By Jessica A. Gold, M.D., M.S.
Sep 13, 2018 @ 8:00 am
Ron Tom/Getty Images

Lately it seems like everyone has been talking about mental health, so it's not surprising that our favorite TV shows are taking on topics pertaining to the psyche more and more, too.

This is Us beautifully and fairly portrays binge eating disorder, alcoholism, and panic disorder. Shameless features a mother and son who both have bipolar disorder, and it thoughtfully represents their challenges. The last season of Handmaid’s Tale showed a variety of responses to trauma, sexual assault, and peri- and postpartum mood disorders. Representation like this on television is a great way to destigmatize mental illness — but that only works if the representation is fair and accurate. Unfortunately mental health storylines are much more likely to be fear-mongering and wildly wrong. As a psychiatrist, this both piques my interest and upends my work-life balance. Whether I’m watching everyone’s favorite medical drama or “reality” TV, it’s impossible not to switch into physician mode, angry on behalf of all of my patients and the many viewers who are being misled.

Here’s why: We learn about ourselves and our world through entertainment. You may think getting information about mental illness from mindless TV is like taking health tips from a Kardashian (and, okay that's fair). But one study published in 2016 in the journal Social Work in Mental Health found that a quarter of college students reported TV and film as their primary source of education on mental illness. In 2014, 25 percent of young adults in California said they would be unwilling to move next door to someone with mental illness. Perhaps this is because they’re used to seeing such people portrayed as violent loose cannons (instead of, say, just like their current next-door neighbor). 

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What we see on TV can influence our behavior, too. Following the release of the first season of 13 Reasons Why, internet searches for “how to commit suicide” jumped 26% higher than what would normally have been expected at the time, and some teen deaths were labeled “copycats.” Searches for “suicide prevention” and “suicide hotline number” also rose by 23% and 21% respectively, according to research into Google data. Hopefully that means the show helped at least some people reach out who wouldn’t have otherwise, but that also further proves how important it is to get these portrayals right.

Consider the inverse: If your drinking problem doesn’t look like a Real Housewives drinking problem, you might think it’s fine, and carry on without seeking needed help. And when shows like our beloved Bravo franchises get mental illness wrong, they seem to be getting it really wrong. Here are 15 examples from this past year that had me screaming at my TV. With any luck, the new fall slate will do better.

 

The Magical Recovery

(Grey's Anatomy, Season 14, Episode 22)

The plotline: Alex Karev realizes his mom has gone MIA. He's worried because she has schizophrenia, and he remembers times in his childhood when she'd wander away from home and be a danger to herself. He rushes to Indiana to find her, fearing the worst, and it turns out she's all better! She's been "sticking to routines" and holding down a job; she looks great and is happy. She tells him she's fine now and that her schizophrenia “got better with age.”

The problem: While it is important that television show recovery from mental health conditions as a possibility, serious mental illnesses like schizophrenia are lifelong. According to John Krystal, M.D., professor and chairman of the Yale department of Psychiatry, symptoms may fluctuate over time, but patients with long-standing illness, like Karev’s mom, may actually see worsened symptoms as they age. The character also alludes to the fact that her medication is somehow working better now that she is older, which Dr. Krystal also refutes. “Unfortunately, so far, our medications are most effective early in the course of illness. As a result, there is a growing emphasis on early detection and treatment.” He adds, “I worry that creating the expectation of spontaneous recovery, which occurs very rarely, would make the vast majority of patients who have chronic symptoms feel discouraged or perhaps feel like a failure.”

 

The Casual, At-Home Opioid Withdrawal

(Grey's Anatomy, Season 14, Episode 21 & 22)

The plotline: Amelia Shepherd, a recovering opiate addict and neurosurgeon, meets the mother of Owen Hunt’s foster child, Betty. Betty is a 15-year-old who is now homeless after she became addicted to opiates that were prescribed to her for a soccer injury, and ultimately transitioned to taking heroin. Amelia wants to help Betty detox, so she takes her into the home she shares with Owen.

