One Flew Over The Cuckoo’s Nest v Modern Psychiatry

There is no doubt that One Flew Over the Cuckoo’s Nest is one of the seminal films in mental health fiction. Its legacy is still strong forty years later – barely a week passes without one of my patients mentioning the film, usually comparing it to the ward or my proposed treatment plan.

One Flew Over the Cuckoo's Nest

But it is exactly that legacy that haunts the fight against mental health stigma. This film has so permeated the public consciousness that when folk think of mental health, they think about One Flew Over the Cuckoo’s Nest.

So, how accurate is it? Are mental health units full of Nurse Ratcheds? What conditions do the ward’s patients suffer from? And is electroconvulsive therapy really that barbaric?

But first:

It is 2015, not 1975.

Why is this point important? Because medicine’s approach to mental illness has changed dramatically over the past forty years. A lot of the problems I identified with One Flew Over the Cuckoo’s Next stem from it being a product of its time. It is partially reflective of psychiatry in the sixties and seventies. Like all contemporary pieces, it is unfair to judge it with a modern eye.

Yet what I hope to do is correct misconceptions that have carried over into today’s thinking around mental health.

One Flew Over the Cuckoo’s Nest takes place in what the sociologist Goffman termed a “total institution”, where a group of people are confined in a controlled setting for a prolonged period of time.

Its features include all activities of daily living taking place in the same location, with a large batch of people all conforming to the same schedule and rules. There is also a marked divide between staff and community members – in this case, patients.

This heightened control becomes obvious in the film when McMurphy (Jack Nicholson’s character) tries to change the ward’s schedule for the baseball World Series. While there is a show of democracy in the voting, the act is rigged by the staff. The belief that order and schedule is vital to mental health is being applied here by force and against autonomy.

The other most obvious point is the institutionalisation of the characters. McMurphy is stunned to find out that most of his fellow patients are voluntary and not compelled to stay on the ward. Then why do they stay?

Because any total institution equips people to survive in that environment and not to grow beyond it. This effect is also widely seen in prisons and the military. These patients have grown so used to the ward that they don’t know how to leave it.

However, psychiatry emptied its institutions in the 1980s, moving towards a “care in the community” model and later to the recovery model. Which basically means wanting people to live their own lives on their terms, with support given to achieve those personalised goals. It is basically the polar opposite of institutionalisation, though we do still cause this in some mental health units – e.g. in forensic mental health services, and in patients who stay for a long time.

Mental illness
One of the questions the doctors ask of McMurphy is whether or not he has a mental illness. It is a question we could also ask of the other patients on the fictional ward of One Flew Over the Cuckoo’s Nest.

Again, we must look at historical psychiatry. The vogue in the mid-20th century was that institutions were the preferred method of delivering mental health services. Therefore, if you had any sign of a mental health problem, into hospital you would go. It was partly based on the scientific thinking of the time, and probably more realistically on the fears within the community of what mentally ill people do if left unsupervised.

Fast-forward forty years to a modern mental health unit. One – given the current state of NHS mental health funding, you’ll be lucky if we can find you a bed at all. Two – only the most severe episodes of mental illness require hospital admission.

I still have older patients asking me if they can come into hospital “for a rest”. Respite admissions were very common in the institution era. Now, I can hardly think of a place less restful than a mental health unit.

Of the main patient characters in One Flew Over the Cuckoo’s Nest, I can’t identify one who requires hospital admission. The so-called “chronics” may require highly-supported living arrangements, but not hospital.

Because all these people are relatively well, they may have problems that could be addressed by long-term therapy, robust medication, supported accommodation, or just a more understanding community.

Not one of them has a definable, recognisable mental illness. Especially not McMurphy.

Nurse Ratched
I had heard terrible things about the iconic Nurse Ratched before watching this film. And yet I found nothing terrible about her.


Here is a woman doing her job in an institution that completely defines that role. She is as much a prisoner of this system as they are. In fact, at times, I realised that I would enforce the boundaries in exactly the same way she did.

Does she make some questionable decisions? Absolutely. I found the dynamic between her and Billy particularly troubling. I also thought the nursing staff did absolutely nothing to de-escalate a situation unless they felt their authority was being threatened, not when they felt their patients were suffering emotional or physical harm.

But do I think she had a vendetta against McMurphy, or wished to bully the patients? No, I don’t. I think she genuinely thought she was doing the right thing.

And those people make for the most terrifying villains.

Never do I hear as much about One Flew Over the Cuckoo’s Nest as when discussing electroconvulsive therapy, or ECT. It is undoubtedly controversial – for one, it is the only form of treatment that requires consent or a second opinion under the Mental Health Act.

And in the 1960s, it went down pretty much as you see in the film. In 2015, however, it is a very different beast. ECT always takes place under general anaesthetic. A muscle relaxant mutes the effects of the seizure on the body. And it’s only given in the most severe episodes of depression and psychosis, usually when people are dying from dehydration and malnutrition.

It is definitely not used as a punishment for bad behaviour. It’s also not used for tranquillisation.

The medication ethics are also pretty shit in One Flew Over the Cuckoo’s Nest. When McMurphy asks what tablet he’s being given, the nurse patronises him and then Nurse Ratched threatens him. Even when compelled to receive treatment, people should be informed about what it is you want them to take. We are trying to move beyond the paternalistic model of medicine where you just do exactly what your doctor says – because why the hell should you?

