The psychokiller strikes again
ER, Channel 4, Wednesday 19 April at 9 pm
ER (Emergency Room), the US television
drama of high adrenaline medical heroics,
has blazed its way into a sixth series. It has
undoubtedly captured the public imagination, with its strong characters, uneasy tensions, and frenetic trauma calls. It
presents highly positive images of health-care professionals, which is perhaps why the BMJ and Nursing Times put two ER
characters on the cover of their recent joint
issue. The programme reaches the masses.
This year, in the week starting 18 January, it
was watched in 21 million out of a possible
99.4 million US households.
In Britain Channel 4 screened two
extraordinary episodes on 19 April, which
caused much public excitement, sadness,
and even grief. The country watched in horror the double stabbing of medical student Lucy and resident Dr Carter.
In the first episode we saw Lucy working
up the case of a young married man, Paul,
who had presented with headaches. Carter
offers minimal supervision. When the man
becomes disoriented she carries out a
lumbar puncture while Carter holds him
down. All examinations and tests are
normal, and when Paul's college friends
describe a recent increase in bizarre and
suspicious behaviour a psychiatry consult is
requested. The psychiatrist is busy, of
course, so Paul remains untreated in a
secluded side room. The episode ends with
Paul's unprovoked and vicious assault on
the medics. Carter falls to the floor to see
Lucy bleeding to near death under the
patient's trolley.
In the second episode (can we really handle more of this in one night?) we see the brutal resuscitation and harrowing surgery
of both victims. In the midst of this clinical
chaos Paul returns. He had escaped the hospital, but was hit by a car. Although Paul is clearly psychotic and has life threatening
injuries, consultant Dr Weaver cannot bring
herself to treat him and hands over his care
to a colleague. Lucy awakes postoperatively,
and, true to form, she diagnoses a pulmonary embolus in herself and then dies. Carter survives.
This was undoubtedly a dramatic and
powerful storyline. But, after seeing the episodes, we became concerned about ER's portrayal of mentally ill people. Did it only
ever show them as violent and dangerous?
We went back and watched 22 consecutive
episodes to see how psychiatric patients
were represented.
In these episodes, there were 28 patients
with psychiatric problems, most often
substance misuse. Six were psychotic. One
man smashed his car with a baseball bat
because of the "demons" telling him to harm
his wife. A woman who thinks she is a bird is
brought into the emergency room in a huge
birdcage. Haloperidol is advised before they
get bolt cutters to release her. A woman
masquerades as a doctor, but is stalking a
male staff member as part of a delusion of
erotomania.
Five patients deliberately harm them.
selves, mostly through destructive acts such
as cutting. One man encourages another to
drill a hole in his forehead, and a depressed
woman threatens to harm others. A man
with mental health problems shoots his wife
and children, and a similar patient kills a
police officer.
Four children are shown with attention
hyperactivity disorder, and four adults with
post.traumatic stress disorder, one of whom
becomes aggressive when recollecting the
traumatic experiences. One child kills
another and there is a suggestion that he has
psychological problems, since a psychiatry
consult is requested. The one example of
suicide is an extreme situation, in which a
man first rapes a comatose patient and then
hangs himself.
These examples suggest to the audience
that mentally ill people are nearly always
destructive, either to themselves or others.
The dominant theme is one of threat. While
it is true that emergency psychiatrists do see
violent patients, we feel that ER over-represents this danger. More importantly, it fails to offer an empathic view of the distress
that mental illness causes to sufferers. We
fear that many viewers will share Dr Weaver's
revulsion at the "psycho" who killed Lucy
and maimed Carter. Even depressed and
suicidal patients are shown harming others.
The series, in making such a strong
association between psychiatric illness and
violence, is following established trends in
television news, drama, and the tabloid
press. It is adding to the process of stigmatisation by the media.
These are strong stories with harrowing
images, and they totally fail to offer a
sympathetic view of people with mental
health problems. It is too late for us to
object formally to the producers, and we are
not suggesting censorship. The irony here is
that this series achieves a high degree of
realism when it deals with medical and surgical emergencies. We wish that it would offer the same degree of accuracy in its portrayal of psychiatry. Where are the cases in which patients are helpfully supported
through the terror and distress of their acute illness?
The proportion of homicides committed by mentally ill people in Britain has
fallen annually since 1957. The challenge
now is to propagate some positive media
stories, creating more accurate images to
capture the public imagination.
Rita Mairead Condren, research registrar, St Vincent's Hospital, Dublin
Peter Byrne, consultant psychiatrist, Kent
studentBMJ 2000;08:175-216 June ISSN 0966-6494
