Electroconvulsive therapy (ECT)

1. Introduction

Version followed: NICE technology appraisal TA59 (published April 2003, last updated October 2009; its depression recommendations were replaced by depression guidelines, catatonia and mania recommendations unchanged); NICE NG222 (depression in adults) only as a patient charity summarises it [uncertain: secondary summary]; Mental Health Act 1983 section 58A as shown on legislation.gov.uk (up to date to 15 October 2026), with the not-yet-commenced Mental Health Act 2025 amendments noted; the US FDA final order of 26 December 2018 as the American Psychiatric Association summarises it; Texas Health and Safety Code chapter 578 as one example of US state law. Legal and regulatory status checked October 2026.

Scope note: ECT is a medical procedure prescribed and delivered by a hospital ECT team (psychiatrist, anaesthetist, specialist ECT nurses). A psychotherapist never delivers it, recommends for or against it to a client, or advises on its settings. This guide is written for the psychotherapist working alongside the treating team. It contains no stimulation settings, electrode-placement details beyond naming the types, session-number counts or anaesthetic drug information.

What it is: under a general anaesthetic and a muscle-relaxing medicine, a brief electrical stimulus is passed through electrodes on the head to bring on a short generalised seizure [source: Rethink Mental Illness, ECT page, updated March 2026]. The types named in the field are bilateral, unilateral and ultrabrief-pulse variants [source: Rethink; NICE TA59 compares bilateral and unilateral; ultrabrief named only as a type] [uncertain]. The idea of how change happens comes from the original observation that induced seizures improved some severely ill patients [source: Kirov, Waves of Hope, 2024 excerpt]; the biological mechanism is not covered here [uncertain]. NICE frames the goal as "rapid and short-term improvement of severe symptoms" [source: NICE TA59, 1.1], and the FDA requires labelling to state that the device provides short-term symptom relief and that long-term safety and effectiveness have not been demonstrated [source: APA Resource Document 2019].

Brief history: ECT was first developed in Rome in 1938, spread rapidly worldwide, declined after antidepressant and antipsychotic medicines appeared in the 1950s and amid negative media portrayals, and survives today mainly for severe depression (including psychotic depression), catatonia and severe illness that has not responded to other treatment [source: Kirov 2024 excerpt]. It is commonly credited to Ugo Cerletti and Lucio Bini [uncertain: secondary, unverified]. Modern ECT is given under short-acting general anaesthesia with muscle relaxation [source: Kirov 2024 excerpt]. Around 2,000 people a year receive ECT in the UK, with higher use in Sweden and lower in Italy [source: Kirov 2024 excerpt]. ECT remains contested: patient-advocate authors argue that lasting memory loss is more common than services acknowledge [source: Robertson and Pryor 2006], and survivor and clinician accounts differ sharply [synthesis]. The therapist needs to hold both perspectives.

2. Framework

The treatment itself is organised by the ECT team. The psychotherapist's work runs in parallel across five phases [synthesis: phase structure is this guide's organisation of the official steps below].

Phase A: Consideration and referral. Goal: the client's severe or life-threatening presentation reaches a psychiatrist who can weigh all options, ECT among them. Official indications by jurisdiction:

England and Wales (NICE TA59, unchanged parts): ECT only for catatonia or a prolonged or severe manic episode, to achieve rapid short-term improvement after other treatments have not worked and/or when the condition is potentially life-threatening. NICE does not support the general use of ECT in schizophrenia [source: NICE TA59]. For depression (NG222), a charity summary states ECT can be considered for severe depression if the person chooses it based on previous experience, if a rapid response is needed (for example when life is at risk), or if other treatments have not worked; it should stop as soon as side effects outweigh benefits or the aim is achieved [source: Rethink, secondary summary of NICE NG222] [uncertain].
USA (FDA, final order 26 December 2018): ECT devices are Class II (special controls) for catatonia or a severe major depressive episode in major depressive disorder or bipolar disorder, in people aged 13 and over who are treatment-resistant or need a rapid response because of the severity of their condition. All other uses (for example schizophrenia, mania, under-13s, people not meeting those criteria) remain Class III. The FDA did not define "treatment-resistant" or "rapid response". The FDA does not regulate how physicians use the device off-label, and APA expert consensus supports some uses outside Class II [source: APA Resource Document 2019].
Other jurisdictions (Scotland, Northern Ireland, Ireland, EU, Australia, Canada) are not covered here [uncertain]; check local mental health law and guidance.

