Insight
Essay
High spirits: heavy metal and mental health
In the wake of the 1999 Columbine High School massacre,
Columbine, CO, USA, in which 12 students and a teacher
were murdered, early news reports falsely claimed that
the killers had been wearing Marilyn Manson t-shirts. With
his white-painted skin and vampiric androgyny, Manson’s
theatrical brand of shock rock had caused outrage among
US conservatives throughout the 1990s. The association
between Marilyn Manson’s music and the murders quickly
swept through American public consciousness. In 2017,
the band’s eponymous singer told The Guardian that the
accusations of inciting violence through his music destroyed
his career at the time. This was, however, not the first time
that metal had been associated with violence; the link
being made in the media and the court of public opinion,
rather than by researchers and clinicians. 9 years before the
Columbine murders, in Sparks, NV, a lawsuit was brought
by the families of two young men, one of whom had died
by suicide, the other having been seriously injured in an
attempted suicide. The lawsuit claimed that the decision to
end their lives had been encouraged by listening to music
by Judas Priest earlier that night. Former Black Sabbath
frontman Ozzy Osbourne, now best known to the general
public as the shambolic but endearing paterfamilias of
The Osbournes, was similarly implicated in 1985 in the death
by suicide of an American teenager; Osbourne stated that
this was a misinterpretation of the lyrics of his provocatively
titled song Suicide Solution.
Heavy metal music, or simply metal, characterised by
loud, distorted guitars, energetic rhythms, and often
screamed or shouted vocals, has long battled accusations of
ties to violence. Beyond being blamed for mass shootings
and suicide, the bands and fans have been accused by the
genre’s critics of glorifying racism and sexism, and recklessly
promoting a culture of hedonistic excess, rife with drug and
alcohol use and an unhealthy obsession with the occult.
In the early 1990s, violence, church burnings, and white
supremacy plagued the Norwegian black metal scene. Metal,
however, is a microcosm of wider society, with a minority
willing to corrupt the art to cause harm. Responding to
footage of Pantera frontman Phil Anselmo shouting “white
power” on stage in 2016, Machine Head vocalist and
guitarist Robb Flynn spoke for fans around the world when
he released a video in which he said “there’s no place for that
[behaviour] in metal, and if there is a place for that in metal,
count me out”.
With a dual emphasis on loudness and technical
proficiency, to non-fans metal can appear sonically abrasive,
distressing, or even threatening. Metal’s lyrics too, not shy
about exploring the dark, depraved, and unpleasant aspects
of human nature, can appear to casual music listeners as
www.thelancet.com/psychiatry Vol 8 February 2021 105
potentially harmful. However, to most fans, the satanic For more on From The Inside see
stereotype or depiction as dangerous or deadly could not be https://www.cambridge.org/
core/journals/the-british-
further from the truth. From the exhilaration of the feeling of journal-of-psychiatry/article/
breaking taboos to the comfort from listening to the candid famous-case-of-alice-cooper-
examinations of life’s most difficult moments, metal is to psychiatry-in-pictures/
B416A68F1552484FCF
millions of fans worldwide an essential tool for maintaining D569440A7B2ED6/core-reader
and improving mental health.
Metal’s emotional scope is vast. Anger, anxiety, depression,
loneliness, post-traumatic stress disorder, self-harm,
suicidality, phobias, paranoia, and intrusive thoughts
are all part of the musical palette of metal musicians.
This depiction of mental health problems and emotional
struggles has evolved since metal’s beginnings in 1960s’
industrial Birmingham, UK. Alice Cooper’s 1978 album
From the Inside recounts the singer’s time in a New York
psychiatric ward. Straitjackets, brutish guards, and sadistic
nurses paint a cartoonish picture of life for patients who
have been sectioned. This degrading portrayal of individuals
with mental illness reappeared on Anthrax’s Madhouse
in 1985, and the clichéd trope of uncontrollable asylums
persisted. To the casual ear, metal might sound like noise,
but listening more closely reveals interesting tensions and
contradictions, both musically and lyrically. Alongside the
pantomime projection of hyper-masculinity is an illustration
of vulnerability. In a world that wrongly values macho self-
reliance while stigmatising the expression of emotions,
particularly for boys and men, this willingness to admit
to experiencing severe emotional hardship is immensely
valuable. And it has continued and developed over the
decades. A striking example is on Korn’s 2019 The Nothing.
