Is mental illness denialism a death sentence?

A decision by Pakistan’s highest court, to define schizophrenia as “not a mental disorder” has caused some consternation for legal advocates and psychiatrists. As a result of this ruling, Imdad Ali, a 50 year old Pakistani man can now be executed for a crime he committed in 2001. Ali has a diagnosis of schizophrenia, which his lawyers hoped would mean that (although he has been convicted) he could not be executed as punishment. This hope seems to have been grounded in the fact that Pakistan is signatory to a UN agreement, that individuals like Ali will not be executed if they are “not capable of understanding the crime and the punishment”.

Psychiatrist Joe Pierre has argued that antipsychiatric thinking may play a role in this case. It certainly seems that way superficially. Here’s his reasoning:

1. Imdad Ali is going to be executed because the court has cast doubt on the reality of schizophrenia
2. Mental illness denialism casts doubt on the reality of schizophrenia
3. Mental illness denialism may have fed into this judgment, and may lead to similar results elsewhere.

I think there might be grounds for placing more distance than this between mental illness denialism (something I have pushed back against) and the Pakistani court’s decision. Although the court does seem to make an outrageous ruling (its judgment explicitly states that schizophrenia is not a mental disorder, as defined by the country’s own 2001 mental health ordinance), the grounds for that decision may be closer to the mainstream of psychiatric thought than journalists are accepting. This is a judgement that (despite headlines) seems to have to do not with schizophrenia’s existence, but rather with its periodicity. It’s true (and widely accepted) to say that schizophrenia is not a condition which always effects you in the same way at different times. People with the diagnosis of schizophrenia have a waxing and waning in their degree of mental capacity.

Pierre mentions the insanity defense twice, but that does not appear to be relevant to this case. Ali has already been found guilty, which presupposes that he was a) declared fit to stand trial, and b) not considered “insane” at the time of the crime. There is no incompatibility here. In schizophrenia, the psychosis and disorientation come and go. We think nothing of keeping separate the insanity defense, competency to stand trial and diagnosis per se. Thus, it is possible (under US law at least) to have schizophrenia, be declared fit to stand trial and be found guilty of the crime, provided you were mentally competent at the relevant stages.

This case seems to hinge on whether Ali is competent to be executed. It is a repugnant question. If, like me, you abhor the death penalty it doesn’t seem coherent to imagine people could be competent in the relevant way. Nonetheless, it is a well-established legal framework in the US. It has been unconstitutional since 1986 to execute an "insane" prisoner, which means someone has to decide whether an individual remains "insane" at the time of sentencing. The key detail is that the evaluation of competency to be executed is a decision distinct from the simple presence of a mental disorder. 

This idea is apparently what is being explored now in Pakistan. Here is what the judges seemed to have decided (from what is admittedly a fairly obscure judgement): schizophrenia shows a fluctuating course, therefore it is not a permanent mental disability, therefore it does not fit Pakistan's 2001 mental health ordinance definition of mental disorder; therefore Ali is competent to be executed. This chain of inference doesn’t seem right to me, and yet it is not that far from how things work in many US states. If Ali were on an American death row there would be no question about the legal status of his schizophrenia, but his competence to be executed would be an open question. You can make part of your living as a forensic psychologist, at least in certain US states by conducting assessments that bear upon this question. Entire books are written on the topic.

Pierre has a question in his subtitle: “could mental illness denialism result in the same thing happening in the U.S.?” Before we become concerned about mental illness denialism (an undoubted problem), we might wonder whether the court in Pakistan, rather than denying the reality of schizophrenia (it says explicitly in it judgment that it isn't) is clumsily contesting its nature. Then, rather than worry about this thinking spreading to the US, we should glumly acknowledged that the situation here is not much better.

A strange sad walk though asylum history

It is late afternoon on a warm fall day. New England is quiet and crisp under a pale blue sky and waning orange light. I am alone in a clearing, surrounded by radiant autumn leaves and the cold uniform stones of a cemetery.

In the heart of rural Connecticut, just under a kilometre from a river that wends through the state down to the Long Island Sound, is the graveyard for residents of what was once the state asylum. It is a lonely place, set back from a tarmacked road so that you have to drive along a wide gravel path with the dust kicking up behind you.

The cemetery sits in the lee of a valley with the huge crumbling redbrick buildings of a 19th century hospital just up the hill. Many of those are still in operation but now constitute a network of modern mental health services; inpatient units, community outreach teams and assorted therapeutic services. Although only a stone's throw away, they seem a million miles from this quiet corner. 

An air of calm prevails, with nothing but birdsong and the rustle of dry leaves to break the silence; a quiet that has a grim resonance to it. Although cemeteries are usually places of memory and melancholy reflection this is a peculiarly sad memorial. Other such places I have visited in America are brimming with the stories of the people they house. Whole patches of Queens are devoted to huge granite slabs bearing Irish or Italian names. Walking through them one is struck by the vigour of transatlantic migration, the keenness of struggle, and the strength of kin. 

