Insulin coma therapy

1. Introduction

Version followed: insulin coma therapy (insulin shock treatment) for schizophrenia, c. 1933 to the 1960s, as described in the historical account of Freudenthal and Moncrieff (2021, History of Psychiatry) and Doroshow (2007, Journal of the History of Medicine and Allied Sciences), with NICE CG178 for current care. The treatment is not recommended in any form.

Insulin coma therapy (also called insulin shock therapy) was a physical treatment for schizophrenia, and sometimes other psychoses. Patients were deliberately and repeatedly put into hypoglycaemic coma. The Austrian psychiatrist Manfred Sakel reported his results to the Medical Society of Vienna in 1933 and published them in 1937. The treatment spread rapidly across Europe and North America and was used until the early 1960s. It was largely abandoned by the late 1960s, though there are reports of later use in Australia (1974) and China (1985) [source: Freudenthal and Moncrieff 2021].

Its proponents' theory of change (attributed, not endorsed): Sakel described an "annihilating assault" on the nerve cell that would let older, healthier pathways re-establish themselves. In 1958 he said the treatment selectively killed diseased cells so that "dormant ones" could take over. Other proponents proposed hormonal, metabolic or oxygen-related mechanisms, or likened it to a "physiological lobotomy". Psychoanalytic writers suggested that shared fear on the unit, close patient-staff bonds, and induced dependency and regression were the active ingredients [source: Freudenthal and Moncrieff 2021].

Controlled studies in the 1950s did not support a specific effect. In 1953 the junior doctor Harold Bourne published "The insulin myth" in The Lancet. In 1957 a randomised trial at the Maudsley, Bethlem and Cane Hill hospitals (Ackner, Harris and Oldham, The Lancet) found no difference between insulin coma and a comparison coma produced by another drug. The authors concluded that "insulin is not the specific therapeutic agent" [source: Freudenthal and Moncrieff 2021]. Contemporary mortality estimates ranged from 0.5% to 4.5%. Post-mortem and animal studies showed irreversible brain cell destruction [source: Freudenthal and Moncrieff 2021].

For the psychotherapist today, the treatment matters mainly in three ways:

as a lived memory for very old clients, and more often for their children and grandchildren;
as part of the institutional history of psychiatry that shapes some clients' distrust of mental health services;
as a case study in how treatments can be adopted on enthusiasm and local impressions rather than evidence [source: Doroshow 2007; Freudenthal and Moncrieff 2021; synthesis].

2. Framework

Historical phases, in outline [source: Freudenthal and Moncrieff 2021; Tattersall 2009; Doroshow 2007]:

Origin (late 1920s to 1933). Sakel first used insulin in morphine withdrawal and then in schizophrenia in Vienna. He claimed that 70% of his first series fully recovered and 88% improved well. Later commentators noted that his patients were recent-onset outpatients, "an earlier and more recoverable group" [quoted by Freudenthal and Moncrieff from Henderson and Gillespie].
Rapid spread (1934 to the 1940s). Government public-health bodies were promoting the treatment by 1939, and the press reported it favourably [source: Freudenthal and Moncrieff 2021]. By the late 1930s most psychiatric hospitals in England and the USA had dedicated insulin units [source: Tattersall 2009]. The Retreat in York began using it in October 1938 [source: Wellcome Collection, Retreat Archive RET/6/25]. A trade-press review reports that 54% of American mental institutions offered it in the early 1940s [source: Soreff and Bazemore 2006; uncertain: secondary]. Use in the USSR is reported in the secondary literature [uncertain: not verified]. The same review reports a 1992 survey describing continued frequent use in Ukraine [source: Soreff and Bazemore 2006; uncertain: secondary].
The insulin unit as a world of its own (c. 1933 to 1960). Doroshow describes each unit as having its own staff, routines and attitudes, an operating-room-like setting, and dramatic local recoveries. These gave psychiatrists "a strong sense of efficacy" and helped them see themselves as physicians [source: Doroshow 2007, abstract]. Intensive nursing attention was part of the regime [source: Freudenthal and Moncrieff 2021].
Challenge and decline (1953 to the mid-1960s). Bourne's 1953 critique, the 1957 randomised trial, and the arrival of chlorpromazine led to decline. Freudenthal and Moncrieff argue the treatment was "quietly forgotten" rather than formally rejected. Some textbooks still called it "a landmark in psychiatric progress" in 1969 [source: Freudenthal and Moncrieff 2021].

