Conjuring the ‘Insane’: Representations of

Mental Illness in Medical and Popular Discourses

Sathyaraj Venkatesan & Sweetha Saji

National Institute of Technology (Trichy), India

Representation, primarily understood as ‘presence’ or ‘appearance’ with an implied visual component, is a critical concept in the cultural milieu. Conceived as images, performances, and imitations, representations propagate through various media: films, television, photographs, advertisements, and other forms of popular culture. As such, representations of mental illness perform a pivotal role in framing perceptions about the mentally ill. These representations influence and shape public perceptions about the illness. This essay aims to analyze how mental illness is perceived, represented, and treated in popular culture and medical discourses. In so doing, the essay lays bare the ideologies and the symbolic codes that undergird these representations and the consequent stigma confronted by the mentally ill. Taking these cues, the essay close reads popular representations of mental illness in movies, newspapers, advertisements, comics, and paintings and the articulation of stereotyped images of the mentally ill in a medical discourse which externalize madness in distorted physiognomic features. In so doing, the essay exposes the negative implications of these representations on the personal and social lives of the mentally ill and negotiates the significance of personal accounts of mental illness experience as a means of reclaiming their identity.

Keywords: Media, mental illness, metaphors, representation, stigma

“The selection of a specific representational system is related

to the entity described but is not interchangeable with that entity.

It is the means by which the observer can order his perception of reality.”

--Seeing the Insane Sander Gilman

“And I have known the eyes already, known them all—

The eyes that fix you in a formulated phrase,

And when I am formulated, sprawling on a pin,

When I am pinned and wriggling on the wall,

Then how should I begin

To spit out all the butt-ends of my days and ways?

And how should I presume?”

--“The Love Song of J. Alfred Prufrock” T. S. Eliot

Representation, primarily understood as ‘presence’ or ‘appearance’ with an implied visual component, is a critical concept in the cultural milieu. Conceived as “clear images, material reproductions, performances, and simulations” (Baldonado, 2017), representations propagate through various media: films, television, photographs, advertisements, and other forms of popular culture. In Picture Theory, W. J. T. Mitchell elaborates the function of representation thus: “representation (in memory, in verbal descriptions, in images) not only ‘mediates’ our knowledge (of slavery and many other things), but obstructs fragments, and negates that knowledge” (p. 188). In other words, representation does not only mediate the knowledge we consume; it also affects knowledge through fragmenting and negating the knowledge. Thus, representation constructs knowledge. Second, Mitchell resists the notion of representations as particular kinds of objects. Instead, he treats them “as relationship, a process, as the relay mechanism in exchanges of power, value, and publicity” (420). Mitchell’s model proposes an approach to representation with an eye toward the relationships and processes through which representations are produced, valued, and exchanged. As such, Andrew Edgar and Peter Sedgwick in Key Concepts in Cultural Theory characterizes ‘representation’ as “the ‘presentation’ or construction of identity [which] may be closely allied to questions of ideology and power, and to the forms of discourse implicated in the procedures whereby such images are created” (p. 225). In a similar vein, Ella Shohat (1995) poses some fundamental questions on the nature of representations and the ideologies that frame them: “[e]ach filmic or academic utterance must be analyzed not only in terms of who represents but also in terms of who is being represented for what purpose, at which historical moment, for which location, using which strategies, and in what tone of address.” (p. 173).

Shohat’s questions on the ideological framework that determines the nature of representations also lay bare the politics of representation. Rather than perceiving representations as “harmless likenesses” (Baldonado, 2017), they must be analyzed for how they impact perceptions. Stuart Hall addresses the politics of representation in Representation: Cultural Representations and Signifying Practices in that he approaches representation as to the medium or channel through which production of meaning happens. He assumes that objects or people do not have stable, true meanings, but rather that the meanings are produced by participants in a culture, who have the power to signify something (p. 19). Clearly, for Hall, representation involves understanding how language and systems of knowledge production work together to produce and circulate meanings. Representation becomes the process or channel through which these meanings are both created and reified.

As such, abuse of the power of representation can be observed in several socio-cultural phenomena, especially in the context of AIDS in the 1980s and slavery during colonialism. Nancy L Roth and Katy Hogan in Gendered Epidemic: Representations of Women in the Age of AIDS (1998) explore the representations of AIDS in mainstream and medical discourse along these lines. As such, they cite several mainstream media and medical news reports which represent AIDS as “a new mystery disease plaguing gay men”; “epidemic of immune deficiency” and the plight of “hemophiliacs and infants, the ‘innocent victims’ of the epidemic” (p. 115). They underline the role of perspective or framing in the production of negative representations of illness based on “media frames” theory of Hall. In so doing, they seek to explain how “hegemonic discourse selects, orders, or excludes certain versions of reality in its effort to organize the world according to its purposes” (Roth &Hogan, 1998, p. 136).

