Sharon Packer, MD
How times change. The more things change, the more they stay the same.
Each of those seemingly contradictory statements apply to our topic of mental illness in popular culture.
Fifty years ago, in 1966, legendary songwriters saluted the psychotic state. The Rolling Stones sang about “My 19th Nervous Breakdown.” Rolling Stone magazine described Mick Jagger and Keith Richard’s song as “a lyrical breakthrough, with references to drugs and therapy.”1 The song peaked at No. 2 on the Billboard Hot 100.2 The Stones performed the song on The Ed Sullivan Show, the Sunday night TV show that catapulted up-and-coming entertainers to stardom.3
“They’re Coming to Take Me Away, Ha-Haaa!” by Napoleon XIV (Jerry Samuels) also made it to the Billboard Hot 100 in that very same year: 1966. “They’re Coming to Take Me Away, Ha-Haaa!” reached No. 3 by week 3, but plummeted after two New York Top 40 music radio stations banned the song, fearing that it might offend the mentally ill. The ban inspired teen protests and arguably boosted the song’s profile and prestige. The commotion made it even more memorable. Many of today’s baby boomers can still recite the lyrics they heard as teens in 1966.
In 1966, and throughout the early 1970s, society vacillated in its attitudes toward “mental illness”—as evidenced by the polarized reactions to Jerry Samuels’s novelty song about the “funny farm” and “men in white coats.” On one hand, counterculture/youth culture valorized psychotic states, as happened during the romantic era, when artist Francisco Goya (1746–1828) inadvertently started the trend as his career as a court portrait painter neared its end. Goya’s chronic lead poisoning (related to lead-based white paint) led to visions, deafness, and tremor. His mental state declining, his imagery changed from prim and proper to dark and diabolical.
Psychedelic drugs of the 1960s and 1970s replicated psychotic perceptions and were sought after because of those very qualities—although Sandoz Laboratories intended those research drugs to treat schizophrenia or at least illuminate the mechanisms behind this severe mental illness. Drugs that since became known as “psychotomimetics” (because they mimic psychosis) took center stage in the countercultural circus. Only a small percentage of the American public used LSD (5 percent, per Lee and Shlain’s book, Acid Dreams: The CIA, LSD and the Sixties Rebellion4), yet LSD-like imagery saturated the media, inspiring posters, graphic art, even fashion, as well as so-called psychedelic music. Stories about psychologists-turned-“high priests” of LSD were told and retold5—but in 1966, Sandoz recalled the LSD it had supplied to medical researchers and withdrew its formal support of once-serious studies that got out of control and created chaos (as well as cultural change and a permanent place in popular cultural history).6 Still, per the reigning counterculture’s ethos, psychosis was aspired to, not avoided or stigmatized as it is today.
In 1966, cult films proclaimed the counterculture’s preference for psychotic states over ordinary activities of daily life and certainly instead of wartime activities. Alan Bates starred in a Scottish film (King of Hearts) about a World War I soldier sent to disarm a bomb left by the German army. Everyone in the town has fled except for jubilant asylum inmates, whose incarceration has sheltered them from the goings-on in the “real world.” Instead, they celebrate daily life and dance through the streets. One calls herself “Columbine,” adopting the name of a flower (like the “flower children” of the era). The soldier falls in love with her and opts for the delusional world of asylum inmates over the “insanity” of those who wage war on the outside. As the film ends, he arrives at the asylum gate, without clothes but with a birdcage in hand, waiting to enter the asylum. Philipe de Broca’s King of Hearts (1966) remains a cult classic to this day, a vestige of the antiwar movement and an endorsement of the value of retreating from the “real world” of sanity, in favor of pursuing more pleasant alternative realities and avoiding war’s conflicts and conflagrations.
As the years passed, King of Hearts retained its loyal following and evoked fond memories of a bygone youth culture, but critics of King of Hearts have since denounced the film’s stereotyped portrayal of the asylum’s inmates. They claim that their childlike insouciance and cheerfulness are, well, childlike and thereby do a disservice to persons with mental illness. Let me point out that critics exist to criticize and so it should be no surprise that some critics damned this lighthearted comedy almost as vigorously as mental health advocacy groups condemn slashers for their unkind portrayals of psychiatric patients.
