Should characters in a fantasy setting attribute mental illness to evil magic and curses? Maybe, if one in four people in the modern world still do.

Should characters in a fantasy setting attribute mental illness to evil magic and curses? Maybe, if one in four people in the modern world still do.

Mental disorder remains something people don’t understand well. I’m not speaking of our painfully limited understanding of the human brain (although that doesn’t help matters). My work requires me to spend quite a bit of time sitting with people suffering from depression, anxiety, or even scarier disorders and trying to understand why they believe they’ve fallen ill. I work in a major Western city, and the majority of my patients are educated people, often people who hold jobs in the sciences, but none the less, many still look for, or at least consider, a more “magical” explanation for their symptoms than “something is wrong with my brain.” Personally, I absolutely do not believe that mental disorder is a medical illness and that our brains are more than capable of malfunctioning without help from elves and spirits, but when a scientist looks me right in the eye and asks if I think he or she could be the victim of the “evil eye,” I have to feel for them. People seek explanations for things they can’t understand.

A number of authors have therefore asked the question: if we “modern” people are so willing to look to the metaphysical to explain mental disorder, what about those lacking our educations? Several papers have been published about this over the years, any one of which could be used as a model for how people living in a medieval fantasy setting might conceptualize mental disorder. I’ve mentioned work like this in the past, but this week a study out of India caught my eye and it seems worth sharing.

Modern India is in some ways an interesting comparator for medieval fantasy societies. India is in some ways one of the most advanced countries in the world, and in other ways, much less so. Cutting edge scientific advancement exists alongside some of the poorest and least educated communities in the world. Although it’s a country composed of several rapidly evolving nations, it’s also a land very much ruled by religion and spirituality, as is sadly evidenced by the slew of religiously-motivated killings there in recent years. Modern India is also heir to the traditions of Ayurvedic medicine, one of the richest and oldest “alternative” medical systems in the world, which gives many people there a reason not to adopt Western medicine. The Indian people exist at a curious moment of cultural shift where many different ways of looking at the world are equally dominant, much as how someone living in Waterdeep or Absalom has to navigate life in a world where some people warp the laws of physics with magic while others are refining the principles of the steam engine and the plasma rifle.

In this study, the authors recruited people who came to an outpatient psychiatry department with a diagnosis of depression and asked them to explain why they believed they had developed their symptoms. They were allowed to list as many explanations as they wanted to but were also asked to identify which they felt was most important. While a small number simply couldn’t explain why they were ill, most endorsed one or more explanations and about four out of five people gave more than one explanation. Many blamed some they had eaten, or suggested that they had “nerves,” or that they were weak people. Most could find a life stressor, such as family or workplace problems, that were making them depressed. A majority felt that they had psychological problems, grief, or loneliness. About forty percent blamed fate, a quarter felt they were being punished for bad deeds, half believed it was the will of one god or another, and a full quarter suspected that they were the victims of a curse or the evil eye. Obviously, all of these numbers add up to more than 100%, which means that in all likelihood a majority of the people who believed that they had been cursed also believed to some extent that they had a real medical illness. A majority of people felt that the “most important” cause of their illness was psychological problems or social stressors, about one in ten felt that karma or bad deeds were at fault, and nobody felt that the primary problem was a curse (or at least, they didn’t admit it to a doctor). Women were more likely to blame a supernatural cause than men, but otherwise there seemed to be no differences in responses based on age, urban versus rural living and so forth. Amazingly, higher education seemed to be associated with MORE belief in supernatural causes, which I found strange enough that I had to reread that section of the paper several times.

The bottom line is that when you put it all together, about one half of all people showing up in hospital believed that a supernatural cause was responsible for their depression; it may not have been the most important factor, but it played a role. Don’t forget that the people studied here are also only those who made it to a hospital. You would have to imagine that a significant proportion of people who would be inclined to subscribe to folk or magical explanations for their illnesses wouldn’t come to hospital and so wouldn’t be represented in the study.

Does any of this apply to a fantasy world? While we should be careful to draw conclusions, the paper illustrates something about human nature. We crave explanations for things, and even when we “know better,” the magical or religious explanation is often a tempting one. Scientific explanations are often unsatisfying because they leave a lot of unknowns; yes, a medication that increases serotonin in the brain will improve depression, but we don’t really understand why, or how, or how much of a difference it makes if we simultaneously raise or lower norepinephrine. In contrast, “evil eye” is a self-contained story that explains everything, except possibly for who sent the curse. The easy answer is often a very tempting one, especially if you live in a world where your depression really might be because of a rakshasa.

More than four years ago, Dr. Eris Lis, M.D., began writing a series of brilliant and informative posts on RPGs through the eyes of a medical professional, and this is the one that appeared here on November 7, 2015. Lis is a physician, gamer, and author of the Skirmisher Publishing LLC OGL sourcebook Insults & Injuries, which is also available for the Pathfinder RPG system.