Paula A. Treichler (2006) questions the correspondence that is presumed to exist between “the representation of [AIDS] virus and its reality” by examining the features of culture that determine the form in which reality is constructed and the “role of language in articulation and popularizing a particular construction” (p. 151). Treichler (2006) observes that by 1986, the major newsmagazines in the US were running the cover stories on “the grave danger that AIDS posed to heterosexuals” (p. 18). As such, representations of AIDS as a ‘gay disease’ in news magazines, televisions, and posters in a way not only protects “sexual practices of heterosexuality but also heterosexuality’s ideological superiority” (Treichler, 2006, pp. 22-23). These ideological tools were operated in subtle ways of visual representations of AIDS in popular magazines. The severity of the epidemic was heightened by a shift from images of gay men with their arms entwined, aloof gay man in a backlit apartment, and prostitutes in red working the streets at night to nuclear families, “innocent victims” and middle-American patriots who were at ‘risk.’ For instance, the July 1985 issue of Life magazine contributed a distinct iconography of the epidemic that suggests this shift. As Treichler (2006) observes:

In living color, photographs of people with AIDS stared out at the reader: an African-American soldier in uniform, saluting; the Burks, a white all-American nuclear family (father, mother, daughter, baby-son); and an attractive young blonde woman. In bold red letters, the cover warned that “NOW NO ONE IS SAFE FROM AIDS.” . . . The cover illustration made visual the magazine’s position: “AIDS is a problem for all.” An effort was made, in other words, to articulate AIDS to important elements of liberal democracy—we’re all equal, we’re in this together, we are family—and to freight the “faces of AIDS” on the cover. (pp. 75-76)

Representations, thus act as ideological tools of interpretation that control perceptions about the marginalized who do not hold power over their representations. Stereotyped representations of Africans served as ideological tools supporting colonialism and slavery. Moreover, they served to justify racial difference, segregation and protected the freedom that white supremacists enjoyed. European representations of Africa and its people as ‘dark,’ ‘savage,’ and ‘violent,’ perpetuated a perverse opposite to its ‘civilized’ life, thereby maintaining European superiority as self-evident. Edward Said, in his analysis of textual representations of the Orient in Orientalism(2000), proposes that representations cannot be realistic:

In any instance of at least written language, there is no such thing as a delivered presence, but a re-presence, or a representation. The value, efficacy, strength, apparent veracity of a written statement about the Orient, therefore, relies very little on, and cannot instrumentally depend, on the Orient as such. (p. 88)

Said dispels the objectivity claimed by European representations of Africa as constructed images interspersed with clear ideological content.

Similarly, representations of mental illness perform a pivotal role in framing perceptions about the mentally ill. These representations are not devoid of meaning and hence influence and shape public perceptions about the illness. Sensationalized images of the mentally ill, for instance, leads to stereotyping of mental illness as a disease of deviance contributing to the stigma that negatively impacts those who experience the travails of the illness. Ato Quayson (2007) in “Aesthetic Nervousness” argues that “the representation of disability oscillates uneasily between the aesthetic and the ethical domains” and that the disability representation “from the perspective of the disabled” is crucially distinct “from the normative position of the nondisabled” (p. 205). Worse still, scientific accounts of mental illness are also not productively equipped to dismantle misconceptions; instead, they concentrate on symptoms over the lived experience of the patients as individuals. As Gilman rightly comments on the negative visualizations of madness in medicine and popular art in Seeing the Insane, our understanding of the mentally ill is predicated on “the continued presence in society of older images of the insane, images that overtly or covertly color our concept and serve to categorize them upon first glance” (1982, p. iii). As these mediations of madness can be copied or reproduced, their accessibility increases on a mass level and gradually leading to its legitimization.

This essay aims to analyze how mental illness is perceived, represented, and treated in popular culture and medical discourses. In so doing, the essay lays bare the ideologies and the symbolic codes that undergird these representations and the consequent stigma confronted by the mentally ill. Although ‘popular culture’ is interpreted as “the culture that appeals to, or that is most comprehensible by, the general public,” the term is used frequently “either to identify a form of culture that is opposed to another form, or as a synonym or complement to that other form” (Edgar & Sedgwick, 2005, pp. 190-191). As such, popular culture may refer either to “individual artefacts (often treated as texts) such as a popular song or a television programme, or to a group’s lifestyle (and thus to the pattern of artefacts, practices and understandings that serve to establish the group’s distinctive identity)” (p. 191). Taking these cues, the essay close reads popular representations of mental illness (such as schizophrenia and bipolar disorder) in movies, newspapers, advertisements, comics, and paintings and the articulation of stereotyped images of the mentally ill in a medical discourse which externalize madness in distorted physiognomic features. In so doing, the essay exposes the negative implications of these representations on the personal and social lives of the mentally ill.

Mental Illness: Definitions and Perspectives

Psychiatry, one of the oldest of the medical specialties in the treatment of the mentally ill, grew into prominence by the dawn of modern science and during the Enlightenment. Grounded on scientific postulates, psychiatry followed the method of investigation with clear and detailed case descriptions and objectives. However, the influence of the Enlightenment ideals, which emphasized the value of dignity and individuality of the human being led to the inclusion of a variety of psychotherapeutic techniques personalizing the care to the individual’s needs. In such an amalgamation of the benefits of modern science with the philosophy of the Enlightenment, psychiatry gained a moral grounding that it strived to maintain. By the rise of Freudian psychoanalysis as an alternative approach to mentalscapes in the mid-twentieth century, psychiatry was challenged with its declining emphasis on observable signs and symptoms. Psychoanalysis in general, focussed on intrapsychic conflicts over diagnosis and classifications. As a response to this critical turn, the American Psychiatric Association (APA) codified various psychiatric disorders in the Diagnostic and Statistical Manual of Mental Disorders (DSM). Although the DSM existed before the rise of psychoanalysis, it was in 1980 that the APA initiated the need for a definition of mental disorders in the third edition of the DSM. Aimed at maximum reliability and validity, DSM-III and its revised fourth edition gradually became “universally and uncritically accepted as the ultimate authority on psychopathology and diagnosis” (Andreasen, 2007, p. 111). Mental illness, as given in the DSM, refers to the spectrum of cognition, emotions, and behaviors that interfere with interpersonal relationships as well as familial and societal functions (Johnstone, 2001). As such, the DSM is still commonly recognized as the ‘psychiatric bible.’