Phases of the psychotherapist's work [synthesis]. The treatment is no longer offered in mainstream services, so the work is about legacy, not current exposure.

Phase A: Recognition and orientation. Notice when a history of insulin treatment, an "insulin ward" or long-stay hospital care appears in a client's or family's story. Orient yourself historically. Move on once you understand what the client is bringing: their own memory, a family story, a records search, or general distrust of psychiatry.
Phase B: Assessment and safety. Assess current mental state, trauma responses, cognitive status (for an older client, with medical colleagues), suicide risk, and the client's current care relationships. Move on once immediate risk is managed and any medical or cognitive questions have been routed to the right professionals.
Phase C: Meaning-making and processing. Do trauma-informed work on institutional experiences, family narratives, shame and stigma, and grief. Move on once the client can tell the story with less distress and has a working account of what happened and why.
Phase D: Repair, advocacy and follow-up. This covers access to records, testimony and oral history, engagement with current services on the client's terms, and connection with peer and survivor networks.

Pace the work to the client [synthesis]. Where the client also has a current psychotic disorder, NICE describes CBT for psychosis as at least 16 one-to-one sessions and family intervention as at least 10 meetings over 3 months to a year [source: NICE CG178, information for the public].

3. Guiding principles

Never provide, recommend or refer to the practice. Practical meaning: if anyone proposes coma or shock-based "revivals", decline and use the professional concerns route (see 4.15) [synthesis; APA Ethics Code Standard 3.05 governs multiple relationships; other ethics points are synthesis].
History as the historians tell it. Practical meaning: attribute claims (Sakel's theories, success rates, mortality figures) to their sources and say where figures conflict. For example, mortality estimates ranged from 0.5% to 4.5% in one review and were quoted at 1 to 10% in a trade-press review [source: Freudenthal and Moncrieff 2021; Soreff and Bazemore 2006; the 1 to 10% figure uncertain: secondary].
No replication detail. Practical meaning: do not discuss how comas were induced, doses or ward routines, even if a client asks out of curiosity. Talk instead about experience, meaning and effects [synthesis].
The client's experience is the primary text. Practical meaning: let the client's or family's account lead. Former patients described the treatment as "unpleasant" and "dangerous", and some felt "liberated" when it stopped [source: Freudenthal and Moncrieff 2021]. Do not argue them out of either fear or gratitude [synthesis].
Even-handed about mixed memories. Practical meaning: some patients and staff of the era remembered dramatic recoveries, and clinicians believed in it locally [source: Doroshow 2007]. Hold that alongside the evidence that it had no specific effect, without ridiculing the people involved [synthesis].
Trauma-informed care. Practical meaning: follow SAMHSA's principles of safety; trustworthiness and transparency; peer support; collaboration and mutuality; empowerment, voice and choice; and cultural, historical and gender issues. Actively resist retraumatisation [source: SAMHSA via youth.gov].
Institutional distrust is often earned. Practical meaning: treat suspicion of psychiatry in affected families as an understandable response to history, not as "non-compliance" [synthesis].
Medical questions go to medical professionals. Practical meaning: concerns about lasting brain or cognitive effects, or about current medication, are routed to the client's GP, psychiatrist or memory service. Never advise starting, stopping or changing a medicine [synthesis].
Supported care is the alternative. Practical meaning: for current psychosis, point toward what NICE recommends (CBT for psychosis, family intervention, arts therapies), offered with choice [source: NICE CG178, information for the public].
Privacy and naming. Practical meaning: former patients, including relatives in a client's story, are discussed by role in any notes, teaching or publication, never by name without consent [synthesis].
Humility about the profession's history. Practical meaning: the treatment was promoted by mainstream bodies and stayed in textbooks after the trials. Be open that today's practice can make errors too [source: Freudenthal and Moncrieff 2021; synthesis].