Phase B: Assessment, information and consent. Goal: a documented risk-benefit assessment (anaesthetic risk, other illnesses, expected adverse effects, especially cognitive impairment, and the risks of not treating), with particular care in pregnancy, older people, children and young people [source: NICE TA59, 1.2 to 1.3]; valid consent or a lawful alternative route. Moving on: the team has consent or legal authority; the client has had information in an accessible format and language.

Phase C: The acute course. Format: treatments in a hospital ECT suite, as an inpatient or outpatient, under general anaesthesia given by an anaesthetist; relatives usually wait outside the treatment room [source: Kirov 2024 excerpt; Rethink]. Clinical status is assessed after each treatment, and cognitive function is monitored throughout [source: NICE TA59, 1.6]. Session frequency and number are set by the treating team and are not given here.

Phase D: Ending the course. Criterion: treatment stops when a response is achieved or if adverse effects appear; cognitive function is assessed at least at the end of each course [source: NICE TA59, 1.6]. Repeat courses for catatonia or mania are considered mainly for people who responded well before [source: NICE TA59, 1.7].

Phase E: After the course. Goal: relapse prevention, memory support, resumption of psychotherapy. NICE TA59 states ECT is not used as maintenance therapy for depressive illness, allowing only short continuation within its stopping and repeat-course rules [source: NICE TA59, 4.3.7, 7.5.9]. The APA, in contrast, states maintenance ECT benefits many patients and should sit within a broader plan that may include medication and psychotherapy [source: APA Resource Document 2019]. These positions differ; continuation decisions belong to the treating team [uncertain].

Legal framework: England and Wales (checked October 2026).

Mental Health Act 1983 s58A applies to ECT. For detained patients and for young people under 18 (detained or not), ECT may not be given unless one of these applies: (3) a patient aged 18 or over consents, and the approved clinician in charge or a second-opinion appointed doctor (SOAD) certifies in writing that the patient understands the nature, purpose and likely effects and consents; (4) a patient under 18 consents, and a SOAD (not the clinician in charge) certifies understanding, consent and that the treatment is appropriate; (5) the patient cannot understand the treatment, and a SOAD certifies this, that the treatment is appropriate, and that it would not conflict with a valid and applicable advance decision or a decision by a lasting power of attorney donee, a deputy or the Court of Protection. Before certifying under (5) the SOAD must consult a nurse and one other professional involved in the patient's care who is neither a nurse nor a doctor [source: legislation.gov.uk s58A]. A detained patient with capacity who refuses therefore cannot lawfully be given ECT under s58A [synthesis drawn from the three conditions above].
Section 62 (urgent treatment): s58A is subject to s62, under which ECT may be given urgently only where immediately necessary to save life, or (if not irreversible) immediately necessary to prevent serious deterioration [source: legislation.gov.uk, MHA 2007 s28 inserting s62(1A)] [uncertain: the wording of s62(1) itself is not reproduced here]. A patient charity notes the Care Quality Commission says emergency ECT against an advance refusal happens only in exceptional circumstances [source: Rethink].
Mental Capacity Act 2005: for informal adult patients who lack capacity, ECT may be given in their best interests; an adult (18+) with capacity can make a legally binding advance decision refusing ECT, best put in writing and shared with family, the care team and GP; a health and welfare attorney, a deputy or the Court of Protection may decide, and an Independent Mental Capacity Advocate (IMCA) can support the person [source: Rethink]. The Mental Capacity Act route is disapplied for informal patients under 18 who cannot consent [source: legislation.gov.uk, MHA 2007 s28(10)].
Mental Health Act 2025 (Royal Assent, enacted text dated 18 December 2025): replaces the "capable of understanding" test with a capacity test (competence for under-16s); adds a duty (new s56A) to consider alternatives and involve the patient in decisions; requires certificates to confirm that duty was met; renames the role "second opinion appointed doctor"; and replaces the urgent-treatment rule for ECT with a new s62ZA, under which a patient with capacity who has not consented may be treated urgently only with SOAD certification, with an exceptional fallback (s62ZB) where a SOAD cannot be appointed in time. These amendments were shown as prospective (not in force) on legislation.gov.uk as of 15 October 2026 [source: legislation.gov.uk, MHA 2025 Treatment crossheading; s58A page] [uncertain: commencement dates not confirmed]. legislation.gov.uk also notes an exclusion for Wales under 2008 Welsh regulations whose scope is [uncertain].
Service standards: the Royal College of Psychiatrists' ECT Accreditation Service (ECTAS, set up 2003) accredits clinics against its Standards for the administration of ECT by peer review on a three-yearly cycle; ECTAS also sets standards for nurse-administered ECT [source: ELFT ECT Policy v3.0 (2019), citing the 14th edition, 2018; Leicestershire Partnership NHS Trust ECT policy v7 (approved October 2024), which cites the ECTAS standards of 2021 and describes the three-yearly cycle of self-assessment and ECTAS peer review] [uncertain: the edition current in 2026 is not confirmed; check with the clinic]. NICE asks trusts to ensure ECT is given only by trained staff and audited with service-user input [source: NICE TA59, 7.2, 7.6].