These stones have no names, instead each is inscribed with a number. A simple designation made by the state hospital at a time when the people who died in such institutions were overwhelmingly anonymous and alone. At first glance it appears a relatively small plot of land, but look at the slabs and you see them creeping up to mark the resting places of over 1600 people. 

It is almost unbearable to think about the individual chains of events that must have led to so many forgotten people being buried here. At a time when all varieties of psychological and physical suffering were grouped into a morass of stigmatized hopelessness, individual stories were routinely submerged beneath an ocean of pessimism and neglect. 

I find myself hoping that at least each burial was attended by a ceremony of some sort, that the staff on the wards had fond memories of the people they were saying goodbye to. At a conference earlier this year I saw historians of madness discuss the turn toward investigating their subject from the perspective of the patients. The anonymity of this secluded graveyard feels like a vivid testament to the need for that scholarship.

Happily there has been an injection of much needed attention here. Between 2001 and 2015, a coalition of people, including retired pastors and the Connecticut Alliance for the Mentally Ill, have overseen the construction of a separate memorial linking the numbers on each of those headstones to the names of those buried beneath. Now three larger slabs stand at the front of the cemetery, with a dignified reminder of the fact that so many humans are buried here. 

Two news articles covered the process of creating the new memorial. This long piece in the New York Times came out just months after the attacks on the World Trade Center, and compared the sheer quantity of numbered dead with the losses experienced in that disaster. This article in the local Hartford Courant marked the successful completion of the project. Both contain moving stories about families finally filling in the gaps in the stories of lost relatives. Multiply them by 1,686 and you can acquire some sense of the human scale.

How could it happen? What made it seem like an anonymous resting place was dignity enough for the people of this graveyard? The Times piece quotes the hospital's chief executive as saying "The reason the patients' names are not on the stones is not to protect their confidentiality, but so it wouldn't bring shame on their families", but that is only partly explanatory. Why was it possible for shame to outweigh the basic human expedient of recognition in death? The question produces a vertiginous feeling. How obvious it seems now that serried ranks of numbered headstones resembles more closely an anonymous mass grave than a respectful final resting place. Which of our current institutional practices will one day look so patently wrong?

What do you mean "invalid"?

Here is a common statement made in debates about psychiatric diagnosis:

"[psychiatric disorder x] is an invalid construct"

This "validity critique" of psychiatric diagnosis arose after the technical overhaul of DSM-III, when the psychometric properties of such classifications became a powerful way of understanding their flaws. Originally, it came from seminal work by Richard Bentall and Mary Boyle, both of whom queried the construct validity and predictive validity of DSM-defined schizophrenia. This was an original and useful way to raise problems with schizophrenia-talk, and it has happily found its way into the mainstream of psychiatric discourse. Unfortunately these contributions get kind of watered down in the endless repetition of a "invalid construct" claim as quoted above. What gets left behind is the veneer of apparent truth, without any substantive meaning.

To say "valid" or "invalid" is not very helpful in itself. Those are words that have both a specific technical psychological meaning and a broader lay meaning. Validity in psychometrics is a term used to describe the extent to which a test or checklist measures something that is actually there or successfully predicts some other event. To understand what is meant by "valid" (or "invalid") we need to ask valid in relation to what? Thus a given questionnaire could be an invalid predictor of suicide, but still be a valid indicator of severely depressed mood.

Psychometric validity is difficult to nail down in the realm of diagnosis because it is not clear what might count as a validating criterion. Bentall and Boyle point out several facts about the diagnosis of schizophrenia, including the fact that symptoms do not cluster together and that functional outcome is not uniform. Those are good things to know, and they undermined pervasive myths about the schizophrenia diagnosis.

But in the broader, lay sense of the terns, it is all but impossible to meaningfully say whether diagnosis [x] is really "valid" or "invalid". What, after all, do those words really mean in this context? The dictionary definition simply suggests "grounded in fact", or "reasonable or cogent". On this definition, surely it is valid to say "I feel ill" (if your first person subjective experience tells you as much), or "I have schizophrenia" (if the technical language using community agrees as such).  If I have a set of experiences that feel subjectively like illness, cause me to meet DSM-criteria for a disorder and that DSM-diagnosis provides a constructive narrative for helping me to live the sort of life I want for myself, is it still an "invalid" diagnosis? In the technical sense of "invalid", it is arguable. In the broader lay sense of "invalid" it seems the answer is a resounding no!

Another way that psychologists increasingly talk of validation is in terms of recognizing the reality of people's experiences. Thus we validate people's sadness or anger by joining with their perspective and agreeing that anger or sadness was a reasonable thing to feel under the circumstances. Failure to do this is called "invalidating", meaning that it seems to undermine the reasonableness of an emotion. Invalidate someone's emotions and you show them they are wrong to have felt them. Invalidate someone's experience of reality and you hint to them that they are crazy.

Talk of lack-of-validity has been a valuable addition to understanding psychiatric diagnosis. But when it gets isolated from its underpinning arguments, validity talk in this context can be invalidating.