See also group therapy. Is group therapy for everyone? Nope. Should you be compelled to do it? Probably not. The evidence suggests that any compelled therapy will be pretty much useless. It requires consent and active participation. It requires a trained facilitator who won’t use the threat of your mother against you (and should instead be looking into those mother issues, because that seems a significant factor in this case).

I’ll be honest: I really enjoyed this film.

It shows people with mental health problems as individuals, with in-depth characters, dreams and desires. It didn’t do psychiatry a lot of favours, but then 1960s psychiatry didn’t do itself a lot of favours.

I find it difficult that so many people still turn to One Flew Over the Cuckoo’s Nest as their benchmark for what mental health and psychiatry are actually like.

How do we combat that? We include more characters with mental illness in our dramas, our comedies, our documentaries. We tell the truth about mental health now.

What did you think of One Flew Over the Cuckoo’s Nest? Leave a comment!

REVIEW: The Other Side of Silence – Linda Gask

As a psychiatrist, I walk a fine line of understanding. While I can try to empathise with the people I see in my clinics and on my ward, I cannot truly know their experiences. Sometimes that helps to give me the distance of objectivity, and sometimes it leaves me lacking.

Linda Gask has a markedly different perspective. She is a psychiatrist and academic who has experienced mental health problems from both sides – that of a clinician and that of a patient.

In her book The Other Side of Silence: A Psychiatrist’s Memoir of Depression, Linda draws on both her professional knowledge and personal experience to take the reader on a “guided tour” of depression – using her own life and anecdotes about patients to illustrate the complexity of this illness and its manifestations.

What I love about The Other Side of Silence is that it sets aside the traditional, medical model of psychiatry and instead embraces a whole-person, holistic approach to the illness. It looks at depression not as a disease of neurotransmitters and recovery models and care programme approaches, but as an experience that happens to people and affects their lives. We see up-close and personal the effect it has on Linda’s life and the course it takes.

However, she also retains the perspective of the psychiatrist. The reader is left in no doubt that they are in the hands of a doctor, a professional with clinical expertise on this subject. Linda’s narrative moves effortlessly from a psychiatrist’s analysis to a patient’s point of view. She shares encounters from both sides of the table – her own work with patients and her own experiences of being tended to by professionals.

I highly recommend The Other Side of Silence if you want a real account and contemporary understanding of depression, particularly with the supporting knowledge of a medical perspective. I can also recommend it if you have a personal experience of depression and are struggling to understand it, or are already on that journey. I think it is particularly relevant to professionals and those trying to maintain or reclaim the functioning of their lives. In fact, I recommend it so highly that I have already lent my copy to a friend.

Linda Gask (MB. ChB, Msc (Psychiatry), PhD, FRCPsych, FRCGP) was born to a Scottish mother and English father and brought up on the east coast of England in Lincolnshire. She trained in Medicine in Edinburgh and is now Emerita Professor of Primary Care Psychiatry at the University of Manchester. She has worked as a consultant psychiatrist in the North of England over the last 25 years. Now semi-retired, she lives with her husband and cat in a stone house in the Pennines and also spends an increasing part of her time in Orkney. You can follow her blog at and on Twitter as @suzypuss.

You can buy The Other Side of Silence: A Psychiatrist’s Memoir of Depression at all good book retailers. Here are a few to get you started:
Google Play

Add to Goodreads

#WriteInclusively – We Can All Do Better

Yesterday, the news broke on Twitter that SC had been removed as co-host from Query Kombat and Nightmare on Query Street, popular query competitions designed to help win an agent or editor.

The reason? His “passion for the Write Inclusively campaign may be unsettling or umcomfortable for people who don’t write from the POV of ethnic characters, or who don’t portray ethnic characters as ‘honestly’ as [he] would like.”

Okay. I’m not going to talk about the decision, as many articulate people have already commented on Twitter. I am going to talk about my personal struggle to write diverse books and why we should strive to do better.

I have written before about my difficulties identifying as a queer woman of colour, and about feeling responsibility for writing diverse books.

My first novel Binary Witness is shit on diversity. Despite having a female protagonist, it doesn’t even pass the Bechdel Test. One of the only queer characters is a victim. There are no prominent people of colour. It does work to accurately portray mental health issues, because that is a significant fever of mine, but that is all.

The worst thing is that I didn’t even realise it. It was only about six months after publication, when I was talking about diversity in fiction, that I realised how I had unconsciously written an all-white, heteronormative world. In my defence, the real Cardiff isn’t a hotbed of diversity, but it’s certainly moreso than my novel would suggest.

In Code Runner, I decided to do better. I introduced a woman of colour who I intended to replace a white male recurring character. I included a couple of microaggressions towards her. However, she was largely in the background – she smiled and did her job. It was a start.

In my latest WIP The Deaths of Miss Gray, I was determined to work hard. My nineteenth century London must include real people. I have queer characters of differing stripes, who flaunt their sexuality based on their privilege. I have characters of colour who suffer prejudice and discrimination, though I could’ve done more with this. I have women front and centre.

And yet still I can do better. In Amy Lane book 4, I can include more of Indira’s experience as an Asian woman in Wales. In Deaths, I can explore what happens to the black performer Cassandra when she ventures into the white, well-heeled parts of London.

We can all do more. We can all do better.

The point is that we have to be willing to accept we need to grow and learn. The writers that feel uncomfortable at being told their portrayals aren’t accurate? Those are growing pains. You need them to become a better writer.