4. Intervention inventory

The interventions below are the psychotherapist's own work; steps not drawn from a cited source are marked [synthesis]. None of them involves any part of insulin coma therapy. The risks to keep in mind throughout are retraumatisation, unrecognised cognitive impairment, suicide risk in people with serious mental illness, and renewed distrust of services.

4.1 Building your own historical literacy

Purpose: Be able to hear an insulin-treatment story accurately, without minimising it or sensationalising it. Use this before working with older clients or with families researching psychiatric history [synthesis].
Steps:
1. Read a peer-reviewed overview, such as Freudenthal and Moncrieff 2021 on the evidence, or Doroshow 2007 on life inside the units.
2. Learn the key dates and turning points: Sakel's 1933 report, spread in the 1930s, Bourne's 1953 critique, the 1957 trial, and decline in the 1960s.
3. Know the range of harm estimates and where they come from.
4. Note what you do not know, such as practice in a particular country or hospital, and mark it as uncertain in your own notes [source: Freudenthal and Moncrieff 2021; Doroshow 2007; synthesis].
Example language (illustrative): "I know something about the insulin units of that period, but I'd like to hear what it was like where your father was."
Watch for: Overconfidence, or reciting figures at the client. Working well looks like the client correcting or adding to your picture, and feeling taken seriously.

4.2 Recognising a history in intake or life review

Purpose: Identify past exposure to insulin treatment or other mid-century physical treatments, and the long-stay hospital care that often came with them. Use this with clients born before about 1945, and with anyone describing a parent's or grandparent's psychiatric admission [synthesis; dates per Freudenthal and Moncrieff 2021].
Steps:
1. Ask open questions about past mental health care, hospital stays and "treatments you remember".
2. Listen for terms such as "insulin ward", "shock treatment", "the coma" or "the unit".
3. Do not lead with technical names. Let the client name it.
4. Record what the client reports in their own words.
5. Flag it for a fuller, paced history later (4.3) [synthesis].
Example language (illustrative): "Some people who were in hospital in those years had treatments that are no longer used. Is there anything from that time you'd want me to know about?"
Watch for: Visible distress, change of subject, or dissociation when hospital topics come up. Slow down. A sign it is working is the client choosing to say more, now or later.

4.3 Trauma-informed history-taking of institutional experience

Purpose: Gather the client's account of treatment and institutional life in a way that avoids retraumatisation [source: SAMHSA principles via youth.gov; synthesis].
Steps:
1. Explain why you are asking and that the client controls the pace and depth.
2. Ask about the overall experience before particulars: daily life, relationships with staff and fellow patients, and how they felt afterwards.
3. Do not ask the client to describe procedures in detail.
4. Check in on distress regularly, and agree a stop signal.
5. Close with grounding and an orientation to the present.
6. Ask what they would like done with what they have shared [synthesis].
Example language (illustrative): "You don't need to go into the details of what was done. I'm more interested in how it was for you, then and now. We can stop whenever you want."
Watch for: Dissociation, flashback-like states, and shame. Former patients have described the treatment as "unpleasant" and "dangerous" [source: Freudenthal and Moncrieff 2021], and fear on the units was noted by contemporaries. Signs it is working: steady arousal, and the client reports feeling heard rather than examined.

4.4 Assessing current trauma responses and mental state

Purpose: Find out whether past experiences are driving current symptoms (for example, intrusive memories, avoidance of hospitals or doctors, hypervigilance), and assess any current psychotic, mood or anxiety disorder [synthesis].
Steps:
1. Use a structured, validated trauma measure appropriate to age and setting, without reproducing items to the client beyond its licensed use.
2. Assess current mental state.
3. Ask specifically about medical avoidance, such as declining needed care for fear of being "put under".
4. Formulate the links between the past and the present together with the client [synthesis].
Example language (illustrative): "Sometimes what happened in hospital long ago still shows up now, for example as dread before a medical appointment. Does anything like that happen for you?"
Watch for: Fear of anaesthesia, of hospital admission or of injections. Coordinate with the client's medical team so they can plan accommodations. Working well: the client can name their triggers and agree a plan for them.

