Horror Writers Association Blog

Depictions of Mental Health in Fiction by Edward P. Cardillo


The Importance of Getting It Right

“It’s okay, officers. I’ve got this.” Dr. Max Power, psychologist, cocked his shotgun as the police surrounding the dilapidated house parted, deferring to the hostage negotiator. He strolled up to the front door, opened it, and entered the house.

In the living room, he found the serial killer watching the live news coverage of the standoff, with a knife to a woman’s throat. “Back off! I’ll kill her! I swear!”

“Take it easy,” said Dr. Power. “I’m here to help.”

The serial killer pulled at his scraggly hair with his free hand. “It’s the voices, man. And the multiple personalities. And my OCD and ADHD. I can’t take it anymore.”

Dr. Power stroked his chin, thoughtful. “That’s fascinating. Tell me more.”

“I’m also experiencing derealization right now, man.”

“Let the woman go, and we’ll talk.” Dr. Power tensed, suddenly struck by a psychic vision. “I know about your childhood…about what you saw. Your parents were murdered right in front of you.”

The killer’s eyes bulged. “How did you know that? You couldn’t possibly have known that!”

Okay, that’s enough. What’s wrong with this scenario…other than everything?

Mental health is a popular subject matter in many works of psychological horror, true crime, and thriller genres, but many times the writer gets the details wrong…sometimes egregiously so. The above scene is an exaggeration of the point. Writers make mistakes, but what difference do a few inaccuracies make? Poetic license, right? While some readers may not notice, many others will, pulling them out of the story you want them to enjoy, making for sloppy writing.

So, how do you get it right? I’m sure you’re telling yourself, ‘Research.’ Sure, research is important, but what kind of research? Well, there’s the Internet…As you likely already know, there is a great deal of misinformation on the Internet, particularly about medicine and mental health. Remember that time you were sick and you looked up your symptoms, only to come to the conclusion that you had three days to live? Boy, were you relieved to find out from your physician that it was only a sinus infection. The truth is, anyone can post just about anything on the Internet posing as an “expert.”

If one can’t trust the Internet, where does one find accurate information about mental health professionals and various diagnoses? You happen to be in luck, as I’m a clinical psychologist. Here’s a head-start. Let’s start with mental health practitioners.

What we don’t do:

  • Wield firearms, blowing up entire city blocks to hunt serial killers
  • Use psychic visions to glean facts about individuals or portend the future
  • Jump into the middle of hostage negotiations because we were in the neighborhood
  • Sit in an armchair, clad in a smoking jacket while puffing on a pipe, listening to our patients talk about their problems
  • Just listen…being paid enormous fees to just listen, which in itself magically cures whatever troubles the patient
  • Treat friends or family
  • Romance our patients

What we are/actually do:

  • To be a licensed psychologist, one must typically earn a bachelor degree, masters, and a doctorate in the form of a Ph.D. or Psy.D., as well as pass a licensing exam after one year of post-doctoral supervision.
  • Work in a variety of settings, including schools, hospitals, nursing homes, colleges/universities, business organizations, prisons, and private practice. Our evaluations can serve a variety of purposes. In treatment settings, we evaluate for the purpose of diagnosis and treatment, as well as evaluation of capacity to make treatment decisions. In schools, we evaluate the educational needs of students, helping to allocate services to those who need them. In colleges, we can conduct vocational evaluations to help students identify areas of interest and corresponding careers. For the courts, we can evaluate competency to stand trial, serve as expert witnesses, or conduct court-mandated counseling (e.g. anger management).
  • A psychiatrist and psychologist are not synonymous. Psychiatrists are physicians with some training in mental health. While some practice talk therapy, all prescribe psychotropic medication. While psychologists have some training in anatomy, physiology, and psychopharmacology, most only practice talk therapy, except in those states that allow prescription privileges.
  • There are different schools of psychotherapy, such as psychodynamic therapy, behavior therapy, and cognitive-behavior therapy. Each has its own method of conceptualizing and treating disorders. Different graduate programs specialize in different types of psychotherapy, so you’ll want to make sure your character’s education matches their practice.

