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Mental Illness Primer for Speculative Fiction Creators: Contents page

I wrote the primer from slides that I prepared for a talk. I know this is doing it backwards but someone requested a Table of Contents so:

Part 1: Why Should I Care?

Part 2: What is Mental Illness

Part 3: How to Assess Mental Illness

Part 4: Mini Case-Study: Buffy

Part 5: Electroconvulsive Therapy

Part 6: Suicide and the Sandman

Part 7: Hush and the Freakshow

 

 

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Mental Illness Primer for Speculative Fiction Writers 5: Electro-convulsive Therapy

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.

Examination of Buffy s6ep17 shows superficial attendance to reality of mental illness. 

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: Electro-convulsive Therapy

One Flew Over the Cuckoo's Nest

One Flew Over the Cuckoo’s Nest

I’m going to go ahead and say this from the start: Electro-convulsive Therapy (ECT) is both safe and effective. ECT is a controversial topic, but not a controversial treatment. The problems with public acceptance of modern ECT are understandable, but historical and subjective. As a writer/filmmaker, you need to know how ECT was performed in the historical era you are writing in.

The essential feature of ECT is the induction of seizures by way of electric current.   Electricity gets a bad rap in psychiatry, yet it is used all the time in medical treatment e.g. Defibrillators, TENS (Transcutaneous Electrical Nerve Stimulation) machines, diathermy in surgery to name a few. Nobody gets upset about all this, so it is not electricity that is the problem.

History 

Convulsive treatment started in the late 1930s out of an erroneous belief that people with epilepsy did not suffer from schizophrenia. The scientists of the day decided that induced seizures might cure schizophrenia. They used electricity, but also chemicals like cardiazol. With time electricity became the only method of inducing seizures.

We do, however, need to place the use of ECT in historical context. There have been, unfortunately, many abuses of psychiatry. Some of these have been nefarious, others well-meaning though paternalistic, but all led to some degree of suffering. This is not a talk on history, but a few key points should be noted. Psychiatrists in Nazi Germany subscribed to Lebensunwertes leben (‘lives unworthy of life’) and allowed or encouraged thousands of patients to be killed in ‘Action T4’ which is  believed to have been a dress-rehearsal for the extermination of Jews and Roma. The Soviets also gave us something called ‘Sluggish Schizophrenia’ which was a euphemism for dissident behaviour and the use of psychiatry for social control.

Asylums were seen by some as places to keep the mentally ill apart and (with hints of eugenics) to stop them from breeding. Interesting side note: being gay was considered a mental illness at this time.  The plight of patients on the Greek Island of Leros discovered in 1989 should remind us that such abuses are still possible in modern times. All kinds of purported ‘treatments’ emerged including insulin coma therapy, water dousing, centrifuging, mechanical restraints, psychosurgery, shock treatment, etc. By the end of WWII only ECT, psycho-surgery and Insulin Coma therapy survived as effective physical treatments for serious mental illness.

In the 1950s psychotropic drugs were discovered (by mistake while we were trying to make antihistamines). The simultaneous massive social change at the time along with the work of Goffman, Laing and Foucault as well as a financial incentive for governments led to the progressive closure of asylums. I am aware that I have simplified and collapsed a number of events and interpretations, but you can look these up. They are a matter of public record.

What’s important with respect to ECT is that it still drags around the historical and socio-cultural baggage of the asylums, inhuman treatment, coercion, paternalism, experimentation, eugenics and the immense human suffering that preceded modern mental health treatment.

When is ECT given today?

 ·        Severe depression ·        Catatonia·        Prolonged or severe mania·        Especially if there is refusal of food or drink 

What Does Modern ECT Involve?

In simple terms the psychiatrist explains the procedure and reasons for choosing that treatment option. They should seek consent in writing. The individual should undergo a physical assessment to ensure that there are no physical ailments that might make ECT risky. There should be a baseline memory test. Ideally, there should be a chat with an anaesthetist. After double-checking the consent, anaesthesia and muscle relaxation is induced. The pulse of electricity is applied with electrodes and seizure activity is monitored. The patient then goes on to recovery.

So, in summary:   Consent, anaesthesia, muscle relaxation, seizure, recovery.

It is usually about as dangerous as a dental procedure. You can read more about it from the Royal College of Psychiatry page

The events in the Jack Nicholson film may have happened once, but not any longer. ‘One Flew Over the Cuckoo’s Nest’ was already dated at the time of its release in 1975. It was based on a book published in 1962 (during the wave of asylum closures mentioned above).

Smallville s3e9 ‘Asylum’: Lex Luthor gets ECT

Lex Luthor gets science fictional ECT

Lex Luthor gets science fictional ECT

 ECT is a plot device in this TV programme about the early years of Superman. Short term memory loss is a side-effect of ECT. Lex Luthor’s father wishes for his son to forget something so he engineers a dose of ECT to perform a memory wipe. It would have been more useful to get Clark Kent to kiss Luthor. This episode is an incredibly negative portrayal of the mentally ill and displays ignorance of how ECT works. It describes ECT as “draconian” and risking irreparable brain damage and successful in 50%. ECT cannot be used to wipe memories. The patient will not remember the treatment or scream. ECT in the episode is done without anaesthesia.

