Mental Illness in Fiction

I’ve been seeing a trend in book reviews questioning the use of mental illness in works of fiction, as a plot device or even the main theme of a novel. (And yes, that includes reviews of one of my books.)

Also, it happens to be Mental Health Awareness Month, so this is a good time to address the topic.

This post has more questions than answers.

Some reviewers declare they will not read or favourably review any book that uses mental illness as a plot device to create tension or conflict.

But what about the unreliable narrator? What about the psychological thriller? What about the character who does terrible or puzzling things because of mental illness?

When might it be OK?

  • Never?
  • If the writer has experienced mental illness and writes from that experience
  • If the writer has done extensive research on the specific illness in their story and/or interviewed people who have experienced it, and writes about it respectfully
  • If the writer has had the manuscript reviewed by a sensitivity reader
  • If the writer avoids stereotypes or tropes associated with mental illness
  • If there are trigger warnings in the book description and/or at the beginning of the book
  • If mental illness is not explicitly mentioned in the story, even though one or more characters display what might be termed symptoms?

If it’s never okay, that means writers are limited to pure evil (whatever that is) to motivate the serial killer, or inexplicable confusion for the unreliable narrator. Or simply an inexplicable tendency to lie. Is it okay to leave it up to readers to carry out a diagnosis?

And why is it okay to show murder, bloody combat, and child abuse in fiction, but not mental illness?

What about all those characters who remember or discover terrible things that were done to them as children?

Psychological conditions are common in real life and therefore in fiction. It’s just as unacceptable to pretend they don’t exist as to treat them casually and thoughtlessly. But I see objections, in recent reviews and articles, to writers using the terminology or descriptions of symptoms because it’s “unfair,” or because it might “trigger” a reader who has experienced or is experiencing mental illness.

And what about suicide? Is it ever okay to mention or depict that in fiction? Strangely enough, even though a search on “mental illness in fiction” brings up many articles that say don’t do it, a search on “suicide in fiction” yields lists such as “the 10 best suicides in literature.” Is suicide just too useful as a plot device?

And what about trigger warnings? How detailed should they be? What about spoilers?

For what it’s worth, I think it’s undeniable that a greater awareness of mental illness requires us writers to avoid treating it casually in our fiction. We must think of it as something that can affect any of us, rather than a peculiarity of people who are “not us.”

Have you read or written books that mention or include mental illness? Is anyone prepared to revise their published works to address issues mentioned here?

For a more extensive look at the issue, have a look at this post from Rabbit With a Red Pen.

The Wikipedia entry titled “Mental disorders in fiction” lists numerous works that include mental illness.

70 comments

  2. Thank you for this insightful article, Audrey. I think that, in a free society people have the right to write whatever they wish to. That is the mark of a democratic and liberal society. Having said that, I do feel that writers should research subjects carefuly (including mental illness) prior to putting fingers to keyboards. If a fictional account of mental illness is badly written then those with experience of mental health issues do, of course have every right to point this out.
    As regards existing novels, one of my favourit works is Wuthering Heights. One could, I believe make a very good case for arguing that Heathcliff is mentally ill (although this is never explicitly stated in the novel). He bribes the sexton to open Catherine’s grave so he can look on her dead body. In addition, he tells Nelly Dean that he sees ghosts and demons. Alternatively, one can argue that Heathcliff is evil (whatever that means), but perhaps his wickedness stems from him being mentally unwell.
    As someone who is blind (and I appreciate that blindness is different from mental illness), I have no objection to authors portraying blindness in their works. I dislike poorly researched portrayals of people who are blind and strongly believe that authors should research (and ideally speak to blind people prior to putting pen to paper), however authors should be free to publish poorly researched books (but they should not be surprised when they receive scathing reviews as a consequence of having done so.
    Finally, I don’t think it is healthy when authors are constantly looking over their shoulder just in case they offend someone or other. The fact is someone or other will always take offence, and there are certain individuals who derive positive pleasure from saying how offended they are by a particular book.
    Best wishes. Kevin

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    1. Well said, Kevin. This line in particular resonates with me: “Finally, I don’t think it is healthy when authors are constantly looking over their shoulder just in case they offend someone or other.”

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    2. Thanks for these comments, Kevin. Somehow it seems worse to have personally offended someone than to have bored them or annoyed them with bad grammar.
      I think writing about mental illness is similar to writing from the point of view of an identifiable group other than the one to which you belong. There is a risk of offending someone. And as you point out, a few people enjoy expressing how offended they are.