4.5 Cognitive and medical liaison

Purpose: Route concerns about lasting effects to medical colleagues. Historians report irreversible brain cell destruction in post-mortem and animal studies, and hypoglycaemic brain damage [source: Freudenthal and Moncrieff 2021; Tattersall 2009]. A study of long-institutionalised older patients reportedly found no greater cognitive decline in those who had received the treatment [source: Soreff and Bazemore 2006; uncertain: secondary, original not verified].
Steps:
1. Note any memory, concentration or neurological complaints.
2. With consent, refer to the GP or physician, a memory service or old-age psychiatry.
3. Do not attribute current cognitive problems to the past treatment yourself.
4. Adapt therapy to the client's cognitive capacity: shorter segments, written summaries, and family involvement if the client wishes [synthesis].
Example language (illustrative): "It makes sense to wonder whether that treatment affected your memory. A doctor is the right person to look at that, and I can help you raise it."
Watch for: Rapid cognitive change (route it urgently). Never comment on medication. Working well: the medical question is in the right hands and therapy continues alongside.

4.6 Suicide-risk assessment and safety planning

Purpose: People with serious mental illness, and people revisiting institutional trauma, may be at raised risk. Assess this whenever distress rises or a hard history surfaces [synthesis].
Steps:
1. Ask directly and calmly about suicidal thoughts, intent and plans, using current standard risk-assessment practice.
2. Build a collaborative safety plan: warning signs, coping steps, people and places, professional contacts, and making the environment safer (storage and removal of means, without discussing methods).
3. Give crisis resources: 988 (US), or Samaritans 116 123 (UK and Ireland).
4. Involve the client's care team as agreed or as risk requires [synthesis].
Example language (illustrative): "When people go back over painful memories like these, they sometimes have thoughts of not wanting to be alive. Has that been happening for you?"
Watch for: Hopelessness, withdrawal and sudden calm after distress. Follow safe-messaging: no method detail and no glamorising. Working well: the client has a written plan and knows who to contact.

4.7 Accurate, non-sensational psychoeducation

Purpose: Give the client or family a sourced account of what the treatment was believed to do, and what the evidence later showed. Use this when they ask "why did they do that?" [source: Freudenthal and Moncrieff 2021; Bourne 1953 and Ackner et al. 1957 as reported there].
Steps:
1. Ask what they already know and want to know.
2. Explain in plain terms: it was widely promoted, including by public-health bodies, and clinicians believed it worked. Later trials found no specific benefit, and it carried risks of death and brain injury.
3. Avoid all procedural detail.
4. Offer reputable reading, such as open-access history articles or museum and archive pages.
5. Check how the information has landed [synthesis].
Example language (illustrative): "At the time, many doctors sincerely believed it helped. When it was tested properly in the 1950s, it didn't do better than the comparison, and it carried real risks."
Watch for: Information triggering anger, guilt ("we agreed to it"), or grief. Pace it. Working well: the family's questions shift from "why" to "what now".

4.8 Working with mixed or ambivalent memories

Purpose: Some people remember the unit with gratitude, warmth toward staff, or a sense of recovery. Others remember terror. Many hold both. Doroshow documents the dramatic local recoveries and the attention on the units, and contemporaries suggested the attention itself may explain benefit [source: Doroshow 2007; Tattersall 2009 citing Bourne 1953].
Steps:
1. Reflect both sides without correcting either.
2. Explore what helped: the people, the attention, the hope.
3. Explore what harmed.
4. Help the client hold an integrated account, which can also guide what they seek from care now [synthesis].
Example language (illustrative): "It sounds as if the nurses' kindness really mattered, and at the same time the treatment itself frightened you. Both can be true."
Watch for: Therapist pressure toward a single story, in either direction. Working well: the client can speak about it without needing to defend or condemn it.

