Clanging critics

Television depictions of individuals with psychiatric disorders have recently received increased media attention, particularly after the premiere of the ABC series Wonderland, which showed the day-to-day workings of a psychiatric hospital in New York City. That series was cancelled after only 2 airings owing to poor ratings. Even so, those 2 episodes generated vehement criticism from the National Alliance for the Mentally Ill (NAMI) and others for depicting psychiatric patients as violent and frightening, although television critics in general lauded the series. Condren and Byrne, in their critique of ER, raise similar points about the portrayal of psychiatric patients as “violent and dangerous” and “nearly always destructive, either to themselves or others.”

We take issue with many of the authors' overgeneralizations and frank misstatements about the presentation of psychiatric patients on ER. We have always sought to portray a variety of patients on the show, and as such, some psychiatric patients are violent, but most are not. By focusing on 1 patient, a man with schizophrenia who killed the character Lucy Knight and injured John Carter, the authors jump to the false conclusion that we are somehow saying that all people with schizophrenia are violent and dangerous.

Violent patients in the emergency department are likely to be under the influence of alcohol or drugs, psychotic, or suffer from a personality disorder, mental retardation, or an organic condition.¹ Although “violent behavior in psychiatric patients is no higher than in normal patients... paranoid patients are especially worrisome, particularly when they shift from generalized paranoia... to a specific person or group.”² Paul Sobriki, the character with schizophrenia portrayed on ER, presented with headaches that were misdiagnosed as meningitis. As Lucy and Carter attempted a lumbar puncture, Paul begged them to stop, pleading: “What're you putting into me? Stop, it hurts... You're sticking me in my back... You're sticking me. Stop hurting me!” Carter and Lucy should have recognized that their kicking and screaming patient was not a typical presentation for an adult undergoing a lumbar puncture. That was a terrible mistake on their part and on the part of the attendings, which was dealt with in the following episode. However, we were careful in setting up Paul's paranoia so that when a knife was available (it was lying beside a Valentine's cake), Paul picked it up and used it against the 2 characters he perceived to be his tormentors. To say, then, that the episode ends with Paul's “unprovoked” assault fails to take into account the careful depiction of his psychosis. Were we saying that everyone with schizophrenia stabs their physician? Hardly. We were showing 1 case, and only 1 case.

What is particularly misleading about the authors' critique is that they use the episode in which Lucy and Carter are stabbed as a straw man for performing what turns out to be a selective and highly misleading retrospective analysis of previous episodes dealing with psychiatric issues. Their subtextual premise is that if 1 episode showed a psychotic patient being violent, then all others must do the same.

We find it strange, yet convenient for their premise, that the authors failed to mention several episodes within the previous 22 that depicted a woman with schizophrenia, Coco, who gave birth to a baby and was helped by Nurse Hathaway not only to stay on her medications but to learn how to care for the infant. Coco was psychotic when she delivered the baby on the street, but in 2 later episodes, Hathaway worked with her so that she could keep her baby. The message: a woman with schizophrenia can be treated successfully with medication and, in this case, can be trusted to care well for her baby with some supervision.

Rather than address each example the authors give to bolster their spurious argument that ER depicts “mentally ill people [as] nearly always destructive, either to themselves or others,” we will highlight the most egregious. First, one of the “hyperactive” children, Seth, a boy of 11 who cut himself when he angrily smashed a window, was found by Lucy not only to be depressed but taking a combination of drugs (Mellaril [thioridazine hydrochloride], Inderal [propranolol hydrochloride], and clonidine hydrochloride) that was causing severe side effects. Lucy learned this by taking a thorough history and by listening empathetically to Seth. She even asked the psychiatric attending if she could follow up with Seth on a regular basis to be sure he was doing all right. “Where are the cases in which patients are helpfully supported through the terror and distress of their acute illness?” the authors ask. These are 2 of many examples. Why did the authors, once again, fail to note this? Because it clashed with their half-baked theory that ER for some reason only presents psychiatric patients as inhuman monsters.

Some of the examples cited are not to be taken as seriously as the cases of schizophrenia or depression. The episode in which “one man encourages another to drill a hole in his forehead” was played as bizarrely comical, as was the one of the woman who thought she was a bird. The show does take place in an ER after all, where all modes of human behavior are seen.

On ER we strive to show an array of medical and psychiatric problems that pose interesting treatment and ethical dilemmas to the doctors and nurses. We consult regularly with psychiatrists from the National Institutes of Health, UCLA, and Harvard to ensure that our depictions are realistic and responsible. We have recently shown how difficult it is to treat anorexia and bulimia and, in the past, have presented patients with depression, bipolar disorder, and drug addiction. In fact, a major story line now for ER is depicting John Carter's drug addiction and treatment. Last season, the doctors failed to notice his problem until a medical student caught Carter injecting himself with fentanyl. Then, all the doctors worked together to intervene and to save Carter's life and career. Need we say more about compassion and empathy?

In the future, we hope that researchers take a less selective view of the show to bolster their simplistic claims. We welcome debate and responsible dialogue about the depiction of psychiatric patients, and we certainly will strive in the future to be more compassionate in our portrayals, particularly because viewers do form opinions about psychiatric illnesses, at least in part, by what they see on television. We ask in return that researchers like Condren and Byrne present a fairer analysis of the stories. After all, we share the same goal: to portray psychiatric disorders honestly, informatively, and with empathy.