We need to tell each other when we fall short so that we can all do better. And that is why we have #WeNeedDiverseBooks and #WriteInclusively.

Right now, my books don’t meet the threshold for #WriteInclusively – and I’m asking myself why. Are you?

5 Mental Health Truths from Inside Out

When I first heard about Disney Pixar’s new film Inside Out, I knew it would be a winner. What I wasn’t prepared for was how well it handles emotions, personality and their psychological underpinnings.

Here’s five lessons about mental health you can take away from Inside Out and how they can help both writing complex characters and your personal wellbeing!


Forced Joy is Unhealthy
If you are trying to make yourself or others feel happy all the time, you are heading for trouble. When Riley’s mom tells her that they both need to stay happy for their father, a whole load of warning klaxons went off in my psychiatry brain. No one can be happy all the time. I am a natural optimist but I don’t smile every hour of every day.

In Inside Out, the character of Joy wants everything in Riley’s life to be happy. It is her desperation to achieve this that leads to Riley’s (and Joy and Sadness’) catastrophe. When big life events happen, it’s natural to feel sadness, anger, fear and even disgust. Denying them is like letting a wound fester – much worse consequences down the line.

One Dominant Emotion Can Ruin Your Life

If one emotion is driving all your interactions, something has gone wrong. The adult characters in the film all have emotions seated at a large table – each one has a place in driving that character, though one has the “hot seat” in the centre. My friends and I were talking about who has the driving seat in our lives – I’m definitely a Joy, while my husband is a Sadness. One of my more cutting, sarcastic friends is Disgust and I’m sure we all know a few Angers.

But if that emotion drives all the time and excludes the others, that represents A Big Problem. The characters of Inside Out could be illnesses: Sadness might be depression, Disgust can form OCD, Anger can lead to aggression and violence problems, and Fear can lead to a number of anxiety disorders. Something is needed to redress the balance.

Emotional Blunting is The Worst

At a critical point in the film, the emotional console at Headquarters shuts down and greys out – Riley feels nothing at all. This is often considered one of the worst situations in mental health, particular for people with depression. It’s not that they’re sad – they just don’t care anymore. It’s also a symptom of burnout and increasingly common in the workplace, particularly frontline emergency services.

What can be done about it? It seems to represent a psychological shutdown – everything is overwhelming, so feeling nothing is most protective. A process of rest, recuperation and acknowledging what led to the problem, as well as professional mental health care, can help deal with the underlying situation.

Mixed Feelings are Mature

At the end of Inside Out, Riley’s memories aren’t sharply divided according to her emotions but a mixture – Joy with Sadness, Anger with Fear, etc. One of the thought distortions often seen in disorders of mood, anxiety and personality is “black and white thinking”. This means that something must either be good or bad, positive or negative, helpful or unhelpful. In its extreme form, it’s known as splitting.

However, shades of grey are the norm. The ability to accept that a moment can be both happy and sad – from where we take the word bittersweet – is part of emotional maturity. To get all psychodynamic on you, Melanie Klein developed the concept of the paranoid-schizoid position, also called “good breast, bad breast”. It refers to an infant being unable to realise that things can have both good and bad parts, like the mother who owns both the breast that gives nourishment and the one that does not provide when the infant is hungry.But this is an infant phase – moving beyond it is part of growing into adulthood.

Accept Sadness

For me, the most powerful part of the film was Sadness and particularly Joy’s relationship with her. At the start, Joy never wanted to let Sadness drive. She tried to stop her touching the memories as she was “turning them sad”. She wouldn’t let Sadness talk about things that made her feel sad and she tried to contain her within a tiny circle – a classic repression if ever there was one.

And when Sadness made a core memory (an important concept in Inside Out and, well, life), the fight between them led to both of them being expelled from Headquarters. However, Joy starts to appreciate Sadness. Joy cannot rouse Bing Bong, Riley’s imaginary friend, but by validating his hurt and upset, Sadness enabled him to move on and help them. By the end, Joy realises that sometimes Sadness needs to drive and Riley is better for it (I may also have cried at that point).

Recent concerns in psychiatry have highlighted the problem of medicalising natural sadness. For example, giving antidepressants for a normal grief reaction. You should feel sad when a loved one dies. You should feel sad when a life event causes upheaval in your life. It was only when Riley expressed her sadness that she allowed her parents to express theirs, and brought them all closer together.

What are your thoughts on Inside Out? Was there a particular message or benefit you took from the film? Let me know in the comments!

Do Writers Have a Duty to Accuracy?

When writing about mental health problems, I often emphasise accurate and sensitive portrayals of mental illness. But how important is accuracy in writing? Should the story come first?

Daisy Head plays Amy Stevenson  in The Syndicate - (C) Rollem Productions - Photographer: Matt Squire
Daisy Head plays Amy Stevenson in The Syndicate – (C) Rollem Productions – Photographer: Matt Squire

Last week, controversy surrounded the season finale of BBC One’s drama The Syndicate. Amy, a character with Type 1 Diabetes, complained of having low blood sugar and was later administered insulin.

The Juvenile Diabetes Research Foundation (JDRF) criticised the episode, as giving insulin to a person with low blood sugar is dangerous. Karen Addington, Chief Executive in the UK of JDRF, said:

“Television writers and producers have a responsibility to portray life with a condition such as type 1 diabetes accurately.”