As the album creeps towards a barrage of heavy guitars, the
introduction is interrupted by frontman Jonathan Davis
breaking down and crying, revealing the struggles he faced
being back in the recording studio for the first time since his
wife’s death.
But might this focus on the melancholy aspects of existence
risk becoming morbid? From Iron Maiden’s musings on the
final hours before execution to the horror-inspired brutal
Tim Birkbeck
 Insight
For more on metal and anger
processing see https://www.
frontiersin.org/articles/10.3389/
fnhum.2015.00272/full
For more on metal fans and
suicidality see https://www.
research.manchester.ac.uk/
portal/en/publications/this-
corrosion-a-systematic-review-
of-the-association-between-
alternative-subcultures-and-the-
risk-of-selfharm-and-
suicide(8f25577b-9258-4e2a-
bdac-0faf3c50baf3).html
For Heavy Metal Therapy
see https://heavymetaltherapy.
co.uk/
106 www.thelancet.com/psychiatry Vol 8 February 2021
growls of gore from any number of extreme metal bands,
metal is, as T S Eliot wrote of John Webster, “much possessed
by death”. Is this exposure to such negative themes harmful
to listeners?
Music journalist and co-host of Riot Act podcast
Remfry Dedman told The Lancet Psychiatry that listening
to metal “is a wonderful way of opening the door to those
feelings [of mortality]. It’s a positive thing to talk about
something that is an inevitability for all of us”. He added,
“I think it’s healthier to talk about those [negative emotions].
Getting those feelings out instead of bottling them up is
clearly a far more positive thing for your mental health”.
Similarly, Eva Spence of metal band Rolo Tomassi told
The Lancet Psychiatry that listening to metal “can help
through emotions of anger and pain and I find it to be a
release for pent up emotion”. Spence spoke of what she sees
as the openness and honesty of the genre, in which mental
health problems are easily identified, “so if you’re struggling,
you can sometimes find a connection to how you’re feeling
within the lyrics. I feel that in itself opens up the discussion
and often bands are very open about sharing the meanings
[of lyrics] and talking about those experiences during shows,
on social media, and in interviews”.
Rebellious, defiant, and emotionally intense, many fans
discover metal in their teenage years. Genevieve Dingle,
associate professor in clinical psychology at the University
of Queensland, Australia, told The Lancet Psychiatry that
“younger adults are much more likely to use music to
immerse in states like sadness and anger. They’re using music
as a way of understanding negative emotions and learning
about them and how they feel”. Dingle said that adolescents
immerse themselves in different emotional states as a way
of practising and learning to regulate those emotions. She
added that “[adolescents] are trying out these dramatic
mood states and working their way through them”.
For over 50 years, parents have worried about the anger-
inducing effects of enjoying music that is characterised as
angry and antisocial. In 1985, amidst the USA’s so-called
satanic panic, the Parents Music Resource Center compiled
a list of 15 songs that the committee found to be the most
objectionable for their lyrical content, which included sex,
violence, drug use, and the occult. Most of those songs were
metal. Dingle, however, said that we have no evidence that
when angry people listen to metal, listeners keep getting
angrier. In fact, Dingle said, “if [individuals] are feeling really
fired up and angry and the music [they listen to] is really
high tempo, it can match how they’re feeling and help
them to regulate that [emotion]”. At least one small study
showed that fans of metal in an induced angry state who
subsequently listened to metal reported afterwards decreases
in subjective ratings of hostility, irritability, and stress.
