5 Tropes about Mental Illness You Need to Stop Writing / Guest Post By Natalie Dale, MD / A Writer's Guide to Medicine

 

5 Tropes about Mental Illness You Need to Stop Writing

 

By Natalie Dale, MD

 

Tropes exist for a reason. They are familiar, comfortable, and can provide a shared vocabulary with readers. In a skilled writers’ hands, tropes can be deployed or subverted in unique and original ways. But when it comes to mental illness, there are a few tropes that, even in skilled hands, have the potential to be quite damaging. This list is by no means exhaustive–I didn’t even begin to touch on tropes regarding specific conditions, such as ADHD, Autism, OCD, Schizophrenia, and Tourette’s–but it contains some of the most damaging and prevalent tropes regarding mental illness. In this post, we’ll discuss five prevalent tropes regarding mental illness and how to avoid them in your writing.

5)   Evil ECT

“Just lie here, bite down on this strap while I stick these electrodes to your head.”

 

“But I don’t want–”

 

“I promise it won’t hurt a bit.”

 

*Flips switch* *muffled screams*

 

In this trope, a character is strapped onto a table, electrodes placed on their head. Without warning or consent, electricity floods through them. Their limbs jerk and they grimace or cry out in pain. It’s horrifying to watch or read about. And it’s not how ECT works, at least not anymore.

 

Electroconvulsive therapy, or ECT, is a procedure that uses electricity to treat serious mental illnesses, ranging from treatment-resistant depression to catatonia. It is an incredibly effective treatment that can alleviate symptoms in as little as six sessions, or about three weeks. By comparison, most medications for depression take at least six weeks to take effect.

 

The stigma surrounding ECT comes from the early days of the procedure, when higher doses of electricity were used, and without anesthesia. Back then, side effects could include everything from permanent memory loss to fractured bones due to the incredible strength of the convulsions caused by the high voltage. Invented in the 1930s, the procedure as it was performed back then was barbaric at best. Then again, during that same time, doctors were touting cigarettes as a “healthy choice.” Medicine has come a long way since then.       

 

Nowadays, people receiving ECT do so under general anesthesia, as they would for a surgical procedure. They’ll be given a muscle relaxant to minimize convulsions, a mouth guard to prevent them from biting their tongue, and supplemental oxygen through a face mask. Throughout the procedure, their blood pressure, heart rate, breathing rate, and blood oxygen levels are closely monitored. The electrical activity of the brain is also measured using an electroencephalogram, or EEG.  

An ECT induces a brief seizure, an electrical storm in the brain, that lasts less than a minute. Because of the anesthesia and muscle relaxant, the only outward sign of this storm might be some small, rhythmic twitching of their foot. Then the anesthesia wears off and they’re taken to a recovery area. The whole procedure lasts only 5-10 minutes.

 

The main side effect of ECT is confusion and anterograde amnesia, or the inability to form new memories. However, these side effects are always temporary and are usually limited to the minutes and hours just after the procedure.

 

ECT is an important weapon in a psychiatrist’s arsenal. It works faster than many medications and can be used in treatment-resistant disease. It can also be used for people who can’t take the usual medications, such as pregnant women or people experiencing serious side effects. Yet many people are too terrified to try it even though it might save their life, due to the stigma surrounding the procedure.

4)   Bohemian Bipolar

“Hey, is your mom coming to Thanksgiving?”

 

“No idea. She’s so bipolar, I never know what she’s going to do.”

 

“Hopefully she won’t show up wearing a coconut bra again!”

 

Characters with bipolar disorder–or any mental illness for that matter–are often portrayed as free spirits, artists, bohemians, and hippies prone to extreme moods and wild emotions. They flit from idea to idea, relationship to relationship, their lives fragmented, scattered, and disorganized.