Legal framework: USA (checked October 2026). Consent rules are set by state law, and the APA advises following state consent requirements and revisiting consent when risks or benefits change or when moving from acute to maintenance treatment [source: APA Resource Document 2019]. Example, Texas (Health and Safety Code ch. 578): ECT is prohibited under age 16; people aged 16 and over give their own consent unless an involuntary patient has been judged legally incompetent, when the guardian of the person consents based on what the patient would have wanted; a state-standard consent form must explain the purpose and nature of the procedure, the likelihood, severity and duration of side effects and serious risks, especially memory loss (including possible permanent loss) and death, that medical experts disagree about effectiveness, and the likely extent and length of improvement with and without ECT; the form is given and explained in plain language, in the person's primary language if possible, before each treatment; consent obtained by coercion or undue influence is invalid; for people aged 65 and over two physicians must certify medical necessity before each series; consent may be revoked at any time with immediate effect; providers report outcomes including memory loss and fractures quarterly to the state [source: Texas HSC ch. 578]. Other states' statutes are not drawn on [uncertain].

3. Guiding principles

The decision is medical and the client's, not yours. Never recommend for or against ECT, or a change to it; route all treatment questions to the ECT team or prescriber [synthesis].
Consent is ongoing and can be withdrawn at any point. Remind clients of this; NICE asks that people be reminded they can withdraw consent at any time [source: NICE TA59, 1.4]; in Texas revocation takes effect immediately [source: Texas HSC ch. 578].
No pressure, including the threat of compulsion. NICE states consent must not be obtained by coercion, including the threat of compulsory treatment under the Mental Health Act [source: NICE TA59, 1.4]. Notice and name pressure from family, staff or yourself.
Shared decision-making. NICE describes a joint decision based on an informed discussion of general and individual risks and benefits [source: NICE TA59, 1.4 to 1.5]; the 2025 Act would add a statutory duty to involve the patient [source: MHA 2025 s11, prospective].
Honesty about memory, including uncertainty. Official sources describe memory effects as real, sometimes prolonged, and greater with bilateral treatment [source: NICE TA59; FDA via APA]; some authors argue that even unknown risk is something patients should weigh [source: Robertson and Pryor 2006]. Do not reassure beyond the evidence and do not dramatise beyond it [synthesis].
Take subjective memory complaints seriously. Early self-ratings are unreliable during acute confusion, and deficits may only become clear months later [source: Robertson and Pryor 2006]; listen, record and pass on, without attributing everything to depression [synthesis].
Involve carers and advocates where the client wishes. NICE encourages carer or advocate involvement [source: NICE TA59, 1.4]; under the Mental Capacity Act an IMCA can support the person [source: Rethink].
Respect advance decisions and prior wishes. Help clients record and share them; never draft legal documents yourself [synthesis; legal basis: s58A(5); Rethink].
Capacity fluctuates. Severe depression, catatonia, mania and post-treatment confusion all affect decision-making; raise capacity concerns with the team rather than assessing formally yourself unless that is your role [synthesis].
Accessible information. NICE calls for evidence-based leaflets in accessible formats and languages [source: NICE TA59, 1.10]; Texas requires the primary language where possible and adjustments for hearing or vision impairment [source: Texas HSC ch. 578].
Continuity of the therapeutic relationship. Stay a stable, non-judging presence before, during and after the course, whatever the client chooses [synthesis].
Integration, not substitution. The APA places ECT within a broader plan that may include psychotherapy [source: APA Resource Document 2019]; plan how therapy resumes after the course [synthesis].
Transparent information-sharing. Agree in writing what you will share with the team and when, including the limits of confidentiality for risk [synthesis].

4. Intervention inventory

Part A describes how the treating team delivers ECT, at a descriptive level only, so you can explain it accurately and recognise problems. Part B covers your own interventions.

Part A1. Who delivers ECT

Purpose: know whom to contact and what each role does.
Steps: identify the referring psychiatrist (in England, under the Mental Health Act, the approved clinician in charge of treatment), the ECT lead consultant, the ECT nurse or coordinator, and the anaesthetist. In the UK a consultant anaesthetist gives the anaesthetic [source: Kirov 2024 excerpt]; some accredited UK clinics run nurse-administered ECT under a named lead consultant, with ECT nurses who have specific training, supervision and competency checks [source: ELFT ECT Policy v3.0]. Ask whether the clinic is ECTAS-accredited [source: ELFT ECT Policy v3.0].
Example language (illustrative): "Would it help if we found out together who your named ECT nurse is, so you know who to call with questions?"
Watch for: no clear named contact; this is a gap to raise with the referring team [synthesis].

