The Movie Unsane is Insane in its Portrayal of Mental Health Care

A recently released movie, Unsane, starring the remarkable Claire Foy, highlights the plight of Sawyer Valentini after she’s been involuntarily committed into an inpatient psychiatric hospital.

This post does contain spoilers to the movie so stop reading if you don’t want to know more about the film.

The crux of the story is that Sawyer believes her stalker has made his way into the psychiatric unit where she is a patient— whether or not that is the case is the mystery.

Unfortunately, the way that psychiatric care is highlighted in the film is disturbing at best. At worst, I hope it doesn’t deter anyone from seeking mental health treatment if they need it.

Problem One: Not disclosing to a patient why she’s being admitted. The genesis of Sawyer’s admission into the psychiatric unit stems from a visit with a counselor where she discloses at times she thinks about hurting herself. She’s left unattended (a no-no if you think someone is suicidal) and the next scene is a nurse escorting her into an intake room. The nurse never fully explains to the patient the reason for the admission and leaving it out doesn’t really increase the drama of the scene— it just makes the nurse look mean and uncaring. Simply, a nurse could say, “Your mental health provider has placed you on an involuntary hold because she’s concerned you’re going to hurt yourself. ” Then the heroine can argue with her about why she feels the admission is unnecessary.

Problem Two: Having the patient undress but allowing her to keep her bra. A bra is considered a ligature risk and patients can’t have anything on their person that they might use to hurt themselves. Hair ties, piercings, and other jewelry are all removed.

Problem Three: Drug injection sites. Emergency drugs for agitated patients are usually given IM (intramuscular) and not IV (intravenous) to the neck or arm. Can you imagine trying to start an IV on an agitated patient? It’s much easier to land a needle in a large muscle group then to try and finesse a tiny IV catheter into a moving target.

Problem Four: Leaving a patient alone in restraints all night. There are very specific regulations around restraints and significant documentation that goes along with it. Patients in restraints are continuously observed by a staff member and circulation to their extremities is checked often. Also, the patient must be offered bathroom breaks at a minimum of every two hours and you can’t deny them food as punishment. The goal is always to get patients out of restraints as soon as they can be safe— and that doesn’t always imply that they are calm.

Problem Five: A mixed gender open unit. Need I say more?

Problem Six: That psychiatric care is an insurance scheme for money and that patients are intentionally kept until their insurance money is exhausted. This is a large crux of the movie to the point that one of the patients is actually an undercover police officer trying to uncover the scam. This is the most disappointing aspect of the film. There are so few mental health beds around the country right now that it is not difficult to fill them. Here’s a news article here, here, here, and here— which all posted within one week. Trust me, mental health facilities can keep their beds full without perpetuating insurance schemes.

Overall, an interesting movie, but portraying the current state of mental health care in this country would have only increased the tension and drama for this film.

Reverie: Not so Medically Dreamy

NBC has launched a new summer show titled Reverie.  In it, Mara (ex traumatized cop, maybe psychologist) is recruited by a company specializing in making-your-dreams-come-true via a hyper advanced virtual reality program. The participants receive an implant that allows them to interact virtually with a program partly of their design.

Problem becomes, some of the clients don’t want to leave. Hence, our heroine, Mara, is recruited to go in after them and pull them back to reality.

In the first episode, it’s noted that the client has been in his dream world for two weeks and it’s commented by the staff that he’s essentially comatose. The man is lying on a bed connected to an ECG monitor and some oxygen via nasal cannula as pictured below. They give the man two days left to live providing a time pressure for the heroine.

However, medically, this man would have already been dead because they are not providing for either hydration or nutrition. This could be solved simply medically by inserting a feeding tube via his nose and providing free water interspersed with bolus liquid feeds. After all, thousands of people live in comatose states for years if their basic medical needs are met such as oxygen (if needed) and nutrition.

The heroine, Mara, is psychologically damaged. She’s had a significant personal trauma she hasn’t quite worked through. There is also a concern expressed by the designers of the program that something might not be quite right with it. When Mara enters the virtual reality program for the first time to retrieve a voluntarily trapped client they run an EEG on her which measures brain waves.

After she successfully retrieves the client, there is a conversation between the designer and lead dream architect that something is wrong with Mara’s EEG— something that indicates she could have a mental illness.

An EEG cannot diagnose a mental health disorder. Its use might be to determine if a patient has a medical cause that may be masked by some psychiatric like complaints such as a seizure disorder or sleep disturbance.

In episode 2, the producers must have gotten some feedback that they needed some actual medical equipment if they were concerned about these clients suffering medical complications. This time, a woman’s heart is going into erratic rhythms, specifically V-tach, because of the stress she’s under in her dream scape. But the medical equipment must make sense. What’s pictured in the photo to the right is what we call a rapid fluid infuser. It delivers IV fluids very quickly. Typically, it would be used in a trauma patient or one who is suffering from overwhelming sepsis where rapid delivery of IV fluids can be lifesaving. It is not appropriate for this patient who is suffering from a heart arrhythmia— much better to park a defibrillator at her bedside.

Have you watched Reverie? What do you think of the show’s premise?