Story-telling is part of what it is to be human. From children to adults, our entertainment is story-driven: not only films, novels or plays; but even sporting matches, political events and conflict, are all shaped into a narrative to be most easily understood and remembered. As psychiatrists, we encourage patients to tell us their story, and making sense of the narrative is the start of therapy. In short, stories are how we interpret the world. Fairy-tales are so old that some, like Cinderella, are common to almost every society. The purpose of such stories is not just teaching children language, but social learning. Frequent themes are justice and injustice; kindness and cruelty; danger and security. The most compelling stories are often those which involve a confrontation of the hero or society with an evil or malign force. This might be personified into a monster, or witch; or represented by a foreign or alien race. ‘The other’ is used in fiction to define the values of the hero by contrast with an alternative, shadow group or individual. Often the ‘other’ is that defined by society as inferior: racially, morally, or in terms of class or gender. Or it may be ‘other’ merely by being transgressive, violating the social norms.

‘Madness’ has been used as the ‘other’ in some the oldest plays we know of. In history, theories of mental illness have ranged from divine punishment to moral failings. Without a cure, and with fear of the social stigma, sufferers were shunned (Dubin & Fink, Reference Dubin and Fink1992). But as divine theories of madness have been replaced by biological and psychological, our fascination and fear of insanity appears to have only grown. The popularity of horror films exploring the boundary of what is real and what is imagined bears testament to this. Perhaps due to the vanquishing of more obvious external foes, the ultimate ‘other’ is now an internal betrayal by one’s own mind. And frequently in film, more frequently than in real life, mental instability is linked to erratic and violent behaviour. ‘Madness’ in film and drama can be a vehicle to advance the plot, or it can be depicted with sensitivity. By looking at the uses to which psychiatric illness is put; when it is used as ‘other’, and when not; we can deduce some of the values and attitudes society holds, or wishes itself to hold.

Sadly, media references to psychiatric illness disproportionately focus on danger. A total of 77% of psychiatric patients depicted on television are violent, compared to less than 3% of patients in reality (Dubin & Fink, Reference Dubin and Fink1992). And in the United Kingdom, up to two-thirds of items about psychiatry or mental illness on UK television refer to violence (Philo, Reference Philo1996). In this vein, frequently cited among the best horror films of all time, are films which play on our twin fears of insanity and violence. Psycho (Hitchcock, Reference Hitchcock1960) contains arguably the most frightening murder scene in film, and an unhinged murderer who subverts traditional archetypes by first appearing odd, guarded, but not immediately ‘mad’. The fact that the audience is initially unsure if he is the killer builds the sense of paranoia. Similarly a sense of uncertainty and brooding malice pervades The Shining (Kubrick, Reference Kubrick1980) where a writer’s mental balance is overturned by a combination of stress, alcoholism, and either hallucinations or paranormal events, culminating in murderous violence to his own family. The Silence of the Lambs (Demme, Reference Demme1991) features not one, but two murderous psychopaths, one of whom is actually a psychiatrist himself. Violence in these films seems inextricably linked to psychiatric illness and loss of normal moral controls.

The threat of violence hangs over Shutter Island (Scorsese, Reference Scorsese2010) from start to finish. This plot-twisting film begins as a mystery, when the FBI enter an Alcatraz-like forensic psychiatric hospital to investigate a missing person, and uncover sinister experiments and conspiracies by the psychiatrists in charge. The opening of the film graphically depicts the multiple elements needed to contain these ‘violent’ inmates: leg irons, locked cells, high walls, armed guards, chain fences, and a cold, forbidding surrounding sea. The contrast between these restraints and the frail physicality of the patients only underscores how dangerous these people must be, to require such precautions. Through flashbacks, we learn that protagonist’s wife murdered their three children in the grip of a nihilistic delusion; and back-stories of violent behaviour are furnished for other inmates. While the film’s final twist casts a new light on the bizarre nature of the island, and changes the staff from amoral experimenters to humane psychoanalysts; the linking of psychiatric illness with unpredictable danger is the abiding image with which viewers are likely to be left.