 

There is some truth to this trope. When in a manic or hypomanic episode, people with bipolar can become extremely invested in their work, pursuing a newfound interest with single-minded intensity, letting everything else fall away. When depressed, they can become moody or irritable, and may withdraw from their normal activities of living. But just because your character has bipolar doesn’t mean they’re eternally in a mood episode.

 

Bipolar disorder is not a personality type; people suffering from the disease do not necessarily share any specific personality traits. It is an episodic condition, meaning that people with the disorder experience episodes of either mania/hypomania or depression. In between episodes, their moods are completely normal. This means that as long as they aren’t actively in an episode, you can’t tell who has bipolar just by looking at them.

 

And no, people with bipolar aren’t perpetually experiencing mood episodes. The number of episodes a person has in their lifetime varies greatly. About 10% of people with bipolar ever only have one episode in their life, while some people can have multiple episodes in a single year. And while there is a link between creativity and bipolar disorder–Kay Redfield Jamison wrote a whole book on the topic¹– not everyone with bipolar is creative or artistic. All over the world, there are accountants, mechanics, and corporate paper-pushers suffering from the disorder as well.   

 

The other problem with this trope is how “bipolar” or “mentally ill” are often used, not as a medical diagnosis, but as descriptors for generally unlikeable characters. They may have heightened emotional responses, unpredictable mood swings, or be flighty and unreliable. But using bipolar or mental illness as a synonym for crazy is both hurtful and inaccurate.

3)   Head Injury Amnesia

“You’re awake! I can’t believe that brick hit you straight in the head!”

 

“Excuse me, who are you?” *Looks down at hands* “And…who am I?”

 

Popularized by daytime television, in this trope, a hit on the head causes autobiographical amnesia. The affected character forgets everything about who they are: their name, the faces of their loved ones, even their personal tastes, like whether they prefer chocolate to vanilla.  Maybe it’s because I was a neurologist, but this trope drives me bonkers.

 

Autobiographical amnesia is the loss of memories pertaining to identity. It is super rare. When caused by head trauma, it is always found alongside significant brain damage. One fascinating case study details a forty-three-year-old doctor who lost his identity after a traumatic brain injury. After his injury, he didn’t know his name or recognize himself in the mirror. He didn’t recognize his family, his lover, or even his dog, and was convinced that he was only seven years old.² He also had a laundry list of other ailments, ranging from difficulty speaking to personality and IQ changes, and was paralyzed on half his body.² In other words, if your character gets autobiographical amnesia from a hit on the head, they’re going to have a lot of other problems to deal with. 

 

If you need a character to develop autobiographical amnesia without the other signs of brain damage, instead consider Dissociative Amnesia. Affecting ~1.8% of the population, Dissociative Amnesia is a poorly understood psychiatric disorder usually brought on by trauma or stress.³ However, the amnesia is usually localized, meaning that your character would have amnesia for a traumatic event or for certain periods of time, rather than a total loss of all autobiographical memory. Generalized amnesia, in which your character completely forgets their entire life history and/or their identity, is extremely rare. And it is also usually temporary. 

 

But here’s the good news: this trope gets some things right. Post-traumatic amnesia really does exist! In fact, it’s pretty common; about 25% of victims with concussions have some sort of amnesia.⁴. Post-traumatic amnesia comes in two flavors. In retrograde post-traumatic amnesia, the victim forgets the events leading up to the injury. In retrograde amnesia, people usually only lose the minutes leading up to the injury, but they can sometimes forget the hours or even days before the injury. In anterograde post-traumatic amnesia, the victim has trouble forming new memories after the injury. Notice how the victim doesn’t forget important biographical information in either case. Both kinds tend to get better with time, though retrograde usually improves faster than anterograde.⁵

 

This should probably go without saying, but if a hit on the head can’t cause amnesia, it can’t fix it either. Quite the opposite. Repeated head injuries can lead to chronic traumatic encephalopathy (CTE), which can significantly worsen memory loss. CTE causes a constellation of symptoms ranging from trouble concentrating, confusion, disorientation, and memory loss to aggression and tremors. Football players are particularly susceptible to this condition. Aaron Hernandez, a former player for the New England Patriots, was found to have severe CTE on autopsy, after a history of violent behavior led to the killing of a friend and then himself.⁶ 

2)   Insane equals violent

“Captain! Evil McMasterplan has released the inhabitants of the insane asylum. They’re flooding into the city now!”