Those King of Hearts asylum inmates are far removed from movies’ violent mental patients that invoke the ire of present-day detractors of mass media. Some argue that the overrepresentation of psychotic characters in cinema misrepresents the majority of persons who seek treatment for mental illness. And many Americans do indeed seek treatment for various mental woes—20 percent of the population currently gets prescriptions for psychotropic medications and some 25 percent will receive a diagnosis of mental illness at some point in their lifetimes. Only a small minority of those persons suffer from serious mental illness such as schizophrenia or bipolar I disorder, the latter of which may include psychotic features as well as mood swings. Depression is much, much more common than mania, and even persons with “manic-depression” (now known as bipolar disorder) typically spend far more time in the depressed phase than in flamboyant, attention-grabbing, hyperbolic manic episodes. Statistics aside, the manic phase of bipolar disorder gets much more screen time than the decidedly more prevalent depressed phase.
There are good reasons why we do not see many movies about depression as a stand-alone condition (unless it ends with suicide). Depressive states do not make for interesting movies. Depressed persons sleep more, move little, talk less, and hardly socialize at all (although some depressives pace endlessly and aimlessly). For cinema that depends upon visuals and dialogue, the dramatic manic phase of bipolar disorder is far, far more interesting. Perhaps a skilled writer could do justice to depression—and many have succeeded over the centuries—but movies can be boring (unless, perhaps, they are Bergman’s or “art cinema”). Kierkegaard’s brooding journals, several of Dostoyevsky novels, even Goethe’s Sorrows of Young Werther captured the spirit of sadness and suicide, and remain classics to this day. More recent works, many by women writers, have eloquently translated dark feelings into words. Even more recently, poignant graphic novels and memoirs wed image and word, with powerful effect and to public acclaim.
However, novels, poems, and memoirs, even when illustrated, do not share the persuasive power of the moving image. And so cinema bears the brunt of the criticism about mass media, even if the film is based on a previously-published novel that tackled the very same topics.
There is no denying that slashers portrayed psychosis (and Down syndrome) as scary and dangerous. Slashers peaked in popularity in the late 1970s, and continued through the early 1980s and even longer, in modified form. In hindsight, slashers began in earnest with Hitchcock’s Psycho (1960). Norman Bates is not identified as a mental patient until the film ends, when a psychiatrist explains the origins of his bizarre behavior. Until that moment, his obsession with taxidermy and his mother’s clothes, his social awkwardness and isolation, and his escalating arguments with an unseen “mother” suggest that something is seriously amiss.
Did the entertainment industry set out to degrade and devalue persons with mental illness when it released unsavory portrayals of persons with psychosis?7 I doubt it. Do Hollywood films about mental illness compare to Nazi-era films such as Jud Suß (1940), which spread vicious anti-Semitic propaganda and reified racial discrimination policies outlined by the Nuremburg Laws of 1933? Highly, highly, highly unlikely. Are Hollywood filmmakers diverting their resources to advocate Nazi-style extermination of “mental defectives,” chronically mentally ill persons, or “incurable alcoholics,” as occurred during the Third Reich’s formal T4 program?8 Not by a long shot, on all counts—although one might expect to find (non-existent) crossovers, given the vitriolic allegations made against the movie industry and against the media in general.
I am more inclined to turn to economic determinism to explain the proliferation of such films at certain points in time. After one slasher proved profitable and popular, it led to another and another, since success breeds success. Soon enough, an entire genre emerged. Perhaps Psycho launched this trend, and perhaps Hitchcock’s masterpiece reflected society’s unease about releasing more institutionalized patients in the mid-1950s, after the antipsychotic medication Thorazine became available in the United States and made it possible to move previously incurable patients from locked wards to open communities. Or perhaps Psycho’s commercial and critical success simply reflected Hitchcock’s mastery of his art and nothing but. Or both.
As to why the public appreciates these themes enough to patronize movie houses (in the days before TV reruns of first-run films, video releases, or pay-per-view broadcasts), I would consider the unquantifiable contribution of “schadenfreude.” Schadenfreude refers to the enjoyment experienced when learning of someone else’s failures or misfortunes—not because of the spectator’s sadistic streak but because of the sense of relief that comes from learning that someone else—and not oneself—suffers from an affliction that strikes a certain percentage of the population. Even the German-speaking psychoanalysts could not coin an adequate English term for this common reaction and retained the German word. This is a very primitive, visceral reaction that is almost biblical in nature. It reminds us of myths about the angel of death or the grim reaper who must capture a set number of souls, but can stop their “harvesting” after meeting their quota. Knowing that someone else besides ourselves has incurred some miserable fate that is known to afflict a certain percentage of the population assures us—the spectators—that our own number is not yet up.
How to explain the rise of slasher franchises two decades later? It is plausible that unique social and medical conditions of the early 1980s, when AIDS emerged, encouraged the slashers’ proliferation in that era. AIDS connected the dots between sex and death (once known in psychoanalytic lore as “Eros and Thanatos”). Slasher victims were typically sexually free young women who got their come-uppance and implicitly “merited” death sentences as retribution for their sexual “sins.” This recurring meme seemed so much more real after AIDS emerged.
