Thursday, June 03, 2021

How to Include Mental Health Issues in Our Fiction

By Bethany Henry

Part of The How They Do It Series

JH: When writing about mental health issues, it's important to get it right. Bethany Henry shares eight tips on how to write about mental health in a healthy
and helpfulway.

Bethany Henry writes fantasy novels, and blogs about writing and wellness at When not writing, she can often be found on the frisbee field, drinking tea, or reading picture books with her two little girls. Sign up for her email list for weekly posts on writing craft—along with fun extras like quotes and freebies.  

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Take it away Bethany...

Historically, we writers haven’t always done a great job representing mental health issues. People living with mental health issues have been primarily portrayed in fiction as villains, shown through stereotypes, and/or described with inaccurate terms and implausible symptoms.

Writers should do better. We need to do better.

After all, with great power comes great responsibility. I learned that from a story, because you know what? Stories have power. And part of that power includes the responsibility to represent mental health issues well.

(Really, there’s a responsibility to represent all people well, but that is beyond the scope of this post. Here’s more with 7 Tips For Writing Across Cultures and Token or Broken? Writing LGBT*.)

When mental health issues are misrepresented, it can do more than pull a reader out of a story—it can lead to real-world harm.

Harmful stereotypes and inaccurate information can be easily internalized. What do you think happens when we primarily see people living with mental health issues cast as the evil villain? It doesn’t matter that in the real-world the huge majority of people living with mental health issues are far more likely to be victims of a violent crime than to commit one—we believe the stories over the facts.

Mental health issues may be more common than you think. Estimates show that approximately 1 in 5 Americans experience mental illness in a given year. Including mental illness in our stories is reflective of real life.

Especially since we often put our characters through traumatic experiences, which could increase the odds of them experiencing mental health issues such as PTSD, depression, anxiety, etc. Including these dynamics in our writing is realistic.

Perhaps most important of all, including accurate and respectful representation of individuals living with mental health issues is a way to help normalize these experiences, provide education, and reduce negative stigmas.

Representing mental health issues well can have a powerful and positive impact on our world.

This doesn’t mean we need to shoe-horn mental health issues into every corner of our stories. That’s not really very helpful or respectful, either. But if you choose to include mental health issues, be mindful about what you’re saying to your readers about those issues.

Here are eight considerations to think through when including mental health issues in our fiction:

1. Take Mental Health Seriously

Evaluate why and how we include these topics. It can be incredibly valuable, honest, and powerful to include mental health issues in our fiction.

However, it’s important to remember that mental illness is not a “quirk” or here for anyone’s amusement. It should never be used for comedic purposes, nor should it be used to add drama or “excitement.” Mental health issues should not be used as a convenient excuse each time we need our protagonist to do something out of character or to cause problems.

Mental illness is not a meaningless thing for us to play with.

We need to ensure we aren’t using mental health issues as a cheap thrill or easy and shallow plot device to manipulate at will. This overlooks the complex nature of mental illness and it disregards people’s real experiences.

Mental health issues can be a challenge for a character to face in a similar way physical health issues (or a myriad of other issues) could be seen as challenges. They are just another aspect of life.

For example, a character may experience anxiety which causes them to struggle in certain social situations, or they may experience depression which leads them to take medication to help stabilize their moods. These experiences can influence a character and be part of their character arc, but it doesn’t necessarily need to be the central part of the story.

Mental health issues can certainly play a role in the story’s overall plot, but should never be used as a gimmick.

2. Focus on the Person

A person is always a person—they are not a stereotype or a diagnosis.

Our character development should be more than slapping a label on them or making them a walking stereotype. Instead, our characters should be well thought out both in relation to any mental health issues as well as other components.

It can be easy to fall into harmful stereotypes without thinking. We go, sure, let’s just make the neglectful parent be diagnosed with depression and stay in bed all day—character development done. Yet this simply feeds into a negative and harmful stereotype! With a cultural history full of misrepresenting individuals with mental health issues, be careful not to fall into that trap.

This doesn’t mean we can never show individuals with mental health issues in a negative light, but it does mean we need to acknowledge and show the full character, not just their diagnosis. The issues are so much more nuanced than stereotypes allow for.

Every person is complex and everyone’s experience with mental health issues is different. We should always be careful to craft and flesh out our characters to ensure they are a whole person and not a stereotype.

Each person has unique challenges, yes, but they also have hopes, dreams, weaknesses, and strengths. We need to do our research (always!) and do the work to ensure our characters are portrayed in full.

(Here’s more with Under Development: Ways To Create Characters)

3. Always Research

Say it again louder for the people in the back—always research.

As with so many things, research really is key.

One of the most common and straightforward misrepresentations I’ve come across related to mental health issues is the portrayal of schizophrenia being manifested through multiple personalities. However, even a brief google search or a peek at the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, 5th Edition) can provide a fact-check in this instance: the experience of multiple personalities is called dissociative identity disorder (DID) which is completely unrelated to a diagnosis of schizophrenia.

It's also incorrect to describe someone as being “so OCD” when really, we mean they are a perfectionist or particular about cleanliness. These personality traits are different from having a diagnosis of OCD.