What about specific disorders and diagnoses? One just needs a psychology textbook, right? You have a friend who was a psychology major; she can help. That’s a good starting point, however, the textbooks only provide broad snapshots of diagnostic criteria. What about the fine details? What is it really like to be autistic or have PTSD? How do people present with these difficulties?

Ideally, if you want to obtain a wealth of detailed information about a particular diagnosis, you would want to speak to a psychologist who has experience in treating the disorder. Graduate programs in clinical psychology and medical schools are filled with professionals who both teach and work in treatment settings. Look up some programs in your area and ask around. All it takes is a phone call. Maybe set up a meeting where you can discuss your subject matter in detail.

You will also want to obtain case studies to gain details about a specific diagnosis and how it presents. There are books used for college level abnormal psychology classes containing case studies. Maybe there’s a biography written by someone living with the disorder of interest. Sometimes, there are support groups online that post case studies or testimonials, although I would exercise caution with any information found on the Internet regarding its validity.

Through these research methods, you might learn that autistics frequently also present with OCD and tic disorders, or that schizophrenia is not the same as diffusion identity disorder (i.e. multiple personalities). Schizophrenics are statistically non-violent. They’re more likely to experience auditory hallucinations rather than visual hallucinations. Those suffering with Parkinson’s disease may experience visual hallucinations of Lilliputian people climbing all over the furniture. You might learn someone disagreeing with you in an argument does not cause PTSD. Individuals with Down syndrome can hold jobs, belong to unions, be artists or acrobats, and even act in movies or write books.

Sometimes a person can present with multiple, related psychiatric or developmental disorders. However, only properly executed research will tell you which disorders can present together (comorbidity), and which typically do not. Don’t overdo it, giving your character so much mental illness that it is unrealistic and completely overwhelms who they are. Those suffering from mental illness are human beings. They are parents, siblings, spouses, children, grandparents. Many hold jobs, have hobbies, love someone and are loved. Introducing mental illness in a character, if not done correctly, can come across as gimmicky, or worse yet, incorrectly disparage a group. For example, I cannot tell you how many times I’ve heard about a prospective employer assuming a veteran applying for a job had PTSD or was homicidal or suicidal. This misperception is largely gleaned from inaccurate movie and television depictions of veterans. Inadequate research and relying on “rule of cool” will lead to you contributing to the vast ocean of misinformation floating out there. When depicting mental illness or developmental disorders in your work, you have a responsibility that goes beyond entertainment. Do not take it lightly.

So, why do it? In depicting mental illness or developmental disorders in your work, you have an opportunity to tap into the diversity of human experience. You can weave a touching tale of existential struggle and the overcoming of adversity. You can inspire others, and they can identify with your characters. In my zombie duology, The Creeping Dead (Severed Press), a character with Down syndrome becomes the heart and soul of the human resistance. The resilience of a community struck by a superstorm on the Jersey Shore was an homage to the real-life victims of Superstorm Sandy and how they came together as a community to rebuild and persevere. In The Odd Tales of an Old Man (J. Ellington Ashton Press), an autistic boy offers a unique perspective on family conflict and brings his family together. Readers either managing mental illness or a loved one with a developmental disability have told me they were touched by my characters. Others, suffering with various chronic medical conditions, tell me that my books have gotten them through some very rough patches in their lives.

As a writer who also happens to be a psychologist, nothing makes me happier.

EDWARD P. CARDILLO is a clinical psychologist working in geriatrics as well as with children, teens, and adults diagnosed with Down syndrome and autism spectrum disorders. Besides providing psychotherapy, he advocates for his patients, interacting with schools and various agencies on their behalf to help assure that their needs are appropriately met. An active, voting member of the Horror Writers Association, he also writes horror, science fiction, and dark fantasy for Severed Press and J. Ellington Ashton Press. He is the recipient of three Readers’ Favorite International Book Awards as well as J. Ellington Ashton Writer of the Year 2013 and JEA’s Fire and Ice Award 2015. He has two novels and one short story in the Facebook Zombie Book of the Month Club Hall of Fame. His novels The Creeping Dead” and I Am Automaton were both international best sellers on Amazon. He is a husband, father, painter, Dungeon Master, billiards enthusiast, and home brewer of beer.

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