These patterns in film genres repeat themselves. For instance, in 1975, Steven Spielberg’s Jaws became a big-budget, high-grossing blockbuster film. The unexpected success of Jaws inspired more movies about “natural evil,” often action-adventure-oriented and special effects-laden—not because the filmmakers harbored unspoken (or even unconscious) anti-shark attitudes, and probably not because directors or producers or actors were “working through” traumatic childhood swimming memories left over from summer camp or because someone on set wanted to taunt someone with shark phobias. More likely, someone saw possibilities of future box office success with Jaws look-alikes and knockoffs. (Admittedly, Jaws did change popular attitudes toward oceans and made many people fearful of swimming in unenclosed spaces.)
The big screen may bear the brunt of these antimedia attacks, but television shows’ attitudes toward persons with mental illness has not gone unnoticed. An article in U.S. News predictably condemned television, citing scholars that claim that “mental illness is misrepresented in the media,” in that “mental illnesses are all severe—or all alike” [on the small screen].9 Quoting Diefenbach’s research, the author complains that “depression only accounted for 7 percent of the psychiatric disorders shown on TV. However, 12 percent of the characters suffered from some form of psychosis—experiencing delusions or voices, or losing touch with reality” … [but] “In reality, depression is much more common than mental disorders such as schizophrenia and bipolar disorder…. The real-world relationship is going to be that depression outnumbers the family of psychotic disorders by about 6 or 7 to one.” Yet on TV, “the most extreme cases—and the rarest disorders—tend to be disproportionately represented.”
In a way, I am surprised that the author is surprised. For this should not be so surprising, if we compare representations of mental illness on television to representations of medical illness on TV. Since the early days of television, medical dramas, soap operas and occasional comedies have enjoyed prime time spots. Many such shows became household words (think Ben Casey, Dr. Kildare, Quincy, House, or ER). Yet how many of those family doctors and ER doctors or neurosurgeons or pathologists (in the case of Quincy) diagnose only mundane medical woes? Few, if any, even though medical care is replete with mundane care, as attested by the oft-quoted medical expression, “when you hear hoofbeats, don’t look for zebras” (implying that hoofbeats herald the arrival of ordinary horses much more often, so look for ordinary illnesses first).
In my experience as a medical student rotating through general surgery at a private lakefront hospital in Chicago (intended to offset the rigors of rotations at Cook County Hospital), I mostly scrubbed on hernias or hemorrhoids. Rotations on surgical “specialty services” might have offered more intriguing possibilities, but death-defying heart transplants or heroic separation of Siamese twins were all but nonexistent. Yes, occasional GSWs (gunshot wounds) or stabbings arrived at the emergency room, but all in all, most surgeries performed outside of major trauma centers did not make for interesting dinnertime conversations, either for the doctors or the medical students (though possibly for the patients and their families). Can you imagine a medical show that showcases the day-to-day OR schedule of a community hospital—instead of interesting and unusual cases that make it to prime-time TV? Where would Quincy or House be, were it not for the so-called zebras they diagnose?
Much the same could be said for pediatrics rotations at the university hospital that treated inner city residents, farmers, and their families who traveled from all over Illinois, as well as children requiring specialized hematology, cardiology, or nephrology services. Apart from the fact that children develop different diseases than adults, the pediatrics ER and clinic visits were predictable and revolved around mundane medical care. Only very, very rarely do checks for nuchal (neck) rigidity require spinal taps to rule out the uncommon meningitis case. Can you imagine a medical show filled with repeated ear inspections, sore throat swabs, and temperature-taking, rather than rare leukemias that require bone marrow transplants from reluctant, missing, even imprisoned relatives (some of whom might need presidential pardons or prison furloughs so they can donate life-saving cells)?10 Children on medical shows may suffer from uncommon brain cancers, sickle cell crises, or status epilepticus, or need transfusions that their parents’ religion prevents—but those life-threatening cases constitute a tiny percentage of consultations compared to the vast numbers of earaches, sore throats, and benign bellyaches.