Fuelling the controversy are findings of high suicidality
among fans of metal. These findings have been used by
some in the media to lend credence to spurious notions
of causality. “It’s easy to say the music is creating these
problems”, Dingle explained, “when actually it could be
that the music is reflecting the problems they’re already
experiencing and is some way for them to understand and
match a negative emotional state”.
Serena Cherry, guitarist and vocalist for UK band Svalbard,
has spoken openly about her depression. Cherry told
The Lancet Psychiatry that “when you’re suffering from a
bout of depression, you lose that ability to connect with
anything you’re doing or anyone around you.” While working
on Svalbard’s latest album When I Die, Will I Get Better? Cherry
described feeling possessed. “It was as if someone else
was [writing music] for me”, she said. “I remember being
really anxious about going into the studio to record the
album because I didn’t feel like it was finished, I didn’t feel
aware of what I’d done”. The result is a frank exploration
of mental health issues, the objectification of women,
rape culture, and more, drifting between bruising riffs and
expansive atmospheric passages. The song Listen to Someone
pleas, “Don’t tell me it’s OK / To not be OK / Then wince at
everything I say”. If, as mental health campaigns state, it
is time to talk, Cherry points out that people need to be
prepared for what they hear. Cherry said that “writing about
those horrible experiences [of depression] and turning it into
a metal song harnesses the pain to turn it into something
empowering. The more you represent [mental health
problems], the more awareness you can spread, and the
more awareness [that exists], the more understanding.”
Awareness of mental health issues in metal seems
to be growing, for both musicians and fans. Stadium-
fillers Metallica laid bare their struggles in the 2004 film
Some Kind of Monster, which documents the band’s time
with a therapist, hired to help repair members’ relationships,
strained by egos and addictions past and present. And in
September, 2020, in his autobiography Confess, Judas Priest
singer Rob Halford wrote about the adverse mental health
effects of having hidden his sexual identity for much of
his life. Testament to the role of metal in maintaining
mental health is peer-support project Heavy Metal Therapy.
Kate Quinn is a clinical psychologist who founded the group
for users to share their experiences of how metal has helped
them to deal with or overcome mental health issues. Quinn
told The Lancet Psychiatry that the project “is based on the
idea that sharing stories with each other is really helpful,
sharing stories of recovery and how metal has helped people,
and also the peer-support element, so that people support
and encourage each other by putting playlists together
that are about different emotions and different mental
health themes”. Some of those stories shared on the Heavy
Metal Therapy website include how metal has helped with
overcoming bullying, providing comfort in bereavement,
managing anxiety, building confidence, and more. One
user describes how he works with the voices he hears to
decide what to listen to: the angrier the voice, the heavier

the Metallica song. The process, he states, helps him to
connect to different voices, which he describes as being like
“honouring the different parts of myself”.
Metal is replete with references to mental health problems.
In many ways, metal complements the work of the Hearing
Voices Movement, advocating an understanding that does
not pathologise hearing voices, but frames the experience as
a valid, subjective, and meaningful response to a life event.
Stigma is often a substantial barrier to being able to talk
about uncomfortable experiences, but hearing one’s own
experiences reflected in a song’s lyrics can be encouraging.
Quinn described the apparent paradox of the calming
effect of angry music and said that listening to metal was
an important way of controlling her own anxiety. She said,
Book
The war at home
When addressing mental wellbeing during the First World
War, we probably think first and foremost of shell-shocked
military personnel. Yet there were about 100 000 civilians
in Britain’s mental hospitals at the start of the 20th century,
whose story goes far beyond warfare’s indirect effects
of dislocation, deprivation, and anxiety. For men, the
largest single category of diagnosis on admission to four
very different so-called lunatic asylums in or near London
(Colney Hatch, Claybury, Napsbury, and Hanwell) was not
a version of post-traumatic stress disorder; it was alcohol
misuse. For women, it was so-called prolonged mental stress.