However, this codification aimed at defending psychiatry’s scientific status had a dehumanizing impact. In being reduced to mere checklists, clinicians who frequented the DSM as a toolkit failed to approach patients as individuals. The immediate requirement of codified data was fulfilled at the cost of comprehensive descriptions that addressed patient needs. Moreover, certain categories of mental disorders listed in the DSM were not tested for validity. Also, taking into account the different forms of interference caused by mental illness in an individual’s daily functioning, a study by Hardcastle and Hardcastle (2003) revealed that 30% of all general practitioner consultations involved mental illness. They also reported that one in four people is prone to mental illness at some time in her or his life. Adding to this crisis, as Horgan (2013) remarks, unlike “definitions of ischemic heart disease, lymphoma, or AIDS, the DSM diagnoses are based on a consensus about clusters of clinical symptoms, not any objective laboratory measure.” In the absence of a valid theoretical basis for drug treatment, the mentally ill are often over-medicated and given prescriptions based on assumptions.

In the subsequent editions of the DSM, alternative perspectives from social, cultural, political dimensions were regarded as significant prerequisites accompanying the characteristic symptoms of a particular diagnosis. These additional aspects of diagnosis were aimed at developing clinicians’ sensitivity to the patients’ resilience and personal experiences over their perceived deficits. The latest edition of the DSM (DSM-5) has created a common lexicon used by psychiatrists and mental health care providers in the diagnosis of mental disorders. Evolved as a comprehensive guide to understand the nuances of living with and perceiving mental disorders, the DSM-5 takes into account both clinical and cultural symptoms in determining the diagnosis. As such, the manual provides a list of factors and interview questions in terms of race, ethnicity, language, religion, social customs, geographical origins, etc. in reckoning a patient’s illness experience. Further, it also devotes distinct chapters on personal stories of mental illness, thus validating the significance of cultural background and unique personal traits alongside objective symptoms.

Subject to a range of revisions in four preceding editions and a review process made public through a website www.DSM-5.org, the current revision process was labelled as more open and democratic. In rectifying several limitations of the previous edition (DSM-IV), DSM-5 strived toward a more dynamic concept of culture. DSM-IV had de-emphasized the significance of social contexts and depicted “culture as residing largely within individuals” (Lopez and Guarnaccia, 2000, p. 574). Most definitions also tend to portray culture as a static phenomenon and do not clarify how individuals negotiate various cultural spheres. In this context, the revisions in DSM-5 was lauded for its inclusivity and broadness. For instance, DSM-5 deeply elaborates how culture should be understood:

Culture refers to systems of knowledge, concepts, rules, and practices that are learned and transmitted across generations. Culture includes language, religion and spirituality, family structures, life-cycle stages, ceremonial rituals, and customs, as well as moral and legal systems. . . These features of culture make it crucial not to overgeneralize cultural information or stereotype groups in terms of fixed cultural traits. (American Psychiatric Association, 2013a, p. 749)

As such, the APA has commented that its fifth edition “incorporates a greater cultural sensitivity throughout the manual” (as cited in Bredström, 2017). However, the manual tends to be read as a representative voice of authoritative musings on mental illness and is accepted globally as the rule book for diagnosing mental disorders. Despite these claims, there are prevailing criticisms against DSM-5 as a “fiction” which medicalize human experience.¹ Gary Greenberg in his The Book of Woe: The DSM and the Unmaking of Psychiatry argue that “by imposing a pseudoscientific model of our ‘hopelessly complex’ inner world, it creates a ‘charade’ of non-existent disorders” (as cited in Hicks, 2013). Critiqued for its over-diagnosis and over-treatment, even psychiatrists admit that the DSM is flawed.

Moreover, the latest edition of the DSM, which claims to be more inclusive of sociocultural contexts and the distinctions across ethnic boundaries risks being relevant only for some patients. The latest edition still subscribes to static notions of culture by specifying certain symptoms as ‘universal’ and others as ‘culturally specific expressions.’ For instance, in case of panic attacks, “uncontrollable crying and headaches” were listed as culturally specific while “difficulty breathing” was listed as the primary/universal symptom (American Psychiatric Association 2013b).

In this context, Foucault’s genealogical perspectives on mental illness and institutions align with the voice of the vulnerable subjects in the clinical equation even in contemporary clinical settings. Foucault analyses how society conceived the defining attributes of the mentally ill throughout history in his seminal book Madness and Civilization: A History of Insanity in the Age of Reason (1965). Focusing on the Renaissance to the twentieth century, Foucault observes that the figure of the ‘madman’ had shifted from being an insider to an outsider from society. Consequently, the ‘insane’ became an outcast who must be confined, studied, and treated as a medical object. As part of this historical evolution, asylums were established, which were meant to discipline the subject kept under the supervision and authority of the doctor. Later, with the intervention of positivist concerns in medicine and psychiatry, these regiments of power operated in less visible forms. Even in the contemporary medical discourse, symptomatic and categorical prescriptions on mental illness naturalize the authority of medical voice over multiple expressions of the illness experience. For instance, Foucault’s (1965) view of madness as “a reification of a magical nature” (p. 276) which implies the translation of a concept into an object correlate with objectives of modern psychiatry. As such, madness is not treated as an abstraction that can be used to make sense of reality, but as a biological reality that in reductive terms awaits clinical detection. The DSM-based diagnoses, in particular, ratify such reification as recent studies observe that diagnostic categories of the DSM are “nothing but conventional groupings of symptoms” (Vanheule, 2014). Umbrella terms used to designate a collection of symptoms, thus get popularized as disease conditions that cause these symptoms, consequently affecting laymen and blinding professionals towards the subjective dimensions of mental illness.