Given these precedents, why would anyone expect ordinary yet common psychiatric symptoms—such as anxiety—to merit more attention than hernias and hemorrhoids accrue on ER shows? Perhaps our expectations of representations of psychiatric conditions are higher, since “mental cases” occur on a continuum with “the human condition,” and force us to distinguish ordinary suffering related to life’s unfair blows (or even life’s expected losses) from diagnosable and distinctive disorders that deserve diagnoses as “mental illness.” Humans have good reason for concern about the so-called human condition that intrigued philosophers and poets throughout history, long before such suffering fell under the rubric of “mental illness.” To be fair, I should add that it is not always easy to distinguish pathological reactions to extreme stress or loss from “ordinary” or expected reactions, as demonstrated by the heated debates about labeling grief following bereavement as major depressive disorder or about conflating “shyness” with a diagnosable and (pharmacologically treatable) social anxiety disorder.11
Some of those who blame movies and mass media for stigmatizing mental illness also claim that such negative portrayals deter persons who need treatment from seeking treatment. Critics make eloquent arguments and present persuasive data, but without necessarily contemplating the contribution of direct-to-consumer (DTC) pharmaceutical advertising. DTC ads became legal in the US in 1985, but skyrocketed after 1997, when the FDA further loosened its rules on television “infomercials.” Previously, advertising psychiatric medications had been discouraged but was not officially outlawed.
DTC ads do not necessarily tout a product—some merely supply information about symptoms and recommend consultations with doctors.12 Sources such as The New England Journal of Medicine note that such ads can prevent underprescription of medications while they also encourage overutilization.13 Think of them as dandruff commercials from the 1950s, which showed the hapless dandruff sufferer—who never suspected his dandruff—brushing off specks of skin from the shoulders of his dark suit, as others looked on with expressions of scorn and disgust. Those ads aimed to increase awareness of dandruff, for starters, as much as they sought to sell special shampoos. Similarly, DTC pharmaceutical ads try to convince viewers that they suffer from new conditions before they push new products to treat those conditions.
We know that DTC ads drive up health care costs, and increase demand for expensive brand name medications in lieu of less costly generics, yet we do not fully understand their impact on attitudes toward mental illness, among the public or professionals, except for the fact that those ubiquitous ads sell prescription medications. A 2016 Medscape article14 that summarizes a research study from The Journal of Clinical Psychiatry (September 2016) is more cautionary and adds more specific data. It notes that psychiatric medications represented 20 percent of the most advertised drugs between 2014–2015 and were 10 percent of the 100 top-selling drugs.
To date, only the United States and New Zealand permit pharmaceutical ads targeted directly to consumers (as opposed to health care professionals or hospitals). In the wake of this advertising trend, more and more consumers are exposed to DTC advertising imagery and are presumably influenced by those ads—for why else would pharmaceutical manufacturers invest their stockholders’ money in such pricey propaganda? Those ads that began on TV commercials now pop up on social media, in Internet searches, on personal mobile devices as well as computers. As most of us know by now, a Google search for a symptom, a click on a medication ad, or a visit to a manufacturer’s Web site guarantees a barrage of ads for products promising to treat the symptoms—or the disease complex that the symptoms suggest. Ads for competitors’ products appear instantaneously and without provocation. Were Andy Warhol alive today, he might be painting repeat images of bouncing, smiling antidepressant pills instead of Campbell’s soup cans.
Ads for psychopharmaceuticals remind viewers that they need treatment, often for conditions that they never knew they had before an unsolicited ad flashed on their cell phone screens. (Some ads target specific demographics that are likely to use such products or choose audiences with online purchasing histories that correlate with histories of other persons who purchased their products.) Very often, medications that were developed for psychosis or schizophrenia are marketed as “depression adjuncts,” to be prescribed to persons whose mental distress is far-removed from such serious psychosis. Some of the most profitable medications on the market started out as powerful antipsychotic agents. The overwhelming majority of those medications are prescribed in doctors’ offices (and not even in psychiatrists’ offices, since primary care physicians or nurse practitioners prescribe about 85 percent of psychiatric medications).
Clearly, it is not in the interest of those powerful marketers to stigmatize their potential market and push it away, especially after they invest millions (or more) of advertising dollars. In contrast, it is in their interest to convince their audience that psychiatric symptoms, be they major or minor, can be—and should be—treated with their products. Pharmaceutical ads are not so new—they abounded in the days of patent medications. Displays of those compelling—and often amusing—graphics abound on Pinterest and other social media sites. Patent medications went by the wayside long before television made its way to most American homes and long, long before the advent of computers and mobile devices. Over-the-counter nonprescription medication advertising remains a fixture on television commercials, although many were revised or eliminated as regulations tightened. (Think of early Geritol commercials, which promised to pep up iron-deficient geriatric consumers—without disclosing the high alcohol content of the vitamin and mineral tonic hawked by smiling grey-haired male models.)
