INTERVIEW: Sara Barnard on Mental Health in YA and Beautiful Broken Things

In Freudian Script, we love to hear how authors tackle the accurate and sensitive portrayal of mental health problems in fiction. Sara Barnard, author of Young Adult novel Beautiful Broken Things, tells us her tale.

beautiful broken things cover

What led you to explore issues of mental health in Beautiful Broken Things?

I was interested in the aftermath of trauma and violence, and how these experiences can affect young people as they grow and develop. In a lot of cases, unfortunately, people recovering from past pain go on to struggle with their mental health. It struck me that we don’t see much of this in YA fiction – stories tend to focus on the traumatic event itself and not what comes next – and I wanted to change that in a very small way with the book I wrote.

I was also aware of how mental health is so often used as The Big Issue in YA, as if it is the defining feature of a character. So I wanted to also feature a character who had mental health issues that were incidental to the actual plot, to show that living with a condition like bipolar disorder – as Caddy’s older sister does – can be part of everyday life instead of a big drama.

There’s a lot of stigma around mental health. What do you think are the best ways to combat it?

I think fiction can be really important in this area – in books and on TV, we should be seeing truthful and authentic portrayals of a range of mental health issues. For many people, this will be the first (and sometimes only) time they are exposed to a particular mental health condition, so it’s important that it’s not one-dimensional or stereotypical. It also shouldn’t be used as a transparent plot device – this is one of my biggest bugbears with mental health in TV and books.

As a writer, would you recommend any particular films/TV shows/novels that do a good job of portraying mental health that other writers could use as inspiration?

Holly Bourne’s novel Am I Normal Yet? contains an amazing portrayal of a teenager struggling with OCD. She’s in recovery but is fearful of relapsing – this is also something we don’t see enough of in books or on TV.

What would you like to see more of in terms of young adult characters?

It would be great to see a little more of characters living with conditions rather than a story being based entirely around them “discovering” they have a condition, if that makes sense. Mental health – and physical health – is about so much more than the initial diagnosis, and it would be nice to see a bit more of that reflected in fiction. Though I think we are getting better.

What one piece of advice would you give a person struggling with their mental health?

Talk to someone. That doesn’t have to mean in person, or even someone you know personally – those of us who struggle with mental health are very lucky in one important way, which is that we’re living in the age of the internet. Taking that first step of finding help can be as simple as opening a webpage.

And what advice would you give to writers looking to portray that struggle accurately and sensitively?

Ask! Again, the internet exists, so there’s a whole world of information available on so many aspects of mental health. Research is so important, but I also think that should be done with the character in mind, rather than as something separate from them. So rather than “How does bipolar disorder affect teenagers”, for example, it would be “How does bipolar disorder affect MY character, with this life and this family, with these character traits?” etc. Just like people in real life, a character doesn’t begin and end with their mental health. If you are true to the character and their struggle, it will follow naturally that the portrayal will be accurate and sensitive.

But having said that, I’d recommend finding a beta reader you trust to check your novel specifically to give you feedback on the mental health aspect.

sara-barnard-author Sara lives in Brighton and does all her best writing on trains. She loves books, book people and book things. She has been writing ever since she was too small to reach the “on” switch on the family Amstrad computer. She gets her love of words from her dad, who made sure she always had books to read and introduced her to the wonders of secondhand book shops at a young age.

Sara is inspired by what-ifs and people. She thinks sad books are good for the soul and happy books lift the heart. She hopes to write lots of books that do both. Beautiful Broken Things is her first book and a dream come true.

Freudian Script: Work-Life Balance

Another junior doctors’ strike, another blog post from me!

My theme, however, is one that is relevant to all professionals but particularly writers of all stripes. I am talking about the mythical work-life balance.

rock-balance What is work-life balance?

This term is most commonly used when talking about the proportion of life spent on employment compared to family, hobbies and rest. It is most often applied when talking about how jobs can be all-consuming and gradually take over your entire existence, like a life-sucking parasite. Ahem.

One of the reasons the junior doctors’ contract negotiation is so emotive is the discussion of Saturday working – is Saturday a normal working day or is it special? Retail jobs, for example, mainly consider Saturday a normal working day, as do the police. Professional jobs consider Saturday a non-office day in the main, but people may be working from home. Schools and childminders definitely consider Saturday a non-working day.

