Monday, November 12, 2018

Unsane - It Sure Is

I watch TV while working out - usually Amazon, Netflix, or HBO.  It is all on the Amazon Fire interface.  Today I saw Unsane advertised and despite my aversion to the ongoing One Flew Over The Cuckoo's Nest portrayals of psychiatry - I decided to watch it on the strength of Claire Foy as the leading actor.  Could the actor save the predictable portrayal?  I was skeptical but forged ahead anyway.  The film was a Steven Soderbergh film and I later learned that he shot it on an iPhone 7 Plus.

In the introductory section we learn that the main character Sawyer Valentini (Claire Foy) has moved from Boston to Pennsylvania.  She is a financial analyst in a bank and does financial analysis and reports.  We see her in a contentious phone call with a client in the opening scene.  He coworker expresses some concern and another coworker looks and rolls his eyes.  She meets with her boss and the conversation has overtones of sexual harassment.  Later there is a computer dating scenario where she ends up at her apartment with the date and starts to react like he is assaulting her.  She ends up taking some medication out of a medicine cabinet.  Later we see her Google "Support groups for stalking victims".  She drives out to a psychiatric facility for an initial appointment and that is where the drama begins.  I am going to list the problems point-by-point.

1.  She meets with the intake staff person and describes her concerns about being stalked as well as the residual "neurosis" (her term) of being in an new city and having a tendency to see her stalker everywhere. At one point she alludes to feeling depressed at times and thinking about whether there is any point in going on.  The staff person asks her if she has ever had suicidal ideation and she goes into a detailed discussion of Therapeutic Index and how she would be experimenting with that if she was going to attempt suicide (translation - overdosing).  The therapist leaves and has her complete routine paperwork.

2.  She completes the "routine paperwork" that is also described as "boilerplate" and learns that in doing so she has voluntarily committed herself for 24 hours.  In other words she was tricked into being hospitalized and that trick was apparently irreversible.

3.  While voicing strong objections she is asked by a nurse to disrobe, be searched, and change into hospital clothing.  The nurse's tone is threatening and she complies.

4.  She is taken to a psychiatric ward of about 10 people.  It is a combination of men and women and they are all locked into a room with no supervision all night long.  She is threatened by the other patients, gets into a physical confrontation with two of them and is eventually sedated in the same 10 bed ward in full view of the other patients with no safety monitoring.  She is subsequently restrained in the same manner in full view of all of the male and female patients and not protected.

5.  She finally sees the psychiatrist the next day.  He does the world's most cursory evaluation - largely reading chart notes in between phone calls.  It lasts about 5 minutes. She makes a compelling argument to be released. He informs her that she needs to stay another 7 days based on her assaults on another patient and staff. At no point in the interview does he ask her any direct questions about depression, suicidal thinking, or the details of the incidents of aggression.

6.  She befriends another patient who has smuggled in a cell phone and convinces him to let her use it.  We learn that the patient with the cell phone is really an undercover reporter investigating the hospital.  She calls her mother who comes to the facility and demands that they release Sawyer. The psychiatrist refers her to an administrator. The administrator gives her an irrelevant sales pitch on all of the good work that is done there and passive-aggressively acknowledges that it is her mother's prerogative to contact an attorney in order to get her daughter freed. 

From a creative and artistic standpoint - it was apparent to me from the outset that Sawyer's reality testing was not impaired.  Hypervigilance is not psychosis. So when she recognized her stalker on the nursing staff passing out medications it was not a surprise.

Spoiler alert right here - if you really wanted to be surprised see another film.  If you don't want to know the ending to this predictable one stop reading right here.

A series of implausible scenes unfold that depend both on the stalker as nursing staff and Sawyer's transformation to homicidality bent on killing the stalker/staff person. The stalker gives Sawyer a "megadose" of methylphenidate a stimulant a - controlled substance. Special effects at that moment seem to indicate she has some kind of psychedelic experience from the drug.  The stalker is warned by the nurse that he has to be more cautious of "we could lose our jobs." The stalker ends up killing two patients and torturing one of them with cardioversion paddles - right out of the old action series 24.  Some reviews of the film think this was an electroconvulsive therapy device - more proof that old Hollywood stereotypes about psychiatry don't ever go away.

The stalker traps Sawyer in an isolated seclusion room and in an excruciatingly long exchange, she tricks him and ends up stabbing him in the neck.  Like most films of this genre, he survives and recaptures her outside of the hospital and kidnaps her.  During the kidnap sequence we learn that he killed her mother and the hospital staff person who he has been impersonating.  Sawyer gets another chance to kill him and apparently does in the most gruesome manner  possible.

We flash forward 6 months and see Sawyer eating at a restaurant with a friend.  She looks out into the room and see the profile of a man who appears to be the stalker. She hears him saying things the stalker would say.  She grabs a steak knife and approaches him from behind.............. 