Part A2. Pre-treatment assessment

Purpose: explain what the client will go through before a course.
Steps: the team documents a risk-benefit assessment covering anaesthetic risk, other medical conditions, likely adverse events (especially cognitive impairment) and the risks of not having ECT, with extra care in pregnancy, older age and young people [source: NICE TA59, 1.2 to 1.3]. FDA-required product labelling covers pre-ECT assessment, cognitive monitoring and the intended population [source: APA Resource Document 2019]. The APA advises baseline and ongoing cognitive screening and documenting target symptoms, their severity, and benefits and risks compared with alternatives [source: APA Resource Document 2019].
Example language (illustrative): "Before any treatment, the team will check your physical health and how your memory and thinking are working now, so they have a starting point to compare with."
Watch for: the client not knowing whether a baseline memory check was done; encourage them to ask [synthesis].

Part A3. Information and consent process

Purpose: explain the steps to valid consent.
Steps: the client receives written information (in England, leaflets covering risks and alternatives, in accessible formats and languages) and discusses general and personal risks and benefits; consent is usually written [source: NICE TA59, 1.4, 1.10; Kirov 2024 excerpt]. In Texas a state-standard form and supplement are given and explained before each treatment [source: Texas HSC ch. 578]. The APA advises revisiting consent when risks or benefits change and when moving from an acute to a maintenance phase [source: APA Resource Document 2019]. When the person lacks capacity, the legal route depends on jurisdiction and status (see section 2).
Example language (illustrative): "Signing a form doesn't lock you in. You can say no before any treatment, and the team should check with you."
Watch for: consent described to you as a single event; clients who believe refusal is not possible [synthesis].

Part A4. What happens at a treatment

Purpose: give an accurate, non-sensational picture.
Steps (descriptive only): the person usually fasts beforehand as instructed by the team [synthesis]; in the ECT suite they receive a general anaesthetic and a muscle relaxant, and a mouth guard protects the teeth; electrodes are placed on the head (unilateral or bilateral, as the team decides); a brief electrical stimulus brings on a short seizure, which the muscle relaxant largely prevents from showing as body movement; the person wakes in a recovery area [source: Rethink; Kirov 2024 excerpt]. Relatives usually wait outside the treatment room [source: Kirov 2024 excerpt]. FDA labelling covers EEG monitoring, anaesthesia and neuromuscular blocker use [source: APA Resource Document 2019]. Choice of electrode placement and all settings are the treating team's decisions and are not described here.
Example language (illustrative): "From what the official leaflets describe, you're asleep under an anaesthetic for the treatment itself, and the muscle relaxant means your body stays mostly still."
Watch for: fears shaped by films or historical images of unmodified ECT; correct these with official information, not reassurance from memory [synthesis].

Part A5. Monitoring during the course and stopping

Purpose: know what the team checks so you can feed in.
Steps: clinical status is assessed after each treatment, cognitive function is monitored throughout and at least at the end of the course, and treatment stops when the aim is reached or adverse effects appear [source: NICE TA59, 1.6]. In England, any service must also have legal authority in place throughout (s58A certificates) [source: legislation.gov.uk s58A].
Example language (illustrative): "Your own sense of how your mood and memory are going matters to that review. Shall we note it down so you can tell them?"
Watch for: no cognitive review at the end of a course [synthesis].

