Girl, Interrupted (1999) is a psychological drama based on the memoir of Susanna Kaysen and her stay at a mental institution during the 1960’s. The opening shot of the film shows Susanna in the basement of a mental institution and then quickly cuts to her being treated in the ER after an attempted sucide. Susanna is subsequently admitted to Claymoore, a local psychiatric hospital for women, and questionably diagnosed with borderline personality disorder (BPD). BPD is characterized by “a pattern of instability of interpersonal relationships, self-image, affects, and marked impulsivity” (Towsend, Morgan 2017). Although Susanna’s suicide attempt and sexual history reflect instability and impulsivity, her overall personality does not correlate with the diagnostic criteria of BPD. This accurately depicts the fact that BPD was a relatively new diagnosis in the late 1960’s and did not become better understood until several years after.
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At Claymoore, Susanna meets several women with varying disorders including Lisa, a sociopath who is clearly the leader of the girls on the ward. Sociopathy or antisocial personality disorder, is marked by a “pattern of socially irresponsible, exploitative, and guiltless behavior that reflects a general disregard for the rights of others” (Towsend, Morgan 2017). They often manipulate others for personal gain and in the film, Lisa is no exception. Her magnetism and boldness quickly draws Susanna in and she eventually influences Susanna to stop complying with her treatment. The pair eventually run away from the facility together and end up staying the night at Daisy’s, a former patient. Daisy is a bulimic who was sexually abused by her father, and after enduring a brutal verbal assault by Lisa, winds up commiting suicide. Susanna is horrified by Lisa’s cold and crass reaction to Daisy’s death and eventually returns to Claymoore without her to follow through with her treatment. Before Susanna is due to leave, Lisa returns and reads Susanna’s diary aloud to the other girls on the ward. There is an intense verbal altercation between them which leads to Lisa’s attempted suicide but she is eventually dissuaded by the other girls. Susanna visits Lisa before she leaves and the film ends with her reflection on her time spent at Claymoore and the inherent nature of what it means to be mentally ill.
Role of Healthcare Professionals
Upon arrival and admission to Claymoore Psychiatric Facility, Susana is oriented to the facility with a short tour and an explanation of the rules by her nurse, Valerie. Nurse-patient relationships in mental health settings are key components in helping patients recover (Valente, 2017). Throughout the film, Nurse Valerie attempts to maintain order in the facility as Susanna and the other patients in the ward are easily manipulated by Lisa, another patient who was diagnosed as a sociopath. Valente describes these professional relationships as providing a safe, trustworthy, reliable, and secure foundation for therapeutic interactions (2017). Nurse Valerie suggests that Susana write more and talk to her doctors about her feelings in order to better cope with her borderline personality disorder diagnosis.
A psychiatric consultation consists of three main parts: gathering necessary in-depth information to come to an appropriate diagnostic formulation, establishing a doctor-patient relationship, and initiating and continuing various therapeutic measures (Lakdawala, 2015). Dr. Melvin Pottis, the first psychiatrist Susana sees at the facility, uses non-therapeutic communication techniques during their psychiatric consultation. For example, he stated “you been feeling bad in general right, you been feeling depressed. It was then you tried to kill yourself last week.” This type of interaction demonstrates ineffective use of beneficence, one’s duty to act for the benefit of others or to promote the good of others (Townsend et al., 2017). Dr. Wicks, a female psychiatrist, on the other hand, uses therapeutic communication in all of her encounters with Susana. Dr. Wick meets with Susana for therapy sessions three times a week and eventually discharges her from the facility with a short and long term treatment plan.
Psychiatric Hospital “System”
The film depicts the 1960s and the hospital where Susanna arrives has strict rules and dictates patients’ daily routines. Nurses perform “checks”, or repetitive rounds on the unit to locate patients’ whereabouts and to monitor their activities according to a schedule that corresponds to the severity of each patient’s illness. All patients’ possessions are confiscated to avoid injuries. The psychiatric nursing care of that time was not focused on advocacy for patients and, as a result, patients’ rights were neglected. Neither patients nor their families participated in the decision-making process regarding their goals or treatment and once patients were “checked in” to a psychiatric hospital, they resided there for years. Patients could not refuse treatment; failure to comply with this rule was punished by seclusion. The staff was not properly educated and acted unprofessionally in many instances. For example, some nurses shared news about their personal life with patients, allowed themselves to be sexually involved with patients or acted in a rude manner, calling them names or addressing patients by their diagnosis.
