Psychiatry is at war with Netflix. Granted, the battle’s in my head, and I may be the only one who knows of its existence, but I can still say with certainty that I am not the only mental health professional unnerved by Netflix’s continued attempts at portraying adolescent psychiatric illness with little apparent regard to the accuracy of these depictions. Since January 2017, I’ve felt as though I’ve been playing whack-a-mole with Netflix programs about teenage mental illness: 13 Reasons Why, Atypical, To the Bone, and The End of the F***ing World. Try as I might, I can’t seem to find my patients, actual teenagers with psychiatric illness, in these portrayals.
In my job, I see 20-year-old anorexics so sick that they have no teeth and thin, brittle hair, appearing closer to 80 years old and little resembling the witty, lively patients with severe eating disorders in the movie To the Bone; in my experience, it’s often challenging for brains chronically starved of calories to muster such cleverness. I see bruised and battered parents broken over how to continue caring for autistic children, who, now adult-size, lose control of aggressive impulses in frightening way—a far cry from the intelligent and near-quaint high-functioning high school senior in Atypical. I have had patients whose struggles with depression lead them to go for days without showering, who stop going to school and cease seeing their friends, a picture that somehow doesn’t come through in 13 Reason Why’s Hannah Baker, whose suicide the series is built around explaining. And while hypersexuality can certainly be a symptom of bipolar disorder, one attempt at a clandestine sexual encounter underneath a table does not a diagnosis of bipolar disorder make, despite this suggestion from 13 Reasons Why’s second season.
The distorted portrayals of these diagnoses are not, to me, the most startling things—it’s the failure to depict what actually goes into treating psychiatric illness, or even any treatments at all. If I was a teenager, my takeaway from these shows would be “Lots of teenagers have psychiatric illnesses, but good luck doing something about it.” To judge from these examples, the only options are going to a fancy, and likely unaffordable, residential program (both 13 Reasons Why and To the Bone), weekly therapy with a somewhat nebulous goal (Atypical), or even suicide (13 Reasons Why). Even with short-term inpatient psychiatric care, the relapse rate of opiate use following detoxification without medication-assisted treatment is 63 percent; with no care at all for his heroin addiction, 13 Reason Why’s Justin was practically doomed from the start.
With all psychiatric illnesses, many teenagers will have relapses in symptoms, and they deserve to see characters who, like them, know that quelling their symptoms is more like marathon than a sprint. It requires continued hard work, sometimes taking a medication with side effects like fatigue or weight gain, going to weekly therapy, group therapy, or abstaining from certain teen “rites of passage” like substance use or staying out late. While a strong social network may improve treatment outcomes, research (in this case, a randomized clinical trial, often considered the gold standard in evidence-based medicine) indicates that a combination of medication and psychotherapy is the most effective treatment for adolescents with depression—not getting a girlfriend, or sheer willpower.
It is naïve to think that accuracy is Netflix’s primary objective, but why are these portrayals so challenging to make accurate? Is it because teenagers wouldn’t find them dramatic enough? This is unlikely, given that so many in their target audience are eagerly awaiting a representation of their own lives on the screen, finally able to see characters whose struggles are their own. Twenty percent of youth say that they have experienced a psychiatric illness severe enough to impair daily functioning; 11 percent of teens age 13–18 are estimated to have a mood disorder, 8 percent an anxiety disorder, and about 5 percent a substance-use disorder. And while I have had many thoughts about my profession, “It’s boring!” certainly hasn’t been one of them. Could it be because severe mental illness can be incredibly hard to watch? But 13 Reasons Why hasn’t shied from graphic portrayals of sexual assault and suicide, portrayals that have led to myriad other criticisms from the mental health community. So perhaps we should ask ourselves a more productive, even answerable, question: “Are accurate portrayals of teenage psychiatric illness and a captivated adolescent viewership mutually exclusive?”
My answer is a resounding “Not in the least.” My teenage patients regularly patrol the internet looking for accurate information about their illnesses‚ though not always finding it, at least the “accurate” part. Online television can reach a far wider audience than most mental health professionals will see in the whole of their careers; adolescents spend on average two hours per day watching television or film; at most, I see a patient an hour a week. What kind of message are we sending our youth if we assume that they need to be lied to in order to get them to pay attention? Shielding teens from the ins and outs of psychiatric illness may stem from a desire to keep them dramatically engaged, but comprehending the nuances of psychiatric illness and treatment can be lifesaving for teenagers. In certain states, minors have the ability to consent to certain substance use and mental health treatments themselves. Seeing the truth about a treatment discussed, the good and the bad, in a recent, popular show could represent a glimpse of familiarity in an otherwise strange and overwhelming situation. After all, to use the words of 13 Reasons Why creator Brian Yorkey, when asked about the provocative portrayal of sexual assault in the second season, “We believe that talking about it is so much better than silence.” And on that, Mr. Yorkey and I (and likely countless other mental health professionals) heartily agree. I would only add that, for the sake of my young patients, the talking should be based in reality, and not Hollywood’s imagination.