When we consider how many advertising dollars are spent on these pharmaceutical ads, and how profitable pharmaceutical sales can be in the United States, we must wonder why so many lobbying groups (some of which are funded by pharma) protest so loudly. If Dr. Jonas Salk, inventor of the polio vaccine, were making these allegations, we might take them at face value, for the altruistic and high-minded Salk refused to patent his discovery because he believed that protecting public health and preventing infantile paralysis overrode the importance of profits. However, most present-day practitioners and Big Pharma boards of directors are far-removed from Dr. Salk. We would be foolish to believe that pharma-funded lobbying groups have only the public good in mind when they protest “misrepresentations” of mental illness in media.
In short, entertainment-oriented mass media is not America’s only exposure to mental illness. Moreover, not all entertainment denigrates persons with mental illness. Some media romanticizes mental illness or portrays patients as super-powered or extra-talented. Many media representations of mental illness celebrate the accomplishments of persons with mental illness and recognize that some of the most enduring contributions to culture were made by persons who were formally or retrospectively diagnosed with mental illness: Poe, Van Gogh, Cobain, Goya. Outsider artists and “autists” (autistic artists) gained currency in the 20th and 21st centuries, so much so that prestigious Ivy League art schools train MFA students to emulate such “raw art.”
Unlike residents of Nazi Germany, the imaginary inhabitants of 1984, members of the armed forces, or persons remanded to rehab for DWIs (driving while intoxicated) or other drug offenses, no adult in America is forced to view specific films or TV shows. We can choose our entertainment. With trailers, teasers, and reviews so easily accessible through apps or the Internet, no one needs to walk into a movie theater or turn on a TV show without some awareness of what is to come. Even though films and broadcast media are persuasive, and some films have been shown to change attitudes, it is likely that persons who deliberately choose to watch negative depictions of persons with mental illness already have preset notions about mental illness and are seeking to validate their views. That said, our choice of entertainment often functions as a Rorschach test, and tells us what we want to see. It is not propaganda.
In other words, the “hypodermic needle” model of media influence is not necessarily correct, even if it is touted so often as to make it appear accurate. The hypodermic needle model references the belief that “behaviors [or attitudes] are essentially injected into hapless consumers,” as psychologist Christopher Ferguson, Ph.D., explains in the November 24, 2016 Psychiatric Times edition and in other publications as well. Focusing largely on media-mediated aggression more than on attitudes, Ferguson elaborates on newer theoretical models such as Self-Determination Theory and Mood Management theory. Such models contradict the more moralistic models that assume that imitation of behavior or attitudes is “automatic, universal, and purposeless.” That is not to say that some films are not persuasive; the anti-ECT attitudes adopted by medical students after a single viewing of One Flew Over the Cuckoo’s Nest have been well-documented by social psychologists and others. Yet let me point out that Milos Forman’s film about mistreatment in a mental hospital did not make spectators think less of the patients under Nurse Ratched’s charge. Rather, Cuckoo’s Nest made medical students (and the public) mistrust the mental hospital staff. The viewers commiserated with the mental patients/inmates and presumably identified with those who were victimized and subjected to punitive (rather than curative) electroconvulsive therapy.
We can argue these points back and forth indefinitely, but arriving at a consensus, as if this were a jury trial, is not the point of this collection. We do not seek a totalizing explanation of all representations of mental illness in media or pop culture. Just the opposite. We emphasize pop culture’s pluralism, and include chapters by scholars with diverse points of view and from varied academic backgrounds. We deliberately avoid knee-jerk, antipopular culture reactions. While it may be politically correct to blame pop culture for almost anything, such claims are not necessarily factually correct.
This single volume does not cover all the many fascinating topics relevant to this theme—that venture would require a multivolume encyclopedia at minimum. To my regret, we do not have as many chapters on music or musicians as I had wished, so it is my hope that my own musical references at the start of this introduction will offer some recompense for this admitted shortcoming. The topic of popular music and mental illness is vast, and has been a subject of study since ancient times. In the Hebrew Bible, David soothed the soul of the paranoid King Saul by playing his harp, while the Greeks linked music to wine, debauchery, and altered states of consciousness (anticipating the 1960s adage about “sex, drugs, and rock and roll”).
At this point, I must mention other aspects of mental health that are intentionally not included in this volume, such as substance use disorders. Even though substance use disorders are listed as psychiatric disorders in the American Psychiatry Association’s DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, 5th edition), essays exclusively related to the representation of substance use disorders in popular culture were culled out, not because substance use is not important or relevant, but, contrarily, because it is so very important and so prevalent as to merit many separate studies. In a few instances, essays address substance use disorders that are comorbid (that coexist) with other mental illness, to emphasize the difficulty of determining which is the cause and which is the effect, or which is the chicken or the egg.
