Stage Left: Mental Illness and Treatment in NEXT TO NORMAL


[video: A still frame of the cover to the next to normal cast album, showing a woman's eyes and a house on a purple background. Lyrics to "I Miss the Mountains", the song playing, are at the link]

As a mentally ill musical theatre fan, depictions of characters who share that trait with me typically fall into one of two categories: they a) don't exist or they b) make me rage. next to normal comes closer than most shows to getting it right, in a lot of ways. But where it fails, it fails hard.

The show is unusual for being centred on mental illness, firstly. The main character, Diana, has bipolar disorder and this is what drives the central conflicts of the show (I'd love to see a musical where a character being mentally ill was just part of their character, but that's another issue entirely...). There are things about this approach that the show does right—Diana is a suburban mother, and a fairly ordinary one. She is not a Tortured Artist or Prodigy or any of the other tropes discussed in this New York Times article on the show. The writers consulted closely with professionals in crafting their approach, and in many ways it shows. In his review, Tony Brown of Cleveland.com writes favourably of the show and speaks openly of his own Bipolar II diagnosis, empathizing strongly with Diana's character.

So what's the problem? Well, there are several. But the one that I was personally most irked by was the show's irresponsible and harmful depiction of how mental illness is treated. Early in the show a series of medication adjustments is portrayed in an extended musical sequence, "My Psychopharmacologist and I." Mostly the number is cute—Diana has an appointment, lists her side effects, gets a new treatment. I can empathize with that (and it has a hilarious riff on "My Favourite Things" midway through!). The resolution, however, features the following exchange:

DIANA: I don't feel like myself...I don't feel anything.
DOCTOR: Hm. Patient stable.

Every time I get to this exchange I want to scream at my CD player. Psychiatric medication, contrary to what the creators of the musical apparently think, is not supposed to stifle all feeling. As someone on a medication I am happy with, I still feel. What it does is regulate my feelings so that I am functional and not, y'know, sitting in a corner in the dark for hours on end (this has happened). And perpetrating the stereotype that psych meds "destroy feeling" or interfere with how one relates to the world? Is not at all helpful.

This is not the only glaring problem in the show's representation of psychiatric treatment, however. At the close of the first act, Diana undergoes electroconvulsive therapy. For starters, I would question whether her informed consent—a prerequisite for ECT and indeed most therapies!—was obtained, as the scene in which she signs the papers seems mildly coercive at best—it seems clear textually that she is not at all comfortable with the therapy, and may be acceding primarily due to pressure from her husband and doctor. Her reluctance is clearly displayed in songs like "Didn't I See This Movie?"

DIANA (sung): What makes you think I'd lose my mind for you?
I'm no sociopath, I'm no Sylvia Plath
...
So stay out of my brain
I'm no princess of pain

And yet...she goes through with it. Her husband talks her into signing, and she undergoes treatment. At which point she promptly loses some twenty years of memory. Which...no. Right upfront I will admit I don't know a lot about ECT. Much of what I do know is from research for this post. I know ECT can cause memory loss. I know this can affect memories of events from years prior. But all of the memory? A nineteen-year gap in which she remembers nothing about her family or living situation? That, I am pretty sure, does not happen. It's a way of sensationalizing a therapy course which, while controversial, has helped many people. (IMPORTANT SIDE NOTE: I do not know enough about ECT to conclusively support or condemn its use. I know it has both pros and cons. It still does not work in the way this musical portrays it).

next to normal won the 2010 Pulitzer Prize for Drama. And despite what I've talked about here, I am a big fan. I respect what the creators were trying to do, but at the same time feel they needed to do better. They needed to portray this in a way that did not alienate those who have chosen to pursue treatment through the medical establishment. Yes, it's just one show, but it's one of very few theatrical pieces that have tackled mental illness this centrally, and the creators have spoken about their desire to get it right. Which they did not. And the fact that the show won the Pulitzer...this just serves to reinforce the idea that it does get things right, that it is saying things that are meaningful instead of harmful. And that's a problem.

