We’re Worried, Darling: A Critical Review of the Depiction of ECT in a Modern Film

[This article contains spoilers]

The film Don’t Worry Darling was a pop culture force in 2022, garnering significant media attention (1, 2) and drawing impressive viewership via streaming platforms (3). In many ways, the film is progressive, with its dystopian and feminist themes. However, as psychiatry trainees, we believe its depiction of unmodified electroconvulsive therapy (ECT) contributes to a persistent trend in Hollywood that perpetuates stigma toward psychiatric care. Here, we critically evaluate the film’s depiction of ECT and then briefly review the literature on media representations of ECT, ultimately highlighting the impact of these depictions on patient care.

Near the end of Don’t Worry Darling, as the protagonist Alice begins to unravel the dystopian nature of her reality, she is taken by strangers and subjected to ECT without an anesthetic, a paralytic, or her consent. The scene features chilling music as Alice seizes against hard restraints, undergoing ECT as a form of mind control. This fear-evoking and archaic depiction of ECT is a recurrent trope in modern media. Reviews have shown that films typically depict ECT negatively, most often as a means to obliterate identity, induce insanity, punish, persecute, or murder (4, 5). Matthews et al. (4) conducted a review of 39 movie scenes depicting ECT and found that only three scenes included standard safety features and that the procedure was voluntary in only 33% of scenes. This overrepresentation of negative depictions extends to social and news media; studies have demonstrated that of the YouTube videos featuring ECT, those depicting ECT in an unmodified or negative context receive significantly more views (6, 7).

It is important to acknowledge that these prototypical depictions of ECT are rooted in historical truths from psychiatric practice prior to deinstitutionalization. During this time, psychiatric patients endured significant abuse across many aspects of their care. ECT was unregulated and often administered in multiple sessions per day, leading to significant cognitive side effects, or it was used to treat inappropriate conditions, such as asthma, psoriasis, or alopecia (8). Additionally, before the regular use of anesthetic and paralytic agents, there was a significant risk of fractures or maxillofacial trauma (8). These cognitive and safety risks contributed significantly to the media’s criticism of the procedure. ECT has also been used historically in extreme cases with the explicit intention to cause cognitive changes or to achieve mind control, which led to its further condemnation. For example, the physician Lucio Bini developed a protocol for regressive ECT with the goal of achieving “destruction” of the patient’s memory and pathological experience. In addition, it has been reported that Nazi physicians used ECT to force people deemed emotionally unwell back to work, although the frequency of this occurrence is debated (8).

These historical practices, which have inspired ECT-related tropes, contrast starkly with modern clinical practice. ECT has been established as one of the most effective treatments for resistant psychiatric conditions, including depression, mania, catatonia, and suicidality, with an impressive safety profile (9–13). Knowing that the cognitive changes associated with the procedure can be extremely difficult for patients, researchers have worked diligently to delineate the nature of these changes and to develop effective techniques to mitigate this risk. Modern practitioners adjust lead placements, pulse shape (traditional sine wave pulses are associated with worse cognitive impairment), pulse width, and time between treatments and carefully titrate doses of electricity to ensure that patients experience minimal cognitive side effects (14). Furthermore, with the introduction of safety features, such as paralytics and bite guards, the risk of fracture or maxillofacial trauma is minimal. Most importantly, the majority of patients treated with ECT view it favorably. Both a 2010 review of 54 studies evaluating patient attitudes toward ECT and a 2019 narrative literature review concluded that most patients have a positive view of ECT (15, 16). Furthermore, these studies suggested that patient dissatisfaction with ECT was largely due to inadequate pretreatment counseling, which has improved over time (16).

Although frightening depictions of ECT may make for compelling storytelling, we believe it is essential to reflect on the impact of this trope on patient and provider bias. Despite its efficacy, ECT remains extremely underutilized, with stigma, ill-informed regulatory barriers, and lack of access contributing significantly (17). It has been demonstrated that the media predominantly informs individuals’ understanding of ECT (16, 18, 19). The overrepresentation of negative portrayals in films, news, and social media contributes to the public’s misconceptions and fear about the procedure (19). This negative bias toward ECT extends beyond patients and their families to providers, including medical and nursing students. Prior to psychiatric clerkships, most medical and nursing students would advise against ECT, believing that it was dangerous and painful, on the basis of their exposure to media portrayals (19, 20). This is further evidenced by a study demonstrating that after watching movie scenes portraying ECT, more students would advise against the treatment for their own family and friends (21).

For patients experiencing serious psychiatric conditions, stigma may prevent them from seeking or accepting essential behavioral health care (22). Fear-based depictions of ECT proliferate misconceptions and bias, which can serve as a barrier to care for patients for whom other treatments have failed, and ECT may provide some benefit, including those with severe suicidality. As psychiatric trainees, we are often first-hand witnesses of this issue. Anecdotally, one of the most difficult things we have learned during residency is how to unravel the bias toward ECT for patients and families of patients in dire need of treatment.

In recent decades, mental health professionals have successfully collaborated with media stakeholders to develop guidelines for safely reporting psychiatric phenomena. For example, after numerous studies validated the risk of suicide contagion with certain types of media coverage and validated the ability of responsible reporting to decrease suicide risk, mental health professionals developed guidelines for safe reporting on suicide. The Canadian Psychiatric Association created a set of guidelines (published in 2009 and revised in 2017) for the safe reporting of suicide-related coverage (23), and similarly, the American Foundation for Suicide Prevention has identified best practices and recommendations for reporting on suicide (24). In the case of ECT, initiating this dialogue between behavioral health providers and media stakeholders to determine best practices for portraying ECT in the media may be a solution that mitigates the persistent stigma surrounding this practice. Ultimately, we call for film makers to critically consider the impact of their portrayals of ECT and be mindful of the influence that it may have on patients’ perceptions of and access to this treatment. In an era when Hollywood is making strides to improve representations of mental health care (25), it is time for the film industry to understand that peddling anti-ECT stigma as entertainment can mean life or death for some vulnerable patients.