Depictions of Mental Illness in Fiction, Part 1
As a psychology major in college, I took courses on abnormal psych, cognitive psych, evolutionary psych, social psych, and psychopharmacology, to name a few. I spent two years as a research lab assistant as part of my program. During my junior year, I decided to volunteer at Austin State Hospital, the oldest psychiatric facility in Texas. This was my first experience being around individuals who required inpatient mental health treatment. Despite my education, I had little real-world exposure to people who had mental illness.
Before this, my impressions of mental illness were formed by what I read in books and saw on screen. I didn’t know anyone who was taking antidepressants or mood stabilizers, and I didn’t know anyone who was in therapy. At least, that’s what I thought. No one talked about it—or maybe I hadn’t been listening. It wasn’t until I decided to focus on psychology and social work that I became more aware of the silence around mental illness and the ways in which media depictions play a part in reinforcing that silence.
In discussions around diversity and representation in writing, I don’t often see mental illness included in the conversation, despite its prevalence in society and the lack of representation in fiction. With that in mind, I decided to write this two-part post about common issues I’ve seen in depicting mental illness and treatment, ways to work toward getting it right, and examples of accurate and authentic representation. I also asked the Twitterverse for their thoughts, and I’ve done my best to incorporate the many great responses I received.
A few notes before getting into it:
“MI” stands for mental illness. “Fiction” refers to fictional media of all types, not just novels. “Creators” refers to content creators like authors and screenwriters.
When I talk about accuracy and authenticity, I’m referring to depictions where symptoms are generally in line with the diagnosis and that the representation isn’t reduced to harmful stereotypes or tropes. One depiction cannot capture the experiences of every person who lives with a specific diagnosis and there isn’t necessarily a “right” way to show MI.
Understanding mental illness
According to the CDC, “mental illnesses are conditions that affect a person’s thinking, feeling, mood or behavior, such as depression, anxiety, bipolar disorder, or schizophrenia. Such conditions may be occasional or long-lasting (chronic) and affect someone’s ability to relate to others and function each day.”
Global data from 2017 showed that around 15% of people had at least one mental or substance use disorder. In the US in 2015, about 1 in 5 adults had a mental illness within the previous year and about 1 in 25 adults had a serious mental illness that resulted in functional impairment.
How fiction fits into the picture
Why is it important to portray mental illness accurately and authentically in fiction? I believe that all media, regardless of news or fiction stories, contributes to a cycle of stigma and shame.
As illustrated by the statistics above, mental illness affects a large number of people, but because of stigma, many don’t talk about it. Therefore, unless someone has personal experience with MI, their exposure to it is often limited to media portrayals.
MI isn’t shown frequently in fiction. When MI is shown, it’s often done in stereotyped, inaccurate, or harmful ways. It’s frequently used as a plot point to create conflict, seemingly without much thought or research.
These limited depictions cause readers and viewers to form impressions of those with MI that are based on these stereotyped, inaccurate, or harmful portrayals. This feeds stigma or creates fear.
This stigma and fear discourages people from talking about MI.
And so the cycle continues.
When there are more accurate depictions of MI in fiction, the cycle can start to change.
Creators tell stories about people who have MI in ways that are well-rounded, nuanced, and human.
These depictions cause readers and viewers to form impressions of those with MI that are well-rounded, nuanced, and human. This helps break stigma and challenge fear.
Seeing more authentic depictions may encourage those with MI to speak up or seek support.
People who don’t have personal experience with MI may learn of others in their life who do, and they start to see MI beyond what’s portrayed.
These are both simplified versions of what might happen in real life, but I wanted to illustrate why media representation matters. With fiction, there’s often the argument that creators can do whatever they want with their stores because they’re not real. However, the people who consume that fiction are real, and the effects of that fiction can be real too.
Depictions of mental illness
The International Classification of Diseases (ICD-11) is published by the World Health Organization and is used by most countries to diagnose physical and mental illnesses. The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) is published by the American Psychiatric Association as the primary MI diagnostic tool for mental illness in the US. Diagnostics aren’t perfect. Clinicians have to use their judgment based on signs, symptoms, tests, and scans. Many diagnoses share similar features, and diagnosing one MI is usually done by ruling out others that don’t quite fit or by seeing that a medication is ineffective. Symptoms manifest in different people in different ways, and there can be cultural differences as well. Additional influencing factors include an individual’s personality, environment, co-occurrence of other diagnoses, and support system. All of this is to say that there’s no one-size-fits-all depiction of what mental illness looks like, even with the same diagnosis. One depiction of one character’s experience with MI won’t be representative of everyone, but when it’s done in an authentic way, it helps pave the way for more.