 

*Horrified silence*

 

“Call in the National Guard. They’re our only hope now.”

 

In fiction, insanity is often synonymous with violence. From psychotic serial killers to deranged ex-wives, the mentally ill are often depicted as unpredictable and dangerous. But the truth is much more complicated.

 

People with mental illnesses are much more likely to be the victims of violence than its perpetrators. One study found that men with mental illness were more than twice as likely to be subjected to violent crime than their non-mentally ill counterparts; for women, their risk was tripled.⁷ And victims of violent crimes are more likely to become perpetrators themselves.⁸

 

Some studies have shown a slightly elevated risk of violence in psychiatric patients, particularly if they are acutely and seriously ill. But the elevated risk of violence in people with serious mental illness is minimal: 2.9% vs. 0.8% of the general population.⁹ Most people with serious mental illness will never commit violence. In fact, the overwhelming majority of violence in the population–about 96% –is not attributable to mental illness.¹⁰

 

It’s also important to note that violence among the mentally ill occurs primarily in people with personality and substance use disorders, such as drug and alcohol addiction.⁷ Violence amongst people with other serious mental illnesses, such as schizophrenia, depression, and bipolar disorder, occurs at much lower rates.⁷

 

Often, aggression amongst the mentally ill is inextricably tied to confounding factors, such as poverty or a history of abuse; one study even found that psychiatric patients had the same likelihood of committing violence as their non-mentally ill counterparts, once their neighborhood was accounted for.⁹ And the biggest risk factors for violence are the same in the mentally ill as they are for the general population: being young, male, single, and poor.⁹     

 

The trope of the violent psychiatric patient is both inaccurate and dangerous. It contributes to the stigmatization of mental illness and may justify the victimization of the mentally ill. The vast majority of people with mental illness will never become violent, and those that do become violent often do so because of the same environmental factors that inspire violence in everyone else. 

1)   Starts with Suicide

“I need my protagonist to start out in a really bad place.”

 

“I know, why don’t you have their best friend commit suicide!”

 

Lots of books, movies, and TV shows start with suicide attempts. Often, a suicide attempt is the inciting event that sets the story in motion. But starting with suicide is the mental illness equivalent of Fridging; the author oversimplifies a complex, multifaceted disease just to increase the protagonist’s internal turmoil. The act itself is given little regard or attention, it merely serves to further the plot or character development.

 

The problem with this trope isn’t just unoriginality; it can be actively harmful. Starting with a suicide doesn’t give context to the complexities of the act. Often, it is blatant sensationalism, intended only to draw in the audience.  At its worst, portraying suicide in this way risks glorifying the act of suicide. When that happens, it can lead to a dangerous phenomenon: copycat suicides.

 

Sadly, copycat suicide is a real phenomenon. Suicide methods used by celebrities are five times more likely to be used by the general public in the months following their death¹¹. In 2016, two five-year-olds died by hanging themselves, mimicking a suicide that they’d recently watched on TV.¹¹ In 2017, two teenagers in California committed suicide shortly after watching a particular episode of 13 Reasons Why; their parents believe their deaths were directly triggered by the show and sued.¹²

 

Copycat suicides are so common the phenomenon has a name–the Werther Effect. In 1774, Goethe published The Sorrows of Young Werther, in which the eponymous character shot himself in the head, then died slowly and with great suffering. The publication of this book was followed by so many suicides of people dressed as Werther and using the same method that the book was banned all across Europe.¹³ And Goethe isn’t the only example. After the publication of Derek Humphry’s Final Exit, which promoted asphyxia as a suicide method, deaths by asphyxiation rose by 313%.¹⁴  

 

As a writer, you need to be aware of this phenomenon. Please note that I’m not saying you shouldn’t write about suicide. I’m just asking that you do your research and treat the act with as much complexity and dignity as you would any other life-threatening illness. Ensure your book does not glorify suicide or treat suicide as the only way out. By the same token, do not turn your book into a how-to manual for someone looking to kill themselves; keep the details vague, or make them up altogether. You could literally save someone’s life.