4.9 Narrative and life-review work with older survivors

Purpose: Help an older client place the institutional period within a whole life story, reducing shame and restoring agency [synthesis].
Steps:
1. Map the life chronologically with the client, including before, during and after hospital.
2. Highlight strengths, relationships and achievements.
3. Revisit the hospital period at the client's pace.
4. Explore what the client would want others, such as family, to understand.
5. Optionally produce a written or recorded life story owned by the client [synthesis].
Example language (illustrative): "Hospital was one chapter. I'd like to understand the whole book: who you were before, and everything since."
Watch for: Fatigue and cognitive limits (4.5). Working well: the client describes themselves as more than a former patient.

4.10 Family and descendant work

Purpose: Support children and grandchildren who carry stories, silences or fears from a relative's treatment. These might include fear of inheriting illness, family shame, or anger at the institution [synthesis].
Steps:
1. Map the family story: who knew what, what was never said.
2. Separate fact, family legend and uncertainty, and mark gaps honestly.
3. Address heredity fears by routing genetic or medical questions to medical professionals.
4. Work with intergenerational patterns such as secrecy and avoidance of help-seeking.
5. Offer joint sessions if the family wishes [synthesis]. Where a relative currently has psychosis, NICE recommends family intervention with the family's agreement and a check that everyone is happy with how it is going [source: NICE CG178, information for the public].
Example language (illustrative): "Your grandmother's time in hospital was never talked about, and yet it seems to have shaped how your family deals with any sign of distress."
Watch for: Scapegoating of the relative or of one parent, and family conflict over "digging it up". Working well: the family can talk about the history openly and with less fear.

4.11 Supporting records and archive searches

Purpose: Help a client or family who wants to find a relative's hospital records or understand the institution. Historic records survive in archives, for example The Retreat's insulin coma therapy records (1940 to 1952) at the Wellcome Collection, and a 1946 to 1948 insulin treatment record book at the Science Museum Group [source: Wellcome Collection RET/6/25; Science Museum Group co535089].
Steps:
1. Clarify what the client hopes to find and what it might mean to them.
2. Prepare them for distressing or clinical content, and for gaps.
3. Signpost record-access routes (the archive holding the hospital's records, the local records office, or the current health provider). Access rules vary by country and by how old the records are [uncertain: not verified].
4. Plan a session to process what they find [synthesis].
Example language (illustrative): "Before you open the file, let's think about what you might find and how you want to look after yourself when you read it."
Watch for: Records written in the stigmatising language of the period, which can shock. Working well: the client integrates what they find without being flooded by it.

4.12 Grief, guilt and moral injury (families, former staff and their descendants)

Purpose: Address guilt in relatives who consented on a patient's behalf, and moral distress in former nurses or doctors, or their descendants. Doroshow notes how strongly staff believed in the treatment [source: Doroshow 2007; synthesis].
Steps:
1. Name the guilt or moral pain.
2. Place decisions in their historical context: the treatment was promoted by public-health bodies and medical leaders [source: Freudenthal and Moncrieff 2021].
3. Distinguish responsibility from blame.
4. Explore reparative actions the client values, such as testimony, education or commemoration [synthesis].
Example language (illustrative): "Your mother agreed to what the doctors said was the best treatment available. That was what she knew then."
Watch for: Using "context" to dismiss real harm. Hold both. Working well: less self-punishment, and more capacity for honest remembering.

4.13 Repairing trust with current mental health services

Purpose: For a client or family member who now needs psychiatric care but distrusts it because of this history [synthesis].
Steps:
1. Validate the distrust as historically grounded.
2. Explain what current guidelines recommend. For psychosis, NICE recommends CBT for psychosis, family intervention and arts therapies, with personal choice considered [source: NICE CG178, information for the public].
3. Support the client in preparing questions for their care team and in being involved in decisions.
4. With consent, liaise so the team knows the history [synthesis].
5. Do not comment on medication choices; route those to the prescriber [synthesis].
Example language (illustrative): "Given what happened to your father, it makes sense to be wary. Today's guidance puts a lot of weight on your choice and on talking therapies. Shall we work out what you want to ask?"
Watch for: Disengagement from needed care. Working well: the client attends and feels able to speak up.