Instead of accurate and authentic depictions, harmful stereotypes and tropes about mental illness are often used, such as those listed here.
Characterizing everyone with MI as violent or blaming violent behavior on MI. A 2015 review that looked at research on mental illness and mass shootings in the US stated that “at the aggregate level, the vast majority of people diagnosed with psychiatric disorders do not commit violent acts—only about 4% of violence in the United States can be attributed to people diagnosed with mental illness.” Despite this, fiction tends to show characters who have MI (especially those with psychosis) as being violent toward others. People with MI can exhibit violent behavior, just like anyone can, but studies have shown that those with MI are more likely to be the victims of violence, not the perpetrators. But when almost every depiction of someone with MI is linked to violence, the audience’s perception can be skewed to believe that the majority of people with MI are violent. On the flip side, the behavior of those who do commit violent acts is often attributed to MI, rather than other factors like drug or alcohol use, childhood trauma, or ideology.
Showing those with MI in one-dimensional or flattened ways. Instead of seeing nuanced experiences of people with MI, we often get depictions that are stereotyped, one-dimensional, or wrong. These are just a few examples.
Having major depression doesn’t mean someone is always in bed crying.
Having bipolar disorder doesn’t mean that someone vacillates between being happy and sad in a given day. It’s marked by mood dysregulation, usually with shorter periods of mania (days to weeks) and longer periods of depression (weeks to months) and regulated periods in between.
Having obsessive-compulsive disorder (OCD) doesn’t mean being neat and washing hands all the time. OCD is marked by obsessive, intrusive thoughts or images that can be relieved by carrying out certain actions, often in a ritualistic manner. It’s not a fun or quirky personality trait.
Having Alzheimer’s disease or other dementias doesn’t mean always being happily confused or amusingly repetitive. These are real, progressive diseases that lead to the loss of memory, executive function, mobility, insight and judgment, and functional abilities, and they eventually result in death.
Using diagnoses and terms interchangeably. Mental health diagnoses are not all created equal. Many of them share similar features, but they aren’t interchangeable. Schizophrenia is not the same as dissociative identity disorder (DID, formerly known as multiple personality disorder), even though it gets confused as such. Obsessive-compulsive disorder is not the same as obsessive-compulsive personality disorder. Mixing diagnoses and terms implies that mental illnesses can be lumped together or switched around without thought.
Using diagnoses and terms casually or flippantly. When terms are thrown around in a casual—and usually inaccurate—way, it trivializes what it means to actually have the disorders. Being happy and sad in a short time (or having two opposing characteristics) doesn’t make something bipolar. Being attentive or organized doesn’t mean someone is OCD. Being sad doesn’t equal depression. Being nervous doesn’t equal anxiety. Personality traits or temporary moods are not equivalent to clinical diagnoses that can lead to significant impairments.
Showing only the extremes of being “normal” or being out of control. Often, a character is portrayed as either “normal” (and therefore without MI) or completely out of control, violent, or functionally impaired. There aren’t many depictions of characters who are high-functioning and also have MI. This furthers the divide between people who do and don’t have MI because it gives the impression that someone with MI cannot be happy, healthy, loved, or successful.
Showing everyone with MI as looking different from the norm. Not everyone who has MI looks disheveled or unhygienic. You can’t pick someone out of a lineup and say “Yup, this one has major anxiety” or “She has the eyes of someone with PTSD.” In media, people with MI are often shown with odd mannerisms or speech patterns or clothing, again as a way of “othering” them.
Labeling with ableist slurs. Words like “crazy” or “psycho” have historically been used to stigmatize individuals with MI as exhibiting behavior that’s outside the norm. These words, and others like them, have since become general insults to disparage anyone whose behavior is unwanted, often because it’s confusing or complex. These labels are frequently applied to women, particularly those who are outspoken or emotionally expressive, as a way to dismiss them. These terms perpetuate the idea that mental illness is bad and anything associated with it is also bad.
If you’re writing about mental illness, examine whether you’re using any of these stereotypes or tropes and, if so, where the ideas came from. When we get our knowledge about certain groups from fictional representations rather than from those who actually have experience with it, it’s easy to copy the same troublesome depictions.
Final thoughts
If I didn’t have a background in psychology and the experience of volunteering at an inpatient psychiatric hospital, it’d be likely that most of my impressions of those with mental illness would be formed from what I read in books and watched on screen. That’s why I believe it’s important for fictional stories to represent mental illness accurately and authentically. In part two, I discuss how mental health treatment is stigmatized and shown in harmful tropes, explore ways creators can work toward authentic portrayals, and share what media representations have been praised.
