There’s a lot of stigma surrounding mental disorders and many misconceptions about them, so it’s not surprising that many problematic assumptions make their way into fiction. This is especially true for psychosis, which is often considered more frightening and incomprehensible than conditions like depression. Since I’m a philosopher writing about these issues, a spec fic geek, and long-time madperson, I’m here to set you straight.
1. There Is Correct Terminology
Unfortunately, there’s not one single correct term that writers can confidently use for madness and psychosis.
First, diagnoses change over time. One diagnosis might be split into several, or several diagnoses might be subsumed under one. When a disorder or neuro-atypicality gets a new name, the diagnostic criteria often change a bit as well. For this reason, scifi stories set in the future that use present-day diagnoses could age badly.
In Philip K. Dick’s novel Clans of the Alphane Moon, former psychiatric patients have formed their own cultures around their respective diagnoses on a terraformed moon. Much of the psychiatric terminology is now dated. For instance, one group is called “heebs,” short for “hebephrenics.” Hebephrenia used to be its own subtype of schizophrenia, characterized by cognitive dysfunction and emotional disconnect, but schizophrenia is now considered one condition.
A spec fic story set in the present day in our world can of course employ present-day diagnoses. Otherwise, you have a couple options. First, you can simply avoid labels. Mythcreants has previously argued that it’s often good to explicitly state that a character has some psychiatric or neuropsychiatric condition when this is the case, but one need not use a specific diagnosis to do so. A character might explicitly suffer from psychological problems with certain symptoms and receive treatment for them, even if no specific diagnosis is stated.
Second, you can invent a fictional label. In the Swedish fantasy series The Oldena Saga,* a teacher at a magic school tells student Ella that she has an “imbalance” in her soul. This has both ups and downs – she’s good at thinking outside the box and coming up with swift unorthodox solutions but can be too impulsive and reckless with her magic. She also has trouble focusing. She’s given a magic spell that temporarily calms her down and helps her focus. Made-up diagnoses like this one can be a good solution for stories set in alternate worlds or the far future. While a negative label like “imbalance” can be useful for representing common experiences with psychiatry, a neutral label can offer stronger wish-fulfillment and requires less care to avoid upsetting anyone.
A trickier issue is whether to use medical terms or go with “mad” and “madness” (sometimes spelled with a capital M), like scholars do in the academic field of Mad Studies and activists in the Mad Pride movement. Generally speaking, medical terms are preferred by people who are more psychiatry-positive, and “mad” and “madness” by people who take a more critical stance. People highly critical of psychiatry sometimes label themselves “psychiatry survivors”; they might have traumatic experiences of coercive care and terrible medication side effects. To be clear, words like insane, maniac, nutter, etc., are also used as self-descriptors by activists – I sometimes use them myself – but I think it’s better for sane people to stay off them.
While there is no safe choice with regards to terminology, you can still consider which terminology particular characters are most likely to adopt when talking about themselves.
2. Madness Makes You Oblivious
There is a myth that psychotic people are oblivious to what goes on around them, especially if they’re difficult to understand and communicate with. Janet Frame’s largely autobiographical Faces in the Water provides a vivid illustration of how harmful this myth can be. She tells the story of her long stay in a mental hospital in New Zealand during the 1950s and 1960s. She started out in one of the nicer wards. Seriously mad people were kept in horrible conditions in a different part of the hospital, but she was told that this was unproblematic; they were allegedly too mad to know. She trusted what she was told until later, when she was moved to the terrible ward herself. Then she found out how wrong she had been.
Even though conditions in psychiatric wards are generally much better nowadays, abuse still happens, and it can still be rationalized away by insisting that mad people are too oblivious to suffer from the way they are treated.
The Norwegian TV series Maniac exploits this myth for comedic effect. The main character Espen lives in a drab psychiatric ward. He experiences the most amazing hallucinatory adventures, unaware of the real conditions under which he lives.
Interestingly, this myth was replaced by a much more realistic depiction of madness in the American remake of Maniac. The American main character Owen has schizophrenia. It is sometimes difficult for him to know what is real or not, but this is presented in a subtle and realistic manner. Both Owen and love interest Annie experience amazing adventures in fantastical environments, but that’s because it’s a scifi story using fantastical elements. Owen and Annie (who suffers from depression and self-hate) enroll in a study of a new, experimental therapy, where they are given scifi drugs and placed in a virtual reality machine.