However, Kay Mellor, writer of The Syndicate hit back. In her statement she made a number of points in her own defence.

I would like to examine some of those points.

Not A Medical Drama?
The Syndicate is in no way a medical drama or a serious documentary about how to treat diabetes.”

While I may have watched a lot of House at medical school, doctors do not learn medicine from television. Why, therefore, is medical accuracy more important in a medical drama than in any other TV show? What is the point of accuracy anyway?

There are two possible answers to this. One – accuracy is important because we should portray things correctly. Or two – accuracy is important because it enables a show to feel authentic. Writers want the audience to suspend disbelief and immerse themselves in the world. If it is authentic, it will feel authentic.

But with The Syndicate, medical accuracy doesn’t necessarily add to the authenticity. So, why bother?

Did Not Do The Research?
“I based the story of Amy around a young woman I spoke to who said when she’s been eating or drinking something sugary her blood level spikes [high] but then after a time her level drops dramatically. She told me she needed the insulin to stabilise her levels. Maybe it’s a case of no two people being exactly the same.

Mellor says she “researched and spoke to people who were diabetic” while writing the show. In science, the lowest form of evidence is an expert opinion. It is interesting that this is the evidence most favoured by the journalism. It is also interesting how Mellor has taken one woman’s story and extrapolated from it, to the point where she puts so much faith in this story that she thinks it contradicts the JDRF.

Taking insulin after eating or drinking something sugary is entirely sensible. It stores the glucose from the blood stream. If the glucose keeps sloshing about, however, it will eventually be peed out and the blood glucose level will drop. If it drops too low, that is a hypoglycaemia attack. That is not a good time for insulin. That is a very bad time for insulin.

Which is information Mellor would’ve received if she had asked a medical expert. Or consulted a diabetic resource. I imagine she did those things, but chose to emphasise the personal testimony of this particular woman instead.

I have often advocated looking at personal stories to help mental health accuracy. Is this foolish? Is science a better teacher than a person’s lived experience?

For The Plot?
“…like any dramatist I have to take dramatic license sometimes to make the story work.”

“…Amy is a young woman who is diabetic but also quite manipulative…We have no idea if she is lying or telling the truth at any given time.

“…Amy had been through a traumatic time with her boyfriend and clearly feels unwell and confused, she could well have made an error saying her blood sugar was low.”

“Also we have no idea what the chemist said to Spencer or what he did as a consequence… we have no idea how much time has passed.”

Mellor appears to be saying that plot trumps accuracy every time. I have seen this writing advice given time and again. Is it right that story comes first and everything else is just window dressing?

Mellor gives two possible explanations for her version of events – either Amy is lying or Amy is mistaken. She then gives a possible explanation for Spencer’s actions.

Let’s look at the on-screen events: Amy says her blood sugar is low, then later says she thinks she needs insulin. Spencer looks up diabetes on the internet, then goes to a chemist to get insulin. The chemist gives him advice. Spencer returns with insulin and administers it to Amy while she is sleeping.

It appears that Mellor may have wanted the following: Amy is vulnerable, loses consciousness and requires medical treatment. Spencer goes to get medical treatment. Spencer returns and then holds some control over Amy via the treatment.

It is possible to do this with an accurate portrayal of diabetes. It requires a couple of lines here and there, but it holds its overall shape. For example, Amy could treat her hypo with a sugary drink (as she suggests) and then send her blood sugar high. She might then remember she needs her insulin.

Sometimes Writers Screw Up
“Sometimes it can be difficult when I have one hour to tell a big dramatic story, beats are missed and hard facts can be lost.”

And this is the crux of the matter, really. Also, the closest Mellor comes to admitting she made a mistake.

What does a writer do when they’ve fucked up? When I was eagerly looking at readers’ comments on The Amy Lane Mysteries, I stumbled across a thread where I was criticised for my depiction of hackers. I am not a hacker. I am fairly computer literate, but only on the surface of things. I did research into digital forensics and cyber crime. However, I did not speak to hackers and I did not ask an IT professional to check the novel for errors.

What then could I do? I could’ve a) apologised for my mistakes b) argued that my version served the plot or c) quietly tried to improve.

The differences between Mellor and me are that I wasn’t publicly confronted and that, apart from annoying some folk, no harm comes from my mistakes.

However, the inaccurate portrayal of illness can be very harmful. In the case of diabetes treatment, it can be lethal. People believe what they see on television. It’s why there are so many campaigns for the accurate depiction of CPR, a life-saving skill that most people have only seen on TV.

In mental health, that harm comes from the perpetuation of stigma. With every mad killer, another weight is added to the overflowing pile of stereotypical portrayals. Another person is put off seeking help due to fear.

And from that standpoint, do writers always have a duty to accuracy, regardless of the plot?

Do you think writers should put story or accuracy first? Should writers apologise when a mistake is made or should they fight for their story? Let me know in the comments!

On Strange and Norrell and Madness


The BBC has once more proved the worth of the licence fee with the stunning adaptation of Susanna Clarke’s novel Jonathan Strange and Mr Norrell.

Now we’re all had time to digest the series, I wanted to think on the depictions of “madness” in the adaptation and what writers can learn about depicting mental illness, particularly in the fantasy genre.