The Stigma of Mental Illness

The history of diagnoses and treatment of the mentally ill reveals a range of practices and beliefs that centered on the autonomy of the healer and the vulnerability of the patient whose identity across centuries shifted from being an insider to an outcast lodged in isolated asylums. In the Middle Ages, the mentally ill were considered to have been possessed by evil spirits, thus trapped in a supernatural phenomenon. Such perceptions led to bizarre treatment methods like trephining, a treatment procedure which included chipping a hole or trephine into the skull to create an opening that would release evil spirits and thus cure the person’s illness. In many cultures, mental illness is perceived as divine punishment imposed on a person who sinned against God and, therefore, as something an individual had imposed on himself.

Consequently, the mentally ill were treated with religious rituals to drive out evil spirits and included exorcisms, incantations, and prayer. Also, the perception of the mentally ill as morally weak resulted in them being jailed as criminals and often put to death (Corrigan& Watson, 2002). Through time, individuals with mental illness were metaphorically described as ‘wild beasts’ that needed to be confined. The belief about mental illness was later altered by the Greek physician Hippocrates, who rejected the supernatural perspectives about mental illness and argued that psychological symptoms have natural causes, just like physical symptoms. Institutions like the Bethlem Hospital that isolated the “insane” in the thirteenth century, to the Salpêtrière Hospital that was built in the seventeenth century, grew in number and sophistication. The close of the eighteenth century witnessed paradigm shifts regarding mental illness in parts of Europe. ‘Mad-houses’ where the ‘violent’ and ‘dangerous’ were accommodated changed to ‘asylums’ where the mentally ill could be treated and brought back as functional individuals in society (“History of Mental Illness”).

Several studies (Crisp, Gelder, Rix, Meltzer et al., 2000; Bryne, 1997; Heginbotham, 1998) have demonstrated how those with mental illness still suffer from social and perceived stigma. Psychiatric labels that discriminate the mentally ill from the rest of the society causes social stigma, characterized by prejudicial attitudes and discriminating behavior. On the other hand, when the sufferers of discrimination internalize the feelings of shame, it is referred to as perceived stigma or self-stigma, leading to poorer treatment outcomes (Perlick et al., 2001). Etymologically, the word ‘stigma’ comes from the Greek word ‘stigmata’ which refers to “a mark of shame or discredit; a stain, or an identifying mark or characteristic” (Merriam-Webster Dictionary). About mental illness, stigma is a multifaceted construct that involves attitudes, behaviors, and feelings. It is “a collection of negative attitudes, beliefs, thoughts, and behaviors that inﬂuences the individual, or the general public, to fear, reject, avoid, be prejudiced, and discriminate against people with mental disorders” (Gary, 2005, p. 980). Moreover, stigma acts as a mediating process which legitimizes and normalizes discrimination and violence against people suffering from mental illness. Surveys conducted among the general public demonstrate that most people approached the mentally ill with caution and presumed that they were generally hard to talk to. Such negative impressions often persist in people across cultures despite most of them being aware of the travails of mental illness through witnessing the illness condition in close familial and social circles. More recent studies (Wang & Lai, 2008; Reavley & Jorm, 2011) reveal that a significant proportion of the public considered that people with mental illnesses such as depression or schizophrenia were unpredictable, dangerous and they would be less likely to employ someone with a mental health problem. In an initiative of the Scattergood Foundation, general stereotypes of the sort are studied and addressed based on statistical facts. In response to the predominant stereotype about the mentally ill as dangerous and violent, they remarked:

Most people with mental illness never commit acts of violence and are more likely than others to be victims of violence. The reality is that people who do not have mental health conditions commit most violent crimes. In fact, according to data from the National Epidemiologic Survey on Alcohol and Related Conditions, only 3% of people with mental illness are violent. That means 97% of people with mental illness are not violent. (Scattergood Foundation, 2018).

The mentally ill are labeled as deviants by society; as dysfunctional individuals in the framework of society. Becker (1963) remarks, “[s]ocial groups create deviance by making the rules when infraction constitutes deviance and by applying their rules to particular people and labeling them as outsiders” (p. 9). As the mentally ill inhabit an alternate reality, it is assumed that they are naturally bound to break the rules of a particular society. Ironically, the understanding of what constitutes ‘abnormality’ differs from one society to another; in other words, what is abnormal for one society or culture may be normal for another. However, Kleinman (2009) argues that mental health professionals themselves, family members, and sufferers are often the most effective and efficient transmitters of stigma due to factors such as poor conditions of care and social/financial burdens of care (p. 603). Stigma in psychiatric institutions enables serious abuse of the mentally ill as evidenced in several studies: use of “unmodiﬁed electroconvulsive therapy”; violence, including sexual violence: “Against adults and children…by staff or fellow patients” (Patel, Kleinman, and Saraceno, 2012, p. 367). Furthermore, seclusion and isolation, as well as passivization and inactivity of patients in psychiatric institutions, amplify the obstacles to patients’ subsequent participation in the ordinary life and everyday social experience (Patel, Kleinman, and Saraceno, 2012).