Dementia (such as Alzheimer’s Disease or Huntington’s Disease) is also excluded from this collection, even though the dementias that impair cognition and memory are classified as psychiatric or behavioral disorders in both the DSM-5 and in the ICD-10 (International Classification of Disease). Again, this circumscribed and specialized topic, which falls on the threshold of psychiatry and neurology, deserves a separate study to do it justice and to consider our society’s evolving attitudes toward aging, memory, intelligence, and behavioral disinhibition. We find thoughtful treatments of this topic in a wide range of movies, from Memento (2000), to Rise of the Planet of the Apes (2011), to Still Alice (2014). Outsider art by older persons, some of whom have suffered strokes or other age-related neurological illness, is equally important and has been given attention in museum shows and folk art exhibitions and deserves more attention.
Similarly, developmental disorders or intellectual disability (formerly known as “mental retardation”) that begin in childhood are not subjects of our study, even though persons with cognitive limitations commonly show behavioral changes that require psychiatric intervention. Considering that some films featuring persons with such disorders, such as Charly (1968) or Rainman (1988), remain among the most beloved or best-known films of all times, this topic is also ripe for a thorough review in a more specialized collection.
Yet another unfortunate omission from this volume is essays on pop cultural representations of children’s mental illness, found most notably in The Exorcist (1973) and elsewhere. Debates about the proper diagnosis and treatment of childhood behavioral disorders are legion, and engage parents, teachers, pediatricians, child psychiatrists and psychologists, the courts, and CPS (child protective services), for starters. Literary and filmic depictions of bizarre behavior in children invite almost as much discussion as currently contested—but increasingly used—psychopharmaceutical approaches to treating such behavior. (Once-popular long-term hospitalizations, residential schools, “wilderness programs,” or even “juvie” (juvenile hall) for delinquent children have caused contention as well, but pharmaceutical approaches, often untested and used “off-label” for children, have taken center stage in 21st century debates.)
Edited collections by Markus P.J. Bohlmann and Sean Moreland (Monstrous Children and Childish Monsters: Essays on Cinema’s Holy Terrors, McFarland 2015) covers one slant of this broad topic, and includes my own essay about Ritalin prescriptions for MBD (minimal brain dysfunction)/proto-ADHD diagnoses in The Exorcist (1973) (“Demon Drugs or Demon Children: Take Your Pick”). Amazon’s book listings show several academic publications about diametrically different media memes regarding children. Since we were all once children, each of us is qualified in one way or another to opine on the topic of children and aberrant behavior.
Another issue that this collection does not address, and for which I offer no apologies, is the topic of “madness” (as opposed to mental illness), and for very good reasons. This book specifically covers mental illness, although allusions to madness seep into some sociologically-oriented essays which conflate madness and mental illness. Again, that omission does not imply that madness is not significant, but simply that madness and mental illness carry very different connotations. “Madness” is a descriptive bestowed by society—not by organized medicine or mental health professionals. “Madness” is shorthand for behaviors or perceptions that fall grievously outside of a given society’s social norms. What one society deems “mad” and therefore undesirable may be esteemed in another society, making the study of madness the purview of the anthropologist, if not also the psychiatrist.
Mental illness, in contrast, denotes disorders that are identified as illness and are diagnosed as pathological by medical or psychiatric practitioners. Mental illness is a medical/mental health rubric whereas madness is a sociological construct. In our contemporary American society, the medical/mental health establishment decides who is mad and who is not and then translates those behaviors or perceptions or cognitions into DSM terms. In that case, the American Psychiatric Association (which publishes DSM) substitutes for the “elders” of less complicated societies and spells out its views in published and often revised volumes. The American Psychological Society, comprised of non-medically trained psychologists, comments on such controversies as well. At times, there is no consensus, and in those cases the DSM is revised once again, after several years of careful study.15
Importantly, please note that mental illness is not synonymous with insanity, even though the two can be conflated and (incorrectly) used interchangeably. “Insanity” is a legal term, not a clinical term. The courts of law determine who is sane and who is insane, and who can be held criminally culpable for their unlawful actions, be lawfully deprived of freedom of movement (e.g., confined to a psychiatric ward), or denied financial independence (e.g., deprived of the right to execute a valid will), or the right to self-determination (e.g., refusal of medical treatment) because such persons lack mental capacity for safe decision making. The courts typically seek psychiatric opinions to make these legal—rather than clinical—decisions.