But does this actually influence public perceptions of psychiatric patients? After all, medical dramas are not known for their veracity: cancer diagnoses in film are generally a shorthand for terminal illness, and onscreen CPR is practically failsafe. Surely people can tell the difference between fact and dramatic licence? It appears not. Just as the public believes survival rates from cardiac arrest may be as high as 75% (Mattu, Reference Mattu2008), they also associate psychiatric illness with a high risk of violence (Pescosolido et al. 1999). A survey of US citizens showed over 60% rated people with schizophrenia as being a high risk of violence. In the United Kingdom, while most of the public support de-instituionalisation, they nevertheless do not want a psychiatric clinic in their neighbourhood, due to perceived risk (Reda, Reference Pescosolido, Monahan and Link1996). Heather Stuart (Reference Stuart2003) found that people are more frightened by a murder carried out by a psychotic perpetrator than by a murder in the course of a robbery. She noted that the public ‘most fear violence that is random, senseless, and unpredictable and they associate this with mental illness’.

Personalising and externalising the most feared form of violence might serve two purposes: allowing a ‘safe’ thrill at vicariously experiencing such a taboo; but also locating this feared concept in a group of people clearly different from ‘normal’ society. If it’s ‘them’, then it’s not ‘us’. Tajfel’s Social Identity Theory identifies self-esteem and identity as formed from membership of a social group, such as family, nationality, religion or profession (McLeod, Reference McLeod2008). Those in the ‘in-group’ derive a more cohesive identity by comparing themselves favourably to an ‘out-group’, or ‘other’. The mentally ill, throughout history, have been examples of the ‘out-group’, and many portrayals of psychiatric illness in film and theatre continue to fulfil this role, despite the statistical evidence that the most common reasons for violence are socioeconomic, demographic, and substance misuse; and mental illness in itself is neither necessary nor sufficient cause for violence (Stuart, Reference Stuart2003).

Madness in film and theatre may be depicted in two broad ways: either as a primarily internal insanity which then spills out into external destruction; or as an overturning of a person’s internal equilibrium by external chaos. The former instance is exemplified in The Shining (Kubrick, Reference Kubrick1980), with a man’s inexorable loss of mental control culminating in the ‘random, senseless and unpredictable violence’ that the public so fears (Stuart, Reference Stuart2003). The latter type is more typically associated with the classics. The plays of William Shakespeare (1564–1616) feature numerous instances of ‘madness’, often precipitated by the structure of society being inverted or perverted. Insanity is seen as an almost inevitable, and understandable, response to an insane world. In King Lear, when the natural order of society is upturned, and his emotional ties cut, Lear becomes insane with grief and anger. But in becoming ‘mad’, he develops insight into himself and the world, leading to his redemption. In Macbeth, there is no such redemption. The abomination of regicide and its aftermath drive Macbeth and Lady Macbeth, in particular, to extremes of distress, hallucination and insomnia.

An interesting distinction can be drawn between the ‘madnesses’ of men and women; with disordered emotional extremes usually depicted as feminine in character. In Hamlet, the prince’s feigned madness indeed has ‘method’ to it, whereas overwhelming grief, rejections and despair drive Ophelia to incoherence and then to suicide. Elaine Showalter (Reference Showalter1985) has analysed how the dramatisation of Ophelia has changed with society’s changing attitudes to women. In the Elizabethan era, Ophelia’s progressive dishevellment and suggestive singing as her mental state deteriorates, would have connoted links between insanity, unrequited love and female sexuality, in the syndrome known at the time as erotomania or melancholia. By the 18th century this sexuality was significantly cut: Ophelia would display only ‘proper’, dignified madness. Ophelia was later lauded by the Romantics for her sensibilities, before being used by Victorians to exemplify the diagnosis of hysteria. Showalter notes that Ophelia-like drawings were used in medical textbooks to illustrate hysteria, at the same time as patients seemed to borrow from the Ophelia-like depictions of madness they had seen on stage. Ophelia’s madness is not ‘dangerous’ in the traditional sense, but the degree of editing and interpretation applied to Ophelia throughout history shows the danger and threat of madness to societal and feminine norms.

Transgression of social and moral norms could even induce madness, in Ancient Greek theatre. Femi Oyebode (Reference Oyebode2012) has traced the function of madness in Greek plays, and notes that madness can either be cast upon humans by the gods; or as in Oedipus Rex (Sophocles, 496–406 bc), ensue from unbearable internal conflict, such as when Oedipus blinds himself after the murder of his father. Oyebode quotes Simon (Reference Simon1978) to explain: heroes go mad ‘when their world is collapsing around them. Their madness is part of a frantic attempt to hold on to what they know and think right’. Overall, madness in Greek theatre is usually short-lived, and followed by a return to sanity. This is, then, madness with a narrative method, a madness which might seem incoherent to those in the play, but has a definite meaning to the audience.