Medical Discourse and the Stigma of Mental Illness

The field of biomedicine is not immune to popular beliefs about mental illness. According to Corrigan & Watson (2002) and Hugo (2001), most mental health professionals also subscribe to negative stereotypes about mental illness. Statistical surveys conducted as part of their study has revealed that medical professional groups were less optimistic about prognosis and long-term outcomes in this regard. Ironically, the approach of the general public towards the mentally ill is much healthier as they at least acknowledge the individuality and identity of the sufferer. People with mental illness commonly report “feeling devalued, dismissed, and dehumanized” by many of the health professionals who treat them. Such stigmatizing experiences include “feeling excluded from decisions, receiving subtle or overt threats of coercive treatment, being made to wait excessively long when seeking help, being given insufficient information about one’s condition or treatment options, being treated in a paternalistic or demeaning manner, being told they would never get well, and being spoken to or about using stigmatizing language” (Knaak, Mantler & Szeto, 2017). The dehumanizing approach of mental health professionals not only contributes to the stigma (Penn & Martin, 1998) but also result in worsening the condition of the ill (Sadow et al., 2002).

Although inhuman treatment practices in asylums could be linked to the cultural factors that shaped physicians’ prejudice towards the mentally ill as impassive exiles from a ‘normal,’ functional society, the typology of illustrated histories of medicine legitimized such attitudes. Sander Gilman, in his seminal investigation of the illustrated histories of mental illness, traces several examples that reflected the cultural history of madness and legitimized its claims in academic psychiatry. Gilman in Seeing the Insane (1982) and Picturing Health and Illness: Images of Identity and Difference (1995) critically examines visual representations of the mentally ill across centuries as “cultural fantasies of health, disease, and the body” (1995, p. 18). Gilman unveils the selection and editing involved in choosing visual representations of the mentally ill and claims that the use of pictures in medical texts cannot be deemed as naïve but highly manipulative. The overarching claim of these representations, Gilman argues, is that there is no internal reality to be examined, only the external world internalized and represented in art (1995, p. 19). Irrespective of the medium—illustrations or photographs—these visual representations emphasized the need for the psychiatrists to see the patient and his/her signs and symptoms as the key to diagnosis. Intriguingly, such medical iconography was not distinct from the presumptions of madness in the general iconography of Western representational art. As such, the field of psychiatry was obsessed with creating a visual epistemology from which the subjectivity of the patient was completely absent. As Gilman (2011) observes:

Picturing is moved from being an individual act in a historical context to that of the collective, self-labeled as “scientists” without much consideration to the mechanisms present. . . . It is, as Peter Novick argued decades ago, the creation of an academic notion of the subjectivity out of the subjectivity of the historical agent.

As such, these visual representations control medical perceptions of the mentally ill binding the general misconceptions and anxieties about madness. Most representations followed the beauty/ugly binary based on the patient’s physiognomic features. By the close of the eighteenth century, the association of madness with specific physiognomy had become commonplace in European thought. Although Phillipe Pinel is highly regarded for introducing humane treatment and reform in French asylums, he is also instrumental in altering perspectives on psychopathology. In his Treatise on Insanity (1801), Pinel included two images comparing the shape of the skull of two patients. The analysis further developed to include comparisons with the ideal proportions of Greek sculpture, thus measuring the physiognomy of the mentally ill on the plane of aesthetic perceptions (Gilman, 2014, p. 73).

Moreover, such perceptions even led various psychiatrists to propose comparisons with the physiognomy of animals to perceive the mental status of their patients and to distinguish them from the ideal structure of a normal person. For instance, August Krauss’ table of animal analogs demonstrates how madness was perceived in terms of patient’s physiognomic features. Hidden implications of such parallels drawn between physiognomic ugliness and mental impairment connote to the construction of categories of beauty/health and ugliness/illness. These essential categories may cater to the aesthetics of a particular group or class as well as specific individual aesthetics of the time. Here, Krauss’ question of physiognomy and the features of the various breeds of horse could be read as encoded in the cultural ethos of science in the nineteenth century. In this context, Gilman (2011) rightly comments on the necessity to keenly observe the nuanced braiding of the public and private reveries of mental illness thus:

The role of the study of medical (in the broadest sense) representations, or perhaps better, images of health and illness and their attendant social and cultural settings need to be addressed. The function of representations and those trained to study and analyze them in the history of medicine is to knit the function of public and private representations with the continuities and discontinuities in attitudes and beliefs both within and beyond the health sciences.

These prejudiced manifestations of the mentally ill not only affect the physician’s attitude towards the mentally ill but also precipitate negative metaphors in the cultural discourse on mental illness.

Representation of Mental Illness in Popular Culture

As in medical discourse, a tendency to visualize mental illness also exists within art and popular culture. A careful analysis of the history of visual representations of the mentally ill reveals a set of repeated, stereotyped ideas/images from the 16^th century to contemporary popular culture. Cumulatively, these representations of the mentally ill reflect the dominant attitudes and behaviors towards them, that is, a constant fear of the Other. Further, they also reinforce the presumed boundaries between normal and abnormal. The stereotypical cultural representation of the diseased body and its psychological manifestation as a dangerous ‘other’ is reflected in illness discourses across time.

In making a clear distinction between the ill and the healthy, several representations in art also characterize the mentally ill as animals devoid of human qualities. As Foucault remarks, “madness had become a thing to look at: no longer a monster inside oneself, but an animal with strange mechanisms, a bestiality from which man had long since been suppressed” (2005, p. 66). Foucault’s observation unveils the predominant cultural logic of considering the “mad” as a beast which must be confined and controlled. One of the earliest examples of metaphorizing madness as animalistic is reflected in Charles Bell’s Madman (1806). The image reflects the larger cultural anxiety of not being able to identify with a person with mental illness and feeds the desire to alienate them from the ‘normal’ society. The ‘madman’s’ glance directed away from the readers characterized by indignant gestures, suggests unpredictability and impending danger. Like an untamed animal, the ‘madman’ is chained and left naked. Interestingly, the image reciprocates the predominant middle age fantasies about madness. Such persistent notions about the mentally ill reflect the cultural preoccupations of controlling and taming the undesirable—other inconspicuous ways despite centuries of evolved scientific and cultural perceptions about mental illness.