4.14 A client drawn to coma, shock or "reset" cures

Purpose: Some people, often desperate after long illness, are drawn to dramatic physical "resets", including online claims about reviving old somatic treatments or unsupervised hypoglycaemia. Use this when a client expresses such interest [synthesis].
Steps:
1. Explore the hope behind the interest, such as a wish for rapid change, or despair.
2. Share, without procedure detail, that controlled trials found no specific benefit and that the treatment carried risks of death and brain injury [source: Freudenthal and Moncrieff 2021].
3. Assess immediate safety, including suicide risk (4.6) and any intention to self-administer. Treat intended self-induced hypoglycaemia as a medical emergency and route it urgently.
4. Offer supported alternatives (4.13).
5. Never supply information on how it was done [synthesis].
Example language (illustrative): "It sounds as if you want something that will change everything at once. Let's talk about that wish, and about safer ways to get you real help."
Watch for: Covert self-harm, and online communities promoting such methods. Working well: the client engages with safe options.

4.15 When a colleague or institution proposes or uses it

Purpose: Fulfil professional duties if you meet any current use, revival or promotion of coma-based treatment. Use was reported in China in 1985 [source: Freudenthal and Moncrieff 2021] and, in a 1992 survey, in Ukraine [source: Soreff and Bazemore 2006; uncertain: secondary].
Steps:
1. Do not take part, supervise or refer.
2. Document what you observed.
3. Raise the concern through your organisation's clinical governance or safeguarding lead.
4. If patients are at risk, report to the relevant professional regulator or licensing board, health-care inspectorate, or adult safeguarding authority, following the route your regulator publishes.
5. Seek supervision and legal or ethics advice [synthesis]. Where a colleague's role creates a conflict, APA Ethics Code Standard 3.05 (multiple relationships) is relevant. Other ethics points here are synthesis.
Example language (illustrative, to a colleague): "I'm not able to be involved with this. The trials found no specific benefit and significant risks, and I'll need to raise it through governance."
Watch for: Pressure to stay quiet, and risks to patients who lack capacity. Working well: the concern is formally logged and patients are protected.

4.16 Peer support, testimony and oral history

Purpose: Peer support is one of SAMHSA's trauma-informed principles [source: SAMHSA via youth.gov]. Many survivors and families value being heard by others and contributing testimony [synthesis].
Steps:
1. Explore whether the client wants connection with peer or survivor groups for psychiatric-system survivors, or with oral-history projects run by archives and museums.
2. Discuss consent, anonymity and the emotional impact of public testimony.
3. Support preparation and debrief afterwards [synthesis].
Example language (illustrative): "Some people find it helps to tell their story for a history project, or to meet others who went through similar things. Is that something you'd want, or not?"
Watch for: Exposure the client did not anticipate. Working well: the client feels the testimony is theirs.

4.17 Advocacy and commemoration

Purpose: Support a client's own advocacy (for example, for recognition, education, or memorial projects about long-stay hospitals), and the therapist's role in teaching accurate history [synthesis].
Steps:
1. Follow the client's lead.
2. Help them identify goals and allies.
3. Keep therapeutic and advocacy roles distinct.
4. In your own teaching, present the history as historians state it, with patients described by role [synthesis; source: Freudenthal and Moncrieff 2021].
Example language (illustrative): "What would feel like the right acknowledgement of what happened, for you?"
Watch for: Advocacy displacing the client's own healing, or the therapist's agenda leading. Working well: the client experiences agency.

4.18 Reflective practice on the profession's history

Purpose: Use the treatment's rise and fall to sharpen your own scepticism about enthusiasm-driven practice. Doroshow shows how local impressions created "a strong sense of efficacy". Freudenthal and Moncrieff conclude that "scientific evidence did not speak for itself" [source: Doroshow 2007; Freudenthal and Moncrieff 2021].
Steps:
1. In supervision, examine where your own beliefs about a method rest on dramatic cases rather than controlled evidence.
2. Monitor outcomes routinely.
3. Invite disconfirming feedback from clients [synthesis].
Example language (illustrative, in supervision): "Am I convinced because of a few striking cases, or because of the evidence?"
Watch for: Defensiveness. Working well: changes in practice follow outcome data.