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  3. I’m currently working on a piece of fiction where a character kidnapped someone. I’ve made it that he has spent his youth in a psyc ward and that is what has driven him to commit this act. I personally have spent time in hospital so can write from experience. I think mental health is almost an epidemic now and it should definitely be talked about in fiction.

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  4. Excellent post, Audrey. I totally agree that mental illness should be a part of literature — hopefully handled sensitively. Whether addressed directly or hinted at, mental illness has always been an important element in fiction.

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  5. Uh oh. I wasn’t aware that readers are objecting to mental illness in fiction as “unfair” or “triggering.” In my current novel-in-progress, one of the secondary characters has an undiagnosed mental illness. After doing a read-through when I finished the first draft, I made an action item on my revision list to show another side to her to balance her portrayal and make her a more sympathetic character.

    Thank you for raising this question, Audrey. I’ve subscribed to comments for this post to hear what others think.

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    1. I did see comments of the “unfair” sort in reviews of a recent popular book. They seemed to suggest the particular mental illness in the book was used like a deus ex machina, but were a minority.

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  7. No doubt whatever one writes, someone will have an issue with it. Mental illness may be a sensitive subject, but I think it’s good it is getting more airtime. It’s a centralizing theme in my middle-grade series. The mother of one of the characters is affected by all the trauma humans inflict upon Earth. I want readers to think about how we are all interconnected and that even the planet is a living being. Someone, no doubt, won’t like it, but…

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  9. How are you going to create realistically portrayed characters without references to their psychological aberrations? We all have them. Both of my male MCs (Griffen Gwidian and Robbin Nikalishin) have problematic mother relationships, and Robbie has full-blown PTSD after the Darter Disaster (now could he not?)
    Myths contain many psychological difficulties. Hercules went mad and killed his children and his punishment was to perform the 12 Labors. I had to include this in my rendition of my termite Champion Ki’shto’ba Huge-Head, so I made it go mad and kill innocent Workers and Alates after its twin was slaughtered.
    Of course, writers should portray psychological aberrations in their serious fiction. And not in some clinical factual way – they aren’t writing an academic dissertation.

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    1. Those psychological elements are what make your books so interesting, Lorinda!
      Both writers and reviewers have a responsibility to think before they write. Of course reviewers are only expressing an opinion or emotional reaction to something they’ve read, but even so…

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  10. I think it’s incumbent on us as writers to fact-check and possibly have a sensitivity reader check our work, particularly when we’re getting into topics that we may not be thoroughly versed in. (I’m going through this with a main character from another culture in my work in progress.)

    The notion that we shouldn’t use mental illness as a plot device in a novel seems misguided and short-sighted. There has been a stigma attached to mental illness for years and books that are done accurately and sensitively educate and help society accept that this is not a topic to be ashamed of or embarrassed by.

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    1. Exactly, Pete! Respectful and informed treatment is the key. I think books that invoke misguided stereotypes about “the insane” or “crazies” are subject to criticism, but avoiding something that is part of life for many isn’t the answer.

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  11. It’s kind of like how all of the special interests groups who lobby government about their single interest — none of them are willing to recognize that if all the special interests get what they want, we would collapse as a people. It’s the same thing with those who want trigger warnings for situation x and those who say we cannot write y. If writers of fiction did not include all of the terms and the things and the whatevers that might offend a somebody or might bother a somebody or might trigger a somebody, there would be no fiction left in the world.

    It’s rather simple. A writer writes the story he or she sees the way he or she wants. The reader can read or choose not to read. But demanding that writers limit themselves because a reader might be offended? Pffft.

    I think you knew I would respond this way. 😉

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  12. Hi Audrey, a thought-provoking piece. I have written from the point of view of characters suffering “mental health issues”. If it comes from experience, and is handled responsibly, it can be a way of reassuring others they’re not alone. I can’t understand why anyone would suggest it was inappropriate to explore it in fiction.

    One of the things about mental health is the sufferer can feel like they’re the only one in the universe thinking/feeling the way they do. To recognise themselves in a story can help. From a story writing perspective, I’ve found it done at its best when it’s treated as a means of offering a character a different point of view, or an interesting side-take on life. It’s at its worst when it’s self indulgent, or clearly made up by a writer who has never suffered that way themselves, or researched it poorly. And treating it casually or callously is just crass.

    Suicide is, sadly, a taboo subject. Yet it’s also one of the biggest killers, and writers should feel free to explore it, if only to gain a better understanding of it. It’s likely we all know someone who took their own life, and have asked ourselves why, and could we have done/said something to prevent it. Shutting it away as unmentionable helps no one. Naturally, again, it should be handled intelligently. Any writing glorifying/promoting it isn’t going to win any fans.