The relationship between magic and madness
“Magic cannot cure madness.” – Gilbert Norrell

From the beginning, Strange and Norrell was explicit in its discussion of madness and magic, with an alternate early nineteenth century viewpoint. When Sir Walter Pole asks Mr Norrell to cure his wife of madness, Norrell is firm on the point. However, given what we know of Norrell’s role in Lady Pole’s resurrection and his subsequent distancing from fairy magic, Norrell may well be lying. However, his efforts with Strange on curing the King’s madness seem to uphold this assertion.

Jonathan Strange, much later in the book and series, identifies that the King’s madness enables him to see fairies. He then tries to bottle madness so that he too may see the creatures.

Throughout the narrative, we see characters who are labelled as “mad” by others but their individual situations are quite different. Some provide a fascinating interpretation of mental illness, and some are more problematic.

The curse of Lady Pole
“This is madness-”
“Madness is what it is not.”
– Stephen Black and Lady Pole

Alice Englert as Lady Pole and Ariyon Bakare as Stephen Black (C) JSMN Ltd – Photographer: Matt Squire

By most definitions, Lady Pole is not mad. Her situation typifies the idea that insanity is a perfectly rational adjustment to an insane world. This phrase is attributed to RD Laing, a psychiatrist who believed in the lived experience of mental illness above the biological explanation.

When I have previously written on psychosis, I described a person unable to distinguish fantasy from reality. In Strange and Norrell, the writers take this a step further – a mad person can see both reality and the fantastical world of Fairy.

Lady Pole is labelled as mad because she cannot live in both worlds and she speaks nonsense instead of the truth about her situation, due to the fairy rose at her lips. Due to her psychological torment, she attempts suicide and then tries to exact revenge on Norrell. She is rewarded with confinement, restraint, sedation and finally institutionalisation. Her recovery occurs when she is removed from Lost-hope and returned wholly to “reality”, where she decides to leave her husband for better treatment elsewhere.

Mad King George
“Do not be angry! I am a king, you are a king – let’s all be kings together!” – The King

King George is an altogether different case. For one, he is based on an historical figure – George III. The cause of his madness is unknown, but has been described as both melancholy and depression and was possibly related to porphyria, a blood disorder when accumulating chemicals cause various complications including mental illness.

In the adaptation, George III is portrayed as blind, nonsensical and able to communicate with The Gentleman. He is summarily kidnapped through a mirror for Stephen to try to kill him. However, Strange manages to return him to his chambers. The insinuation is that the King is mad and he can therefore see fairies, not that his madness is related to magic.

In the novel, Strange attends the King alone, in defiance of his asylum jailers. They are an interesting study of nineteenth-century alienism, with their three principles of intimidation, isolation and restraint.

Mrs Delgado aka the crazy cat lady
“…a great wind of madness howled through her…” – Strange and Norrell.

It will come as no surprise to regular readers that this particular portrayal is the most problematic for me. A woman who adopts all the habits of a cat while surrounded by them, played for both revulsion and humour, was never going to sit well.

This does resemble the rare clinical condition of clinical lycanthropy, its name deriving from the idea of werewolves. It is believed to be on the psychosis spectrum, with the delusions and hallucinations of the creature the person believes they have turned into.

And Jonathan Strange’s treatment for this woman’s condition? To turn her into a cat. Words, I do not have them.

In one of Strange and Norrell’s infamous footnotes, the novel narrator gives a potted history of Mrs Delgado’s life, with a reference to her descent into madness. It says that she lived quite alone, never speaking to another living soul, and she lost all her languages except Cat. As a precipitating factor for madness, I cannot endorse it.

Jonathan Strange’s quest for madness
“Everything he thought before, everything he knew, everything he had been was swept away in a great floor of confused emotion and sensation.” – Strange and Norrell.

strange madness
Bertie Carvel as Jonathan Strange (C) JSMN Ltd – Photographer: Matt Squire

And, finally, we come to the depiction of madness in our protagonist. This particular brand of madness is part organic and part magical, contained in one dead mouse. Strange contrives to distill madness by putting a magical mouse in a bottle of water and taking drops of it to see The Gentleman.

Preceding this experiment, Strange tells Fiona Greysteel about the magicians who consorted with madmen and endeavoured to become mad themselves. Fiona tells him that old nonsense about creative people being mad and how jolly it is. And Strange lauds her for it.(She does not provide this encouragement in the novel.)

When Strange first ingests the mouse, the adaptation shows a rather lurid representation of his head apparently being torn in many diffrent directions. I was uncomfortable reminded of the idea of multiple personality disorder rather than a psychosis.

The book takes a different tack, where the writer has the advantage of sharing Strange’s thoughts on the experience – a burst of concentrated madness, all different kinds of it, bundled up in one dead mouse. It takes in everything from hypersensitivity of the senses to persecution to dysphoria.

When Strange moderates his experience, he becomes convinced people have candles inside their heads. When it wears off, he is troubled:

“He found he could no longer recall whether people had candles in their heads or not. He knew there was a world of difference between these two notions: one was sane and the other was not, but he could not for the life of him remember which was which.”

What’s interesting about this observation is that it’s very like what happens when people start to recover from psychosis. They often do not snap back to reality, but take a journey there through a period of being unsure of what is real or what is fiction.

Strange’s other experiences involve pineapples and wandering within his own mind, one bizarre and an object for humour, and the other resembling a catatonia or depressive ruminations.

Learning points for writers

What is evident in both the novel and adaptation is that madness is presented both as a dysfunction of the mind, and an illusion caused by magic or induced magically. When exploring either of these points, one gets the impression that the writers are grappling with a chimaera – we’re not sure exactly what it is, but it is large and vicious and frightening.