The problem: These episodes tell a common narrative of opioid addiction in this country: injury leads to prescription medications which lead to heroin. The symptoms of withdrawal are portrayed pretty correctly (sweats, shakes, vomiting, muscle contractions and pain). The point of contention here is that the storyline focuses on Betty withdrawing at home, while Amelia stops by to check on her. (We see this play out in season two of 13 Reasons Why, too, when a teenager detoxes in his friend’s bedroom while a rotating cast of classmates babysit him.)

“Withdrawal is best managed by a physician rather than attempted at home, and there are multiple medications that can make the process both less dangerous and less unpleasant,” says Keith Humphreys, Ph.D, professor of psychiatry at Stanford. (Like the other experts quoted in this piece, Dr. Humphreys did not watch the episodes, and is commenting on best practices in similar situations.) Amelia and her ex-husband Owen, who are both doctors, would've known better than to take on Betty's detox as a side project.

“Movies and television shows tend to focus on detoxification as a trial by fire that purges addiction, but it doesn’t. It just means the acute effects of the drug are gone,” Dr. Humphreys says. And furthermore: “Two of the best treatments for opioid addiction — methadone and buprenorphine maintenance — don’t even require detoxification at all.” In this time of crisis in our country, it is important to know doctors can help, and that you don’t have to go through such a painful ordeal alone (or at all!) in order to get clean. But it’s just as important to know that your friend bringing over Gatorade is probably not going to cut it. 

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The Violence Stereotype

(13 Reasons Why: Season 2, Episode 13)

The plotline: Tyler is a student who is bullied in high school. In the Season 2 finale, he is sexually assaulted by a group of other boys in the school. Afterward, he decides to go to the school dance and “make them pay” using a stockpile of weapons.

The problem: By linking a very violent scene of bullying and trauma to a person’s motivations for attempting a school shooting, this episode suggests that “revenge” shooting is a viable or at least justifiable option. It also suggests that psychological conditions can lead to violence (such as PTSD, which we can assume he would be experiencing, though it isn't outright mentioned on the show). This link, between mental illness and violence, is a dangerous and frankly overused cliche. “A good deal of the demonization of people with mental disorders stems from a marked overestimation of their risk of violence,” says Paul Applebaum, MD, a professor of psychiatry, medicine, and law at Columbia University​​​​​​​. “Media portrayals of violence involving mental disorders reinforces the false view that we should be afraid of our neighbors who need our help and understanding, and should not have to the face the consequences of our fear.” Especially in a country in which gun violence occurs all too often, and perpetrators' mental illness is often the go-to blamed entity, TV portrayals need to be mindful not to add to this stigma.

The Joke Diagnosis
(The Real Housewives of Beverly Hills, Season 8, Episode 3)

The plotline: After Lisa Rinna asked Dorit Kemsley and P.K. (Dorit’s husband) if they were doing cocaine in her bathroom at a party last season, they have been particularly angry with her. P.K. recalls a dinner he had with Rinna, and says, “She was so nice,” and then she “attacked Dorit, attacked me, attacked the whole evening.” Dorit adds, “He thinks Lisa Rinna is schizophrenic.” She goes on to support this claim by describing a time when Lisa yelled at Dorit on a boat in Hong Kong. She says, “She is one person one minute then she's another person another minute… She’s got rage and regret, rage and regret.”

The problem: Psychiatric diagnoses should not be used flippantly or to characterize unwanted behavior. This is not the only time this was done in RHOBH, either. Lisa Rinna previously described Yolanda Hadid as having Munchausen syndrome. People do things we may not like, or that may be hurtful or unpredictable, but that does not make those people mentally ill. Saying so only stigmatizes mental illnesses further, by equating it to bad behavior. Also, “schizophrenic” does not mean “erratic” or “changing one’s mind frequently.” This colloquial usage minimizes the symptomatic constellation that truly makes up the diagnosis.
 

The Make-Believe Treatments

(VanderPump Rules, Season 6, Reunion)

The plotline:  LaLa Kent says she has anxiety and is on a low dose of anti-anxiety medication. In one episode, she makes a baby bottle for herself of warm milk and is seen nursing it before bed. When asked about this in the reunion, she says, “I looked it up; there are many things you can do for anxiety: ice on your wrist…flipping an elastic against your wrist…”

The problem: She is right that elastic and ice are used as coping skills in certain forms of therapy, as a way to help manage emotions. However, I would not put sipping a baby bottle in that same category. I would, instead, call that a regression to childhood that could be harmful, or a symptom in itself. Additionally, this very image (an adult nursing a bottle as a form of treatment) makes mental health management seem silly, non-medical, and non-evidenced based. Trust me, we have treatments that work — this is just not one of them.