5. Handling problems

All responses below are synthesis unless a source is cited.

The client wants procedural detail ("exactly what did they do to me?"). Respond to the need behind the question: to understand, to be believed, or to get records. Tell them plainly, from the sources, what patients went through (the insulin unit, the restlessness, fits and coma, the activities afterwards; 4.7 and the Harm account), without doses, coma counts or how comas were ended, and support a records search (4.11) so they can learn what their own notes say [synthesis].
Overwhelm or dissociation while recalling the unit. Stop, ground, and orient to the present. Return later at a smaller "dose" of memory, or work on present-day triggers first. Check for suicide risk afterwards (4.6) [synthesis].
"It saved me" versus the evidence. Do not dispute the client's experience. Doroshow documents dramatic local recoveries, and contemporaries credited the attention given on the units [source: Doroshow 2007; Tattersall 2009]. Explore what helped (4.8) [synthesis].
Rupture: the client hears you as defending psychiatry, or as attacking it. Name the rupture, ask how you came across, and repair it. Clarify that your role is to understand their experience, not to judge the era [synthesis].
Stuck in rage at institutions. Validate it. Then explore what action, acknowledgement or advocacy might move things (4.17). Watch for anger turning inward [synthesis].
Avoidance of all medical care. This is a safety issue if the client has untreated physical or mental illness. Work gradually on the fear, coordinate with their GP, and support the client to request accommodations [synthesis].
Cognitive limits (an older client). Use shorter, structured sessions, with written summaries and a trusted person present if the client wishes. Get a medical review for any change (4.5) [synthesis].
Family conflict over "raking up the past". Offer separate and joint sessions. Respect each person's right not to take part. Focus on present relationships [synthesis].
Non-adherence to current treatment, linked to this history. Do not advise on medication. Explore the fears, help the client take them to the prescriber, and support shared decision-making as NICE describes for psychological care [source: NICE CG178, information for the public; synthesis].
Client exploring self-administered "resets" online. Treat this as urgent: assess risk, route medically, and follow your safeguarding procedures (4.14) [synthesis].
Your own reactions (horror, guilt about the profession). Take these to supervision. They can tip into sensationalising or over-protecting the client (4.18) [synthesis].
Uncertain facts (which hospital, which treatment, which country). Say what is known and what is not. Mark it uncertain together with the client, and avoid filling gaps with assumption [synthesis].

Harm account

What was actually done

From the mid-1930s to the early 1960s, people diagnosed with schizophrenia, often recent-onset and younger patients considered to have a better prognosis, were treated in dedicated hospital "insulin units" in Europe, North America and elsewhere. There they were repeatedly put into hypoglycaemic coma under specialist medical and nursing staff [source: Freudenthal and Moncrieff 2021; Tattersall 2009; Doroshow 2007]. The units had the feel of an operating theatre, with their own staff and routines [source: Doroshow 2007, abstract]. Records such as a 1946 to 1948 male patients' treatment book at the Science Museum Group log responses ranging from sweating to fits and coma [source: Science Museum Group co535089]. A 1937 account quoted by Freudenthal and Moncrieff describes the patient becoming restless and crying out, sometimes throwing himself about violently, before lying "profoundly collapsed" and salivating heavily in coma; convulsions and full epileptic fits could occur. The units were "tightly controlled and intensively staffed", and patients were expected to join occupational and recreational activities later the same day [source: Freudenthal and Moncrieff 2021]. Seizures and prolonged coma were often treated as part of the therapeutic process rather than as harms [source: Freudenthal and Moncrieff 2021]. The treatment was promoted by public-health bodies and favourably reported in the press. It continued after the 1950s trials showed no specific effect, until drug treatments replaced it [source: Freudenthal and Moncrieff 2021]. Later use is reported in Australia in 1974, in China in 1985 [source: Freudenthal and Moncrieff 2021], and in Ukraine according to a 1992 survey [source: Soreff and Bazemore 2006; uncertain: secondary]. How consent was obtained is [uncertain: not verified].