I don’t necessarily disagree with that. But mental illness is real in our world – it is not caused by magic any more than it is caused by demonic possession or abandonment by God.

Good points for writers to take from this is the sensible explanation of how madness and magic interact from the writers. They lay it out very clearly. We also experience vividly Lady Pole’s situation and how frightening that can be. In the novel, the depiction of the asylum keepers of the King is very well done.

One negative is laughing at the mad antics of the characters. Mental illness can be humourous and it can be alleviated with laughter, but if you choose this route, you are taking a well-trodden path. Just like the mad scientist or the violent schizophrenic, it reinforces a negative stereotype.

The other is this slightly alarming idea of seeking madness. Nineteenth century poets did seek it out, mostly by taking mind-altering substances – it didn’t work out particularly well for them. Madness does not facilitate genius or creativity, with the dubious exception of hypomania and mania, but those are not sustainable and often deteriorate. There are no real consequences to what Strange does, and I think that’s a missed opportunity.

What are your thoughts on Strange and Norrell and madness? What did the adaptation or novel get right or wrong? Would you do anything differently? Has it inspired your own work? Tell us in the comments!

Questions From My Editor

I’ve been fortunate to work with my excellent editor Deb Nemeth on three Amy Lane novels now. In the course of editing my work, she asks me a lot of questions. Some are to expand her knowledge of my characters’ world and some are to challenge me to grow as a writer.

I’m going to share a few (spoiler-free!) questions that Deb has asked me during different stages of editing for Binary Witness, Code Runner and Captcha Thief.

Welsh life


I use a number of Welsh names in my novels, but Jason’s sister probably possesses one of the more challenging ones. Cerys is pronounced “keh-ris”, not anything like “cerise”. Additionally, Owain is less like Owen and more “owe-ein”.


Sticking with names, abbreviations aren’t always universally understood. As Peggy is to Margaret and Betty is to Elizabeth, so Dai is to David in Wales.


Slang is obviously also highly-localised. “Butt” is a piece of South Walean slang, most often found around Cardiff and Newport, and it’s used like “mate”.

Cultural references


As a British author working with an American editor for an international audience, I am forced to confront my cultural bias as to what references are common knowledge outside of my own country.

For those not sharing my brain:
– Myra Hindley was the partner of Ian Brady, together forming the Moors Murderers
– GUM clinic is where you tend to your sexual health – it stands for Genito-Urinary Medicine, but also forms a nice euphemism
– Red-top papers are British tabloids, noted for their distinctive red ink headers
– Chav is a derogatory term for a young, low-income person with a penchant for tracksuits and cheap jewellery. It was popular in the late nineties/early noughties. In my area, we used the word “townies”, so chav was also foreign to me growing up.

I also forget that not everyone is conversant in Monty Python:


and that some idioms are uniquely British, particularly when it comes to rain:


And this is my personal favourite “turn-of-phrase gone wrong” moment:


Calling me out

Like all the best editors, Deb is unafraid to question me when I’ve done something stupid.


Um…well, she…yeah, dunno.


Well, the eggs are gonna get smashed for sure.


*tries to replicate movement with own head, gets dizzy, falls off chair*



Building a better novel


If you’ve read Binary Witness, you will know that Amy doesn’t own a giant, chilled mailbox and that her grocery delivery actually turns up in the lift. In the early designs for Amy’s flat, she lived on the ground floor. In response to Deb’s comments and other practical considerations, I moved Amy up to the first floor (i.e. the one above ground level) and installed a lift at the front.

Because, seriously? A giant, chilled mailbox?


This is one thing I fought to keep, and the reason is this: I actually lived in the house described at the beginning of Binary Witness, with my housemate. My housemate loves Dr Quinn, Medicine Woman and woe betide anyone who messed with her recording. British students have a particular affinity for retro TV and this is the perfect example for me. However, Deb was absolutely right about dating the novel – I instead lost the reference to The Clash.


And sometimes, you just need to explain yourself in-text. Jason loves eighties’ music because it reminds him of his dad, a man he never really knew. An editor’s questions reminds the author that the world that exists inside their head isn’t automatically translated to the page.

But some mysteries can never be explained:


But this one is my favourite…


Binary Witness and Code Runner are published by Carina Press.

The third book in the series Captcha Thief will be released later this year – join the newsletter for updates or add to Goodreads.

INTERVIEW: Ruth F Hunt on Mental Health, Disability and The Single Feather

At Freudian Script, we explore the relationship between mental health and fiction. Our guest Ruth F Hunt has written a compelling debut novel in The Single Feather, tackling the topics of disability and mental health without shying away from the realities.

What led you to explore issues of mental health and disability in The Single Feather?

Since becoming disabled at the age of eighteen, and having Bipolar as well, I’ve been very aware of the missing voices in novels, with a real lack of disabled characters in adult fiction, being a particular problem. As well as having worked with adults with complex needs in a social services department, I’ve also worked in mental health, with my last role being a Trustee with a large mental health charity.

So along with this experience in my personal and working life, I was very aware that in the past few years, hate crime towards people with disabilities has risen and cuts to benefits have disproportionately affected those with disabilities making them particularly vulnerable to abuse. I was also aware that mood and disability are linked. The Christopher Reeves Foundation says that 20-30% of those with a spinal cord injury can present with clinical depression as well.