What does this book include? Divided into five parts this book covers movies; television; popular literature, encompassing novels, poetry, and memoirs; the visual arts, such as fine art, video games, comics, and graphic novels; and popular music, addressing lyrics and musicians’ lives. Some of the essays reference multiple media, such as a filmic adaptation of a memoir, a video game adaptation of a story, or characters that were originally in comics.16
With roughly 20 percent of U.S. citizens taking psychotropic prescriptions or carrying a psychiatric diagnosis, and with many times that number having friends, family members, co-workers or colleagues who use psychiatric services, this topic is relevant to far more individuals than many people would admit. Mental illness is on the radar for almost everyone, and so is pertinent to society overall, given that discussions about mental illness invariably follow the adverse events that society has witnessed in recent years.
The uptick in mass shootings in schools, on military bases, in workplaces, on public transportation, or at large public gatherings casts a harsher light on mental illness, especially since some perpetrators carry mental illness diagnoses at the time they commit their acts, while some have shown symptoms that went undiagnosed or untreated.17 Discussions typically focus on mass shootings, even though mass shootings account for only a tiny percentage of firearm-related deaths. Debates about rights to carry arms—or denial of that constitutional right to persons with histories of mental illness—typically follow these events and turn discussions into political battlefields, with antigun activists typically waging war against gun rights groups. Multiple murders that do not involve firearms (such as drowning one’s children) do not follow the patterns of mass shootings and often involve family members, and so tap into other fears.
Persons with serious mental illness are admittedly three to four times more likely to commit violent crimes, and the concomitant use of intoxicants increases that likelihood, as per a 2016 article in JAMA (Journal of the American Medical Association),18 but most people with mental illness are not violent and are more likely to be victims of crimes rather than perpetrators.
While politically or religiously motivated terrorists make headlines, and claim lives or cripple their victims (and incite terror), for most of us, those terrorists are “others” who are distinct from us and deserve the attention of law enforcement agencies. In contrast, the mentally ill live among us (for the most part), perhaps even in our own homes or in the house down the block. Mentally ill persons attend our children’s schools (and sometimes also teach in them). Seriously mentally ill persons attend colleges in greater numbers than ever before. They visit churches, synagogues, mosques, temple picnics, and yard sales like anyone else. For the most part, persons with mental illness are invisible to others, unless they self-identify. In a way, their ability to pass in a crowd compounds society’s fear that they will act out erratically, without warning, to do us harm.19
Mentally ill offenders leave us wondering who is “mad” and who is “bad,” and when and if illness exonerates otherwise unpardonable behavior. These questions linger in our consciousness and increase interest in these issues. Popular culture offers a forum for playing and replaying these events, and for deliberating difficult decisions that are both moral and medical. Some psychiatric physicians see such pop culture as an avenue for peaceful public interchange of opinions and for challenging our preconceptions, sometimes by presenting provocative imagery that demands response. Other mental health professionals and advocates point a finger at pop culture for sensationalizing and stigmatizing mental illness, perpetuating stereotypes, and capitalizing on the increased anxiety that follows attacks mentioned above.20
In the end, I leave it to readers to make their own decisions, if they feel compelled to make any overarching decisions on such matters at all. Unfortunately, the once-popular arguments about genius and madness that intrigued the Romantics and neo-Romantics of later generations do not seem as compelling as contemporary arguments about violence and illness, but those deliberations may offer some respite from less pleasant realities of real life today. Then again, psychologist and scholar Louis Sass offers an alternative explanation and posits that madness defines modernity and that psychotic perceptions are intertwined with the zeitgeist of the 20th century—so it should be no surprise that the 21st century seems so off-kilter.21
Notes
1. “100 Greatest Rolling Stones Songs,” accessed online November 13, 2016, www.rollingstone.com.
2. Billboard, www.billboard.com, March 19, 1966, accessed online November 20, 2016, www.billboard.com.
3. The legacy of Mick Jagger’s and Keith Richard’s song lives on. “My 19th Nervous Breakdown” was used in Adam Sandler’s spoof on Anger Management (2003), in Stephen King’s Dark Tower series (1982–2012), and in a short-lived TV medical drama, Miami Medical (2010); my thanks to Harold Benson, PhD, professor emeritus, for his exegesis of these lyrics.
4. Martin A. Lee and Bruce Shlain, Acid Dreams: The CIA, LSD and the Sixties Rebellion (New York: Grove Press, 1994).
5. Articles about bankers who sought shamanic hallucinogens graced the front page of coffee-table “family magazines” as early as 1957, well before the start of the 1960s. See R. Gordon Wasson, “Seeking the Magic Mushroom,” Life, May 12, 1957.