Getting basic facts wrong is just poor research and poor writing.

Knowing diagnostic information, realistic symptoms, treatment options, and associated terminology is important if we include mental health issues in our writing.

Even if a character doesn’t have a specific diagnosis spelled out on the page, it’s helpful to understand their mental health issues and what that experience might entail. For instance, it’s useful to have a good handle on what the character’s common symptoms are, their coping strategies, their triggers, and what their response may be to treatment and assistance.

And as with so many things, it’s important to recognize that not everyone’s experience is the same.

This means every person experiencing seasonal depression will not have the same symptoms. Individuals living with bipolar disorder are not identical to one another. While there may be common symptoms, there is no one-size-fits all approach.

Not only do mental health experiences vary from person to person, but they can look drastically different throughout different periods of history and among different cultures

For instance, studies have shown higher rates of physical pain symptoms (such as complaints of stomach, head, or neck pain) in relation to depression among Japanese patients than among American patients? There is a cultural component being explored here regarding the experience of depression.

Getting information from reputable sources (such as the American Psychiatric Association) can help us portray our characters in realistic and respectful ways.

Note: If you are writing from your own personal experiences—thank you. Thank you for sharing your story.

Research can still be valuable in supporting and strengthening your story, of course, but don’t be afraid to share your own experiences even if they don’t “match” other people’s lists of symptoms.

(Here’s more with Let’s Get Ready To Research: Researching For Your Novel)

4. Use Respectful Language

Be careful with the words we use. As writers, we should be extremely aware that words have power.

When referring to mental health issues, strive for “person first” language, such as “person living with schizophrenia” instead of “schizophrenic.” This places the emphasis on the person instead of their diagnosis, acknowledging there are many aspects of the person besides just their mental illness.

We should definitely avoid using derogatory language, such as “crazy” or “nuts.”

Also be cautious of phrases such as “struggling” or “battling” mental health issues. Sometimes a more neutral term such as “living with” mental health issues can be less emotionally charged. Using terms such as “normal” should also be used with caution since it infers that anything different than itself is “abnormal,” which frequently carries a negative connotation. (A preferred term is “typical.”)

Language changes and preferred terms and connotations are fluid, so again we have to do our research! If we are writing about a real-life person then we should use the language and terms they prefer.

5. No Villains

Be careful not to cast characters with mental health issues as the villain.

Writers owe a great apology for the overabundance of times that the sole representation of individuals with mental health issues has been in the form of a villain. There’s no need to add to that number.

I’m tempted to think of exceptions…

But then again, maybe we should just reevaluate our story and characters and cast someone else in that role. Because there is a lot of baggage in this situation and it’s hard to justify writing yet another villain who experiences mental health issues.

(Here’s more with 7 Possible Motives for Villains)

6. Be Cautious with Details

As writers, we’re sometimes known for writing lots of descriptions. The devil is in the details and all that.

And sometimes those details can be good.

Yet there are times when we should take care that the details we include are helpful and not harmful for our readers. Some topics can trigger readers and lead to distress or even harm.

For instance, evidence has shown that stories with detailed portrayals of suicide and self-harm may lead to an increase of these behaviors.

This doesn’t mean we can’t include these topics in our stories, but we should be aware that how we talk about them has an impact and that excessive detail isn’t always helpful. Be careful when describing these topics, and use neutral language to describe suicide instead of terms like a “successful” or “failed” suicide attempt. We don’t want our language to inadvertently be sensationalizing or romanticizing self-harmful behaviors.

Depending on our story, it may be helpful to include a cautionary note to warn readers if there will be potentially triggering content so they can make an informed decision to protect their own mental health.

Obviously, we don’t want to always shy away from hard or complicated topics, and we will never please everyone. (Nor should we try!) But it’s good to be aware when dealing with potentially sensitive issues that might harm our readers.

7. Be Cautious of Magical Recoveries

When characters have abrupt recoveries from mental health issues (whether through a magical solution, a “light-bulb” moment, or by the support of their one true love) it may seem like a dramatic and powerful moment for our plot, but it frequently betrays and cheapens the real-life challenge of these experiences.

In real-life, recovery and management of mental health issues is frequently a very slow, sometimes life-long, process.

Having support from loved ones is life-changing and can make all the difference when facing any challenge in life, yet it doesn’t mean wellness is instant or perfect. That misrepresents both the challenge and the realities of love.

And having magical cures would be nice, yet we don’t want to erase the real experiences of those who live in a world where we don’t have perfect or complete cures.

Being healthy and well in both body and soul is a good goal for our characters to strive for and at least partially reach in our stories—we just want to be careful how we portray that.

And we want to be very, very careful we don’t send the message that acceptance, wholeness, and love only exist once recovery is somehow “achieved.”

Because in reality, all of life is a continual process toward wellness. None of us will ever be perfectly well. And every single one of us is always fully valuable even in our imperfectness.

Instead of magical cures for our characters, we want our stories to be honest. And we want to portray our characters with dignity and respect.