All of the points above are what a psychiatrist would consider to be highly problematic.  By that I mean they would all merit investigation by the appropriate authorities,  legal penalties, and disciplinary action against licensed health professionals. If I was prone to discuss malpractice - the incidents could also lead to that type of civil litigation.  Anyone experiencing a fraction of what Sawyer experienced in this psychiatric hospital should contact the responsible officials or an attorney about what could be done.  In my experience health officials are quite eager to do exhaustive investigations of these complaints both in the case of licensed health care professionals and institutions.  In the film it took a dead body on the premises to get any action from the police.  In real life, a call from Sawyer's mother would be enough to get action in any state that I have practiced in.

The commitment law in Pennsylvania did not seem to be adequately portrayed.  The statute says that any interested party can initiate commitment based on an imminent dangerousness standard.  That was certainly not present in the film.  At no point was Sawyer suicidal and the brief scraps that she was in would not have required physical restraint or forced medication in any setting that I ever worked in.  The maximum period of confinement in the state of Pennsylvania without a court order is 5 days and in this case Sawyer was detained 1 day initially and then another week.  That is a violation of the law.  In the state where I work, the longest period of time that a person can be help without a court order signed by a judge is 72 hours. In cases where it appeared a high risk person would be released, attorneys have always advised me that the person needs to be released according to the law - no matter what the possible adverse outcome.   

There are some continuity problems with the film.  How is it that her stalker would happen to know that she would be inappropriately admitted to a psychiatric hospital and be able to identify and kill a prospective employee in order to work there?  Wouldn't it be much easier to get close to her in real life rather than inside an institution?  And what about Sawyer?  She has insight into the fact that she is hypervigilant and needs to avoid the stalker. Is there a better film just exploring that theme and what happens to people in these situations plus or minus the real stalker?

In the past, my standard for films has been recognizing that they are entertainment and not really about psychiatry.  This film fails at both levels.  I suppose at some point all actors might be interested in doing a horror movie - but the psychiatric hospital as horror genre is as tiresome as it gets.  How many times can you show a gun toting Dr. Sam Loomis battling evil incarnate as a former asylum patient?   How many times can you show hospital staff that are sadistic, abusive, or grossly incompetent? Apparently there is no limit. The idea that a film like this should just be brushed off as fiction minimizes the fact that One Flew Over the Cuckoo's Nest seems to have stigmatized the most effective treatment in psychiatry for two generations.

The psychiatric hospital that Soderberg is reaching for is the spooky old asylum of the late 19th and early 20th century.  What made that asylum spooky was that people were freaked out about severe mental illness.  They did not know what it was and they did not have a name for the symptoms or disorders. They knew that some of their relatives went to these places and never came back. They lived the rest of their lives there.  They were warehoused and never got better.  That was the real scary part.  Most if not all of those places are shut down and have been for a long time.

The real horror story these days is trying to get into a mental hospital when it is needed.  Contrary to Sawyer's experience in the film, nobody is trying to recruit people into hospitals.  They are rationing the beds and turning people away.  All of the beds are typically full.  The emergency department psychiatric staff will do whatever they can to discharge.  A lot of people end up waiting a day or two and just give up and go home.  In some cases if people with mental problems are brought in by the police, the choice is admission to the hospital or jail.  Jail is the most likely outcome.

Jail is the real scary place these days and it has been for at least 20 years.  That is where a diverted patient needs to worry about incompetent or nonexistent treatment, physical assaults, and encounters with the evil people that Hollywood typically, uses to populate psychiatric hospitals.

The real evil out there today - is the system of non care that exists.  That is what people feared - developing a mental illness for which there was no treatment and being sent away for a lifetime. 

That is what Hollywood needs to understand.

That and a ton about modern psychiatric treatment.

George Dawson,  MD, DFAPA

Graphic Credit:  Inked Pixels.  A ghostly figure casts a long shadow down the middle of a dimly lit passage of a dilapidated mental asylum.  Downloaded from Shutterstock per their standard licensing agreement on 11/12/2018.


  1. Wow, I read this column and just wonder, how does this profession survive when we are brutalized just like the Right and Republicans are by the Left and Democrats? There is so much evil and pervasive disdain and disingenuous shrieking for "causes", and not just politically but also in mental health, again, really, how does this profession survive?

    May sound lame and immature, but, digging ditches really does look inviting as an alternative option...

    1. I personally don't ever think that we can forget that at the bottom of all of this is politics. Our professional organizations always seem to ignore this and that is probably why they are politically inept. Psychiatrists marching in an annual NAMI anti-stigma campaign can't compare with a few well placed movies. The fact that the profession has survived all of this nonsense is probably a good sign that the tens of thousands of us who go to work every day are providing a useful service.

      Like I always have said - if psychiatry was as useless as all of the antipsychiatrists claim it is - I would have quite 30 years ago and found a much less stressful job.

  2. Who was the script writer - a Scientologist?

    1. At this point I think it is a cultural meme kept alive and well by Hollywood. It appears that anything psychiatric is always politically correct to distort.