Zany Hallucination Plots

(Orange Is the New Black, Season 6, Episode 1)

The Plotline: Following the prison riot at the conclusion of Season 5, this season opens with Suzanne "Crazy Eyes" Warren watching what appears to be a hallucinated television set. Flipping imaginary channels, Suzanne sees her peers in different shows (Red is a Clown, Piper is on Jeopardy, Nikki is a comic dog). Some of the dialog is grounded in real events (for example, Daya’s exchange with guards who are beating her is reimagined as a dance routine). After about eight minutes of this, we learn that Suzanne is off her medication. We later see her hallucinate her mother as a calm participant in a meeting with investigators, and then she envisions the entire prison ward doing the "Cha-Cha Slide." What fun.

The problem: This is not at all what hallucinations look like in a person suffering from mental illness, and this portrayal leads to further stigmatization and misunderstanding of disease. While we are unsure what Suzanne's diagnosis is exactly, according to Rona Hu, M.D. a clinical associate professor at Stanford University, "Hallucinations are auditory much more often than visual. It's understandable that a TV show or movie, being a visual medium, would prefer to depict visual hallucinations, but I've often thought an accurate and well-done depiction of what auditory hallucinations are like would go a long way in helping people be more compassionate about serious mental illness." Dr. Krystal adds, "Most people experiencing chronic hallucinations develop ways to hide this fact from the people around them. Most commonly, they seem a little distracted." For Suzanne to clap along to the musical number, and point and laugh at what she's seeing, seems to be not just an unlikely and uncommon scenario, but an unrealistic one.

The Patient-Therapist Relationship

(Suits, Season 7, episode 1)

The plotline: Harvey Specter goes to a therapist (Dr. Paula Agard) for panic attacks, and becomes romantically involved with her. After a year has passed, she agrees to date him  because, as Harvey says, “according to the APA...enough time has passed.”

The problem: To say that a romantic relationship between therapist and patient is not something that should be normalized is an understatement. When it comes to former patients, there is some gray area: The American Psychiatric Association says it’s always off-limits, while the American Psychological Association has a two-year rule, with the added condition that the therapist bears the burden of demonstrating that the relationship is not exploitative of the former patient. 

“A therapist who engages in sex with a former patient is exploiting the person’s vulnerability for his or her own gratification,” says Dr. Applebaum. “TV shows that fail to explore these complex issues in a responsible way may mislead people into believing that such relationships are common and accepted (they are neither), and can impact their decisions about entering treatment or fully revealing personal information as part of the process. This might be especially true for people with histories of sexual abuse, who may fear entering a situation in which a sexual relationship can develop.” The therapeutic relationship should always feel like a safe space, and with romantic entanglements looming as a possibility, it may not.

Making Rehab Seem Fun

(Famous in Love, Season 2, Episode 1)

The plotline: Rainer Devon goes to rehab for Alcoholism. The rehab appears very cush with yoga and a pool. He goes to AA meetings, but otherwise seems to enjoy rehab as a place to get away from the drama of his life (he even meets a girl!). He leaves “when he feels ready.”

The problem: Alcohol withdrawal is dangerous. In some people you can have massive changes in heart rate, hallucinations, and it can be life-threatening. "It is hard to predict who will have serious withdrawal symptoms, as you can’t base it on how much they are drinking or for how long," says Anna Lembke, M.D., chief of addiction and the Dual Diagnosis clinic at Stanford. We aren’t privy to the first few days of Rainer’s rehab (due to a time jump) and don’t know if he did suffer serious (or any) withdrawal symptoms. Instead, we see that rehab is a chill time for him, rather than a serious undertaking that requires hard, daily work. This is just as harmful as exaggerating its horribleness. Viewers might be swayed to go to a rehab that is not delivering evidence-based practices, because it looks like a relaxing or fun getaway. 