The remake further shows that rather than making you immune to abuse, conditions like schizophrenia make you vulnerable. Owen’s family tries to gaslight him into giving his brother, accused of rape, an alibi, taking advantage of how Owen is uncertain if he can trust his own memory and mind. Still, he and Annie are provided with a somewhat happy ending, rather than being “liberated by death” like so many other ill, disabled, or otherwise marginalized characters in movies and TV.
3. Mad People Have No Idea That They Are Mad
This misconception is related to the one above, but still distinct. A mad character in fiction might have their own point of view that includes noticing their environment and other people, but still have no idea whatsoever that something’s off about the way they think and feel. In Mike Carey’s novel The Boy on the Bridge, autistic main character Stephen worries that he might be insane (using that word) on top of his autism. He concludes that there is no way of knowing, since insane people never know that they’re insane. Stephen’s thoughts seem to have narrative endorsement; at least, nothing indicates otherwise.
Owen in Maniac is more realistic. He knows he’s got schizophrenia, and he frequently tries to figure out whether things are real or not. It’s a difficult endeavor, but not a wholly hopeless one – for instance, he eventually stands up to his family and refuses to give his brother an alibi. Likewise, the titular Donnie Darko slides in and out of normal and bizarre experiences. He alternates between believing his experiences and thinking that he’s chosen to save the world and seeing himself as a schizophrenic person who hallucinates. Sometimes, he seems to think both at the same time. This is common among mad people in real life; we neither fully trust nor easily dismiss our bizarre and unusual experiences when we have them.
The Star Trek Enterprise season 3 episode Doctor’s Orders provides another nuanced example of a person who goes mad while retaining some insight and also shows how madness might contain comforting and protective experiences besides disturbing ones. Denobulan Doctor Phlox must keep all humans on the Enterprise sedated for four days to protect them from neurological damage from a space phenomenon. Working all alone, he becomes increasingly disturbed by his isolation. He feels better when Vulcan officer T’Pol, who doesn’t mind solitude herself, spends more time with him. When Phlox thinks enemies stalk him through the ship and is close to freaking out, T’Pol is there to console him and use rational arguments to convince him that it’s only paranoia. At the end of the episode, when it’s time to wake up the humans again, there’s a shocking twist – T’Pol was sedated as well. The “T’Pol” that helped and supported Phlox throughout the episode was as much a creation of his own mind as his enemies were.
However, this brings us to misconception number four…
4. Hallucinations Involve Sensing a Nonexistent Person as If They Were Real
In movies and TV, psychotic characters often vividly hallucinate another person, just like Doctor Phlox did with T’Pol. I think this was fine with Phlox, since it had been established earlier that Denobulans are prone to vivid hallucinations when they’re under stress, and that they also consider this a healthy coping mechanism. Therefore, Phlox is not ashamed of his recent madness at the end of the episode, merely happy that his mind came up with a supportive T’Pol to help him out. It was such a beautiful contrast to how stigmatized madness is in the real world and felt great to watch, even though Phlox went mad in a nonhuman way.
A good example of how not to do it is provided by later seasons of Orange Is the New Black (OITNB). In the season 6 episode Who Knows Better Than I, Suzanne Warren has perfectly realistic hallucinations, including seeing and talking to her mother in an interrogation room as if her mother were really there.
Donnie Darko shows the main character hallucinating in a more realistic way. When he sees and talks to Frank the Rabbit, all of reality seems to shift around him into a more dreamlike, surreal state. This is much more common than experiencing the world as normal except for an extra person in the room. Further, when Donnie is in the bathroom talking to Frank and his sister asks whom he’s talking to, he’s abruptly yanked out of the dreamlike state and insists that he’s not talking to anyone. He’s not sure how real Frank is, but he knows that Frank isn’t part of his sister’s world.
5. Antipsychotics Are Magic
When Suzanne Warren thought that her mum sat next to her in OITNB, all it took for her mum to vanish again was the administration of an antipsychotic pill. Even though OITNB is supposed to take place in the real world, they apparently have access to antipsychotic medication nearly as magical as the drugs that Captain Kirk delivers to a forensic psychiatric facility in the Star Trek episode Whom Gods Destroy. In that episode, it’s hard to get the drug into the violent inmates, who have managed to lock up the manager and take over the facility. But once they do, the inmates immediately turn calm and sane again.
