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.