While modern psychiatric hospitals still adhere to strict rules, such as performing rounds or “checks” on patients, having a daily schedule, and not allowing specific objects in patients’ rooms or around them, many rules have been changed. New guidelines have been created and patients became legally protected. For example, restraints and seclusion are considered high-risk treatments because they are potentially dangerous interventions that can result in injury or even death (Citizens Commission on Human Rights, 2018). Such measurements are high risk because the psychiatric patient may perceive them as a form of punishment as they greatly restrict the patient’s freedom. It is for these reasons that accrediting agencies and governmental entities require policies and procedures addressing the use of these treatments (Citizens Commission on Human Rights, 2018). Additionally, according to the Substance Abuse and Mental Health Services Administration (SAMHSA), the Patient Self-determination Act that went into effect in 1991 requires healthcare facilities to provide clear written information for every patient concerning his/her legal rights to make healthcare decisions, including the right to accept or refuse treatment (SAMHSA, 2019). Thus, legally, patients may refuse treatment at any time and may not be subject to any form of reprimands in this regard. Finally, the modern profession of nursing includes the important role of advocating for patients’ rights (Davoodvand, Abbaszadeh, & Ahmadi, 2016). Nowadays nurses include discussion of patient rights as applicable during team meetings and on patient rounds, as well as including these rights in the nursing care plan.
Impact on Social/Occupational Life
Susanna’s mental illness has a particularly stigmatizing effect because of the time period the film takes place in. During the 1960’s, appearances were of utmost importance and most families attempted to portray an image of perfection. The dinner party scene where Susanna’s mother chastises her for not looking presentable is a perfect example of this fact. Susanna’s reputation is essentially ruined by her mental diagnosis. This is reflected by her mother’s emotional distress and the scene in the ice cream parlor where Susanna attempts to hide to avoid being confronted by the wife and daughter of the man she had an affair with. Susanna’s family dynamics are not therapeutic because the obsession with perfection facilities feelings of shame and guilt. This negatively impacts her participation in treatment by making her distrustful of the staff and psychologists. It is not until she meets with Dr. Sonia Wick, who employs a variety of therapeutic communication techniques, that Susanna begins to positively respond to treatment.
Ego Defense Mechanisms
Ego defense mechanisms are defined as unconscious psychological processes that help a person cope with a stressful event either from the internal or external environment (Waqas, Rehman, Malik, Muhammad, Khan & Mahmood, 2015). In Girl Interrupted, Susana exhibits splitting as one of her ego defense mechanisms. Splitting is characterized by the inability of an individual to achieve object constancy, i.e. the inability to combine and accept both positive and negative feelings (Townsend et al., 2017). The film depicts a scene where she becomes enraged and describes the facility as a torture chamber, thus giving reason to the view that people are either all good or all bad. Sublimation is another defense mechanism used by Susanna. Townsend et al., defines sublimation as the transformation of drives or impulses that are personally or socially inappropriate into activities that are constructive (2017). Susana does this by taking nurse Valerie’s advice and rechanneling her negative impulses into writing.
