Key Learning Points So Far:
The portrayal of mental illness by writers/creators affects stigma. Stigma leads to negative treatment once individual is identified (‘marked’) as mentally unwell.
Mental illness is difficult to define but is socio-culturally determined. Cultural context is important when depicting a character as mentally ill. There should be no drug/alcohol intoxication or organic illness. Behaviour/experience also needs to be sustained in order to attribute it to mental illness.
The assessment of mental illness should draw information from as many sources as possible (self, others, mental health workers), and should consider a change from the baseline.
Trigger Warning: Up to 1 in 4 people can be affected by mental illness so if any of the topics discussed here affect you contact your health professional (General Practitioner in the UK).
Scope: This is for creators of speculative fiction. The idea is to improve depiction of the mentally ill in narratives like film, books, music videos etc. It is just a primer, therefore it will not go into too much detail.
Spoiler Alert: Here there be spoilers. Deal with it. I will try not to reference anything currently showing in cinemas, but I make no promises.
Part 4: Mini Case study: Buffy, the Vampire Slayer season 6, episode 17, “Normal Again”
Before we start please note that I am not examining the entertainment value or artistic merit of these shows/films/comics/whatever. I am only examining their treatment of mental illness. ‘Normal Again’ is one of my favourite episodes. Buffy’s enemies this season are the three nerds. They summon a demon who, during a fight, injects Buffy with a neurotoxin. This causes her to hallucinate and believe she is a patient in an asylum. This splits Buffy’s experience into two realities, and she has to decide which is really real. We’ll call the Sunnydale reality R1 and the asylum reality R2.
Some background: In R1 When Buffy first came to Sunnydale back in season 1, she was said to have transferred because she burned down the school gym. She spent two weeks in a mental institution because of her belief that she was the Slayer. To get released she lied to her parents and the mental health professionals, saying she no longer believed in vampires. In s1e1 she slipped when talking to Principal Bob on the first day of school, saying the gym was full of vampires.
In “Normal Again”, R2, Buffy has been in the asylum for six years, in other words, instead of only spending two weeks, she has been at the asylum the whole time, i.e. through all six seasons of Buffy, the Vampire Slayer. Sunnydale is not real. In R2 both her parents are present, her father who left her in R1 and her mother who is dead in R1. This sets up a sort of wish fulfilment aspect to R2 (note also that the ever-annoying Dawn is not part of it, and her parents are not divorced).
The two realities are set against each other, because in R1 Willow and all Buffy’s friends are trying to find an antidote to the neurotoxin that will cure her of the hallucinations that make her think she is in an asylum, while in R2 the psychiatrist along with both of Buffy’s parents are trying to cure her and discredit the experiences of the Slayer and the Scoobies.
Apart from the obvious cliche of using mental illness as a cop out (“the protagonist was mad all along!”), let’s take a look at what this episode does for mental illness.
Looking at R1 first, can a single dose of toxin cause this kind of elaborate belief system? Unlikely. The kind of hallucinations that a toxin is likely to cause are disorganised, psychedelic experiences. Buffy’s experience is unlikely to be so consistent, so organised, so lucid. It is bound to be mixed in with illusions and hence respond to environmental cues like noises, speech, tactile stimulus, and light (in other words, it is an example of delirium). Would the solution be to ingest an antidote? Not really. As long as the toxin isn’t fatal the idea would be to support the person through it, until the toxin washes out of the system. In fact, introducing more chemicals into the system can make the delirium worse.
But let’s look at D2. We are told that Buffy Summers suffers from undifferentiated schizophrenia. There is a very clear statement that her violence was in response to delusional beliefs as opposed to random. The idea that she burned down a school gym because she believed it to be full of vampires would have earned her an admission to a mental health unit because fire setting is very high on the risk assessment list. We should award points for the depiction of the doctor and other mental health staff as benevolent. Too often in fiction the mental health staff are seen and depicted as evil. See ‘Ward 6’ by Anton Chekov and of course ‘One Flew Over the Cuckoo’s Nest’ (book and film).
In the early scenes the nursing staff inject Buffy with what we assume is a tranquiliser.
Problem one: they inject into the bicep. No. You’d be looking at a more stable site when the patient is struggling.
Problem two: only two people are restraining her. No. It takes about five people to safely restrain one person, six if you count the person who will administer the medication. To use two people is dangerous for the patient and the staff performing the restraint. Lest you think this is not important, people have died during restraint both in mental hospitals and in police custody. It has to be done safely.
I can’t speak for America, but in the UK psychiatrists do not wear white coats. That kind of thing went out decades ago along with asylums. I do not think they do in America, but I’m willing to be corrected.
Doctor: “She’s lucid. Keep talking, maybe the sound of your voice will ground her.”
Yeah, not for undifferentiated schizophrenia. Maybe for delirium in D1.
In D2 Buffy’s parents ask if she will get better and be how she was before. This is a common and entirely understandable question which is asked many times in situations like this. That Buffy has created a secondary world to support her primary delusion is excellent writing. This is also what tends to happen. A single delusion develops which the patient believes to be true. The problem is moulding the rest of reality to fit the delusional belief. This can lead to secondary delusions which both emanate from and support the primary delusion. The nature of the delusion having Buffy as the central figure is also important. True psychiatric symptoms tend to be self-referential, meaning the person suffering from the illness is usually the subject of the abnormal belief.
The doctor brings up the creation of Dawn as an inconsistency in Buffy’s fantastical world as if the inconsistency would unravel the delusions. In my experience that does not matter. By definition delusions are tightly held beliefs. The subjective certainty is resistant to counter arguments. If you could argue your way out of them they would not be delusions in the first place (we will return to delusions later).
The doctor goes on to describe the narratives in the first six seasons of Buffy, talking about how they are no longer comforting and are falling apart. I should point out that symptoms of mental illness are seldom comforting. In my opinion the doctor veers into fantasy which is wilful and reversible use of the imagination with full knowledge of unreality. Delusions are not voluntary. Throughout the episode in D2 the doctor and her parents keep trying to convince Buffy that Sunnydale isn’t real, as if trying to talk her out of it. This search for an “awakening moment” is a myth. While one should not agree with delusions, trying to talk someone out of them rarely yields results. The episode also perpetuates the myth of the dramatic cure moment, when loved ones or a dedicated therapist are able to “reach” or “break through”. This is one of the (many) reasons that people tell depressed patients to “snap out of it”. It is not helpful.
“You have to start ridding your mind of those things that support your hallucinations”. No, no, no. There is talking therapy for hallucinations, but this is not it. The doctor spews a lot of nonsense here.
“I’m afraid we lost her”
This, in my opinion, is the worst offence.
We are led to believe that Buffy voluntarily chose to live in D1, which from the perspective of her parents and doctor is a delusional world. Fine. Buffy is now catatonic. Well:
1. Doctor shines light checking pupilliary response. This has nothing to do with catatonia.
2. Doctor then abandons hope, saying “I’m afraid we lost her”. This is rubbish. First of all, catatonia has clear treatment options. First you try short-acting benzodiazepines and if that doesn’t work you try electro-convulsive therapy. Most people respond to that. In twenty years I’ve never seen a patient not respond to one or both. Catatonia is essentially a movement disorder, with agonist and antagonist muscles firing simultaneously, cancelling out net movement.
Conclusion: this episode does some things right but gets a lot wrong. It does little to improve the viewer’s understanding of contemporary mental illness.