Part A6. Official safety information, including memory effects

Purpose: give clients balanced information drawn from official sources, with the source named.
Steps: know these statements:
- Immediately after treatment: tiredness, headache, nausea, jaw and muscle aches, short-term confusion, especially in older people [source: Rethink].
- FDA-required patient labelling may need to cover confusion and memory loss (short- and long-term), worsening or manic symptoms, pain, burns, physical injury, prolonged or delayed seizures, lung and heart complications, and death; the required warning reads "ECT device use may be associated with disorientation, confusion, and memory problems" [source: APA Resource Document 2019].
- NICE: cognitive impairment occurs immediately after treatment and after a course, is greater with bilateral than unilateral placement, may be prolonged, and the appraisal committee noted that for some people it can outweigh perceived benefit; whether effects accumulate with repeated courses was unresolved [source: NICE TA59, 3.5, 4.1.6, 4.3.8].
- Texas requires disclosure of memory loss, including possible permanent loss, and of the risk of death [source: Texas HSC ch. 578].
- A clinician-edited UK source: up to 40% of patients report temporary memory problems; people may forget events from around the onset of depression and during the course; some memories return but gaps can be permanent; a small proportion report problems lasting months or gaps reaching back years; right unilateral placement causes less confusion and memory loss than bilateral; imaging studies have not shown brain damage [source: Kirov 2024 excerpt].
- A patient charity: memory problems usually end within about two months and most people do not find them very distressing, but some report longer-term loss, difficulty forming new memories and gaps for past events; about one in five report memory problems before ECT, which complicates attribution; research has not found raised risk of brain damage, epilepsy, stroke or dementia [source: Rethink].
- A patient-advocate perspective: retrograde (autobiographical) loss may extend back years and include skills and relationships, not only events; anterograde problems may last around two months; deficits may only emerge at two to six months; surveys cited suggest lasting amnesia affects at least a third of patients; standard screening tests are too crude to detect these effects [source: Robertson and Pryor 2006]. These figures differ from official sources; present them as one view [uncertain].
Example language (illustrative): "Official sources agree memory problems are the main side effect. They differ on how often they last. Here is what each says."
Watch for: your own bias in which figures you share; give named sources and let the client take questions to the team [synthesis].

Part B1. Recognising when to suggest an urgent medical review

Purpose: make sure a client whose presentation may be life-threatening or severe reaches a psychiatrist who can consider all options. Do not suggest ECT specifically [synthesis].
Steps: (1) notice signs such as not eating or drinking, marked slowing or stupor, mutism or posturing (possible catatonia), severe or prolonged mania, psychotic features in depression, or high and rising suicide risk [synthesis, informed by NICE TA59 indications and Kirov 2024]; (2) tell the client you are concerned and want a medical review; (3) contact the GP, psychiatrist or crisis team the same day, or emergency services if life is at immediate risk; (4) document what you observed and whom you told.
Example language (illustrative): "I'm worried about how little you've been eating and drinking. This needs a doctor today. I'm going to call your psychiatrist with you now."
Watch for: delay because the client is "engaged in therapy"; severe states need medical assessment regardless [synthesis].

Part B2. Setting up collaborative care and information-sharing

Purpose: create clear lines of communication with the ECT team.
Steps: (1) get the client's written consent to share specified information with named team members; (2) agree what you will pass on (mood changes, risk, side effects, memory complaints, concerns about consent) and how quickly; (3) get a named contact and an out-of-hours route; (4) agree how the team will tell you when the course starts, pauses or ends [synthesis].
Example language (illustrative): "Can we agree what I'll tell your ECT nurse, and what stays between us unless there's a safety concern?"
Watch for: the client feeling talked about rather than with; copy them into communications where possible [synthesis].

Part B3. Psychoeducation

Purpose: help the client understand what ECT is and is not, using official materials.
Steps: (1) ask what they already know and where it came from (films, family, internet, past experience); (2) offer the official leaflet from their service and a reputable charity page; (3) go through it together at their pace, separating official statements from anecdotes; (4) write down questions for the team; (5) offer first-hand accounts from former patients, both positive and negative, which some authors recommend [source: Robertson and Pryor 2006; Kirov 2024 is a book of patient and family accounts]; (6) do not explain technical settings; refer those questions to the team [synthesis].
Example language (illustrative): "Let's read what the College and the charity say, and mark anything that worries you or doesn't make sense."
Watch for: information overload when concentration is poor; break it into short pieces and repeat [synthesis].

Part B4. Supporting informed consent and shared decision-making

Purpose: help the client make, and keep reviewing, their own decision.
Steps: (1) clarify the decision: what is being offered, why now, what the alternatives are (including not treating) [source: Texas HSC ch. 578 and NICE TA59 list these as required content]; (2) help the client set out what matters to them (speed of recovery, memory, work, family, past experience of treatments); (3) help them prepare questions, for example about expected benefit, memory effects, placement choice, what happens if they stop partway, and follow-up memory checks; (4) suggest they bring a trusted person or advocate to the consent discussion [source: NICE TA59, 1.4]; (5) after the meeting, check understanding and remaining doubts; (6) remind them consent can be withdrawn [source: NICE TA59, 1.4]; (7) if you doubt their capacity or see pressure, tell the team [synthesis].
Example language (illustrative): "What would you need to know to feel this is your decision, whichever way you go?"
Watch for: your own views leaking in; family or staff pressure; a client agreeing simply to please others [synthesis].