The idea that antipsychotics have these magical effects is unfortunately both widespread and harmful. Real-world parents or spouses of people with psychosis disorders who refuse their prescribed medication sometimes think it’s a good idea to slip medication into the person’s food or drink, despite this being illegal. They seem to think that if only the madperson gets the medication in their system, they will become sane, and subsequently happy and grateful for the forced medication. This myth also makes serious and important discussions about the problems inherent in coercive psychiatric care more difficult than they should be.
It can happen that someone’s head clears dramatically as soon as they take the medication, but it’s far from guaranteed. Roughly a third of all people with psychosis are believed to be “nonresponders” – that is, the medication has no effect on their symptoms. Most people who do respond to medication still retain some psychosis symptoms after several years on the pills.
Once again, I thought the theatrical version of Donnie Darko did a nice job here. The main character, after a brief stint off meds, takes his pills again, but he still sees Frank the Rabbit and has other bizarre experiences. His doctor therefore suggests that they should increase the dosage. It’s commonplace for psychiatric patients to go through a lot of experimentation with different dosages, different kinds of antipsychotics, different drug combinations, and so on, in the hope that something will help eventually.
Furthermore, people who believe that antipsychotics magically turn mad people happy and normal tend to assume that the only reason a madperson doesn’t want to take their meds is that they’re just too mad to understand their own good. In reality, although some people do well on antipsychotics, it’s common to suffer bad side effects. These include:
- Loss of creativity – a kind of chemically induced absolute writer’s block, if you will
- Drowsiness and sleeping away one’s days
- Physical problems like muscle spasms (more common with older meds)
- Swift weight gain accompanied by rampant diabetes, liver and heart problems (more common with newer meds)
Even when people resist taking their meds partially for mad reasons, these can still be mixed with reasons that should be comprehensible to anyone: a desire to preserve one’s physical health, wanting to write, create, and do things, not wanting to sleep away one’s life, and so on.
It’s nice that BoJack Horseman didn’t shy away from showing the weight gain that often follows after taking antidepressants, even though it wasn’t extreme, and Diane eventually judged it a price well worth paying for better mental health. I would like to see portrayals of the sometimes very high price that psychotic people must pay for symptom remission.
An unrealistically rosy picture of the treatments that psychiatry has to offer might encourage people to seek help, but will also lead to crushing disappointment later on for many patients. I think it’s better to have a more realistic view from the start. A wise psychiatrist I knew – sadly dead now – said that he practiced “humble psychiatry”; he always told his patients that he’d do his best to help them, but could promise no more than that. Furthermore, if more sane people knew how hard antipsychotic treatment often is on the patients, this might increase their understanding and empathy for mad people who are “noncompliant” with their doctors’ orders.
6. Patients in Mental Hospitals Are Formidable Athletes
After reading the above, you probably realize how unrealistic it is to portray patients with psychosis disorders in mental hospitals as formidable athletes. Examples of this include Harley Quinn in the movie Suicide Squad, who’s been kept in a literal cage and presumably forcibly medicated, and yet is incredibly fit and acrobatic. Another unrealistic example is Sarah Connor, who’s been misdiagnosed as psychotic and locked up for a long time at the start of Terminator 2. We see her strapped down and forcibly medicated, with the understanding that this happens a lot – yet she somehow managed to become amazingly muscular during her stay.
In reality, long-term inmates of psychiatric facilities tend to range from just out of shape to having truly abysmal physical health. Owen in Maniac is once again more realistic. Played by actor and comedian Jonah Hill, he’s got an unremarkable but somewhat chubby physique. Joaquin Phoenix reportedly wanted to go fat for his role as Joker, but sadly didn’t get his wish.
You might wonder whether this stereotype is problematic. Being fit and athletic is a good thing, right? So what’s the problem if people think that a certain marginalized group is fitter on average than they actually are? But the view of psychotic people as fit and strong, even in circumstances where they can’t exactly engage in optimal fitness routines, also strengthens the harmful prejudice that we’re immune to abuse and suffering. Just like we’re supposedly unaware of things that would hurt a normal person psychologically, our bodies are supposedly so strong and hard that we can’t be hurt physically either. This has parallels with racial stereotypes, which claim that Black people are exceptionally strong, hard-bodied, and almost immune to pain.