Lisa Rowe is the main antagonist in this psychological drama, who is diagnosed with antisocial personality disorder. She has been in and out of the psychiatric hospital since she was twelve. Lisa is controlling, manipulative, and deceiving. She bullies others and shows no respect, empathy or remorse for others’ feelings. Lisa clearly displays several ego defense mechanisms characteristical for her disorder, such as rationalization, denial, and displacement. Townsend et al., defines rationalization as attempts to validate unacceptable feelings or behaviors by formulating logical reasoning (2017). Lisa pushes Daisy, a bulimic patient, to her limits by reminding her about being raped by her father and accusing Daisy of secretly enjoying having sex with her father. She calls Daisy weak and mocks her about cutting her arms. As a result, Daisy commits suicide and Lisa validates her words and actions by believing that Daisy needed to hear the truth. Denial is another ego defense mechanism exhibited by Lisa. Lisa negates the existence of a real situation or the feelings associated with it (Townsend et. al., 2017). Shortly after Daisy hung herself, Lisa steals money from her corpse, showing no remorse or sadness toward the situation. Lisa blames Daisy and says that she “deserved her fate”. Additionally, Lisa consistently utilizes displacement as one of her main ego defense mechanisms. Townsend, et al., describes displacement as the transfer of feelings from one target to another that is considered less threatening (2017). Lisa hates being returned to Claymoore hospital and she resents its staff. Unable to let her anger out at the staff, she goes after the patients and openly acknowledges this fact by saying: “You know, there’s too many buttons in the world. There’s too many buttons and they’re just – there’s way too many just begging to be pressed …you know…and it makes me wonder, it really makes me wonder, why doesn’t anyone ever press mine? Why am I so neglected? Why doesn’t anyone reach in and rip out the truth and tell me that I’m a whore, or that my parents wish I were dead?” (Kaysen, 1993).
Nurses have the power to impact mental health awareness in our community. Nursing advocacy is vital towards educating the community regarding different types of mental illnesses, their symptoms and teaching friends and family members to be non-judgmental and accepting. Unfortunately, mental illness continues to be defined as a personal failure. According to the National Alliance of Mental Health (NAMI) there is a relationship between the lack of mental health information and stigma associated with mental health. In the film, we see how this lack of awareness contributed to the sense of shame Susanna experienced. For example, Susanna was not given a clear definition of her diagnosis and the staff was unsure how to explain it. She was not given any other form of treatment options beside being placed in a mental institution nor did she receive a clear description of the medication she was forced to take. All of these factors lead to confusion, uncertainty and shame. The nurses could have advocated for Susanna by taking active measures to change the stigma of mental illness. Today nurses may join a national health organizations such as the American Psychiatric Nursing Association (APNA) or participate in local and national campaigns, community walks, speak at local schools or attend health fairs. According to APNA, nurses must identify and monitor policies that impact mental health at both the local and national levels. More importantly, education must assume interpersonal form in an attempt to identify resources that support mental health and change the negative stigma that mental illness has acquired.
Legal/Ethical Principles + Policy Issues
Townsend et al., defines the right to refuse treatment as a legal right unless the patient requires immediate intervention to prevent death or serious harm to oneself or others (2017). Susana’s breaking point drove her to take an entire bottle of aspirin and chase it with a bottle of vodka. She did not believe this was an attempt to suicide but rather a cure for her headache. This drove her therapist and parents to prepare her for admission to Claymoore psychiatric facility to where she would get the “rest” she needed. The issue that arises is that the treatment plan for Susana was not fully explained to her prior to admission. Additionally, patients have the right to a least restrictive treatment alternative, such as an outpatient setting rather than hospitalization (Townsend et al., 2017). Susanna was only offered to go to Claymoore psychiatric facility and not given other treatment options.
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The U.S. Department of Health and Human Services (HHS) states that with few exceptions, patients have the right to inspect, review, and receive a copy of their medical records that are held by health care providers covered by the Privacy Rule (HHS, 2017). While it is not clear whether Susanna was advised about her legal rights, the film depicts a scene where Susanna and a group of other patients break into the doctor’s office late at night to get access to their charts. It is only then that they find out about their diagnoses and treatment plans. A portrayal of such an event makes one conclude that at that time there were no guidelines or practices in place allowing patients’ access to their own treatment plan information.
The National Alliance of Mental Illness (NAMI) discusses the patient’s right to know what medications they are prescribed. Aside from some restrictions, patients continue to have the right to ask questions regarding their medication treatment. It is part of the ten patient administration rights to provide “client education”. In one of the scenes, Susanna asks “what is this” in regard to the medication handed over to her by a nurse. Without providing any explanation about the medication, the nurse responds “just take it”. Such response can be viewed as an example of poor nursing education that goes against a patient’s right of client education.