Sensationalisation and stigmatization of mental illness are also evident in popular media representations. Perpetuating stereotypes and capitalizing on the increased anxiety, several negative and inaccurate portrayals of mental illness influence the public perception of mental illness. Most movies deploy illness as a trope of violence and crime. Scary and dangerous slashers suffer from psychosis. Alfred Hitchcock’s Psycho (1960), for instance, features Anthony Perkins as Norman Bates who kills a female motel guest. The scene of the murder captures the gruesome details of the slashing and the helplessness of the female victim, Marion, enacted by Janet Leigh. Norman Bates is not identified as a mental patient until the end of the film when a psychiatrist explains the origins of his bizarre behavior. Since Psycho, slasher movies which peaked in popularity in the late 1970s and continue through the 1980s and beyond improvise the same theme. The elements of violence and fear are exaggerated with dramatic special effects in these movies. Otto F. Wahl in Media Madness: Public Images of Mental Illness observes that mentally ill characters in movies and different television shows were more likely to be undeniably violent villains. The adjectives that best describe the mentally ill in these representations were “active,” “confused,” “aggressive,” “dangerous” and “unpredictable” (Wahl, 2003, p. 66).

Several studies (Wahl, Wood, Zaveri, Drapalski, & Mann, 2003; Wilson et al., 2000) have also shown that portrayals of the mentally ill in popular movies are mostly negative and thus perpetuate stereotypes about mental illness. Even in technical details such as framing and point of view, these representations convey that the mentally ill are different from other characters. Moreover, pejorative terms such as “crazy,” “psycho,” “deranged,” and “loony” are often used by other characters to refer to the mentally ill (Goldstein, 1979; Wahl, Wood, Zaveri, Drapalski, & Mann, 2003; Wilson et al., 2000). Apart from Psycho, many films such as Miloš Forman’s One Flew Over the Cuckoo’s Nest (1975), and Tony Bill’s Crazy People (1990) exploit such terms to intrigue and entertain the viewer. The characters themselves are often portrayed with distinctive and unattractive features like rotting teeth or unruly hair (Wilson et al., 2000). In exploring television images of madness, Simon Cross studies “Whose Mind is it Anyway” a British television show, which aims to present the implications of releasing mental patients from asylums. Each shot fully exploits the standard icons of dangerous insanity in the patient’s crooked facial expressions and disheveled appearances. The presenter explains to viewers that a “mentally disturbed man has been seen brandishing a knife at a local restaurant.” The next shot presents a police car with the siren sounding, moving at speed to catch the dangerously insane. Such negative images of violence and control permeate almost all filmic representations of the mentally ill. Films such as Bug (2006), Split (2016), and Bird Box (2018) also draw icons from the violent stereotype of madness. Jane Pirkis and others (2006) in “On-Screen Portrayals of Mental Illness: Extent, Nature, and Impacts” categorize such stereotypes from filmic representations thus: the homicidal maniac, the rebellious free spirit, the female patient as a seductress, the narcissistic parasite, and the zoo specimen (pp. 528-529). As such, these portrayals reduce the mentally ill to essentially negative categories. In a different vein, few filmic representations also perpetuate unscientific and unrealistic notions about mental illness and coping strategies. Silver Linings Playbook (2012), for instance, presents unrealistic ways of managing bipolar disorder. Although the first half of the movie bluntly portray the dysfunction of the characters and the travails of bipolar disorder on the family, it over-emphasizes an easy recovery when the two main characters engage in a romantic relationship. The Visit (2015) also inaccurately portray those with schizophrenia as struggling with murderous tendencies. The mentally ill characters in the movie are represented as inherently dangerous with odd behaviors, hallucinations, and paranoia.

Comics, “the only proximate medium of film” (Chute, 2010, p.221) is also not excluded from such negative/distorted images of mental illness. Alan Moore and Dave Gibbon’s Watchmen, for instance, presents characters like Rorschach, the Incredible Hulk, and David “Legion” Haller as victims of trauma and are often marginalized and socially excluded. Within such an environment, their mental health problems unsurprisingly worsen. “Rorschach is dismissed as paranoid and crazy by his fellow costumed adventurers, leading him to spiral downward until he believes violent murder to be the only viable option in his war on crime. The Hulk is ostracized for being a monster and becomes even more dangerous the more isolated he gets” (Langley, 2018). Similarly, Batman series also reinforces the violent stereotype of insanity in characters like Two-Face (split personality disorder) and The Joker (Psychopath) who set the standard for a typical villain in most comic books that followed. The New York Times published an article by psychiatrists H. Eric Bender, Praveen Kambam, and Vasilis Pozios in 2011 challenged the distorted representations of the mentally ill in DC comics:

[W]hen contemporary psychiatric terms or disorders have been used in stories; they have been misapplied to explain villainy. As Grant Morrison, a well-known comic author, wrote recently, “The rest of Batman’s rogues’ gallery personified various psychiatric disorders to great effect: Two-Face was schizophrenia.” But Two-Face’s central quality, a split personality, isn’t characteristic of schizophrenia. Similarly, the Joker is often called “psychotic,” despite a lack of hallucinations or other symptoms of a psychotic disorder. True, some say, “these are just comic books.” But such inaccuracies perpetuate harmful stereotypes.