Previously: Flipping the Script on "One Hundred Easy Ways to Lose a Man," "Die, Vampire, Die!" Reflections on Self-Doubt and Advocacy Work

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Comments

15 comments have been made. Post a comment.

i was waiting for a post on

i was waiting for a post on next to normal!

i completely agree with your point that it does deal with the subject of mental illness somewhat right but also fails pretty hard. at points, the book tries but ultimately, it goes for a theatrical experience that leaves those of us dealing with mental illness to feel short-changed. i truly believe it wants to do good but just doesn't exactly know how to go about it.

diana was coerced into signing the papers but i also believe she felt it was the only thing left to do, besides just completely breaking away from her family (which might have not been a bad thing).

okay, i could talk about this show all day! great job. :)

tl;dr ahead

Yessss, two of my favorite topics to talk endlessly about: mental illness and musical theatre!

I'll preface my reply by saying: I have both bipolar disorder and a lifelong obsession with musical theatre, and I have seen "next to normal" a slightly obscene number of times.

I completely agree re: the way ECT is handled by the show. The creators of the show stated in an interview (which I thought I'd saved but apparently did not) that what motivated them to start working on the show in its earliest stages was that the idea that ECT was still utilized fascinated them (the earlier workshop versions of the show were called "Feeling Electric" after a song the doctor sang while administering the treatment), so it's not shocking that the way it's presented is problematic.

I also agree with your issue about Diana's informed consent. One of my major issues with the show is Dan's (the husband) characterization. He is presented as a sympathetic character, in love with his wife and not knowing how to cope with her illness, but I've never gotten that impression of him. I think that, in not knowing how to cope with Diana, he manipulates her by coercing her to go through ECT and then, upon losing her memory, basically reconstructing her past for her to fit his needs. The song I have the biggest problem with in the show is "Better Than Before," when Dan is 'helping' Diana recover her memories. I understand that he was under instructions to take things slowly, but he completely passes over any negative memories (with the intention to "forget the things we should") and continually refuses to tell Diana anything about her past, even when she starts to exhibit the same symptoms as before the ECT. I don't think Dan's character was intended to be viewed this way, but that's how he comes off to me, and I'm glad you pointed out the issue of her questionable consent to ECT.

Finally, I interpret the last line of "My Psychopharmacologist and I" a bit differently. The whole song (aside from Dan's verses) has a kind of knowing quality to it, intended for people who have been through the neverending cycle of meds and side effects. I agree that, in reality, the idea of "Patient stable" in response to feeling nothing is BS. But in the context of the song, I think it makes sense - I've had numerous doctors label me stable because I wasn't feeling anything to the extreme, even if I wasn't feeling much of anything at all. I find the line humorous simply because it echoes my own experiences. (Also, Diana switches doctors after this song, enforcing the idea that such a response is not acceptable.)

IN CONCLUSION I WRITE TOO MUCH BUT I HAVE A LOT OF FEELINGS ABOUT THIS SUBJECT!

You know, I've spent hours

You know, I've spent hours thinking about the depiction of mental illness in next to normal, and I am ashamed to say I never once thought about how seriously problematic "Better than Before" really is. You are completely absolutely right about that and I'm glad you pointed it out. Just wanted to say that. :]

I'm not familar with Next To

I'm not familar with Next To Normal, but I hate it when people spout the idea that meds make patients unable to feel. My meds allow me feel. Without them I'd be either curled up in a ball on the couch because I was too nervous to get off of it (and unable to feel anything other than anxiety), totally numb, or unable to feel anything other than self-loathing (all of these have happened to me).

Just pointin' out that Diana

Just pointin' out that Diana switches doctors after "My Psychopharmacologist and I"--I always had the impression that the exchange you quoted, while meant for laughs, wasn't really supposed to be interpreted as the ideal result of a medications regimen.

"Trope"?

This sounds like it might be kind of interesting to see. (I'm iffy about the quick and easy rhyme of "sociopath" and "Sylvia Plath"--this was not Plath's diagnosis or issue.) I'd have to know more about the doctor character who says "Patient stable." to judge it. I've had experiences with doctors who actually seem interested in my well-being, and those who were just as happy to shuffle me through so long as I reported no recent hallucinations, sported no fresh scars, and didn't seem too flat. Is the doctor supposed to be that sort?

I'm a little perturbed that in explaining that the main character as a suburban mother, you readily dismiss the idea of the mentally ill "tortured" artist as a mere Trope. While the Times article discusses how often this association is made in popular culture, it also cites several real-life examples of people who fit this description. Mental illness afflicts all sorts of people from all walks of life, it's true, but is this somehow more valid because the character is a suburban mother? Does it need to be an either-or thing? Dismissing those of us who work in the arts and happen to live with mental illness as simply being some sort of cliched trope is as damaging as stereotypes that it never happens to other sorts of people.