Writers do not enjoy such demarcation lines. Professional writers can write any time, any place – 3am on Sunday is the same as 10am on Tuesday. Meetings, studio commitments, and play rehearsals might occupy more conventional hours, but writing is 24/7.

For writers with day jobs, we are looking at the balance of work-life-workagain. Bank holiday weekend: three days dedicated to the family, or to the novel?

This is where a broader psychological framework may be helpful in understanding how balance can be achieved.

Mastery and Pleasure
When therapists look to rebuild a life ravaged by depression or another serious illness, they look to balance from the outset. If you are starting from a wide-open schedule with nothing in it but sleep and TV, filling your days can be daunting and anxiety-provoking.

The theory goes that what makes life fulfilling is not merely the pursuit of happiness, but the balance of mastery and pleasure. In plain English – we want to feel useful and we want to enjoy ourselves. You can’t have one without the other. Having a purpose for the day is equally important to having a good time.

Doing household chores is good for you. Taking a walk is good for you. Doing only one of those things without looking to the other isn’t going to lead to satisfaction and contentment. This is why many people get antsy at the end of a holiday.

The other problem is those lines between work and leisure time are increasingly blurred. When your smartphone can fetch your email at any time, and we rarely turn the things off, when are you not at work? Am I at dinner with my husband, or am I also answering my email, Whatsapping my friends, and checking the cricket score?

The current investment in mindfulness, both in healthcare and the wider public consciousness, is partly fuelled by our need to escape distractions. The idea is very simple: be completely in the moment. The execution is very difficult, however, unless you’re a practised yogi. Focussed on breathing and your immediate environment, acknowledging but not engaging with your worries and thoughts, is a powerful experience but not a template for life.

However, principles of mindfulness can carry over well to the everyday. How about this: concentrate on one thing at a time. For example, watch TV but don’t check your phone. Eat dinner, and don’t check your phone. Talk to your partner – and don’t check your phone.

(Aside – I am terrible at this. This blog post has taken me twice as long as it should because I CAN’T STOP CHECKING MY PHONE. Reminder to us all: the “Do Not Disturb” setting exists for a reason.)

Work-life balance in practice
So, how can you improve your work-life balance?

The answer is to look at your life and be honest about what parts are necessary features and what parts of it are bringing what benefits to you.

We have to sleep and we have to eat. We have to work to pay the bills, or have some other purposeful activity in our lives. We have to spend meaningful time relating to other people. We have to do things that we enjoy. These are the building blocks of life.

Here are some simple take-home tips:

Make an activity diary: Look at a week or two and see what you’re doing with your time. Are you spending two hours on Facebook because it’s bringing you joy or because there’s nothing else to do? Did you try to work on that screenplay but were distracted by that Tweet you sent three hours ago that’s had more favourites than you can shake a stick at? Prioritise the things you want and need most.

Recognise what you enjoy: I like going out to dinner, watching my favourite TV shows, practising yoga, reading books, and taking long hot baths. These activities are restorative. Your list probably looks completely different. Recognise these activities and use them to help yourself decompress.

Invest in relationships: You don’t have to spend all your time and energy on a person to have a good connection to them. Yet the time you do put into those relationships means you can rely on that support at more fallow times.

Turn off your phone: I’m not talking about a digital detox, because I think the idea is unsustainable and unrealistic. We need to adjust to having these always-on, always-connected devices in our lives. How important is it to be able to answer your email at any time? Can you afford to put your phone on silent for two hours?

The answer is probably yes. If it isn’t, maybe your work is actually a life-sucking parasite.

How do you strive towards a work-life balance? What strategies work best for you? Is the whole idea an impossible dream? Tell me in the comments!

Junior Doctors: Their Lives in Your Hands

2016-02-10 10.05.49
When I wrote my New Year post, I was ready to leap into frequent updates, including on the important topic of self-care for writers.

Then life happened.

As most of you know, in addition to being a screenwriter and novelist, I am also a junior doctor. On 3rd February, I started a new job as an Advanced Trainee in Psychiatry – also known as a Specialist Registrar, or a psychiatrist who is becoming more specialised in one particular field.

Medicine is a professional vocation that was once very popular, well thought of, and attractive to bright young things looking to make a difference. In many ways, it is still that – but it’s also becoming harder.