    As for trigger warnings, and sensitivity readers, I’m not sure I understand the world any more. The best writing is often dangerous.

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      1. Thanks, it’s easy for me to say, I suppose. Being an independent writer no one has heard of, I’m less likely to find myself cancelled.

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    2. Thanks for these thoughtful comments, Michael. In a way, reading can be a risk, as can stepping out into the world and encountering the unfamiliar.
      I think some reviewers regard introducing mental illness as a kind of plot crutch. Others may be troubled by depictions that do not (or maybe do) match their own experiences.

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  14. I suppose as a purely academic or theoretical topic for discussion the premise that writers should place “any” conditions on their writing is valid. But the constraints, I would say, that should be applied are age-base only. Child-focused stories, vs YA stories, vs full-on adult stories is about the only filtering I’d say is valid in writing.
    Beyond that, what’s the point of writing adult fiction if you have can’t expect readers to accept the FICTION part of the story?
    I’ll be damned if I politically attenuate my writing to appease any particular group of people. Mental illness? That’s a great big target in my book. Ready, aim, fire at all the schizoid, paranoid, psychotic, depressed, bulimic, bi-polar, PTSD tropes out there. Offended? I sure hope so.

    And I think about suicide every-goddamned-day. The first thought in my head in the morning is “Fuck, I’m still here.”

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  15. An excellent post Audrey. Once again you ask the hard questions of writers.
    In bygone ages we polluted our bodies with the smokes, fumes and detritus of the industrial revolution.
    Now arguably it is the mind which is affected by a New Age which, again arguably, started in the wake of two world wars and has been inflamed by the proliferation influences through media sources.
    Who knows?
    I am in agreement with the overall theme of the replies, in that a writer should not be restrained, if as long as they:
    1. Go into the subject with eyes wide open and expect to have to write, re-write and re-write, and also maybe scare themselves a little.
    2. Avoid those ghastly cardboard cut out stereo-types which still make it into mainstream publication.
    3. Ensure they are approaching this in a balanced, informed manner and that will be the big challenge. Offense will only be caused if they are obviously skimming.
    4. Prepared to expect the urge to drop the whole project under the sheer weight of integrity and responsibility to the subject, and then find they are drawn back in.

    As you know I’ve examined some themes of the affects of sustained combat situations, but this was on the back of having read a great deal of sharp-end military history and commentary over the years. That was hard work because I have no direct combat experience, but at the same time felt I owed a certain tribute to those who are expected to deal with that sharp-end.

    Keep up the good work with these challenging posts. Writers will be enthusiastic about discussing them.

    Thanks

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    1. Thanks for reading, thinking, and sharing your thoughts, Roger.
      In reading your novels, I recognized that you have given a great deal of thought about what happens to the minds of people engaged in warfare. I found your characters relatable and nuanced.
      Thanks for the encouragement!

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  16. Pingback: Mental Illness in Fiction | Mon site officiel / My official website

  17. In trying to make sure we do not appropriate a story or experience that is not legitimately ours (race, sexual identity, mental or physical illness, nationality, etc), I wonder if we are artificially precluding ourselves from writing a story that might bring an insight or character that is worth sharing. Your excellent questions, raised that thought as I was reading them.

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    1. I think there is such a thing as being too careful. Writers must write without restraints but exercise some care before publishing. That’s why seeking other opinions (from fellow writers and others) before publishing can be helpful.

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  18. Audrey I don’t know why these “new” ideas pop up. Writing about mental illness is as old as writing. And now it’s not okay? Just like that? I don’t buy it. I’ve written about mental illnesses. I didn’t hire a sensitivity reader or post a content warning. It never occurred to me. But I’ve seen a lot of this in the last several years. First it was taboo to write outside your race, especially if you are white writing from the point of view of a POC. I ran into this a few years ago and did have a friend who was “sensitive” review it for me. I passed. Whew. But then this year I entered a short story in an anthology competition and there was some intense scrutiny about my story as it had rape and kidnapping in it and maybe it should carry a content warning. I changed it, only hinting at the rape. Sigh. The longer you live and write, the more the rules shift. My mother is mentally ill. I have inherited a few of her disorders, but not the most crippling ones. I’ve spent my life trying to understand her. I’ve had therapy. I have read extensively on the subject. Psychology was my college minor. I think that makes me someone who can write about it.