Similarly in Batman # 471 where Killer Croc is given ECT, there are visible sparks, there is no anaesthesia, and the doctors wear surgical masks.

This is the second time Killer Croc appears in this talk. Co-incidence?

This is the second time Killer Croc appears in this talk. Co-incidence?

Some criticism has been levelled at ‘Homeland’ Season one’s portrayal of ECT because the recipient winces when the treatment is applied. I’ve seen what looks like a wince in some patients, although it could be seizure-related.

Please read this 2012 Guardian article from someone who has experienced ECT.

Summary: ECT is both effective and safe. Try to avoid mass media as source material.

Next: Suicide and the Sandman 

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Mental Illness Primer for Speculative Fiction Writers 4: Mini Case Study-Buffy s6e17

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”

PDVD_066

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.

PDVD_041

“Honey, try not to get kicked out?”

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.

"Yeah, no thanks, Willow. That'll just make things worse."

“Yeah, no thanks, Willow. That’ll just make things 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).

But.

In the early scenes the nursing staff inject Buffy with what we assume is a tranquiliser.

PDVD_078

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).

"I am a real doctor. Look at my white coat. "

“I am a real doctor. Look at my white coat. “

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” 

PDVD_084

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.

PDVD_079

“Real doctors use pen torches, so I must use one!”

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.

 Next: Electro-convulsive Therapy

 

 

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Mental Illness Primer for Speculative Fiction Writers 3: How to Assess Mental Illness

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.

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 3:  How to Assess Mental Illness

 

croc

The Batman School of Diagnosis Swamp Thing #66, Nov 1987 DC / Vertigo

Here we see Batman delivering a villain called Killer Croc to Arkham Asylum for the Criminally Insane.

Batman’s reason? Croc killed thirty people with a firebomb. The doctor’s response? “Of course! I-I’ll admit him into a treatment program immediately.”

Killing does not equal mental illness. Not even mass murder can be used as criterion for mental illness. This is incredibly stigmatising.  What tends to happen is that people start to draw erroneous inferences: if killing = mental illness then mental illness = killing. The myth of the psycho-killer is sustained this way. The capacity of mentally well people to commit murder is beyond the scope of this discussion, but just bear in mind that people all over the spectrum of sanity/insanity can commit any kind of atrocity.

There are three key elements to assessing mental illness in any culture. Attendance to these will help nuance your portrayal.

1. I am not feeling myself:  reports by the individual involved stating that something is not right.

2. This person is not okay: reports from other people about the individual, stating that something is not right

3. My assessment shows abnormality: opinion of mental health professional having assessed the situation taking 1. And 2. Into consideration.

 

It its simplest form, these three factors will establish if a person is mentally unwell or not. Let’s take each in turn.

I am not feeling myself

The individual suffering from mental illness knows something is not right. Compared with the baseline functioning of their self something has deviated. This could be anything from a vague sense of unease to a low mood for weeks to sleep loss to auditory hallucinations. The key thing is that something is different. Precisely what is amiss is a different matter, and can be quite contentious. For example, a person who heard voices in his head presented to a dentist in order to have his teeth removed because he thought they were picking up radio transmissions. 

The fact that the person isn’t feeling well does not mean they will disclose this to anybody. This is often a problem. In the easiest scenario a person would take this problem to their family doctor and seek help. It seldom works out that way (see also, Stigma). The person knows that they are not at their basline functioning. Whether they seek help or not depends on the level of insight and/or perceived stigma. Insight is dimensional, not categorical. It can range from complete disbelief that there is anything wrong to appropriate help-seeking behaviour with full awareness. A lack of insight is common in psychotic illnesses, and this is encoded in culture with the idea that if you think you’re mad you probably aren’t. This is not true, by the way.

This person is not okay

Here we mean an observation by people around the sufferer that something is not right. In this day and age, of course, seeing someone walking down the street talking to themselves may mean nothing more than a smart phone with earpiece. It could mean the person is responding to auditory hallucinations. It may also mean bad continuity editing in a Hollywood movie:

"There's no time to add earpieces! Let's get the movie out. Nobody will notice."

“There’s no time to add earpieces! Let’s get the movie out. Nobody will notice.”

Observations by loved ones, frenemies and random bystanders may help inform us about mental illness. A deviation from normal routine, prolonged absences from work, strange behaviour, poor self-care (where there has been previous good self-care), self-harming behaviour can all point to mental illness. Friends and family are particularly important because one assumes that they’ve known the person for a long time and can tell that there’s a problem.

