Treatment and Stress — Roleplaying and Mental Illness

If you haven’t yet, then please read the first article in this series before reading this one. It will give you an idea of my attitudes toward mental illness and roleplaying, and the direction from which I’m approaching the topic. It will explain why I espouse certain viewpoints and attitudes. Keep in mind that some of this material is generalized for the sake of brevity; I don’t want to write a 200,000-word textbook on the subject. Various mental illnesses are quite different from one another, and should be taken as such. Obligatory disclaimer: this information is provided for roleplaying purposes only!

Here are more details about mental illness to suggest plots, themes and dilemmas that you can explore in your roleplaying games. They will also give you a better idea of how mental illness works, and some of the things that the mentally ill go through.

Treatment

While many mental illnesses can be successfully treated, there are quite a few problems inherent in the treatment of the mentally ill. Someone who’s completely out of touch with reality probably won’t understand or be able to keep track of medication. Someone who’s manic thinks he feels just fine and thus doesn’t need medication. Someone who’s depressed doesn’t think it’s worth the effort to seek help. The mentally ill can have “disorganized thinking,” which can interfere with the attempt to medicate in any number of ways.

IN USE: Treatment is one way to take a mental illness that otherwise would make a player character (PC) unplayable and turn it into something worth playing. Don’t let this be a way for someone to neutralize a problem that their character has, however. Remember that treatment is often not so straightforward. Work some more interesting consequences of treatment into the character’s life. We’ll get into more details about drug treatments below; for the moment, just consider how difficult it can be to make sureyou take your medication every day. It’s such a simple thing that can be derailed so easily!

Diagnosis

But wait — there’s more trouble here. You can’t just run a blood test and find out what disorder someone has. A psychologist or psychiatrist has to make his best assessment based on the symptoms he can personally see, test for or find out about. (Some of which might be faked, hidden, symptomatic of more than one illness, or masked by other symptoms.)

Then he has to go through the various drugs (or other treatments) used to treat that problem and pick one to start with. I remember hearing that, judging by treatment experiences, there are probably many different forms of bipolar disorder — but all the psychiatrist can tell is, “it’s bipolar disorder [either type I or type II]. Let’s try one of the drugs that usually works.” Sometimes the only way to diagnose something for certain is to see what medication it responds to!

IN USE: If your players are trying to make things too easy (categorize the mentally ill, hand him off to an NPC, forget about him), play with the trials and tribulations of diagnosis. Misdiagnosis is always possible, particularly if you find the wrong psychiatrist (there are problem people in every profession). Even with the right diagnosis it can take many tries to find the right drug or combination of drugs. Someone could end up on the wrong treatment and turned out on the street again, with more problems than ever before. They could be told they’re fine and to go home and stop wasting the doctor’s time. Any number of complications could happen in the diagnosis step.

One thing that makes diagnosis even harder is that disorders can come in clusters. People often have more than one problem at a time, and untangling that knot and figuring out what to treat and how can take a skilled psychiatrist years.

Drugs vs. Therapy

With respect to depression at least, I’ve read statistics that say drugs and therapy are equally as effective in treating depression. However, if you use them together, they become much more effective than either one alone. You can’t simply give someone a pill and have them instantly become better. It can help a lot, but they usually still have to deal with a number of other things with which therapy can help. For instance, they have to deal with the mess that the disorder may have made of their life up until now. They have to deal with the bad habits and coping mechanisms they may have developed as a means to handle their disorder.

Drugs

So you try a drug. If you’re lucky it works. Even if it works, it could take weeks and weeks (months!) to get the drug up to the right level in your bloodstream; until then it doesn’t have much of an effect. You have to deal with any side effects it might have. Some drugs are toxic at near-therapeutic levels, so you have to get constant blood tests (and what if you get a bad doctor who doesn’t give you the tests?). And then the drug might help — but not enough.

If the drug doesn’t work (which is often the more likely option), you have to wait a while to find that out, all the time experiencing both your normal mental illness and any drug side effects. Eventually you and your psychiatrist decide that the drug doesn’t work (sometimes months later), and you try another. Or you try several different ones at once. There are plenty of people who take complex cocktails of drugs that only partially help them.

Some people “self-medicate” by drinking lots of alcohol, taking illegal drugs, or abusing medications prescribed for other reasons. They find that the drugs help them feel a little better, but of course these drugs can cause other problems of their own.

