Psychiatric hospitals in movies and TV shows are not one-size-fits-all, occupying a space somewhere between a regular medical facility and a prison. Symbolically they represent a lack of control, either within one's mind or from those who refuse to listen to pleas of sanity. Psychological horror thrives in this venue, whether in abandoned buildings left to rot or contemporary fluorescent-lit corridors (minus the loaded name). The history of asylums is stacked with terrifying tales, which is why it is an enticing venue for scary narratives. Playing into fears of our sanity being called into question with no one to advocate for us, the protagonist is often sectioned for a more nefarious reason, gaslit into believing they are going crazy.

The relationship between mental illness and horror is complicated, soured by cheap plot device tactics to shock the audience with a madness motive at the heart of the carnage. Suggesting there is an overwhelming link between mental health and violent behavior is an incredibly dangerous proposition, which has led to decades of stigma. The deranged patient who escapes a facility and kills a couple on Lovers' Lane is a common campfire tale that has frightened generations and spawned multiple horror scenarios. It is an urban legend ticking off scare boxes with little basis in fact.

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In Halloween, Michael Myers is committed to the Smith's Grove Sanitarium after he kills his sister Judith at six years old. He breaks out 15 years later and wreaks havoc on the same Haddonfield neighborhood, a pattern that repeats when he absconds while on a transfer from the same facility to a maximum-security prison in the 2018 reboot. A facility with a flair for the dramatic aesthetic that places each inhabitant on a red chessboard style set-up. The sun-drenched image is far from the dark and dank cliche, but no less eerie. Michael is the personification of evil, which is the only diagnosis Dr. Loomis (Donald Pleasence) made. "I spent eight years trying to reach him, and then another seven trying to keep him locked up because I realized that what was living behind that boy's eyes was purely and simply... evil."

Certain locations lend themselves to horror, from the family home — and the many rooms within that hide secrets and target our vulnerability — to facilities like a hospital that are meant to be a place for healing. "A place of refuge, sanctuary" is one definition of the word "asylum," however, historically this is far from the case. The 1946 horror movie Bedlam, starring monster icon Boris Karloff is a fictionalized version of London's Bethlem Royal Hospital — also known as Bedlam (a word that has become shorthand for a psychiatric facility). Originally founded in 1247, the long history of England's first mental institution reads like a laundry list of mistreatment.

Set in 1761, the film focuses on the century before lunacy reform when inmates were used as "freakshow" entertainment for the general masses. While trying to seek justice and better conditions for the vulnerable inmates, Nell Bowen (Anna Lee) is committed in an attempt to stop her from spilling the secrets of the inhumane conditions. Rather than being "mad," Nell is a victim of those wanting to keep the status quo.

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"Beauty at the Mercy of Mad Men" and "Within the Walls of Horror House!" blast the posters and lobby cards of Bedlam's advertising campaign. Nell is the damsel-in-distress figure even though she is is the one infiltrating the system from within in a bid to change the system.

A common theme running through the psychological horror trope is to imprison a previously "sane" person in an inescapable waking nightmare. In the recent The Invisible Man adaptation, Cecilia Kass (Elisabeth Moss) is institutionalized after she cuts her sister's throat in a crowded restaurant. Of course, it wasn't her hand that did the deed, rather it is her supposedly dead abusive ex-boyfriend Adrian Griffin (Oliver Jackson-Cohen). No one believes her repeated claims that an invisible tech mogul has orchestrated this mental breakdown. To those who are meant to protect and serve, her pleas are the result of a delusion.

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"Since time immemorial, delusion has been taken as the basic characteristics of madness. To be mad was to be deluded," explained psychiatrist and philosopher Karl Jaspers in 1963. On the surface, Cecilia falls into this category, but the audience knows she is speaking the truth. Soon the guards at the facility will find this out the painful way, but it takes all of Cecilia's ingenuity and strength to do so.

Following this gaslighting path, Steven Soderburgh's 2018 psychological horror film Unsane follows Sawyer Valentina (Claire Foy), a woman who accidentally signs a consent form for a voluntary 24-hour admission at the Highland Creek Behavioral Center. Dealing with trauma from being stalked, Sawyer is attempting to get her life back on track. After realizing her mistake, she calls the police, but her signature prevents them from getting involved. Her 24-hour stay gets extended to seven days after she lashes out, which causes her to spiral further. If she was paranoid before, a cycle of restraints and sedation puts her in a vulnerable position she cannot get out of.

Shot on an iPhone 7 Plus, the intimacy of using this device via tight close-ups ensures we are on this journey with Sawyer. As each twist puts her further away from freedom and deeper in the "delusion" hole, the choppy editing enhances our experience as Sawyer's only advocate. The corruption and staff within this facility hark back to the days of Bedlam, suggesting if you do ever have to seek psychiatric in-patient care, what you will be in for will be far from restorative.

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Historically, movies set in a psychiatric facility play with perception and will deploy a twist to undercut the lead character or prove they were right all along. Going back to the birth of cinema as we know it, Robert Weine's 1920 silent horror The Cabinet of Dr. Caligari ends with a "the protagonist was mad all along" plot twist. All the players in his story are fellow inmates and employees of the asylum. Revolutionary at the time, this blueprint leans into the idea that a fantastical story is just that. Reflecting on this period of social unrest and new methods in psychiatry, the era in which a movie is made and/or set impacts the representation of mental health.