Sensationalized media reports of real events also influence the public perception of the mentally ill. Research indicates that most news reports represent the mentally ill person as violent and criminal than benign or sympathetic (Wahl, 2003, p. 67). Along with the prevalent notion of the mentally ill as fundamentally flawed and evil rather than as an ill person, news reports frequently suggest that those with mental illness cannot be cured completely despite treatment. Catering to the common plot pattern of the mentally ill who are bent on terrorizing the innocent, these reports demonstrate the ineffectiveness of treatment for the mentally ill. For instance, newspaper reports like the one published in the New York Post on May 9, 1982, confirms the evidence that former patients will be prone to violence even after treatment. The catchy headline, “Freed Mental Patient Kills Mom” in bold capital letters provokes the readers to assume that those once labeled as mentally ill must be approached with caution. As such, the patients continue to experience the stigma of exclusion and violence throughout their lives, even after being medically cured.

Reports on the mentally ill as the dangerous Other and the deliberate use of phrases like “crazy” in describing them further reinforces the metaphors and stereotypes that dehumanize the mentally ill. In other words, such reiterated usages diminish the “credibility, trustworthiness, and value” of the person suffering from mental illness (Wahl et al. 2003, p. 559). Biased and sensationalized reports as such mislead the public by portraying the mentally ill as aggressive, dangerous, and unpredictable. Pamela Kalbfleisch (1979) studied newspaper homicide stories in the United States to observe recurrent patterns that these reports follow in making issues “newsworthy.” Accordingly, she identifies (i) insanity, (ii) unpredictability, and (iii) victimization of ordinary people as the three basic ingredients for a “top story.” Editors highlight stories with such features, for wider readership at the cost of the stigma that it precipitates towards the mentally ill.

On the contrary, a recent study by Marian Chen and Stephen Lawrie (2017) reveals that “only 5% of the homicides carried out in the general population between 2001 and 2011 were by those with an abnormal mental state” (p. 309). Also, it is found that those with a mental disorder are more inclined to self-harm than harm others. Despite these facts, news media perpetuates sensationalist notions about mental illness that dehumanize patients to the extent that they are defined by these presumed symptoms of their illness.

Additionally, these connotations of violence and unpredictability that are ascribed to mental illness are unrestrainedly followed in reporting other social issues as well. For instance, newspaper articles inappropriately utilize psychiatric terms to refer to those actions/people that it does not approve of. Wahl (2003) cites several examples from newspaper reports in which dictators like Saddam Hussein were repeatedly referred to as “madman” and “as crazy as Hitler” (p. 27). In a recent newspaper report published by Independent, the President of the United States, Donald Trump was referred to as a “psychopath” posing an “enormous present danger” (Kentish, 2017). Although Hussein, Hitler, or Trump are functional individuals who are in control of their faculties, their hostile and fanatical actions are impulsively connoted to mental instability. While subtly acknowledging that these men are not mentally ill, news reports such as these which passively use labels of mental illness without discretion as such discredit those suffering from the illness.

When media representations of mental illness present false perceptions, even medical definitions about mental illness may not serve the full purpose of redeeming the validity of one’s lived experience of illness. W.J.T. Mitchell, in a lecture titled “What, do Pictures Want” argues that madness, as represented in popular media, is not necessarily at the periphery of human experience. Departing from the symptomatic definitions of schizophrenia, Mitchell presents an alternate perspective about the illness which is unavailable in popular representations of schizophrenia. As such, he argues, “schizophrenia can be understood as an intensified form of normal mental activity of the work of reason, memory, and imagination spinning out of control; the perfectly ordinary process of inner vision and audition exaggerated so that fantasy take on a tactile and visceral reality” (Muzeum 2013). His deliberate choice of the words “normal,” “ordinary,” and “reality” reflects an attempt to free madness from its confinement in the discourse of medicine and popular culture as an abnormal and exotic abstraction.

Reinforced by different media representations, such dehumanized metaphors of violence and idiocy permeate into everyday language and slang words which connote to mental illness. As advertisements aim to attract the viewers’ attention, they often deploy slang terms and offensive images of mental illness. Especially, advertisements for peanuts engage in a wordplay on the double meaning of “nuts.” For instance, a particular peanut product was packed as a gift bag in a straightjacket labeled “Certifiably Nuts.” The package was branded with a “patient history,” stating that the owner’s family had been “nuts for generations.” Although tags such as these imply the quality of the product as time-tested, they subtly convey unscientific notions about hereditary links to mental illness (Davidson, 2018). Additionally, pulling a string attached to the peanut package would release hysterical laughter; a characteristic drawn from stereotyped representations of the mentally ill as idiotic. The product and the advertisement tags serve as metaphors of mental illness, which construe and perpetuate negative and stereotyped perceptions about those suffering from mental illness. Interestingly, the product even won the CLIO award for their innovative idea, which denotes the apathy of the advertisement industry to the plight of those with mental illness. Such deliberate use of psychiatric terminology in non-contextual fields not only conveys a lack of recognition of the sufferings of the mentally ill but also promotes distorted notions about the mentally ill in public.

Consistency in the negative representations of mental illness in advertisements further plays a major role in reinforcing the stereotyped perspectives on mental illness. Most visual representations of the mentally ill in advertisements emphasize distinctive physical features. Caricatured wild eyes and unkempt hair, in particular, are defining traits of the mentally ill in these portrayals. Such distinctions underscore the politics involved in the selection of images even though the reality of mental illness is varied and more human.