7. Psychotic People Are Always Villains
While people with conditions like depression or ADHD might often be told their problems can be erased by strength of will, a bigger issue for people with schizophrenia and other psychosis disorders is the perception of us as unpredictable and dangerous. Campaigns that try to decrease stigma for psychiatric conditions often push the view that they are biological disorders of the brain. But this can be problematic, because research shows that an acceptance of biological explanations correlates both with the view that people with these conditions are blameless for their problems and, less benevolently, that they are unpredictable, dangerous, and possibly best avoided altogether.
Social justice sites like Mythcreants frequently stress that in real life, mad people are more often victims of crime and abuse than perpetrators. It’s even debated among researchers whether psychotic people are overrepresented at all among violent criminals if you control for substance abuse. However, proper data is hard to get at, and substance abuse and madness can be deeply intertwined – people frequently drink and use street drugs in desperate attempts to cope with frightening mad experiences. In any case, it would be nice to see more non-villainous mad people in media – and dare I say, even more mad heroes?
In Grant Morrison’s Batman of Zur-En-Arrh storyline, Batman has a psychotic breakdown but continues to chase down the bad guys anyway. This starts when said bad guys capture him and then torment him to break his spirit instead of killing him outright. This trope has been rightfully criticized by Mythcreants already, and I will say no more about it. However, since Batman is the master of preparing for every eventuality, he’s previously engaged in special meditation techniques to ensure that if he ever breaks down like this, he’ll keep going. This is obviously unrealistic, but for my own part, I’m fine with it; it seems so clearly fantastical to me, so obviously something that works in DC’s superhero universe but not in the real world, that I’m prepared to roll with it.
When Batman goes mad, it involves lots of geeky fun shout-outs to bizarre silver-age Batman stories reinterpreted as being about madness rather than space aliens and other dimensions.* He talks to himself, he talks to his imaginary friends, he pictures himself invulnerable and dresses in colorful eye-catching rags rather than his usual black attire, but he keeps going after the villains instead of giving up.
In the midst of all this fantastical stuff, there are some realistic elements to Batman’s madness as well. First, recent research indicates that it might be common to retain a sense of agency and take purposeful action when actively psychotic. This also fits my own experiences. Even if the world alters around me and becomes surreal and bizarre in all kinds of ways, I might still do my best to deal with it and with my situation, rather than being a passive victim of my experiences. Second, there are researchers and scholars who argue that entering a psychotic state sometimes serves a protective function, precisely because it can enable you to remain active and engaged. Otherwise, the same experiences might throw you deep into helpless despair if you, so to speak, remain in regular reality.
In any case, it’s always a great feeling to see a member of your group as the hero of the story. Seeing them as a damsel might be preferable to a constant villain role, but hero trumps damsel any day of the week.
In her article Six Things Writers Should Know About Autistic People, Juliette Dunn wraps up by saying that autistic people are people too. They think and feel and do things for reasons, not because they’re collections of quirks who quirk away because they’re so quirky. Much of what I have said in this article about mad people can be similarly summed up. If someone is in the grip of psychosis, they can be hard or impossible to argue and communicate with. But this isn’t because they’ve turned into a nonperson who doesn’t think, feel, and take in their surroundings any more than a malfunctioning machine does. Even if someone has very different experiences than you, they still experience things, and they might be as frustrated by communication breakdowns as you are.
If you’ve never been psychotic yourself but want to write a story from a psychotic person’s point of view, I suggest you do a lot of research by reading texts written by people with lived experience rather than just delving into the DSM and popular accounts of mental disorders written by psychiatrists and psychologists. There are a number of autobiographies written by mad people about their experiences, like the above-mentioned Faces in the Water. Zooming in on philosophers who’ve tried both to describe and philosophically analyze their own madness, you can read:
- My writing about my own experiences (PDF)
- Paul Lodge’s piece about his experience with mania
- Woter Kusters’s modern classic A Philosophy of Madness: The Experience of Psychotic Thinking, now available in an English translation
However, even if you’re writing a mad minor character, for whom tons of research would be excessive, please write them as a person with reasons and emotions of their own.