Electroshock therapy (now referred to as electroconvulsive therapy or ECT) was first used as a treatment in 1938, which features heavily in anything set or shot in the mid-century. A person being zapped with electricity directly into the brain is a grotesque thought that conjures an image of Dr. Frankenstein. Negative connotations of this method have been derived from pop culture including One Flew Over the Cuckoo's Nest and its use as in barbaric conversion therapy (the diagnosis of "homosexuality" was only removed by the American Psychiatric Association in 1973). The second season of American Horror Story is set in the fictional mental institution Briarcliff Manor which doubles down on every preconceived terrifying notion of an asylum. Primarily taking place in the 1960s when it was an active facility, present-day sequences show the derelict location is still an unwelcome environment to avoid.

American Horror Story Asylum, Sarah Paulson

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Each season of Ryan Murphy's anthology FX series takes on a well-known horror setting or conceit. Choosing an asylum run by the Catholic church in the 1960s provides plenty of scary avenues including exorcism, the so-called threat of deviancy, a Nazi doctor continuing human experiments, and serial killers finding easy targets. Reporter Lana Winters (Sarah Paulson) wants the scoop on new resident Bloody Face but ends up getting a lot more than she bargained for when she meets the real serial killer. Her sexuality is used as a reason to commit her, enduring ECT as a "cure." The accidental patient who claims they shouldn't be there is a common trope in psychological horror, which also includes the 2003 Halle Berry-starring vehicle Gothika in which she plays a psychiatrist-turned-patient and the 2010 John Carpenter horror The Ward. The latter is also set in the 1960s because this is the ideal decade to scream at authorities with no one believing what you are saying.

Along with electroshock therapy, lobotomies are used as a threat in movies and TV shows. Studies have shown that the majority of lobotomies were performed on women and one explanation cites the desire to do away with unruliness. "At a time when women were expected to be calm, cooperative and attentive to domestic affairs, definitions of mental illness were as culturally bound as their treatments. A surgery that rendered female patients docile and compliant, but well enough to return to and care for their homes." Horror does have an issue with stigmatizing mental illness, however, the depiction of asylum treatments being wielded against women as a way to silence doesn't seem too out there when you consider this.

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Horror narratives stumble when they connect extreme violence and mental health as the cause. Asylums are therefore packed with the most dangerous people (like Michael Myers) and the portrayal of such an institution within a 90-minute runtime doesn't leave much wiggle room for nuance. Instead, a diagnosis is used as a plot device to shock or deliver a final act twist. For male characters this often links back to their mother (Psycho) or a dead wife (Shutter Island), putting femininity at the heart of the problem while taking away that woman's agency because she is not around to defend herself. Set 20 years after the events in the first movie Psycho II focuses on Norman Bates' (Anthony Perkins) release from a psychiatric ward. His story is framed before and after treatment, his illness is wielded against him in the sequel, and there is a lack of interest in his rehabilitation.

Revisiting trauma is a horror movie specialty that rarely spends too much time on the actual psychological impact, but the storylines are becoming more sophisticated. One particularly striking aspect of the Halloween reboot is how Laurie Strode's (Jamie Lee Curtis) mental health plays a vital role in the prison she has created for herself out in the woods. This isn't the first slasher to delve into a Final Girls mental state as Nancy Thompson (Heather Langenkamp) works at the Westin Hills Psychiatric Hospital in A Nightmare on Elm Street 3: Dream Warriors. Using her experiences with Freddy Krueger (Robert Englund) in her studies, Nancy is intent on protecting the vulnerable. Using experimental drugs and hypnosis, Nancy gives her all to defeat Freddy.

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Laurie Strode ends up in a regular hospital in Halloween II — we will have to wait a little longer to see what takes place in Halloween Kills — but in Hellbound: Hellraiser II, Final Girl Kirsty Cotton (Ashley Laurence) has been committed after the events of the first movie. Unlike the teens in A Nightmare on Elm Street 3, Kirsty and the other patients are under the care of someone who wants to do harm. The psychiatric care unit is about to become a literal hell on earth.

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Horror is a lens used to reflect the fears and failings of society, which it has done over the last century through its depictions of asylums, sanitariums, and psychiatric facilities. Stories and characters often perpetuate myths surrounding mental illness, but in recent years, filmmakers are relying less on damaging stereotypes in the exploration of the human psyche. In the same year as Bedlam's release, Life magazine published Bedlam 1946, which referred to the "man-made hells" of mental hospitals. No, this was not a behind-the-scenes look at the movie but a horrifying exposé of two U.S. state mental hospitals — one nicknamed the "Dungeon" — that compared findings to the recently liberated concentration camps in Europe. When real people are treated as less than (and institutions are more concerned with imprisonment than rehabilitation) it is easy to see why horror movies repeatedly utilize this space to deliver scares.

Emma Fraser

Asylums in horror, from The Cabinet of Dr. Caligari to Bedlam and beyond