Let us count the ways:

Cuts to NHS funding
One of the first things you learn as a newly-qualified doctor is how to use the fax machine. As a twenty-something in 2010, I hadn’t the faintest idea why we were addicted to this technology, but we still cling to it. Since then, I have added to my repertoire: scanning reports, posting clinic letters, answering the telephone, manning reception, and fixing the photocopier.

When the photocopier ran out of ink before Christmas, we ran up the stairs several times a day to use the only other copier/printer in the building. No new ink arrived because our temporary admin had left and we had failed to hire another one. All other administrators were rushed off their feet, reduced in numbers by a third. Like our community nurses and social workers. Because we have to make yet more savings to our budget.

When I have time, I practice medicine. When there’s no one else to do it, I fix the photocopier.

A Considerate Employer?
Riddle me this: what job do you apply for without knowing where it is, what you’ll get paid and what hours you’ll work? Welcome to being a junior doctor.

I found out the location of my new job in November – an half-and-a-half drive from my new home. I found out what I was getting paid last week. I received my work duties for March yesterday.

When I got married in 2012, I had just started a new job. The medical staffing department in my new hospital couldn’t guarantee that I would have my wedding day off work, and refused to consider accommodating me.

When I finished my last job, I was meant to be working night duty. I would’ve finished work at 9am in one hospital and started at 9am in another. Without my friend’s generosity, I would’ve been scuppered.

Morale is low when your employer isn’t interested in you as a person.

A new contract
You will have read in the media that doctors are getting a pay rise and they’re after more money, the greedy so-and-sos. You may also have read that medics are “militant”, that doctors are ensorcelled by the BMA, and that you should Google your child’s rash (DO NOT DO THIS).

Many others have said this better than me, but I will say it again: if the government want an all-singing, all-dancing seven-day NHS (as opposed to the current seven-day NHS we have for urgent care, emergency care and hospital inpatients), they have to fund it. You cannot take the money for five days’ worth of doctors – and the actual doctors themselves – and spread them over seven days. You may get more doctors on the weekend, but you will necessarily have fewer doctors all the rest of the time.

And we need other professionals. We do not work in isolation. We need investment in allied health professionals – the nurses, social workers, physiotherapists, occupational therapists, psychologists, radiographers, porters and administrators. Or all those “extra” doctors will be pushing trolleys and fixing photocopiers.

How you can support us
Firstly, thank you for reading this post. Being better informed about the issue helps you to be a stronger ally.

Secondly, please support your doctors on the picket lines today. A packet of biscuits or a cup of tea is greatly appreciated, but a word of solidarity or a signature on a petition is even more valuable.

Thirdly, and perhaps most importantly, support doctors’ voices and challenge dangerous ideas about the NHS that are being spread by those in charge. There is a reason I write a disclaimer on my posts when I talk about mental health in fiction. There is a reason we have peer-reviewed scientific journals and not press releases from the Health Secretary. Be good internet citizens, and spread good information.

Thank you.

Hello 2016

Happy 2016! It’s that time of year again. The one in which I tell you about the exciting things that are happening in my writing life right now, and we can anticipate them with glee together.


New Amy Lane novels
The wait is almost over! Captcha Thief, book three in The Amy Lane Mysteries, will land on 4th February. And that’s not all! The fourth book in the series Terror 404 is due for publication in August.

As these will be out in paperback (paperback!), keep your eyes peeled for bookplates and swag and giveaways as the due date nears – the newsletter and Facebook Page are always the first to know.

If you can’t wait that long, check out the Amy Lane short story Car Hacker.

CrimeFest 2016
After the success of last year’s CrimeFest, I will be returning to Bristol this May to do more panels and sign aforementioned books. I’m really excited to part of this festival again and meet so many enthusiastic authors and readers.

Mental Health and Writing
Building on my work combating mental health stigma and #psywrite, I am going to be looking more this year at how writers can look after their own mental health and how awareness of how we tick as creatures can help us create better. Watch this space!

Coming Home
I am also delighted to finally be returning to my beloved Wales. My husband and I are moving back to Cardiff early this year, so I will be languishing in Culture Cymraeg for my future writing endeavours. Happy authors make for better books.

And Much, Much More
As always, there are a number of things I can’t shout about yet, but I look forward to sharing them with you this year.

2016 is going to be a thrilling ride. What are you looking forward to this year?

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!