6. Albert Hofmann, LSD: My Problem Child (New York: McGraw-Hill, 1980); Sharon Packer, “Drugs and the Summer of Love: A Summer Fling, not a Lasting Romance,” in Pop Culture Universe, Eternal Questions Series (ABC-Clio, Fall 2012).
7. For harsh criticism of depictions of mental illness in horror movies and elsewhere, see Otto F. Wahl, Media Madness: Public Images of Mental Illness (New Brunswick, NJ: Rutgers University Press, 1995). Less emotive accounts appear in Jacqueline Noll Zimmerman, People Like Ourselves: Portrayals of Mental Illness in the Movies (Lantham, MD: Scarecrow Press, 2003); David J. Robinson, Reel Psychiatry: Movie Portrayals of Psychiatric Conditions (Port Huron, MI: Rapid Psychler Press, 2003); and Danny Wedding, Mary Ann Boyd, and Ryan M. Niemiec, Movies and Mental Illness: Using Films to Understand Psychopathology, 3rd rev. ed. (Cambridge, MA: Hogrefe Publishing, 2010). For approaches that view madness in movies as metaphors or as historical artifacts, see Fernando Espi Forcen, Demons, Monsters and Psychopaths (New York: CRC Press, 2017); Sharon Packer, Cinema’s Sinister Psychiatrists (Jefferson, NC: McFarland, 2012); or Sharon Packer, Movies and the Modern Psyche (Westport, CT: Praeger, 2007).
8. See Rael D. Stone, “Nazi Euthanasia of the Mentally Ill at Hadamar,” American Journal of Psychiatry 2006 (163:27). Gas chambers originally built for Operation T4 were subsequently repurposed to annihilate Jews and Gypsies. The Nazis halted the gassing of mentally and physically handicapped persons in response to international protests and interventions by clergymen. In effect, those gas chambers served as SS training grounds for the Final Solution.
9. Kirstin Fawcett, “How Mental Illness is Misrepresented in the Media,” U.S. News & World Report, April 16, 2015, accessed online November, 16 2016, http://health.usnews.com/health-news/health-wellness/articles/2015/04/16/how-mental-illness-is-misrepresented-in-the-media.
10. The Blacklist, a 2016 television drama about government agents and their personal and professional intrigues, uses a similar ploy in a hospital scene.
11. Freud’s 1917 essay “On Mourning and Melancholia” explains how persons suffering from melancholia (today’s equivalent of major depressive disorder) behave as if in mourning. Even though much of Freud’s work has been contested over the decades, this essay remains a classic and is relevant (yet often overlooked) to this day.
12. Ishmael Bradley, “DTC Advertising, and Its History with the FDA,” Kevinmd.com, September 18, 2016 (reprinted on Doximity), accessed online November 16, 2016.
13. Julie M. Donahue et al., “A Decade of Direct-to-Consumer Advertising of Prescription Drugs,” New England Journal of Medicine, August 2007; Bryan C. Liang and Timothy Mackey, “Direct-to-Consumer Advertising with Interactive Internet Media,” JAMA 305, no. 8 (2011): 824–5; Jeremy A Greene and Elizabeth Watkins, “The Vernacular of Risk-Rethinking Direct-to-Consumer Advertising of Pharmaceutical,” New England Journal of Medicine 373 (2015): 1087–9.
14. Pauline Anderson, “Direct-to-Consumer Ads Boost Psychiatric Drug Use,” Medscape Medical News, September 19, 2016, accessed online November 20, 2016.
15. Allen Frances, MD, chair of the DSM-IV Task Force, eloquently explains the complicated reasoning behind these processes in his book Saving Normal (New York: Morrow, 2013).
16. Thanks to George Higham, BFA, for his cover art depicting the musical scales, film reels, TV and video game monitors, writers’ plumes, and artists’ palettes that suggest the wide range of pop culture covered in this book.
17. Michael S. Rosenwald, “Most Mass Shooters Aren’t Mentally Ill. So Why Push Better Treatment as the Answer?” Washington Post, May 18, 2016, accessed online November 20, 2016.
18. Seena Fazel et al., “Triggers for Violent Criminality in Patients with Psychotic Disorders,” JAMA Psychiatry 73, no. 8 (2016): 796–803.
19. Aaron Levin, “Media Cling to Stigmatizing Portrayals of Mental Illness,” Psychiatric News, December 16, 2011.
20. Otto F. Wahl, Media Madness: Public Images of Mental Illness (New Brunswick, NJ: Rutgers University Press, 2001).
21. Louis A. Sass, Madness and Modernity: Insanity in Light of Modern Art, Literature and Thought (New York: Basic Books, 1992).