 

Triggering Plotlines

(The Handmaid's Tale, Season 2, Episode 1):

The Plotline: This season opens with the handmaids being punished for refusing to stone Janine to death in the last season finale. We see 45 of them being ushered onto dilapidated Fenway Park, in muzzles, to be hanged. They are forced into nooses as Aunt Lydia reads threatening scripture. As the lever is pulled, no one is hanged, and it becomes clear this was a mock execution. June says (what the viewers are all thinking) in voiceover, "Our father who art in heaven — seriously, what the actual fuck?"

The Problem: There are dangers in showing such a gut-wrenching, hard to watch, and frankly traumatizing scene. For survivors of self-harm or even abuse, this (and the rape scene in episode 10), can be re-traumatizing, and yet the only warning before this episode is the TV-MA card. "We are in an era where everything is shown on TV and this seems particularly dramatic. My own opinion is that much of what is shown is unnecessarily graphic but not just particular to this show,” says Anne Glowinski, M.D., M.P.E. a child and adolescent psychiatrist and professor at Washington University in St. Louis (where I am an assistant professor). “At least a warning that this is graphic and emotionally triggering material would be helpful.”

Voyeurism Into Self-Harm

(Sharp Objects, Episode 1)

The Plotline: In the last few minutes of the very first episode of this psychological thriller, Camille Preaker strips down to go into a bathtub to relax after a hard day of work as a journalist reporting on the disappearance of two young girls in her hometown. As viewers, we see that her skin is covered in self-inflicted scars. Her self-harm becomes more central (and is even shown) as the season goes on.

The Problem: Though the flashbacks hint at some kind of trauma in Camille Preaker's life, we are still not so certain why she cuts, if this is a symptom of a greater disease, or whether she has received help. HBO does provide resources for viewers at the end of episodes, which is important as, per Dr. Glowinski, "self harm is contagious." Yet, one difficulty of the story being a mystery is that we are left guessing why Camille has harmed herself, and what we should take from it. The scars are a fascination at this point in the series, as opposed to a medical symptom viewers can safely put into context.

RELATED: Is HBO's Sharp Objects True to the Book?

Making Suicide a Punchline

(Orange is the New Black, Season 6, Episode 1 and others)

The Plotline: In the first episode of this season we learn that the guards play a game of fantasy inmate and, like fantasy football, have a "draft" to pick their players. In this game, they get points for their inmates’ bad behavior, such as fights or sexual conduct. When one inmate attempts to kill herself, a guard says, "Suicide is worth 14 points, attempted is worth 7."

The problem: Even though this game is designed to illustrate the brokenness of the prison system, and how jaded the guards have become to the people in their care, suicide shouldn’t be used as the punchline in this way; they could’ve made the same point with fights in the cafeteria and illicit inmate hookups; self-harm, in my opinion, goes too far. "The greatest harm is probably that it demeans the struggle that people face when dealing with chronic mental illness, and it could be demoralizing for people who have been struggling with suicidal urges," says Dr. Krystal.
 

Making Light of Dangerous Drug Combinations

(VanderpPump Rules, Season 6, Reunion Part 3)

The plotline: Stassi Schroeder has a bad experience with her boyfriend Patrick at the her birthday party. When asked about it in the reunion she says, “I don’t remember it,” and that she “couldn’t form a sentence” because she was on “Xanax and alcohol.” When asked by Andy Cohen if that was a good idea, she laughs and says, “probably not.”

The problem: Not only is this not a good idea, it is really dangerous. The effects Stassi describes (blacking out) are common with this mixture, but it can also be fatal. “Most of the drug overdose deaths in the country are due to polypharmacy,” says Dr. Lembke. For example, she notes that mixing sedatives (both alcohol and Xanax are sedatives) increases your risk of overdose. “We have focused on the opioid epidemic, but benzodiazepines (Xanax, in this case) are our other prescription drug problem. We have seen a six- to seven-fold increase in benzo-related deaths since the 1970s,” she says. While it might be helpful to showcase this on TV as a warning to viewers, laughing it off makes light of the seriousness of this mixture. “In general, anything that glorifies or makes light of substance use and addiction has corrosive effects, and underestimates the effect of the use of substances on people’s lives, and the damage done by addiction,” she says.

