of the treatment through out the course and following its completion for those receiving treatment and their relatives and visitors. The use of videotapes to inform patients about ECT as part of the consent process is contentious. Baxter and co-workers (1986) com pared a group of patients who saw a factual ECT videotape during a consent process prior to treat ment with ECT with a group who experienced the usual consent process (including written and verbal information). The group who saw the videotape were less sure that they had sufficient information on which to decide whether or not to consent to ECT than the comparison group. The authors suggested that videotapes might have a role in informing relatives rather than patients. Horgan (1990) has put forward a more innovative suggestion for destigmatising ECT and reassur ing people receiving treatment, that partners or close relatives could be present throughout the procedure.
Freeman & Cheshire (1986) concluded that there had been (at that time) insufficient in vestigation of the patient's ability to give informed consent to ECT. I suspect this is still true.  (Selvin, 1987;Durham, 1989) discuss the controversies regarding its use. We have personal experience of strong negative opinions expressed by both professional colleagues and others. Combined with views expressed in the media, which must represent the views of a proportion of the population, we feel that we were justified in using the phrase "widely seen". We are aware of the anecdotal nature of some of this evidence. Our suggestions regarding the use of other formats to aid explanation of the ECT process were not based on personal experience. We would suggest that further work, looking at the efficacy of these methods, would be invaluable. DURHAM.J. (1989)

Training in administration of ECT
Sir: A similar survey to Dr Henderson's on ECT (Psychiatric Bulletin, 1993, 17. 154-155) was carried out among psychiatrists of East Berkshire, using an anonymous, self-completed questionnaire.
Numbers involved were small but may be of some interest as they compared experiences of present trainees with more senior colleagues.
All trainees and eight others replied. Average time in training was 103 weeks for trainees and 19 years for others. Thus most others received their training before Pillard 6k Ellam's original survey of 1981. Questions were asked about points considered to be good prac tice in training to administer ECT. Respondents who were no longer trainees were asked to reply with respect to their original training.
Initial questions concerned consultant cover of the ECT department. Three (t) and four (o) knew that there was a consultant responsible for train ing juniors. No trainees and two others recalled seeing the nominated consultant in the depart ment regularly. Three (t) but all others knew of an allocated person with whom they could discuss problems concerning ECT.
Two (t) and three (o) had received an initial seminar prior to administering ECT. Three (t) and three (o) had the nominated consultant or his deputy present during the initial ECT session, while five (t) and five (o) had ECT demonstrated by a more senior trainee. The number of sessions observed before administering ECT alone varied. Four (t) and three (o) had observed one session, while one of each group had observed more than one.
The study was carried out as part of an audit of ECT in our department. Concern was voiced that trainees' perception of training did not match that of the senior staff who felt that there was a consultant in charge of ECT who made a point of training juniors. The other findings were not challenged. These findings suggest that over the last 10-15 years there has been no great change in the level of training received. In most areas the 'others' did as well as or better than the 'trainees'. PIPPARD

Care programme approach in Shropshire district
Sir: We would like to report our findings from a study undertaken 16 months following the inception of care programme approach (CPA) in Shropshire district. Professionals involved in the initiation and present workings of the CPA were interviewed.
The Planning and Information Department's role to monitor information, and thereby look for needs and changes for future service require ments, were not wholly met. Computer listing of allocated patients was not sent to the relevant keyworkers. This lead to lack of vital communi cation. The sheer volume of forms (20,000 a year) was too great to process with available resources and was regarded as yet another exercise in bureaucracy and red tape unlikely to effect change in clinical practice.
The community psychiatric nursing services (CPNS) were aware of their obligation to the CPA and felt it was a realistic objective despite