One of the ethical nursing responsibilities is to report suspected child, elderly or sexual abuse. This becomes difficult if patients experience hallucinations and their perception of events are distorted (Townsend, Morgan 2017). Nonetheless it is the nurses’ responsibility to explore all perceptions of abuse and report them if necessary. In the film, Daisy is a seasonal resident who suffers from bulimia and has a questionable relationship with her father. Shortly before Daisy’s suicide, Lisa verbally assualts her and taunts her about everyone’s knowing, including the staff, about the fact that her father was sexually absusing her. Because Daisy was a long-term, frequent patient, her case should have been investigated long time ago with a proper nursing management. Studies have shown that in many cases, bulimia is linked to sexual abuse (Hastings, Kern 1994). However, the film takes place in the 1960’s and during that time, such research has not yet been conducted. Furthermore, it is likely that a lack of resources may have prevented the facility from investigating and taking further action in the case of Daisy’s suspected sexual abuse.
As a group, we made a unanimous decision to choose Girl, Interrupted as our film of choice. In order to be fair in the division of work, we chose to split the sections in alphabetical order with the exception of the last section which we all worked on together. As a group, we chose text messaging as our best form of communication. We agreed that text messaging will be the easiest and fastest way to communicate with each other and share our opinions and thoughts regarding the film. Besides text messaging, we met in person as a group on a few occasions to discuss the progression of our paper. All group members agreed to use our course book as the primary theoretical basis for analysis in this paper. In addition to the book, other sources of information were utilized, such as reputable scholarly articles and websites. Throughout our team work, all team members participated in editing process and the validation of sources and their citation in the APA format.
- American Psychiatric Nurses Association (APNA). (2018). APNA council for mental health advocacy. Retrieved from //www.apna.org/i4a/pages/index.cfm?pageid=3637
- Center for Disease Control and Prevention (CDC). (2018). Suicide rising across the US. Retrieved from //www.cdc.gov/vitalsigns/suicide/
- Citizens Commission on Human Rights. (2018). Mental health declaration of human rights. Retrieved from //www.cchr.org/about-us/mental-health-declaration-of-human-rights.html
- Davoodvand, S., Abbaszadeh, A., & Ahmadi, F. (2016). Patient advocacy from the clinical nurses’ viewpoint: a qualitative study. Journal of Medical Ethics and History of Medicine, 9(5). PMC4958925
- Hastings, T., & Kern, J. M. (1994). Relationships between bulimia, childhood sexual abuse, and family environment. International Journal of Eating Disorders, 15(2), 103-111. doi:3.0.CO;2-1″ TARGET=”_blank”>//dx.doi.org/10.1002/1098-108X(199403)15:2<103::AID-EAT2260150202>3.0.CO;2-1
- Kaysen, S. (1993). Girl, Interrupted. New York, NY: Turtle Bay Books.
- Lakdawala P. D. (2015). Doctor-patient relationship in psychiatry. Mens sana monographs, 13(1), 82–90. doi:10.4103/0973-1229.153308
- National Institute of Mental Health (NIH). (2018). Transforming the understanding and treatment of mental illnesses. Retrieved from //www.nimh.nih.gov/health/statistics/mental-illness.shtml#part_154910
- Substance Abuse and Mental Health Services Administration. (2019). A Practical Guide to Psychiatric Advance Directives. Rockville, MD: Center for Mental Health Services. Substance Abuse and Mental Health Services Administration. Retrieved from //www.samhsa.gov/sites/default/files/a_practical_guide_to_psychiatric_advance_directives.pdf
- Townsend, M. and Morgan, K. (2017). Essentials of psychiatric mental health nursing. Concepts of evidence-based practice. 7th ed. F.A. Davis.
- U.S. Department of Health and Human Services. (2017). Your medical records. Retrieved from //www.hhs.gov/hipaa/for-individuals/medical-records/index.html
- Valente, S. M. (2017). Managing professional and nurse–patient relationship boundaries in mental health. Journal of Psychosocial Nursing and Mental Health Services, 55(1), 45-51. doi:10.3928/02793695-20170119-09
- Waqas, A., Rehman, A., Malik, A., Muhammad, U., Khan, S., & Mahmood, N. (2015). Association of ego defense mechanisms with academic performance, anxiety and depression in medical students: A mixed methods study. Cureus, 7(9), e337. doi:10.7759/cureus.337