This classical notion of insanity being an adapatation to an insane world has not gone away. Many modern films work on this theme, but with a twist: now the audience is often not quite sure if the protagonist is sane or not. This leads to a nightmarish quality, as the viewer feels the sands of sanity shift beneath them, trying to judge meaning of events on-screen, and where their own loyalties lie. Fight Club (Fincher, Reference Fincher1999) is one example of this genre. The protagonist is a jaded, disillusioned corporate drone, who has his life transformed by a man on a mission to open all eyes to the hypocrisy of modern society. This they resolve to do by reclaiming masculine values, and so an escalation of violence begins. As they direct violence outwards and attempt to break down the society they perceive as insane, (ironically by transforming ‘corporate drones’ into real-life unquestioning slaves to their new philosophy); the viewer gradually becomes aware that the two main characters are in fact one and the same. We are told that the alter-ego was created due to frustration and impotence at the injustices of life; and invested with all the agency and determination the narrator lacked in his conscious mind. The narrator can only regain control by vanquishing his alter-ego and halting the anarchy. While certainly Fight Club does not depict a true psychiatric illness – being perhaps at best a fictionalised depiction of dissociative personality disorder – its inclusion on popular culture lists of movies with mental illness indicates two things: first, that the general public discriminates little between genuine psychiatric illness and dramatic licence; and second, its readiness to accept that a dissociative alter-ego could be a violent, antisocial psychopath.

While some films, like Fight Club, take dramatic licence with the concept of ‘madness’, others attempt a realistic portrayal of mental illness. Whether this becomes a tragedy, comedy, or horror, then depends on the genre of the film. It has been said that there are only seven basic plots for all stories. In 2004 Christopher Booker went so far as to try identify them, and defined each archetypal plot with examples from classical literature to modern-day film (Booker, 2004). Some of these plots are interesting prisms through which to look at the treatment of psychiatric illness.

‘Voyage and Return’ is described by Booker as a tale where the protagonist journeys into an unfamiliar land, which is initially thrilling and exciting, but then becomes threatening. Finally the hero escapes and returns home with only knowledge to show for his experiences. Examples include Gulliver’s Travels or Alice’s Adventures in Wonderland. This plot structure has also been used for a protagonist developing a psychiatric illness, or, more chillingly, admitted to a psychiatric hospital without reasonable cause. In Girl, Interrupted (Mangold, Reference Mangold1999), the narrator is brought to a private psychiatric hospital after a failed, impulsive overdose. There is no intimation that she is actually seriously unwell, and yet she remains in the facility for a year. She encounters young women with eating disorders, OCD, PTSD and sequelae of childhood sexual abuse; but the most charismatic is Lisa, a self-described ‘sociopath’ who alternates between uniting the group against the restrictive regime, and mentally torturing her fellow patients. The narrator gradually becomes shocked by the cruelty with which Lisa uses the others’ weaknesses for sport, and the consequences on their mental health. The patients may be disturbed, sad, angry, or difficult, but (with the marked exception of Lisa) are not dangerous except to themselves. Unfortunately, this is not always appreciated by the staff, some of whom are shown to react repressively to any disturbance, leading to gross misuse of seclusion, in one emotional scene. The main danger portrayed seems to be not psychiatric illness itself, but its label, resulting in lengthy detention, medicalisation of distress, exclusion from regular society, and the overshadowing of staff’s humanity by the demands of the institution.

Another ‘Voyage and Return’ film which attempts a sympathetic portrayal of mental illness is A Beautiful Mind (Howard, Reference Howard2001). This focuses on the development of psychosis in a talented young mathematician, John Nash, and the impact this has on his career, marriage, and reputation. The director carefully blurs the line between reality and the onset of paranoid delusions, to put the audience in the position of identifying with Nash’s terror and loss of insight. (Another interesting trajectory is trying to determine the point at which his natural aloofness and eccentricity shade from schizotypal to schizophrenia, encouraged along by a punishing work schedule and a talent for spotting patterns in seemingly random data.) Although the main character is generally sympathetic, he becomes aggressive at one point, endangering his son and wife by acting on his delusional beliefs. Later, the fear engendered in others by his illness is seen when the Nobel committee wish to check he is mentally stable before they will award him a prize. While this again reinforces the link between madness and dangerousness, the ultimate arc of the film is redemptive. Nash gains insight into his hallucinations and creates a fulfilling life with the support of his wife.