Part B5. Exploring fear, stigma and ambivalence without steering

Purpose: let the client voice mixed feelings so they reach a decision that is theirs.
Steps: (1) invite both sides: hopes and fears; (2) reflect each without weighting; (3) explore the source of fears (media images, a relative's experience, their own past ECT); (4) separate fears that information can address (take to the team) from values-based concerns (for example, not wanting to risk memories of a child's early years); (5) summarise both sides and ask what they want to do next, which may be "ask more questions" or "get a second opinion" [synthesis]. Never use motivational techniques to move a client towards or away from ECT [synthesis].
Example language (illustrative): "Part of you wants something that might work quickly, and part of you is afraid of losing memories. Both make sense. Which questions would help you weigh them?"
Watch for: a client who says "I have no choice"; check whether that is despair, pressure or a legal reality, and pass legal questions to the team or an advocate [synthesis].

Part B6. Advance decisions, advance statements and advocacy

Purpose: help the client record wishes about ECT while they have capacity, and know their rights.
Steps: (1) explain that in England and Wales an adult (18+) with capacity can make an advance decision refusing ECT, which is legally binding if valid and applicable, and should be written and shared with family, the care team and GP [source: Rethink]; (2) explain that under s58A a SOAD cannot certify ECT for a patient lacking capacity where it would conflict with a valid and applicable advance decision or a decision of an attorney, deputy or the Court of Protection, subject to the urgent-treatment rules [source: legislation.gov.uk s58A]; (3) note that NICE treats advance consents as not legally binding but to be considered [source: NICE TA59, 3.6, 4.3.5]; (4) point to independent advocacy (IMCA under the Mental Capacity Act; an Independent Mental Health Advocate for detained patients [synthesis]) and to legal advice for drafting; (5) outside England and Wales, refer to local law [uncertain].
Example language (illustrative): "If you have strong views about ECT in future, there are formal ways to record them. An advocate or solicitor can help you do that properly."
Watch for: writing legal documents yourself; that is outside your role [synthesis].

Part B7. Preparing a memory support record before the course

Purpose: reduce the impact of possible memory gaps and give a baseline for later comparison.
Steps (all [synthesis], informed by Robertson and Pryor 2006, who propose comparing recall of significant life experiences before and after treatment): (1) with the client's agreement, help them make a personal record of key recent events, people, plans, appointments, work tasks and important dates; (2) suggest photos with captions, a diary and a list of practical information kept securely (not passwords in plain text); (3) record what therapy has covered so far in brief client-owned notes; (4) agree a trusted person who knows where the record is; (5) note the client's own baseline description of their memory now, to pass to the team with consent. This is not a formal cognitive assessment, which is the team's job.
Example language (illustrative): "Some people find it helps to write down what's been happening lately, just in case the weeks around treatment are hazy later. Would you like to start that together?"
Watch for: the exercise raising anxiety; frame it as ordinary preparation, like packing a bag [synthesis].

Part B8. Support during the course

Purpose: maintain contact and safety while the client is having treatments.
Steps: (1) agree in advance whether sessions continue during the course, in what form (shorter, supportive, on non-treatment days) and who arranges transport [synthesis]; (2) expect confusion on treatment days and keep sessions concrete and supportive rather than exploratory [synthesis, based on acute confusion described by Rethink and Robertson and Pryor 2006]; (3) recap at the start of each session and give a short written summary at the end; (4) support following the team's after-treatment advice, for example on driving and important decisions [synthesis: the team's instructions apply; not detailed here]; (5) check for side effects and mood changes each contact (see B9).
Example language (illustrative): "Today let's keep it simple. How have you been feeling since the last treatment, and is there anything you want me to pass on?"
Watch for: the client repeating questions or not remembering the last session; record and pass on rather than interpret [synthesis].

Part B9. Monitoring and passing on adverse effects and mood changes

Purpose: be an extra pair of eyes for the team.
Steps: (1) at each contact ask briefly about mood, sleep, appetite, energy, hope, suicidal thoughts, confusion, memory, headaches and other physical complaints; (2) pass on promptly: new or worse memory problems or confusion; worsening depression; emerging manic symptoms (for example reduced need for sleep, racing thoughts, overspending), which FDA labelling lists among risks [source: APA Resource Document 2019]; rising suicidal thinking; any injury, burns, breathing or heart symptoms or unusual seizures reported [source: risks listed in APA Resource Document 2019]; distress about consent or a wish to stop; (3) for immediate danger, use emergency routes; (4) document what you passed on, to whom and when [synthesis].
Example language (illustrative): "You mentioned you've been sleeping only a few hours and feel full of energy. I'd like to let your ECT nurse know today. Is that OK?"
Watch for: improvements that come with new risk, such as more energy before mood lifts [synthesis].