Therefore I was keen to have a disabled protagonist but I also wanted a mental health storyline to be included in the novel. In The Single Feather there are also a number of characters over the age of sixty, another group often missing or misinterpreted in fiction.

Did you draw on personal experience to craft your characters?

I would say that my own experiences helped a lot. I found it fairly easy to tap into my protagonist’s mindset, and understand how a traumatic experience led her to take a path she might’ve avoided otherwise. I could empathise with her decision to hide her background, due to fear of being ostracised. It can be hard “coming out” and telling people you have a mental illness or something happened that was traumatic in your past. One area I’m particularly interested in is how we present different versions and histories to people, according to who they are, or what situation we are in and how a ‘white lie’ could multiply and threaten new and existing relationships.

When I’ve been using my wheelchair, I’ve also had lots of strange reactions, from being patted, to being spoken about in the third person. How people react to disability, both positively and negatively and how social attitudes and stigma towards disability can impact on the individual were areas I covered in the novel, so my experience here helped as well.

There is a lot of stigma around disability and mental health problems. What do you think are the best ways to combat it?

I agree, there is still a lot of stigma, and also currently demonisation of those with mental health problems or disability in certain sections of the media. That’s why it’s crucial for writers to include disabled characters or those with a mental illness and to have empathy for these characters. 1 in 4 of us will experience mental ill health, and physical disability is again very common. The more the public see these characters in film, TV, public life or in novels, the more they will understand. The more we talk about mental health or disability, the more we hopefully are giving strength to someone like “Rachel” who in The Single Feather is embarrassed to talk about her past.

When I was first injured, the consultant said to me: “You’re still Ruth, don’t let anyone treat you differently.” Just that one sentence helped me enormously. We can replicate that in fiction, by using disabled characters or those with a mental health problem, as a matter of course, not something strange or out of the ordinary.

As a writer, would you recommend any particular novels that do a good job of portraying disability and mental health that other writers could use for inspiration?

There are some books I’ve recently found to be excellent in dealing with a mental illness: The Shock of the Fall by Nathan Filer and The View on the Way Down by Rebecca Wait. Matt Haig’s Reasons to Stay Alive is also good to read, and dispels many myths surrounding anxiety and depression. Kay Redfield Jamison has produced many books on the subject of mental health; An Unquiet Mind is very enlightening.

I’m also currently reading A little Life by Hanya Yanagihara which combines both physical disability and mental health issues and there’s also a temptation by certain characters to “reinvent” themselves, just like what happens in The Single Feather.

As I was writing about complex characters and group dynamics, I also found The Writers Guide to Character Traits by Linda N Edelstein helpful.

What would you like to see more in terms of characters living with disabilities?

As there is such a lack of disabled characters in adult fiction I would simply like to see more writers whether they are able-bodied or not, write about characters that have a disability. They are rich characters to use, and by writing about them, in an empathetic and positive way, you will be helping someone in the real world who has a disability.

What one piece of advice would you give to someone who is struggling with their mental health?

A reviewer said about The Single Feather: “If we truly spend time to get to know each other, we will see that there is more that brings us together than separates us.”

This is the message of the book, so if you are struggling with your mental health, you need to reach out. Your GP will be someone who wants to help, but also try to reach out to your friends and family. The chances are you will find other people who have been in your situation or a situation like it. If you don’t feel you can do that yet, then reach out and talk to the Samaritans (UK phone number: 08457 90 90 90). If you would prefer to communicate by email, you can get in touch with them at:

What advice would you give to writers wanting to portray that struggle accurately and sensitively?

For writers wanting to portray someone who is struggling with their mental health, the first step is to have empathy for your characters. Do as much research as you can, and talk if possible to people who have a mental health problem, so you can hear what it’s like first hand. Language and how people are treated in hospital and in the community changes every now and again, so it’s important to keep up to date. Websites such as Mind and Rethink can help with this. Most of all remember 1 in 4 of us will have a mental health problem; it’s a lot more common than many expect.

photo RF Hunt

Ruth lives in Lancashire and has worked in welfare rights and in social services with adults with complex needs. She paints for commissions and has her artwork in galleries and exhibitions. She loves writing and her debut novel The Single Feather, is available in bookshops, on Amazon (ebook and paperback), and direct from Pilrig Press. Currently she’s studying English Literature and Creative Writing with The Open University.

Ruth is also the special guest for April’s #psywrite on Tuesday 21st April at 8pm BST.

#KillerFest15 – Mental Health and Crime


I was privileged to take part in Killer Reads and Waterstones’ Killer Crime Festival 2015 with a Twitter chat about mental health and crime fiction.

There were some great questions and an ongoing discussion afterwards about crime novels featuring protagonists with mental health problems. Please share your recommendations in the comments.

If you enjoyed the chat, why not check out #psywrite, the monthly Twitter chat about mental health in fiction. We’re taking at break for March but we will be back for your questions in April!

And if you have any detailed queries for your writing, please get in touch – I’m always happy to help with accurate and sensitive mental health portrayals.

Freudian Script: Cannabis and Psychosis

cannabis-psychosisWith the recent study from King’s College London linking “skunk” to diagnosis of psychotic disorders, I thought it would be a good time to examine the link between cannabis and psychosis in detail.

I have previously written about cannabis and psychosis while talking gangs and drugs, but we didn’t look at the evidence base.