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    1. This was a surprise to me as well, Cynthia. First seeing comments in reviews of other authors’ books, and then seeing reviews of one of my books (published more than 10 years ago) mention an irresponsible use of mental illness. I don’t know if it’s a generational thing, but it’s certainly something to be aware of. On the other hand, I don’t think we should censor ourselves.

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  19. Unfortunately, art imitates life. Writers are connecting with what’s going on around them as inspiration for their works. Not sure how I feel either, but violence in books of any kind is not worth my time.

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    1. Some books would be reduced significantly without violence of some sort. I’ve read some incredibly violent fantasies. I dislike detailed combat scenes and never write them, but it’s hard to avoid mention of mental disorders or disturbances, given how common they are now.

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  20. I have written about a suicide as a subplot in one of my YA novels. I gave no trigger warning and I mentioned no mental illness. Yes, suicide among youth is increasing in all countries, but it is not always determined by mental illness.

    In my secondary character’s case, success in sports at young age (18-19) came with increased pressure on him to be able to keep the results further and to improve them for becoming professional. Adding other family problems and the stress of hiding from his family a forbidden love, when said lover broke up with him, it was the straw breaking the camel’s back. With the “all or nothing” conception many youngsters have, he decided it would be over, and did it, in an impulse, without being suicidary before. The novel, once arrived there, focuses on how the ones left behind cope with his death (it was a time when therapy was not available for regular people, only for the rich ones, so they have to discuss with friends, with priests, with elders) and the discussion if it was or was not a mere accident…

    I also have two main characters with PTSD in another novel – two young soldiers who saw combat together and were discharged together on this reason, remaining friends. This time, it is mentioned, because it was diagnosed by doctors. One does not remember anything about himself, neither the name nor the place of birth. The other had blacked out only the last week or weeks of combat, the ones which had shocked him (including the accident which got them together), but he remembers his friend’s first name, which makes everybody believe they had served together for more time. I mention nightmares, when the case is, guilt feelings, and even, after several months living in peace, discharged, the reaction they had at a party at the opening of champagne, pushing everyone down to shelter from the explosion in their mind. I have researched this. I have talked with a staff sergeant who was 2 rounds in Afghanistan, and she confirmed me that everythign I wrote was possible. Rare, but possible. And that doctors still do not know very much about how brain functions and PTSD…

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  21. If mental illness is to be the motivation for some critical plot device, then it has to be ‘real’, and by real I mean clinically accurate. That’s a tough call, but if an author expects us to suspend disbelief then the core elements must be as real as possible.
    Do I see anything ethically wrong with writing about mental illness itself? No, unless it’s inaccurate or simply a ‘cheap’ device to solve a plot problem, in which case it’s the sign of a lazy writer.

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  22. As a reader, I have no objection to mental illness being used as part of a characterisation or as a plot device, so long as it feels reasonably realistic. I find it much harder to believe in the concept of pure evil than the concept of mental illness. I have once or twice come across books where I’ve felt uncomfortable at how mental illness has been shown or used, but these are rare exceptions. Generally speaking, I think that we as a society know that a lot of crime rises out of mental illness and therefore it would be entirely unrealistic for authors to pretend that it didn’t. I may sound brutal, but if authors are expected to avoid all subjects that may trigger some people, then fiction is dead. If I ever feel “triggered” or upset or disgusted by anything I read, I use the simple option of stopping reading and I might write a scathing review. But I don’t suggest that no one else should be allowed to read the book that has triggered me. Banning books before they’re written is surely just as repugnant as banning them afterwards.

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  23. Good questions all. To me, the idea of not being able to include any form of mental illness in a book is censorship. The result would be a skewed version of society. Books and their content should be judged individually.
    Also, what does that say about those who suffer with mental illness? As far as I know, people benefit when reading about others who have the same problems they do.
    I do like trigger warnings, though they need to be general enough as to not spoil the story.

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    1. Thanks, Mollie. As with other writing issues, it depends on us to do our research and look at our work from a reader’s point of view. And asking for second opinions too.
      Ideally, a good book description should indicate enough about the content to serve as a trigger warning for readers.

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  25. I share in your bafflement about writing books that don’t include mental illness, Audrey. To me, mental illness is extremely prevalent as a motivator, and in our society in general. If people who have challenges with depression, anger, abuse, trauma, grief, anxiety, isolation, dementia, and a host of mental health issues can’t be present in our stories, we lose out on all kinds of characters, the good and the bad. Goodbye to books like “Where the Crawdads Sing” and “To Kill a Mockingbird” and “The Outsiders.” So long to every single King and Koontz novel, most murder mysteries, and all books about struggling teenagers.

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