Ack! Oh my gosh, I never

Ack! Oh my gosh, I never meant to imply that living with mental illness as an artist is somehow less valid. Because certainly there are a lot of people with mental illness working in creative fields (I am one of them), and dismissing that experience wholesale would be super-problematic.

Looking back at what I wrote, I should have clarified that I was talking about how our representation in fiction is almost exclusively consigned to one of a couple of narrow roles, while making clear that people who happen to "fit" those depictions still deserve to have their experience validated. I mean, as a queer guy this is also really something I should have thought of, since I do in many ways fit the "fey queer" stereotype so often seen on television and in movies, as well as the ~artsy depressed person~ one. And neither of those make my experience count less than that of people who are not as reflected in the stereotypes in popular media.

I just meant to call attention to how the majority of our appearances in media conform to a specific mold, without castigating those who do fit that mold. The fact that I did not make the distinction clear enough is my fault and my fault alone. I can't add a note into the main post to that effect right at this moment (I am on a library computer and my internet access is time-limited), but hopefully this comment will suffice until I can note my error in the post proper tomorrow.

(Without erasing the original text, obviously, because that would just be problematic in a whole 'nother way)

Feel nothing?

DIANA: I don't feel like myself...I don't feel anything.
DOCTOR: Hm. Patient stable.

This line really hits home for me because one of my symptoms of depression is a lack of feeling. It's this strange thing of just not caring; not caring about work, or friends, not caring about myself; like nothing actually matters. One of the things that my medication does is let's me feel. This whole concept of anti-depressants making you an unfeeling zombie is just alien to me. That means the meds aren't working.

I agree. I have limited

I agree. I have limited experience with medication but I also experience feelings more fully when I am medicated and/or in a well phase. Numbness is one of the more distressing symptoms of my depression.

Great post. I think there is still a tendency for accolades to flow whenever tricky subject matter is tackled, even if it's not done with great sensitivity. This is a problem because I don't think we should be giving cookies to writers who acknowledge the mere existence of marginalized people. (Sounds like this production does earn a few cookies for real, though, so that's good).

Mental Illness and Death **SPOILER ALERT**

I just saw this show a few weeks ago in DC, and I gotta, I loved it! There were some problematic things within the show, of course, but by and large, it was well done!
I believe that the doctor's announcement of "patient stable" was meant to be a comment on our society's desire to sweep mental illness under the carpet, rather than bring it out in the light and deal with it. I think it was meant to poke fun, "How foolish this man is! He thinks he has all of the answers!"
The husband's character, Dan, was an interesting one! He was given the most layers in this work. In the end we come to find out that he hasn't dealt at all with the death of his son. In his song, "Better than Before," I truly think he wanted to make things "better" than they had been before the ECT. Ironically, the very thing he was trying to erase (Gabe), is what brought the family back togerher, however briefly.
My biggest problem with the show was the incredible misleading statements about the DSM IV (inclusive guide to all mental illnesses). Several mentions were made in reference to grief being included in that book, and grief extending past 6 months being "pathological." A) Grief is not recognized as a mental illness in that book, and B) We (thanatologists) are trying to get it recognized, so that we may properly treat clients and bill insurance. Finally, C) We want to avoid the word "pathological," since it is heavy with negative connotations.
My secondary (but still large) problem with this show is that all of the women are "damsels in distress," and all of the men are "heros." Mom has mental illness, Dad spends his life trying to rescue her. His actions may not be ideal, but his intentions seem to be pure. Daughter becomes a drug abuser, has incredible emotional swings, Boyfriend promises it will be ok.
A few things I REALLY DID like, though, are that they showed some real grief reactions, the difference between partners and children, as well as how mental illness affects and can be perpetuated by the entire family, not just an individual. Also, I liked that the showed that drug use and drug abuse can be completely seperate, or entertwined (in the case of both illegal drugs and prescription medication).

I'm so so glad that this is

I'm so so glad that this is being discussed. I don't really have much to add that hasn't already been said better in the post or in the comments, but as a musical theatre fan and a best friend to many who are on meds for various mental illnesses, it's so important to me that these things get talked about--especially about what is done right, what is done wrong and how these things can be improved. That's so huge. Because while fiction doesn't have to 100% mirror reality in order to be a good show (it is fiction, after all), it's important for the sentiments and representation that it creates to be solid and supportive.

