When it comes to the portrayal of physicians in popular culture, psychiatrists are second only to surgeons.1 Far too often, these portrayals of psychiatry have misrepresented our specialty – and stigmatized our patients. Some of the content produced by entertainment giants Netflix and Marvel is a case in point.
That Netflix-Marvel collaboration has proven fruitful, resulting in six television series spanning seven seasons of entertainment to date. Last year alone saw the release of three Netflix-Marvel productions, including Marvel’s “ Iron Fist ” in March, “ The Defenders ” in August, and “ The Punisher ” in November. Given the popularity and ease of streaming Marvel’s Netflix productions, these series have the potential to entertain and inform a wide audience. Unfortunately, however, part of their influence might be to perpetuate stigma and fear surrounding inpatient psychiatric care. Take the inaccurate portrayal of psychiatry in “Iron Fist” compared with the reality of modern psychiatric care, for example.
The second episode of the series (“Shadow Hawk Takes Flight”) shows the main character, Danny Rand , admitted involuntarily to the fictional Birch Psychiatric Hospital in New York City. He was admitted under extremely dubious circumstances: After being drugged by an old friend, Danny wakes up to find himself already admitted to the hospital. This gives the impression that the hospital might have been colluding with the individual who assaulted Danny and that no evaluation was required prior to his admission. In reality, every patient admitted to a psychiatric facility requires an initial evaluation to ensure that they meet the appropriate criteria for that level of care. Collateral information from family and friends can prove helpful in making such assessments, but it would be highly unusual for someone to be admitted solely based on the testimony of a friend without interviewing the patient as well.
While hospitalized, Danny is repeatedly shown in restraints, including four-point restraints, a belt, and a straitjacket. The use of restraints is sometimes portrayed as unprovoked, without evidence of aggression on the part of Danny. In addition, it appears that he is left in restraints for extended periods of time, as he is shown, for example, waking up in the night still restrained. While the use of restraints may be warranted in instances of extreme aggression or violence, the current culture of inpatient psychiatric care has shifted toward safely minimizing the use of restraints and seclusion.2 Straitjackets might be an icon of a bygone era of psychiatric care, but they no longer are a mainstream form of restraint used in the United States. Modern best practices would not result in a nonthreatening patient being placed in restraints and left in them for an extended period of time as shown in “Iron Fist.”
Danny is shown being forcibly administered medications, even in nonthreatening situations. These medications are given via parenteral injection as well as orally, with a psychiatric technician shown roughly inserting a tongue depressor deep in Danny’s mouth, pouring pills into his oral cavity, and manually holding his mouth shut to ensure ingestion. In truth, psychiatric patients are sometimes given intramuscular injections of calming agents when their level of agitation threatens to harm others or themselves. For patients to be given an involuntary injection when not acutely threatening, typically states require some form of legal application for forced medication (a process that does not appear to have been observed in “Iron Fist”). As we know, forced oral medications never should be undertaken given the significant risk to patient (possible choking) as well as staff (bitten fingers).
Staff supervision of patients at the fictional Birch Psychiatric Hospital is extremely poor. At one point, a fellow patient enters Danny’s room dressed in a white coat, pretending to be his doctor. As the conversation progresses, the patient grabs a fork from Danny’s food tray and holds it to his throat, threatening to kill him before being gruffly dragged off by hospital staff. At another point, Danny is shown in four-point restraints, and a patient simply walks into his room and removes the restraints for him. By contrast, in a real, modern inpatient psychiatric facility unit, staff would be routinely providing safety checks on patients throughout the day. If a patient is at risk for violence, sharp metal cutlery would not be included on accessible food trays. Patient attire would be subject to hospital inspection and approval, so it is unclear how or where a patient would have access to a physician’s coat to pull off such an impersonation. And finally, if a patient were sufficiently agitated to require the use of four-point restraints, he or she would be closely supervised and not left alone in an open area where other patients could remove the restraints.
The hospital stays described in “Iron Fist” are very long, and it is strongly implied that psychiatric diagnoses are invented to prolong inpatient care indefinitely. Referring to the duration of his initial involuntary hold, one patient tells Danny: “That what they tell you? Seventy-two hours? (laughs) Me, I had a little incident inside a pharmacy. Seventy-two hours later, I’m a bipolar with mixed affective episodes layered atop a substance abuse disorder. That was 2 years ago. Billy was living under a bridge. Seventy-two hours later, he’s a paranoid personality disorder. That was just over a year ago. And Jimmy was screaming at people in Times Square. Seventy-two hours later, he’s a schizoaffective disorder. He’s been here almost 15 years. Don’t think you’ll be any different.”
Most modern inpatient psychiatric care is designed around short-term hospitalization (days to weeks rather than months to years) with a goal of reintegrating patients back into the community with ongoing outpatient care as soon as they can safely make that transition. In addition, to insinuate that psychiatrists invent diagnoses to keep patients “locked up” insults the integrity of the many dedicated mental health workers who provide care for an ill and often overlooked population.
The most egregious examples of poor psychiatric care portrayed in “Iron Fist” involve illegal or criminal activities. Video cameras placed throughout the hospital transmit a live feed to a shadowy figure who has no role in patient care. A psychiatric technician escorts Danny to a room full of patients hired to kill him. These particular concerns are outlandish enough that perhaps they don’t even need to be directly addressed, but for the sake of completeness it is worth noting that psychiatric hospitals are subject to rigorous oversight from numerous regulatory bodies to ensure that patient care is delivered in a safe and respectable manner and that all protected health information is accessible only by those whose treatment role necessitates such access.
Marvel’s “Iron Fist” seeks to entertain its audience, but it does a poor job of showing viewers a realistic portrayal of inpatient psychiatric care. The show presents a psychiatric hospital as the setting for inappropriate use of restraints, unwarranted use of forced oral and injectable medications, a lack of supervision leading to violence between patients, and even attempted murder accommodated by a hospital employee. Also, the show strongly implies that psychiatric diagnoses are invented for the purpose of continuing inpatient care indefinitely.
In sum, the psychiatric hospital is seen as an inhumane form of imprisonment from which one can only hope to escape with the benefit of a glowing, magical fist. Although this is fiction, these kinds of narratives can have very real consequences in perpetuating stigma against psychiatric care. Ultimately, such storylines undermine the public’s confidence in clinicians seeking to provide caring and compassionate care.
Dr. Weber is psychiatry department chair at Logan (Utah) Regional Hospital with Intermountain Healthcare.
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