Category Archives: neuroscience

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 7: ‘Hush’ and the Freakshow

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. 

Electro-convulsive Therapy (ECT) has a troubled history, but is both safe and effective.

Be sensitive. Suicide should not be a punchline or plot device. Remember that what you write affects real people with real lives. The suicide of Morpheus in Neil Gaiman’s Sandman was nuanced.

 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 7: ‘Hush’ and the Freakshow

 For the final part of this primer we’ll talk about Buffy again. ‘Hush’ is the episode 10 of season 4.

hush1

Before we get to this a few points about the freakshow tradition by way of Bedlam.

There was a guy called Tom Rakewell who ended up in the notorious Bethlem Hospital a.k.a Bedlam. Except that’s not true. Rakewell never existed, but he was a satirical invention of William Hogarth who painted a series of depictions titled ‘A Rake’s Progress’ in 1735. Plate number 8 is Tom Rakewell ends up in the Bethlehem Hospital Madhouse

rake

I’m not going to go into the details of very clear poor care. One particular touch is the inmate carving the name of Betty Careless, a famous sex worker, on a step, perhaps an allusion to neuro-syphillis (General Paralysis of the Insane).  What I would really like to draw your attention to is the two high class ladies incongruously placed. Note how the light falls on them in the painting. Hogarth wanted us to see them in particular. They were there to entertain themselves watching the suffering of the mentally ill. This was very common. The well-to-do would go to asylums and people with mental illness would be put on display.

The treatment of mental illness moved in seizures and spurts towards morality, but the use of psychiatric disorder as amusement continued and survives to this very day, though transmogrified into tropes such as the ‘psycho-killer’.  Historical freak shows such as those promoted by P.T Barnum in the 1800s used mostly physical deformity as a form of entertainment, but shows also included oddly-behaved people who may have been mentally ill. They key feature is the use of physical or mental abnormality as exhibition.

Which brings us back to ‘Hush’.

The monsters of the week are the Gentlemen.

The rhyme about them goes Can’t even shout, can’t even cry, The Gentlemen are coming by. They arrive in a town, steal all the voices, then come at night to carve out hearts from seven people.

The horror of this episode is about failed anaesthesia. If you consider the semiotics, the Gentlemen are doctors (they wear suits, they use scalpels, they have doctors bags, they keep their extracted hearts in specimen jars, they congratulate themselves after successful heart extraction, and come across as genteel). The victims are unable to cry out, which would be the normal way to express pain or to indicate to the doctor or dentist that your flesh is not numb. It’s a great episode and one of my personal favourites. So what’s the problem?

These guys:

guys1 guys2

The assistants, familiars, servants, minions or whatever. They aren’t even named in the nursery rhyme or the episode. They do not matter. They are unnamed, and hence unimportant. While the Gentlemen are doctors the symbolism of these minions screams psycho-killer or mental patient.

They wear strait jackets, their faces are bandaged from psychosurgery, they act brainless, their crouched, almost simian movements and the weird jerky hand movements evokes the extreme side-effects of antipsychotics or some of the problems of Huntington’s Chorea. Interesting side note: the shirts used by the Gentlemen are not contemporary. They would have been used when asylums were around. These minions are made to seem more pathetic by the comparison with the Gentlemen who have graceful movements and who glide about a foot above the ground.

This is the essence of freak show: they are there to entertain by virtue of being mentally ill. The message to your subconscious is the mentally ill do not matter.

Conclusion

What I hope to do (or to have done) is inject some curiosity about the facts of mental illness. Most media representations are largely inaccurate. As writers, artists, film makers or creators of any kind do not shy away from the uncomfortable truth, but find it. You may discover that real mental illness is not sensational, but you must make an effort because with time what you write has the potential to change the experience of real people.

At least, that’s my hope.

(P.S. I know I’m going to regret this, but if you’re creating something and you need an opinion on the way you have portrayed mental illness feel free to contact me. I don’t charge a fee and it all leads to a reduction in stigma.)

 

 

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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 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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Clickity-click: Art and Your Brain

“Although we cannot provide mechanistic explanations, the production of visual art involves more than the mere cognitive and motor processing described. The creation of visual art is a personal integrative experience –- an experience of ‘flow,’ – in which the participant is fully emerged in the creative activity.”

 

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