Abuses of Metaphors of Mental Illness

Although metaphors are often inconspicuously deployed in representations of illness, Elaine Scarry observes that metaphors do not merely function as rhetorical devices but as tools imbued with ideologies that configure popular perceptions about the illness. Scarry in The Body in Pain (1985) discusses how the experience of pain is articulated in language exclusively through metaphors of weaponry and damage (p. 15). Similarly, Susan Sontag (1991) in Illness as Metaphor traces metaphors that conceptualize disease as an “evil, invincible predator” (p. 7). Tracing several figurative uses of diseases as a metaphor for monstrosity and destructiveness in nineteenth-century literature, Sontag attempts to reveal its origin in social prejudices and stereotypes. Sontag (1991) clarifies how military metaphors “contribute to the stigmatizing of certain illnesses and by extension, of those who are ill” (p. 97). Especially in literary representations of diseases like cancer and TB, the predominant metaphors are that of war and invasion; to quote Sontag (1991), “[i]n TB, the person is ‘consumed,’ burned up. In cancer, the patient is ‘invaded’ by alien cells” (p. 14).

In the context of mental illness, popular media like movies and advertisements configure several metaphors as identified by Scarry and Sontag. Advertisements on mental health, for instance, often follow a tragedy narrative with sad faces in dim background and lighting which stereotype mental illnesses like depression as a uniform experience. Worse still are pharmaceutical advertisements where metaphors of sadness and gloom prevail until the patient is medicated with a particular drug. These advertisements portray medication as a sole method of dealing with mental illnesses. Accordingly, these advertisements reconfigure the background setting with metaphors of hope and happiness. For instance, S. E Smith (2011) refers to early advertisements on Prozac®, a drug used for treating depression, which features characters who engage in heavy-handed metaphors like opening the blinds to “let the sunshine in.” In averting the mental health condition, he observes, “[p]atients should just take a pill..... according to the narrative in pharmaceutical advertising, when the truth can be more complicated.” Such portrayals shadow the significance of mental support that friends and family could provide the mentally ill as a path to recovery, apart from medication.

Against such stereotyped representations of mental illness, Sue Estroff argues that mental illness cannot be reduced to an object; it is not “something that someone has, and that is external to whoever is experiencing it” (as cited in Vanthuyne,2003, p. 413). On the contrary, the experience of mental illness is “socially situated, individualized version of a body of cultural knowledge” (Vanthuyne, 2003, p. 413). However, the different cultural idioms and stereotypes that are hierarchically positioned within a network of power relationships constitute deleterious metaphors of mental illness which appropriate subjective experiences to popular expectations. The Peanut advertisement, horror movie posters, and Bill Lee’s cartoon discussed in this essay reveal how metaphors of violence and idiocy frame popular perceptions of mental illness. In a close analysis of these visual representations of mental illness across popular media, one becomes aware of the visual attributes and nuances that construct metaphoric meanings that have a deleterious impact on those suffering from the illness. In this context, Aristotle’s contention proves significant: “Metaphors, like epithets, must be fitting, which means they must fairly correspond to the thing signified: failing this, their inappropriateness will be conspicuous” (1984, p. 2240). Similarly, metaphors of mental illness that circulate in medical discourse through psychiatric idioms prevent the mentally ill and their community from exploring the diverse socio-political perspectives and singular experiences of living with mental illness.

Coda: Implications

The prejudices perpetuated towards the mentally ill and the stigma that it engenders determine the societal attitudes towards those suffering from mental illness. Patients are doubly challenged by the stereotypes that ensue from misconceptions about mental illness, apart from the physical and emotional quandaries of their illness experience. As such, representations that negatively portray the mentally ill would also shape the perspectives of professional and non-professional caregivers towards the mentally ill. Prejudiced assumptions about the illness would cause caregivers to disregard the individuality of patients or the distinct nature of the illness. In this context, the absence of personal accounts of illness or accurate representations of patients’ subjective reality, the mentally ill would be subject to systematic exclusion from civic and social life. Particularly, in policy-making and resource allocation, the mentally ill are denied of opportunities required for quality living ranging from satisfactory job and healthcare facilities to affiliation with a diverse group of people (Corrigan & Watson, 2002).

Furthermore, the representations of the mentally ill as violent and unpredictable in popular media have adverse effects on diverse domains of the patient’s life. Approached with caution and distrust, these individuals would continue to live with shame and guilt despite being cured of illness. As such, the label of mental illness, the exaggerated and grossly distorted representations of it and the self-stigma and public stigma induced by it subtly determine their intrasubjective and intersubjective realities.

Note

¹See Cherril Hicks’ “Dozens of mental disorders don’t exist” published in the wake of World Mental Health Day.

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Correspondence to: Sweetha Saji, Department of Humanities and Social Sciences, National Institute of Technology (NIT), Tiruchirappalli, Tamil Nadu, India.

Sathyaraj Venkatesan (Ph.D., the Indian Institute of Technology (IIT), Kanpur, 2008) is an Associate Professor of English in the Department of Humanities and Social Sciences at the National Institute of Technology, Tiruchirappalli, India. He was a Fellow at the School of Criticism and Theory at Cornell University, New York and currently, an International Field Bibliographer with the Publications of Modern Language Association of America (PMLA). His research interests include literature and medicine, graphic medicine, critical medical humanities.

Sweetha Saji is a PhD Research Scholar in the Department of Humanities and Social Sciences at the National Institute of Technology, Tiruchirappalli, India. Her research concentrates on Graphic Medicine and Medical Humanities.