8. Get Feedback

A final consideration when writing mental health issues is to get feedback—which is actually always super important no matter what stories we are telling!

When including characters living with mental health issues in our stories, it’s especially valuable to have sensitivity readers (such as mental health professionals or individuals who have experienced mental health issues themselves) who can help make sure our story is accurate and respectful.

Receiving feedback is a critical part of writing in general—we simply can’t see errors in our own work sometimes. We often don’t recognize our own biases, stereotypes, or plot holes.

(Here’s more with Questions For Your Beta Readers- And To Focus Your Own Revisions)

Including mental health issues in our stories is both important, and worth taking the time to do well!

And really it all comes down to this: When we write, we want to make sure our characters are fully fleshed out, and that we treat people with respect. Which is what we should be doing anyway!

Let’s love one another and care for one another with our writing.

Our stories and our world will be all the better for it.


  1. I'm sorry you feel so strongly about this but my villian is bent from from birth. He's physchotic from birth. Nobody knows much about him other than he's bad news and seems to think the entire world is out to get him and owes him a do-over. He's going to be far from polite in his dealings with others and I see no reason to make him polite when his actions are exactly the opposite - break and enter, burglary, murder, sexual torture - he's one sick puppy that's just asking to be put down.

  2. Thank you for all of this. One of the best examples of how to get it right is Nicole Melleby's How to Become a Planet. It's spot on in terms of accuracy, and even more so in how respectful she is of the dignity and agency of her adolescent character.

    1. Thanks for your comment! And I'll definitely have to check out How To Become A Planet!

  3. Thanks for this really helpful article. I'd love to see more characters just living with their mental health problems (like in real life) rather than it all being a plot point that conveniently goes away when not needed!

    1. You are so welcome! I'd love to see that more myself!

  4. Thank you for this post. Not only should it be incorporated into a character as simply a part of who they are, but it also reveals a lot about the characters they interact with (if they're aware). Mental health issues, even in real life, are sometimes an excellent way to measure the compassion and kindness of others.

    1. That's a great point, Christina! There are so many different aspects and dynamics that can be shown here.

  5. I haven't created any characters with mental health problems, but I did employ a lot of what you suggest here when trying to write some chapters in my second novel, in which a young teenage boy is trying to get a handle on the accidental death of his father and the subsequent marriage of his widowed mother to his father's brother.

    As a woman in my sixties, what did I know about what goes on in the mind of a 13-year-old boy? I ended up asking one of my nephews (in his twenties), whose mother (my sister-in-law) died when he was only nine, if he was willing to talk to me about what his feelings were at the time. He sent me a lengthy email revealing what he struggled with, his emotional state of being, and so forth. Although the details were not the same, the bruising of the heart was the same.

    I read and re-read that email six or seven times over the course of two or three months, until it had infused me. My finished work read true to my nephew, so I was satisfied. BUT ... it entailed the toughest writing I've ever done.

    I am glad to have risen to the challenge, and learned a lot from it that I can apply to my next work, which is non-fiction about traumatic experiences and their aftermath.

    1. It sounds like you've really put in a lot of dedication in telling people's stories with care and respect! I imagine your novel was greatly enriched through your work. Your non-fiction work sounds like a valuable project as well- best of luck with your endeavors!

  6. I was nervous to read this article because almost all of my books have characters with real mental health issues. Thankfully, according to your advice, I'm doing a good job. I personally have lived with bipolar disorder most of my life and have had an eating disorder since my early twenties. One of my daughters also has bipolar, the other of my daughters also has an eating disorder (and works as a counselor at an eating disorder clinic). We have been living with (sometimes thriving, sometimes far from thriving) these issues and we tend to write what we know. Thank you for your great advice. -Julie L. Spencer

    1. And thank *you* for your writing and for sharing from your lived experiences in your books! The world needs more people like you :)

  7. You can say some people have mental health issues, while some people are just born bad.

    1. The origins of evil and people being "born bad" is definitely an interesting philosophical topic! I appreciate you making the distinction that it isn't mental health issues that make someone "bad" - that can be such a harmful stereotype.

  8. Great advice. I've not written a character with mental health problems. At least, not yet, although I've written about vengeance and jealousy. In the book about jealousy, I've put a warning at the beginning because it deals with such topics as infant death, miscarriage and death in childbirth, which I think could be detrimental to some people. I think putting a warning is a good idea if there are things that might trigger a bad reaction in some people, whether mental health or other things.
    Incidentally, I write fantasy and historical fiction. What are your thoughts on mental health in historical fiction? To be authentic, we must have people behaving, and speaking of people with mental health issues in a less than gentle way. People used to go to 'asylums' as entertainment. How would you deal with something like that?

    1. Great question! Even today there can be plenty of derogatory terms used or hateful speech, and it can be tricky to know what to include in our stories and what to simply leave out. As the author we can also choose if we'll make a point to label it as "wrong" in some way. Every story is different and I'd encourage you to get feedback for more detailed advice, but it sounds like you're already being mindful of how to create fully developed characters as well as to be aware of possible triggers for your audience, so great work!