How it caused harm

Death. Contemporary estimates of mortality ranged from 0.5% (Freudenberg 1947) to 4.5% (Ebaugh 1943), and were about 1% "in practised hands" per Henderson and Gillespie [source: Freudenthal and Moncrieff 2021]. A trade-press review cites 1 to 10% [source: Soreff and Bazemore 2006; uncertain: secondary]. Spencer (1948) estimated death or permanent disability at 3 to 30% [source: Tattersall 2009].
Brain injury. Post-mortem and animal studies showed extensive, irreversible brain cell destruction that correlated with the number of comas. Some suggested this made patients quieter and easier to manage [source: Freudenthal and Moncrieff 2021]. Irreversible coma and post-hypoglycaemic encephalopathy were described [source: Tattersall 2009, citing Kay 1961 and Spencer 1948].
Other physical harms. These included kidney and lung complications, convulsions, transient paralysis and marked weight gain [source: Freudenthal and Moncrieff 2021; Tattersall 2009].
Psychological harm. Former patients described it as "unpleasant" and "dangerous"; one said people "felt liberated" when they no longer had to have it, and a psychiatrist recalled patients being "brought to the jaws of death many times" [source: Freudenthal and Moncrieff 2021]. Some proponents treated fear on the unit as therapeutic [source: Freudenthal and Moncrieff 2021].
Opportunity cost and false hope. Trials found no specific benefit [source: Ackner et al. 1957 and Bourne 1953 as reported in Freudenthal and Moncrieff 2021]. Improvements often faded, leading to retreatment [source: Soreff and Bazemore 2006; uncertain: secondary].

Recognising it today

In older clients, look for memories of an "insulin ward" or "insulin unit", or of "the coma" or "shock" treatment in hospital in the 1930s to 1960s. Also note a long-standing dread of hospitals, injections or anaesthesia, and unexplained lifelong cognitive or neurological problems (route these medically) [synthesis].
In families, look for stories of a relative "never the same" after hospital, silence about psychiatric history, archive and record searches, and fear of inherited illness [synthesis].
In institutions or online, look for any proposal to revive coma-based or deliberate hypoglycaemia treatment for mental illness. This is not a supported treatment [source: Freudenthal and Moncrieff 2021; Soreff and Bazemore 2006].

What to do instead and how to help those harmed

Supported care for psychosis now. NICE recommends CBT for psychosis (at least 16 one-to-one sessions), family intervention (at least 10 meetings over 3 months to a year), and arts therapies, with personal choice considered. It does not recommend counselling, supportive psychotherapy or social skills training as standard, and does not recommend adherence therapy [source: NICE CG178, information for the public]. Medication decisions belong to the prescriber and the client [synthesis].
Survivors. Offer trauma-informed therapy (SAMHSA principles), life-review and narrative work, and medical and cognitive review through the GP or memory service (Sections 4.3 to 4.9) [source: SAMHSA via youth.gov; synthesis].
Families and descendants. Offer family work, support with record searches through archives that hold hospital records (for example the Wellcome Collection), and work on grief, guilt and intergenerational silence (Sections 4.10 to 4.12) [source: Wellcome Collection RET/6/25; synthesis].
Reporting and legal routes. Any current use or revival goes to clinical governance, safeguarding, and the professional regulator or health-care inspectorate (Section 4.15). Clients seeking redress for historical treatment can be pointed to independent legal advice [synthesis].
Survivor and peer organisations. Connect clients with peer support networks for psychiatric-system survivors and with oral-history projects, as those organisations describe themselves [synthesis].
Crisis resources. 988 (US); Samaritans 116 123 (UK and Ireland).

Sources

Web sources:

Works cited as reported in the sources above:

Bourne H (1953). The insulin myth. The Lancet 265:964-968 [as cited in Freudenthal and Moncrieff 2021].
Ackner B, Harris A, Oldham AJ (1957). The Lancet 272:607-611 [as cited in Freudenthal and Moncrieff 2021].
Sakel M (1937), and Henderson and Gillespie's textbook editions of 1950, 1962 and 1969 [as cited in Freudenthal and Moncrieff 2021].

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