In some of these Patreon essays, I encourage writers to explore different beliefs about the world and make them the literal, metaphysical reality of the story: what if the world really were flat? What if you really did have to sing a certain song to make the crops grow? What if diseases really were caused by elemental imbalances, instead of by germs?
I don’t encourage that here. Mental illness is still a topic vulnerable to great misunderstanding and stigma; leaning into past prejudices and misconceptions for the sake of a story risks, at a minimum, trivializing a problem many people grapple with. At worst, it might perpetuate harmful stereotypes. I won’t go so far as to say it should never be done . . . but it’s the sort of thing probably best left alone unless you have deep familiarity with the topic. (And even then, you may face backlash.)
Still, it’s useful to know what beliefs have historically existed around mental illness. A science fiction novel could get away with talking about neurotransmitters and so forth, but that would be seriously out of place in most fantasy novels. And you don’t have to present past beliefs as literal truth to include them in your setting; as history shows, people can have all kinds of beliefs that don’t match the underlying facts.
One of the most common ideas attributes mental illness to demons (using that term in the broad sense of “malevolent spirits”). This is part and parcel of the wider belief that attributed illness in general to demons — and for mental ailments in particular, you can understand why! Incidents of mass hysteria aside, like the “dancing manias” of European history, there’s no evidence of contagion or environmental hazard to explain your suffering; you’re not likely to catch, say, schizophrenia from your neighbor or from venturing into a swamp. You don’t develop any bodily symptoms like fever or a rash, either. Your problem is invisible, and so it makes sense that its cause might be invisible, too.
(It’s worth noting in passing that many modern people who don’t actually believe in demons still externalize and personify difficulties like depression and anxiety. The latter has acquired the colloquial term “brain weasels,” and the depiction of depression as some kind of dark beast sitting on top of the sufferer or lurking in the shadows is common in both speech and art.)
Closely related to this is the belief that witchcraft causes mental illness. It’s a bit like demons — including the part where they might cause you to fall physically ill, too — but with the added facet that now you have someone to blame. It’s much more satisfying to be able to point a finger at a disliked neighbor than an unseen demon . . . though not from the perspective of the accused witch, of course. While punishing them may not lift the “curse” on your child or spouse, you can at least reassure yourself that you’ve prevented them from harming anyone else.
The parallel to bodily disease continues through the idea that mental disorders might be caused by an imbalance of elements or humors. But not all explanations map the mind to the body; one of the most pernicious ideas is that mental illness is the result of some inner failing on the part the person afflicted by it, which you’ll rarely hear anybody saying about smallpox. Some corners of Christianity have framed depression as a sin — a lack of faith in God’s plan and joy in His creation. Even people who don’t frame it in religious terms may think that willpower alone can make a sufferer well.
Even the modern, Western conception of mental illness maps it to disease; it’s right there in the phrase “mental illness.” And for many people that’s liberating, because then it’s a consequence of natural causes rather than personal failing (or someone else’s malice). I should note, though, that this scientific, medicalized framing isn’t universally loved, especially in other parts of the world. Depending on your society, a supernatural affliction might invite everyone to gather together to aid you, whereas a disease is a stigmatizing condition that makes people shun you instead — after all, diseases can be contagious! So not only can the conceptions of mental illness differ between cultures, but so can how they feel about those conceptions.
In fact, mental illness itself can be influenced by culture. The Diagnostic and Statistical Manual of Mental Disorders, a.k.a. the DSM, used to have a section for “culture-bound syndromes” — those considered to be specific to a particular society, rather than universal. (One example I remember from an earlier edition, though I don’t recall what society it’s found in and no longer have that book, was the pathological fear that the penis will spontaneously retract into the body.) This formulation has gone by the wayside in more recent editions, thanks to the recognition that all cultures shape their conceptions of and experiences of distress, not just the non-Western ones that tended to populate that section of the book. Anorexia has increased globally where Western culture spreads; does this not suggest that anorexia might be less “universal” than we used to think?
So what sort of mental illness even appears in a story, and what form it takes, is a matter that can be influenced by worldbuilding. I’ve seen it suggested, though I don’t know if it’s true, that a schizophrenic person in a modern, urban society is more likely to experience their hallucinations as menacing and frightening, while one in a tribal society might be more likely to experience the disorder as the voices of their ancestors guiding them. And that’s where, whether we mean to or not, fantasy writers may end up blurring those lines around the causes of mental illness and what we represent as literal truth: if we write about a character guided by ancestral spirits, we’re probably not even thinking of that as a depiction of schizophrenia, but rather as fantastical reality. We’d say the character isn’t ill at all — and in the context of their world, they’re not!
Because there’s a very real sense in which, for something to count as mental illness, it has to be a problem. This is at the heart of debates over how to handle topics like autism or gender dysphoria, and before that, homosexuality; what’s seen as a pathological disorder when those ways of living are stigmatized or outlawed entirely can be perfectly functional human nature in a more accepting and supportive society.
In light of the above, you might justifiably wonder about the inclusion of mental illness as we experience it now in a setting wildly different from our own. It’s highly likely, for example, that the prevalence of anxiety nowadays is not simply a product of us paying more attention to the issue and diagnosing it when it appears, but also of the society around us: we live in an anxiety-generating environment. How likely is it that a character in a pre-industrial village would have a similar experience?
We can’t answer that for sure, because diagnosing psychological problems on the basis of the historical record is a muddy process at best. Some disorders we can be fairly sure of, like depression or psychosis, but others . . . did George III of England suffer from bipolar disorder, maybe with some co-morbidities, or were his symptoms caused by porphyria, perhaps triggered by arsenic poisoning? We’ll never actually know, and to some extent, anyone who goes looking for evidence of a particular illness is likely to find it, as the record is usually non-specific enough to support multiple interpretations.
But asking whether that illness fits the fictional setting may be missing the point. Some authors will care deeply about that aspect of verisimilitude; others care more about reflecting the world they live in and the experiences they and their readers might have. The hero with anxiety, the heroine with the eating disorder, don’t have to be confined to stories set in something like technological, Western society — they can go slay dragons in a medieval-style world, too. Which means readers who empathize with those characters get to imagine themselves having great adventures.
I like a well-knit setting as much as the next person, where it doesn’t feel like the society I live in is rearing its head out of place . . . but there’s plenty of value in the other approach, too. The question of who should write it is more fraught — as with all conversations around such matters right now, e.g. race, sexuality, religion, and so forth. I don’t pretend to have answers to that, except for this one: If you are going to write about mental illness, do so with compassion and care.