Re: a show where a person has a mental illness that does not become the forefront of the show, we need an In the Heights of mental illness. One of the reasons I love In the Heights is because it portrays Latino people simply as people, not stereotypes or the "problems" of being Latino in a white world (while that is important to talk about, I think ItH's celebration of people is even more important).

ECT, meds

"And yet...she goes through with it. Her husband talks her into signing, and she undergoes treatment. At which point she promptly loses some twenty years of memory. Which...no. Right upfront I will admit I don't know a lot about ECT. Much of what I do know is from research for this post. I know ECT can cause memory loss. I know this can affect memories of events from years prior. But all of the memory? A nineteen-year gap in which she remembers nothing about her family or living situation? That, I am pretty sure, does not happen. It's a way of sensationalizing a therapy course which, while controversial, has helped many people. (IMPORTANT SIDE NOTE: I do not know enough about ECT to conclusively support or condemn its use. I know it has both pros and cons. It still does not work in the way this musical portrays it)."

People can suffer from up to 20 years of memory loss after ECT.

http://www.ect.org/resources/voices.html:
"Memory loss is a major concern among those who have undergone ECT. 83 percent felt that their long-term memory had been affected . This ranged from loss of certain events in their lives, to the inability to remember family members, and in some cases, up to 20 years of memories were erased. Only 17% felt that their long-term memory had not been adversely affected."

Sometimes consent has to be obtained for ECT, but not in every state.So, if the show portrayed involuntary ECT treatment it was not necessarily inaccurate.
http://host.madison.com/ct/news/local/health_med_fit/vital_signs/article...
At what point should a guardian, a doctor or a state be able to order such treatment for people who are severely sick and disorganized in their thinking?
Right now, it depends partly on where they live. In Wisconsin, a state law prevents anyone other than the patient, including parents and other legal guardians, from consenting to ECT procedures. (About 15 years ago, the guardians of a Wisconsin woman named Ruth managed to persuade a court to order ECT for her by arguing that she would die otherwise; Ruth, who was in a catatonic trance, was incapable of communication and was not eating or drinking.) But such strong protections don't exist in many other states. In Minnesota, for example, there have been at least two recent cases in which patients, backed by the advocacy group MindFreedom International, have gone to court to stop forced ECT treatment."

Also, about the the character saying "I don't feel anything," and the dr saying "patient stable." As someone who has taken and supports the use of meds if the patient wants them, I will also be the first to tell you that the often don't work out right away. They can be life savers. Or they can make you feel worse. You still feel on your medication, great, that's good for you. But it's not like that for everyone. As much as I want positive portrayals of folks with mental illness, if a work is discussing mental illness we shouldn't pressure people to whitewash that for some it has an enormous and difficult impact. Like I said, sometimes people take a drug, and still feel, and get better and that's awesome. But insisting that that is all that should be portrayed marginalizes the people that don't respond to drugs in that way.

Loved this musical!!

In my case and I know in the case of alot of the individuals here in Canada who were and have been hospitalized in the past, many psychiatrists DO use meds simply as a way to keep the patients quiet so that they don't feel anything and therefore don't have to deal with them. For years I was drugged out of my mind, so that I couldn't feel any of my emotions, and when you are a survivor of extreme PTSD and also have been given the diagnosis of MPD back when I was 18 now DID (Dissociative Identity Disorder) unless you have a concurrent illness such as bi-polar or an anxiety disorder medication is not helpful because the only way to get past the effects of the trauma are to work through the emotions and memories and that is next to impossible if you are on massive amounts of medication. Also I am not sure which time period this musical takes place in but back in the early 90's at least here in Canada it was very easy to force someone into ECT, treatments and i have many friends that have lost significant amounts of their memory due to these treatments.
And here in Canada although the use of restraints is supposed to be only in extreme cases, if the nursing staff feels that the patient is out of hand all they have to do is make a phone call and the doctors normally have no hesitation in putting the patient in restraints. I am speaking from personal experience from having been put in restraints for 6 weeks because I dissociated and was told I wasn't getting out until I stopped dissociating which is ridiculous when you have a dissociative disorder!!! One of the nurses ended up urging me to use the patient advocate and a lawyer had me out of restraints and discharged in 24 hours. So I guess what I am trying to say is that as a musician and someone who is a lover of musical theater I thought this was incredibly accurate and well done.