Part B10. Memory support after the course

Purpose: help the client manage and make sense of memory gaps.
Steps: (1) ask specifically about memory for recent events, people and skills, not only general wellbeing, because deficits may surface months later [source: Robertson and Pryor 2006]; (2) use the B7 record, photos and trusted others to rebuild timelines; (3) introduce external aids (calendar, phone reminders, notebooks) and routines [synthesis]; (4) validate the client's experience without dismissing or catastrophising; (5) with consent, report persistent problems to the team and ask about formal cognitive review; some authors recommend follow-up testing at around 6 to 12 months with tests sensitive to these effects [source: Robertson and Pryor 2006]; (6) where relevant, support grief over lost memories [synthesis].
Example language (illustrative): "It sounds really unsettling not to remember last spring. Let's look at what you wrote down then, and I'll also ask the team about a proper memory review."
Watch for: problems with work or relationships that the client links to memory; these are reasons to seek review [synthesis].

Part B11. Crisis and safety planning across the course

Purpose: keep a current, shared safety plan before, during and after treatment.
Steps: (1) before the course, review or write a safety plan: warning signs, coping steps, people to contact, professional and crisis numbers, and making the environment safer through storage or removal of means; (2) share it, with consent, with the ECT team and carers; (3) update it during the course if mood or risk changes; (4) after the course, plan for the period when energy returns and for possible relapse [synthesis: standard risk practice, not ECT-specific sources]; (5) note when the ECT team's involvement ends and who is responsible afterwards [synthesis].
Example language (illustrative): "Let's update your safety plan for the next few weeks, including who you'd call if the nights get bad."
Watch for: gaps in responsibility between the ECT team and community care at discharge [synthesis].

Part B12. Integrating psychotherapy before, during and after

Purpose: make ECT one part of a coherent plan.
Steps: (1) before: focus on engagement, hope, practical preparation and decision support; (2) during: supportive, low-demand contact; (3) after: once the team considers the client able, resume or start the evidence-based psychotherapy that fits the presentation, revisiting work that may have been forgotten; (4) agree with the team how therapy fits any continuation plan; the APA places maintenance ECT within a broader plan that may include psychotherapy [source: APA Resource Document 2019] [synthesis for steps 1 to 3].
Example language (illustrative): "Now that your mood has lifted a bit, we can return to the work we paused. Let's start by reminding ourselves where we'd got to."
Watch for: starting demanding work while concentration is still poor [synthesis].

Part B13. Relapse prevention after the course

Purpose: help the client keep gains and spot early signs of return.
Steps: (1) build a list of the client's personal early-warning signs from this episode; (2) agree actions for each, including contacting the team early; (3) share the plan with consent; (4) schedule booster or review sessions [synthesis]. Decisions about continuation ECT, repeat courses or medicines are the team's; NICE notes repeat courses for catatonia or mania are considered mainly in people who responded well before [source: NICE TA59, 1.7].
Example language (illustrative): "What were the first signs last time, before things got really bad? Let's write those down with what you'd do."
Watch for: the client believing relapse means failure; normalise early help-seeking [synthesis].

Part B14. Supporting carers and family

Purpose: carers can help with consent discussions, practical support and memory.
Steps: with the client's consent, offer a joint session to share official information, agree practical help (transport, being with the client after treatment as the team advises, helping with the memory record), and discuss how carers can notice and pass on changes [synthesis]; NICE encourages carer or advocate involvement [source: NICE TA59, 1.4].
Example language (illustrative): "Your partner has asked how they can help. Shall we invite them so we can go through the leaflet together?"
Watch for: carer views overriding the client's [synthesis].

Part B15. Working with clients who had ECT in the past

Purpose: respond to positive, mixed or harmful past experiences, including treatment without consent.
Steps: (1) ask openly what it was like and what they remember; (2) validate memory loss and any sense of violation or coercion without arguing for or against ECT; (3) where there was treatment without consent, consider trauma-informed work [synthesis]; (4) explain routes for questions or concerns: requesting records, the service's complaints process and, in England, the Care Quality Commission's oversight role [synthesis; CQC role in emergency ECT noted by Rethink]; (5) if ECT is offered again, use B4 to B6.
Example language (illustrative): "You've said nobody really asked you last time. That must have been frightening. What would you want to be different now?"
Watch for: your own views about ECT shaping how you respond [synthesis].