Different people respond differently to different drugs. One might have no side effects, while another is flattened by the worst of what the drug has to offer. One person’s illness will respond perfectly to a drug, while another person will see no effect at all (or things will get worse, or they just won’t get better enough). Sometimes, if a person goes off of a drug that worked in the hope that they don’t need it any more, they can have real problems when they go back onto it. It might not work as well for them any more, or they might experience side effects that didn’t bother them before.

IN USE: There are plenty of plot hooks here that could lead into your mental illness-related plot or introduce the PCs to your mentally ill NPC. They could at first see him as just another druggie before they find out there’s more to him than that. They could think he’s a normal guy at first until his medication loses its effectiveness, the side effects become too unbearable and he stops taking it, or he keels over from a toxic reaction. If they’re still thinking of an NPC’s mental illness as a quick problem with a fast medication solution, then side effects, toxic reactions, and ineffective drugs could complicate the matter. Drug effects(and self-medication problems) could make interesting problems for a PC as well.

Cures?

When people think about treating the mentally ill, they think in terms of cures. You go into a hospital for a while, take a break, take some medications, and then you’re okay, right?

Unfortunately not. Most mental illnesses cannot be cured. They are life-long illnesses. Or they come and go on their own schedule. Depressive episodes recur – they are not usually one-time problems. Someone with a mental illness could be on drugs for the rest of her life. Or she might go off of her drugs when things seem better, thinking herself cured, and then she’s caught totally off-guard when everything comes back again a few months or even years later.

Even when you’re dealing with issues that stem from life events (say, for example, low self-esteem problems) rather than biochemical imbalances, getting better still isn’t a straightforward matter. You have to be willing to face all of the most painful parts of yourself in order to improve them in therapy, and you have to find a good therapist you feel comfortable working with. Even then it’s often two steps forward, one step back. And the longer you’ve had the problems before seeking help, the harder it’s going to be to break all of the bad habits associated with them.

IN USE: If your players are determined to get some easy building points for their characters by taking mental illnesses and then getting “cured,” keep in mind that it isn’t that easy. Play with the mercurial and recurring nature of such illnesses. Play with such things in terms of NPCs as well. How do you deal with someone who’s fine sometimes and a real problem at others?

Stress

Stress aggravates almost all forms of mental illness. Stress can trigger psychotic breaks and hallucinations. Stress can push someone from a mild mood swing into a full-blown major depressive (or manic) episode. This is one of the many things that can make diagnosis of mental illnesses very difficult. When someone’s stressed out, how do you know how much of the mental illness is due to “life circumstances” and how much is biochemical in nature? In addition, when stress is involved it’s even harder for the mentally ill to realize that the problem is biochemical. It seems like they’re just dealing poorly with a stressful situation, right?

It can also make treatment similarly difficult. Ideally you treat both the biochemical imbalance and the stressful circumstances. But few things are ideal. How do you know whether an improvement in behavior is due to the medication you’re trying or the therapy you’re trying? How do you know which to continue in what amount? What happens when treatment is going well, and then something very stressful comes along and causes a flare-up of the condition, perhaps resulting in the patient deciding not to take his medication, which makes things even worse? Or someone has been happily stabilized on his medication for years, and then a stressful break-up or a family member’s death causes him to have a relapse.

Many conditions follow a cycle of tension and release. For example, a serial killer or arsonist might be all right until too much stress builds up in his life. Then he kills someone or sets a fire, which releases the tension and leaves him feeling largely all right until the tension builds up again.

IN USE: Tension can provide a valuable clue when mental illness is involved in a plot. What’s the cycle of tension and release? How can the party correlate incidences with stress factors? If a member of the party has a mental illness, even a mild one, then keep an eye on the stress level. If the PC’s stress level peaks, then his problems should probably get worse.

Hopefully these very general issues and suggestions have given you a few places to start when working with issues of mental illness in your roleplaying game. Hopefully they’ve provided a few thoughts about realistic ways to portray mental illness, as well as ways in which realism can actually provide interesting plots and plot hooks. Obviously there are exceptions to every rule, these items are very generalized, and I certainly haven’t covered everything. There are plenty of people who get a decent diagnosis quickly, find the right medication within the first couple of tries, and stay on that medication successfully for decades.

Do a little bit of research into the specific illness you want to work with and look up the details of any drugs used to treat the illness. Do your homework and keep some of the above points in mind, and I think you’ll find that the rest comes fairly naturally!

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