If ECT is executed properly,

If ECT is executed properly, one treatment should NOT cause the degree of memory loss described in n2n. I don't mean to suggest that people who undergo ECT don't experience some memory loss (because they do), but I think we should be careful not to overstate the severity or the regularity of that memory loss. More often than not, autobiographical memory is totally unaffected - people might forget locations of a grocery store or things that happened immediately before or after the procedure, but they aren't usually going to forget 20 years of significant personal memories (like a son who died).

Something else I want to note is that most of the research on memory and ECT examines outdated methods that used different types and grades of current than practitioners would use today. Multiple treatment stints for a long period of time would be the only way to generate memory erasure like that in n2n. Without even considering the efficacy of ECT treatments for chronic suicidal depression and bipolar disorders, I can assure you that the depiction of ECT in the show is seriously sensationalized. Plus, I mean. ECT does work quite well for certain populations. For a lot of patients for whom antidepressants don't work, ECT is the only thing that works.

In general, I just have to agree with the OP about the overly critical portrayal of psychiatric treatments. It's obvious from listening to the music (and reading the synopsis on the wikipedia page) that the writers wanted to create a show that dramatized ECT, but as a psych student and a person with mental illness, I kind of have to balk at its appropriateness in the show. I mean, great, we have another depiction of ECT that fails to underscore its clinical benefits - exactly what the world needs. But, one of the most important points to hammer home for a person with bipolar disorder is MED COMPLIANCE. If you read An Unquiet Mind by Kay Jamison, she details her personal resistance to taking her medications and the trouble she has convincing her patients to take them. The bottom line with bipolar disorder is that pharmacotherapy is not an option; it's a fact of life. So when Diana decides she doesn't want to take medications anymore, her doctor shouldn't transition into ECT so quickly; he should engage in some serious psychoeducation. Diabetics requiring insulin are educated about the importance of compliance. It would have been really great to see a protagonist with a mental illness learning that MEDICATIONS AREN'T EVIL and THEY DON'T MAKE YOU FEEL NOTHING or CHANGE YOUR PERSONALITY, but sometimes they're just something that you have to live with and that isn't the worst thing in the entire world. Particularly with a medication like lithium, it's tough to find the dosage that works best for that individual, but that doesn't mean that no medication is the most appropriate treatment option.

Finally, before this comment gets too long, I just want to refocus myself and address your last two points (in reverse order). First, I don't think the OP is necessarily talking about the medication not working - I think they're problematizing the line "patient stable", which implies that the goal of pharmacotherapy is to eliminate all feeling. You're definitely right - not all medications work for everyone, and because our understanding of neurochemistry is still relatively immature, MDs aren't always spot on when they prescribe a medication. It really is a huge guessing game and a lot of times it's a miss. But the goal is never for a person to stop feeling.

My last thought is re: consent -- just because it's legal doesn't mean it's right. I think that's the point the OP is getting at.

"Better than Before"

Just a note to say that the moment you point in the song "Better than Before' works differently onstage, I think, than it does when you hear it on the cast album. Nothing about Diana's body movement, general affect (or lack thereof), or the way she sings the lines suggest that the audience should believe the doctor's pronouncement. The staging actually does a pretty good job of undercutting his authority, really questioning how medications meant to "control" bipolar often leave patients in, yes, a different, but still uncomfortable, unwanted emotional state. The cast album only gets at a slice of the performance. My sense at the end of "Better than Before," when watching it in the theatre, was that it's clear that Diana is anything but better and that the show is arguing that the doctor is not very good at seeing what's going on in front of him. We also see the effect of this pharmceutical roller coaster on Diana, and I was left wondering if part of her flat affect, "feeling nothing," was a result of the incredible range of medications she's been subjected to, in addition to it being a side effect of her current medication.

A lot of these posts raise another interesting question for me: I'm wondering if it's useful to think about with whom the audience is asked to sympathize in N2N? Though Diana is at the center of the story and the piece is ostensibly about her illness, not all the songs or scenes--and maybe not even a majority--come from Diana's perspective. We, as an audience, are very encouraged to think about the difficulties Diana's illness causes for her husband and daughter. Part of me thinks this is a copout--Diana's the one who wages the most personal battle, but then again, it's refreshing to see a portrayal of the ravages illness can rage on entire family. I guess I'm left wondering if that fuller picture of mental illness in a family, however, undercuts sympathy for the person who actually has the mental illness?