Part B16. Special populations

Purpose: apply extra care where official sources ask for it.
Steps: NICE asks for particular care in pregnancy, older people and children and young people [source: NICE TA59, 1.3]; in England, under-18s need SOAD certification even when they consent [source: legislation.gov.uk s58A(4)]; FDA Class II covers only people aged 13 and over [source: APA Resource Document 2019]; Texas prohibits ECT under 16 and requires two physicians' certification for people 65 and over [source: Texas HSC ch. 578]. For young people, involve parents or carers as the law allows and use developmentally suitable information; for older people, watch closely for confusion; for pregnancy, ensure obstetric input is discussed with the team [synthesis].
Example language (illustrative): "Because you're under 18, the law adds an extra independent doctor's check. Let's go through what that means."
Watch for: a young person's views being sidelined [synthesis].

5. Handling problems

None of the cited sources address the psychotherapist's role directly; the guidance below is [synthesis] except where a source is named.

"Just tell me whether I should have it." Decline warmly and explain why: the decision belongs to the client with the medical team. Offer to help them weigh it (B4, B5) and to prepare questions. Illustrative: "I can't make that call, and it wouldn't be fair to you if I tried. I can help you work out what matters most and what to ask."
Family or staff pressure. Name it with the client, check whether they feel free to refuse, and if pressure involves threats of compulsion, raise it with the team; NICE states consent must not be obtained by such threats [source: NICE TA59, 1.4]. Suggest an advocate.
Client wants to stop partway. Support their right to withdraw [source: NICE TA59, 1.4; Texas HSC ch. 578], help them tell the team promptly, and explore reasons without trying to change their mind. Pass on any risk concerns. If they are detained, explain that the team must consider the legal position and that an advocate can help [synthesis].
Client lacks capacity or is detained. Your role is to keep the client's voice in the process: share known wishes and any advance decision with the team (with consent or as the law allows), support advocate involvement, and be present for the client. Do not obstruct lawful treatment, and do not promise outcomes [synthesis; legal frame in section 2].
Overwhelm and confusion in sessions. Shorten sessions, use written summaries, focus on safety and comfort, and postpone exploratory work [synthesis].
Memory complaints dismissed or minimised. Record the client's account in their words, encourage them to request a formal review, and pass it on with consent; Robertson and Pryor argue subjective reports deserve weight alongside testing [source: Robertson and Pryor 2006].
Grief or anger about lost memories after the course. Validate; help rebuild a narrative with records and others; consider grief-focused work; support the client if they wish to raise concerns formally. Do not argue the evidence with the client [synthesis].
Therapy content forgotten. Expect it; use client-owned session notes and revisit core ideas briefly. Treat it as a practical issue, not resistance [synthesis].
Rupture: the client feels you sided with the team (or against it). Acknowledge it, restate your role and neutrality, and ask what they need from you. Repair is more important than being right [synthesis].
Your own views about ECT. Whether enthusiastic or opposed, take them to supervision. Share official sources, not personal opinions [synthesis].
Emerging manic symptoms or worsening mood. Pass on to the team the same day; FDA labelling lists worsening or manic symptoms among risks [source: APA Resource Document 2019]. Use the crisis plan if risk is immediate.
No response or relapse after the course. Normalise the disappointment, keep hope realistic, update the safety plan and encourage early contact with the team about next options; never suggest specific treatments [synthesis].
Confidentiality conflicts. Follow the agreed information-sharing plan (B2); where safety requires sharing without consent, follow your professional code and tell the client what you shared, unless doing so increases risk [synthesis].
Stigma and secrecy. Some clients hide ECT from family or employers. Help them decide whom to tell and plan how, including what to say about time off and memory [synthesis].
Client asks about "home" or do-it-yourself brain stimulation as an alternative. State clearly that ECT is only given under general anaesthesia in a hospital setting by a trained team [source: NICE TA59, 7.2; Kirov 2024 excerpt], and that you will not give technical information. Refer questions to the prescriber [synthesis].
Uncertainty about the law in your jurisdiction. Check with the service's Mental Health Act administrator or legal team rather than relying on general guides; in England, Mental Health Act 2025 changes may come into force in stages [source: legislation.gov.uk; commencement dates not confirmed] [uncertain].

Sources

Sources (checked October 2026):

Cited indirectly (through the sources above, or marked [uncertain]):

Royal College of Psychiatrists: Electroconvulsive therapy (ECT)
NICE NG222, Depression in adults: treatment and management (as summarised by Rethink)
Royal College of Psychiatrists ECTAS, Standards for the administration of ECT (cited via the ELFT and Leicestershire Partnership policies: 14th edition, 2018, and 2021 standards)
American Psychiatric Association (2001) The Practice of Electroconvulsive Therapy: Recommendations for Treatment, Training, and Privileging, 2nd edition (Task Force report; cited via APA Resource Document only) [uncertain]

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