As I was writing this post, I realised that I’ve also waded into the fields of statistics and research methodology. Hopefully, this will provide some clarity the next time a newspaper starts talking about odds and risk in healthcare.

First, let’s get some definitions on the table.

Psychosis, in essence, is the inability to distinguish what is real and what is not. It is most often talked about it terms of schizophrenia. You can read more detail about it here.

Cannabis is a group of flowering plants native to Central and South Asia. To get biological, there are three main species – Cannabis sativa, Cannabis indica, and Cannabis ruderalis. However, the cross-breeding produces all kinds of different sub-species.

Sativa is the most prevalent and the one used for hemp production. Skunk is a hybrid of sativa and indica and contains two-three times higher concentrations of tetrahydrocannabinol (THC), the main psychoactive chemical in cannabis. UK police seizures indicate that skunk is now the prevalent form of cannabis in the UK.

Cannabis and psychosis: the evidence
People have been looking at cannabis in relation to its mind-altering effects ever since they discovered it could be ingested, which is why a number of ancient cultures used it in religious rituals.

However, scientific research didn’t kick off until the 20th century (before which we used to give morphine and cocaine to babies). The key thing about research is this: you have to know what the researchers were looking for. Research can only answer the specific questions asked – remember that as we take a wander through the history of cannabis and psychosis research:

The most famous study of cannabis and psychosis is known as the Swedish conscript study, published in 1987. Firstly, it was HUGE – 45,570 military recruits followed up for fifteen years. Cohort studies don’t get much better than that.

What’s a cohort study, you cry? It’s when a group of people are followed up over a long time to see what happens to them. It is only observational not interventional – you find what’s there and don’t try to influence the outcome. It is a good research method for looking at causal association – the question of “does x increase the risk for y?”. It’s the method that was used to look at links beteween smoking and lung cancer. However, in defiance of the Latin phrase, “after it therefore because of it” is not always true.

What they found was interesting – “high consumers” of cannabis were six times more likely to develop schizophrenia than non-users. And by “high consumers”, they meant people who had smoked cannabis more than fifty times. Ever. That could be only once a week for a year.

Two points also worth noting:
One – psychosis does not equal schizophrenia. However, this was 1987 and “schizophrenia” was used fairly liberally. We might now recognise schizoaffective disorder, drug-induced psychosis and mania separately.
Two – this was self-reported. Therefore, it’s likely that people underestimated their usage. All told, this is pretty good evidence for a link between cannabis and psychosis.

To reinforce these findings, a Lancet 2007 meta-analysis – i.e. looking at the whole body of research – explored the assocation between cannabis and psychosis. Note here that we’re including studies which didn’t look at cause and effect, but looked at where x and y appear together (though they only included longitudinal studies). The study found that there was a significant association between cannabis and all psychosis (not just schizophrenia) which went beyond the transient intoxication effects. It also concluded there is a dose response – like smoking and lung cancer, the more you smoke cannabis, the more likely you are to develop psychosis.

Skunk and psychosis
Which brings us to the King’s College study. First question – what were their questions? The full title of the study is “Proportion of patients in south London with first-episode psychosis attributable to use of high potency cannabis: a case-control study”.

So, we’re not looking at schizophrenia here but “first episode psychosis”. This is relatively new term arising from the movement for early intervention in psychosis, which is the idea that we prevent long-term disability by throwing in a lot of support at the beginning of the illness. First episode psychosis can be just a one-off episode, or can be the start of schizophrenia, schizoaffective disorder, or bipolar affective disorder.

You will also have caught the word “attributable”, so it seems we’re thinking causation again. However, the methods used can only conclude an association. The introduction goes on to say that the researchers hypothesise that the frequency of use and the potency of cannabis increases risk – i.e. a dose response. They think we should focus more of types of cannabis used, using alcohol as a comparison – it’s not enough to know someone drinks twice a week, but how much they drink per session and what they drink (wine, beer, spirits) matters to the outcome.

“Case control” is a type of study where people with a problem – in this case, first episode psychosis – are compared directly to individuals without that problem but otherwise similar. This helps reduce confounders, factors that could potentially influence the outcome, like gender, ethnicity or socioeconomic status.

Their findings support an increased association between users of skunk and psychosis, and a stronger association for daily use. Media reporting has focussed on this figure of 24% new cases of psychosis related to skunk. The study has calculated this as a population attributable fraction. This means that if you eliminated skunk from the population of South London, you would prevent almost a quarter of first episode psychosis cases in this area. However, this would be unlikely to be the same for Cardiff or the Scottish Highlands.

Conclusions about cannabis and psychosis
With the research evidence we have to date, we can conclude:
– Cannabis and psychosis are strongly associated
– Cannabis has a dose-related association with psychosis – i.e. the more you smoke and the more potent the cannabis, the more like you are to have psychosis
– If we eliminated all cannabis, we would significantly reduce psychosis

This is obviously just the tip of the iceberg. We have not considered how cannabis affects people who already have a diagnosis of psychosis. We also haven’t looked into what influence other drugs might have on the illness.

As my role with Freudian Script is to look at fictional portrayals of mental health, we don’t see a lot of cannabis and psychosis. The amotivational and appetite-inducing side effects are well-covered, but the “stoner movie” subgenre focussses on the comedy not calamity associated with cannabis use.

What are your impressions of cannabis and psychosis? What does this research add to the public debate around drugs? Should Hollywood make more films about psychotic stoners? Let me know in the comments!