My Assessment Shows Abnormality

Assessments by mental health professionals is the next part. A good assessment will take into account #1 and #2. The person would be asked a number of questions including

  • Prior contact with mental health professionals
  • Family History of mental illness (because many illnesses run in families. Note this for when you are designing the character)
  • Drug and alcohol use (note also that in addition to having substance misuse problems people can self-medicate with drugs and alcohol)
  • Physical Health (People with mental health problems tend to have poorer physical health than the general population for various reasons)
  • Forensic History (contact with the Law)

I will not go into every aspect of mental illness assessment, but the more you take into account diverse sources of information the more likely you are to get an accurate picture. This may take time.

Next: Mini Case Study: Buffy The Vampire Slayer, season 6, episode 17

 

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Mental Illness Primer for Speculative Fiction Writers 2: What is Mental Illness?

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.

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 2: What is Mental Illness

 

Everybody thinks they know what mental illness is, and to an extent that may be true, but not as often as one would think.

For example, a person with Cerebral Palsy is often mistakenly assumed to be mentally ill, perhaps due to the similarity of the movement disorders to side effects of antipsychotic medication or movement disorders seen in schizophrenia. Also, the casual observer may mistake a neuromuscular problem with speech as a problem with thought (we’ll come back to this later).

Mental illness is defined in the UK’s Mental Health Act 1983 (amended 2007) as ‘any disorder or disability of the mind’.

But what is the mind? There is no agreement among scientists or philosophers as to the definition. See Jayne, 1976 for an interesting discussion on this.  

To simplify for the purpose of clarity, most would agree that there is more to humanity than the physical being. The software part of us, the ghost that drives the meaty shell, could be termed the mind (yes, that was a ‘Ghost in the Shell’ reference). Mental illness could be defined as dysfunctions of this, except that’s not right either.

Delirium is a state that mimics many if not all symptoms of mental illness and is brought about by a physical problem, often an infection or toxic state. There is a hypothesised condition called PANDAS that is a kind of OCD brought on by a streptococcal infection. Cartesian duality is a joke when considering mental illness. The body and mind are inextricably linked. Look up psychoimmunology.

Definitions, as you see, are difficult and are useful in some but not all circumstances. Their purity is ontologically suspect.

One thing that is certain is that mental illness is socio-culturally defined. Society decides what behaviors and/or subjective experiences are deviant and need treatment or exclusion from the group. This is why the criteria for mental illness differ from country to country. See classification systems ICD-10, Chinese Classification of Mental Disorders (CCMD-3) and the abominable DSM 5. There are those who do not believe that mental illness even exists as a distinct entity, and that those we call mentally ill are responding to the situation society has placed upon them.

As a writer, the important thing to note is the cultural context within which you are defining mental illness. It is not necessarily transferable. A person with depression in Brighton may present different symptoms from a person in Brasilia. Do not extrapolate from what you think you know. Culture determines presentation. It may be completely acceptable for a man in Wisconsin to state that he is depressed, but be complete social death if the same is done in Brazzaville. Depression occurs in both societies, but the symptom mix may be much different. The content of delusions may very well depend on which society the person comes from.

Note that while definition varies, stigma appears to be near-universal.

Note that mental illness tends to be defined or conceptualized as syndromes, which are collections of symptoms that form a distinct entity.

Note that there are many terms in psychiatry/psychology that appear to be simple English, but with different meaning. A simple example is the word ‘paranoid’ which, in psychiatry, means ‘self-referential’ and not what you find in the OED. Likewise ‘depression’ does not just mean ‘sad’.

 

Note also that deviant behaviour/experience does not equate to mental illness.

For you to define something as mental illness there should be:

A. Absence of intoxicants (drugs, alcohol)

B. No organic cause (head injury, stroke, septicaemica etc)

C. Sustained behaviour/experience. A single hallucination does not make you psychotic. A low mood is not enough to diagnose depression, and besides not all people who have depression have low mood. Possession states can be normal in some cultures eg South Sudan Nuer and Jinn possession. Linda Blair was of course not from southern sudan and  we can agree that her experience was abnormal.

D. Suffering in self and/or others

In the next part we will discuss a practical way to determine if someone is mentally unwell.

Next: How to Assess Mental Illness

 

Notes:

Jaynes, J, 1976: The Origin of Consciousness in the Breakdown of the Bicameral Mind. Houghton Mifflin Company, New York

Mental Health Act, 1983

http://www.legislation.gov.uk/ukpga/2007/12/pdfs/ukpga_20070012_en.pdf

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Sharknado…

…Is perfect schlock.

It will remain an artifact of pure film-making ineptitude and if we ever send out an interstellar probe a digital recording of it should be included.

It must be allowed to join films like ‘Plan 9 From Outer Space’ on the lists of worst films ever made.

No, I’m not going to review it. Look, there’s a scene where an object falls into water without any ripples. The effects are that bad. This movie only works as a comedy or a kind of living art installation with which one could teach students how not to make films.

 

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