 

Final Thoughts

 

Avoiding tropes does not mean avoiding writing about mental illness altogether. Mental illness is a reality for millions of people; some studies estimate that nearly 50% of Americans will suffer from a mental health disorder at some point in their life.¹⁵ By doing your research and avoiding harmful tropes, you can use your writing to subvert expectations and help fight against the stigma surrounding mental illness. Thank you in advance. 

AMAZON

From injuring your character to depicting scenes set in the morgue, let Natalie Dale, MD be your guide to writing about medicine.  

Medicine is a world unto itself; lives can be changed in an instant and decisions are truly life-or-death. But it’s also a bizarre and alien world, full of unique settings, confusing acronyms, and a confounding array of different conditions.

 

No wonder writers love to write about medicine. No wonder they get it wrong. 

In the Writer’s Guide to Medicine, Dr. Dale shows you how to accurately depict the world of medicine in your writing and points out the most common clichés and medicine-related pitfalls.

In Volume 1: Setting & Character, you’ll learn:

·        How medical professionals approach an emergency

·        Key sensory details for unique medical settings

·        How to avoid medical clichés.

·        Facts about death and dying

·        Specifics about comas, consciousness, and the infamous “medically-induced coma”

·        The truth about hospital food 

·        And more!

Testimonials

“A highly valuable guide for any writer of fiction whose characters will face any medical dilemma from accidents to aneurisms, torture to toxicity.”

#1 New York Times bestselling author Scott Turow

 

In this brilliantly conceived, well-organized, and superbly executed guide, Natalie Dale has created an invaluable resource for writers. Whether you want to make sure your hospital setting is true-to-life, or emulate how medical professionals really talk and behave, this is the book you need.

– Lidija Hilje, Editor & Book Coach

 

An author’s one-stop oasis of medical information that will supply verisimilitude to not only characters’ situations, but also to their likely reactions, physical and emotional.”

– James Conroyd Martin, author of Fortune’s Child and The Poland Trilogy 

Author Biography

After struggling with bipolar disorder, Natalie Dale, MD, took a leap of faith and left her Neurology residency to focus on her life-long passion: writing. Since then, her short stories and essays have been published in Flash Fiction Magazine, Wyldblood, McCoy Monthly, the READ White & Blue Anthology, and the National Alliance on Mental Illness (NAMI) blog, among others. The first volume, Setting & Character, of her “Writer’s Guide to Medicine” series will be published on December 4^th, 2021, by Ranunculus Press. In her spare time, Natalie organizes an elementary school reading program, runs a writing critique group, and plays violin in a community orchestra. 

Follow Natalie!

Website: nataliedaleauthor.com

Twitter: @DaleNatalie

Instagram: natalierose6627

 

 

Thank you, Natalie, so much for your informative post and for your work to eliminate these harmful tropes!

Everyone, please leave a comment for Natalie!

Works Cited

1. Jamison, Kay R. Touched with Fire: Manic-Depressive Illness and the Artistic Temperament. Simon & Schuster, 1996. 

2. Pachalska, Maria, et al. “A Case of ‘Borrowed Identity Syndrome’ after Severe Traumatic Brain Injury.” Medical Science Monitor: International Medical Journal of Experimental and Clinical Research, International Scientific Literature, Inc., Feb. 2011, www.ncbi.nlm.nih.gov/pmc/articles/PMC3524703/. 