Comedy is not perhaps the first genre that comes to mind when thinking about psychiatric illness in film, yet there are numerous instances, both superficial and insightful. Using dissociative identity disorder, Me, Myself and Irene (Farrelly & Farrelly, Reference Farrelly and Farrelly2000), perpetuated the association of mental illness with violence and anger, and was criticised publicly by mental health advocates, particularly for its marketing strategy. Other comedy films have managed to integrate characters with mental health problems, although it is a difficult balance to strike. The Royal Tenenbaums (Anderson, Reference Anderson2001) is a whimsical black comedy which is steeped in depression. Most of the characters in the film, including the three adult Tenenbaum children, are struggling with issues of identity, self-esteem, and failure. The picture-book style of the film and frequent quips keep it firmly in the land of comedy, as the patriarch wheedles his way back into the family home under guise of having a fatal illness. This neatly juxtaposes the accord paid to physical illness with the lack of recognition given to his children, who struggle on in increasing superficiality and isolation. The film’s emotional crux happens when Richie Tenenbaum faces himself in a mirror, removes any trappings of former glory; his glasses, beard and hair; and cuts his wrists. The shock of this scene, in a film previously melancholic but light-hearted, is thankfully tempered by his rescue and by it serving as one of the catalysts for the family to reassess their lives. It is a testament to the balance of the director that despite this being a comedy, the audience is never made to laugh at others’ distress. Perhaps the biggest danger of psychiatric illness in this film is the way in which we the viewers, along with the characters, overlooked it until it was nearly too late.

Booker’s other two plots which feature in psychiatric themed tales are Tragedy and Rebirth (Booker, 2004). Depending on your viewpoint, both plots can be seen in One Flew over the Cuckoo’s Nest (Forman, Reference Forman1975). The rebirth is of Chief Bromden, who regains confidence, physical and mental strength, and resolve through McMurphy’s defiance of the psychiatric system. The tragedy is obviously McMurphy’s lobotomisation, and yet, as Roger Ebert pointed out, the film is often misremembered as a comedy (Ebert, Reference Ebert2003). It is interesting that a discussion of psychiatric illness in cinema would not feel complete without including this film, and yet the principal characters, McMurphy and Chief Bromden, do not appear to have mental illnesses. Despite the film containing a murder, the viewer gets no sense of danger from the patients. And yet they are seen as dangerous by almost everyone else: the young nurses are frightened, the townspeople are wary, the hospital routine and treatments are designed to cow and control. McMurphy’s disruption of the restrictive ward environment are depicted as laudable, but could also be construed as naive and dismissive of genuine mental illness. Ben Green (Reference Green2007) commented that as a medical student he saw McMurphy as ‘the victim of an oppressive madness machine’, but as a consultant psychiatrist he saw him as ‘a disruptive personality disorder who mocked and abused the system’. While McMurphy certainly mocks and indeed threatens the system; the system is controlling, coercive and holds all the cards in his case. Mocking is the only weapon he has left, and a dangerous one it proves to be.

The attitude of fear towards patients in One Flew over the Cuckoo’s Nest reflects a longstanding association of danger and mental illness. This legacy does not just cause stigmatisation of patients by the rest of society. When persons suffering a mental illness internalise negative stereotypes it can also cause them significant distress (Gray, Reference Gray2002). A way out of this, as suggested by Corrigan and Watson (Reference Corrigan and Watson2002) is to challenge the legitimacy of stigma, as a person’s self-esteem will be influenced by their degree of identification with the stigmatised group. It seems to come back to establishing a new narrative for psychiatric illness.

The use of psychiatric illness in film and theatre has varied depending on the ‘other’ society and the dramatist wish to portray. Frequently, this is violent, or unpredictable; or a form of social transgression. As noted above, not all depictions fall into this category, and there is a movement to depicting psychiatric illness with greater realism and sensitivity. By listening to and portraying stories of mental deterioration and recovery; legitimising people’s experiences; and challenging negative stereotyping with evidence, we can continue to combat the archetype of ‘mad, bad, and dangerous to know’.