Being Held Hostage in a Psych Ward

(Famous in Love, Season 2, Episode 10)

The plotline: On the season finale, Alexis Glenn appears to be suffering from a mental breakdown as she cuts her hair, writes on the wall, and is videotaped by fans singing on the street for money. She is later found by police in a child’s room and arrested and placed on a psychiatric legal hold (also called a “5150”). As a result, Alexis loses her show and her manager. She tells her friends that she was “faking crazy,” and that was her plan all along. As she plans to sign out of the hospital, the nurse tells her, “You do not even get seen by a doctor until it has been 72 hours.” At the end of the episode, Alexis is “trapped” and banging on the walls saying, “I am not crazy.”  

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The problem: This entire premise is a huge problem. The idea that being mentally ill is something to “fake” to get out of any situation is reprehensible and stigmatizing to anyone who actually needs psychiatric care. The characters repeatedly use the word “crazy,” and when Alexis’s friend finds out she was making up her symptoms, she says, “you are insane” (while hugging her and laughing). The word choice here is hurtful and additionally stigmatizing. Furthermore, a 5150, at least in California where the show is set, is a 72-hour psychiatric hold, but law requires a patient be evaluated at least every 24 hours to see if they're ready to be released. Alexis definitely would not be “trapped” for three days without seeing a doctor. A nurse also threatens that the doctor could choose to keep Alexis for 30 days, which is also incorrect. There are many steps in the legal process before anyone would be committed for a month. And worse: All of this makes it seem like in-patient care is a punishment.

More On the Involuntary-Hospitalization Front

(How to Get Away with Murder, Season 4, Episode 9)

The plotline: Laurel Castillo is involved in a twisted power struggle with her father while trying to find evidence to link him to murder and financial crimes. Following the emergency premature birth of her child, she wakes up in a psychiatric ward without her baby. She finds out that her father forged her mental health history to include bipolar disorder as a ploy to keep her away from her new baby. Annalise Keating gets her own therapist (Isaac) to come testify as a second opinion to get her out of the hospital.

The problem: You can’t just be institutionalized because someone says you should be, and this show should not portray that as a possibility. “It is almost inconceivable today that a family member could ‘railroad’ a person into a hospital by fabricating a psychiatric history,” says Dr. Applebaum. The commitment process in every state requires a face-to-face evaluation and documentation that the person has a mental disorder and that, as a result of the disorder, it would be dangerous for the person or others for them not to be hospitalized, he says. Perhaps most importantly, “A psychiatric diagnosis by itself would never be the basis for depriving a mother of custody of her child.” And, yes, this kind of misinformation can have real-world consequences. “When people see scary stories about the misuse of the mental health system to deprive people their rights, it may lead them to be wary of any contact with mental health professionals.” Fewer scary stories that take place in psych hospitals, please!

Making Medication Look Dangerous

(Unreal, Season 3, Episode 5 and 6)

The plotline: Rachel Goldberg goes to “rescue” her father from her mother’s care. He is diagnosed with bipolar disorder and on Lithium, as prescribed by her mother (who also happens to act as the family psychiatrist). Rachel takes her father to set with her and starts helping him decrease his medications. He exhibits serious withdrawal effects and, at one point, he walks in on the “suitress” (like a bachelorette) showering because he got “confused” looking for a bathroom.

The problem: Once again we’ve missed the opportunity to accurately portray withdrawal. No matter the drug (prescription or not) this process should be done under the advisement of a doctor. Additionally, the withdrawal symptoms from Lithium shown in this episode are over dramatized and mostly incorrect. Dr. Krystal notes, when coming off of Lithium, “generally the principal problem is relapse of the symptoms of bipolar disorder.” Instead this episode suggests both that medications are not needed for bipolar disorder, and that they're something to be wary of, because you become dependent on them. (Withdrawal! Confusion!) As a psychiatrist, this is something I'm asked about often. Portrayals that play into that may scare away people from using a medication that is effective, and has saved many lives.

Jessica A. Gold, M.D., M.S., is a psychiatrist, and assistant professor in the Washington University department of psychiatry.