3. Kupfer, David J. Diagnostic and Statistical Manual of Mental Disorders: DSM-5. American Psychiatric Association, 2017. 

4. Barton Straus, Lindsey. “Amnesia: Whether It Predicts More Severe Concussion or Slower Recovery Remains Unclear.” MomsTeam, 26 Apr. 2013, www.momsteam.com/health-safety/post-traumatic-amnesia-retrograde-anterograde-factor-concussion-recovery-severity. 

5. Cantu, Robert C. “Posttraumatic Retrograde and Anterograde Amnesia: Pathophysiology and Implications in Grading and Safe Return to Play.” Journal of Athletic Training, National Athletic Trainers' Association, Inc., Sept. 2001, www.ncbi.nlm.nih.gov/pmc/articles/PMC155413/. 

6. Kilgore, Adam. “Aaron Hernandez Suffered from Most Severe CTE Ever Found in a Person His Age.” The Washington Post, WP Company, 9 Nov. 2017, https://www.washingtonpost.com/sports/aaron-hernandez-suffered-from-most-severe-cte-ever-found-in-a-person-his-age/2017/11/09/fa7cd204-c57b-11e7-afe9-4f60b5a6c4a0_story.html. 

7. Kimberlie Dean, Ph.D. “Risk of Being Subjected to Crime, Including Violent Crime, after Onset of Mental Illness.” JAMA Psychiatry, JAMA Network, 1 July 2018, https://jamanetwork.com/journals/jamapsychiatry/fullarticle/2680807. 

8. Latalova, Klara, et al. “Violent Victimization of Adult Patients with Severe Mental Illness: A: NDT.” Neuropsychiatric Disease and Treatment, Dove Press, 9 Oct. 2014, https://www.dovepress.com/violent-victimization-of-adult-patients-with-severe-mental-illness-a-s-peer-reviewed-fulltext-article-NDT. 

9. Deangelis, Tori. “Mental Illness and Violence: Debunking Myths, Addressing Realities.” Monitor on Psychology, American Psychological Association, 1 Apr. 2021, https://www.apa.org/monitor/2021/04/ce-mental-illness. 

10. Varshney, Mohit, et al. “Violence and Mental Illness: What Is the True Story?” Journal of Epidemiology & Community Health, BMJ Publishing Group Ltd, 1 Mar. 2016, https://jech.bmj.com/content/70/3/223. 

11. Çelik, Mustafa, et al. “Copycat Suicides without an Intention to Die after Watching TV Programs: Two Cases at Five Years of Age.” Noro Psikiyatri Arsivi, Turkish Neuropsychiatric Society, Mar. 2016, www.ncbi.nlm.nih.gov/pmc/articles/PMC5353244/. 

12. Kindelan, Katie, and Sabina Ghebremedhin. “2 California Families Claim '13 Reasons Why' Triggered Teens' Suicides.” ABC News, ABC News Network, 28 June 2013, abcnews.go.com/US/california-families-claim-13-reasons-triggered-teens-suicides/story?id=48323640. 

13. G. Niederkrotenthaler T. Herberth A. Sonneck. “The ‘Werther-Effect’: Legend or Reality?.” Neuropsychiatrie : Klinik, Diagnostik, Therapie Und Rehabilitation : Organ Der Gesellschaft Osterreichischer Nervenarzte Und Psychiater, U.S. National Library of Medicine, https://pubmed.ncbi.nlm.nih.gov/18082110/. 

14. Stack, S. “Media Coverage as a Risk Factor in Suicide.” Journal of Epidemiology & Community Health, BMJ Publishing Group Ltd, 1 Apr. 2003, jech.bmj.com/content/57/4/238. 

15. Reeves, William C., et. al. “Morbidity and Mortality Weekly Report (MMWR).” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 2 Sept. 2011, http://www.cdc.gov/mmwr/preview/mmwrhtml/su6003a1.htm?s_cid=su6003a1_w.