Fully one tenth of men were admitted with general paresis
of the insane—now known to be late-stage syphilis—and it
accounted for one sixth of deaths in the asylums. A former
old-age psychiatrist who went on to do a PhD in history,
Claire Hilton effectively deploys the methodologies of both
disciplines to study the treatment of these civilians in a time
of national emergency. Her book Civilian Lunatic Asylums
During the First World War: A Study of Austerity on London’s
Fringe is the 22nd in a prolific series entitled Mental Health
in Historical Perspective, and it equals the high standard
of its companion titles. Hilton thoroughly contextualises
psychiatric care, bringing insights into the governance
processes that for centuries have mediated or negotiated
relations between the state and local political entities, law
enforcement, medical personnel, communities, families,
and patients, for the shifting benefits of different groups.
Prominent themes include the impact of regimented and
authoritarian relations on both the treatment of patients
and the provision of such basics as food, warmth, bathing,
work, and recreation (the dynamic of staff–patient relations
on the wards is brought out particularly well in chapters 4,
6, and 8). Hilton has a profound awareness of what made
asylums tick. Descriptions of the patients’ psychiatric
www.thelancet.com/psychiatry Vol 8 February 2021 107
Insight
“being able to engage with something, rather than trying to
turn away from it all the time, is a cathartic thing”.
This idea of catharsis comes up a lot among metal fans
and musicians. At its best, metal takes an unflinching look
at life’s harsh realities, and provides a complex emotional
response. This is not important not only for individuals with
formal mental health diagnoses, but for anyone who has
struggled to face life’s difficulties. Amidst a global pandemic,
when misinformation is rife, and political and behavioural
responses are deeply polarised, metal’s combination of
emotional realism and gothic escapism could be the perfect
soundtrack to our lives.
Jonathan Blott
condition are humane but often harrowing, those of their
experiences of institutionalisation haunting and occasionally
disturbing. Regrettably, none of the asylum records have
collections of patient letters, used by Allan Beveridge and
others to nuance accounts of their treatment, derived from
inspection reports of each institution’s lay management or
visiting committees and the national Board of Control for
asylums. While some might rush to condemn past practices,
which do not live up to apparently perfect modern standards,
Palgrave
there is here an empathetic understanding of the problems
and possibilities of institutional psychiatry a century ago,
its outcomes determined by staffing, power structures, Civilian Lunatic Asylums
During the First World War:
resources, legislation, and regulation—all mediated through
A Study of Austerity on
distinctive Victorian and Edwardian social attitudes towards London’s Fringe
gender, class, illness, and public versus private priorities. Claire Hilton
To take one specific example of Hilton’s analysis, the short Palgrave Macmillan, 2020
pp xix + 294 pp; 23 illus.; 11 illus.
section on suicide (on the early modern history of which I in colour, open access
have published) handles the curiosities of the law sensitively ISBN 9783030548711
and without sensationalism (both suicide and attempted For Allan Beveridge’s research
suicide were criminal offences until 1961). on patient letters see
Hist Psychiatry 1998; 9: 431–69
The stories of the four asylums and their people are told in
For Rab Houston’s History of
close detail in bite-sized sections within chapters (albeit these Psychiatry podcast and Twitter
impede the flow of the argument), but the broader lessons feed see https://arts.st-andrews.
history teaches are also clearly explained. As Hilton puts it: ac.uk/psychhist/ and
@HistPsychiatry
“The past has continuity with the present and the future.”
Thoughtful and reflective, balanced and fair, her critiques
can nevertheless be as devastating as they are relentless;
for example, the harmful effect of the 1890 Lunacy Act on
innovation in care is a theme that pervades the book. Both
empathy and relativistic perspectives have their limits and
Hilton has a keen eye for, and a palpable indignation about,
instances of abuse and neglect, fudging and failure. Her
conclusion about the high rates of death from tuberculosis
in mental hospitals stands in for many changes in care she