Saturday, 20 May 2017

The first modern survivor advocate?

I could not but respect the mind that had laid out so comprehensive and devilishly ingenious and, at times, artistic a Third Degree as I was called upon to bear. And an innate modesty (more or less fugitive since these peculiar experiences) does not forbid my mentioning that I still respect that mind. 
A Mind That Found Itself-p.31
Clifford Beers seemed to have everything going for him. A young and talented graduate of Yale, he started work at the New Haven tax office in 1897 anticipating a better job in New York. Months later his dream was realised and Beers took up a job for an insurance company near Wall Street, staying until 1900. But all was not well and Beers increasingly succumbed to what he later described as depression and depletion of his vitality. Beers moved home to his parents in New Haven, rapidly descending into fantasies of suicide. Unable to tolerate his "terrific nervous strain" any longer, Beers threw himself from the fourth floor of the townhouse in which his parents lived.

Beers' darkest moment was the start of one of the most extraordinary stories in psychiatric history. To become a psychiatric patient in America at the start of the 20th Century was to fall mercy to entrepreneurial hacks or sprawling and anonymous state asylums. Beers experienced both of these, but would later go on to be one of the most important survivor advocates in history. It started with his memoir A Mind That Found Itself (a title I love for its mind boggling implications) in which he writes of his experiences of what then passed for mental health care.

Beers spent time in three different institutions, two private sanatoriums before being moved to the state asylum in Middletown. His description of what he encountered is a disarming mix of the tragic, the enraging, and the comic. Beers is repeatedly beaten and restrained, including in a "muff," something I hadn't learned about before reading his book. A picture of one (courtesy of MissCreepers) helps us to understand how it would work:

He also describes acutely the petty and largely invisible cruelty experienced at the hands of staff unable to recognise and constrain their own punitive impulses. A Mind That Found Itself is a catalogue of small but poisonous interactions which escalate to physical violence. Beers does not profess complete innocence in all this and does not shy away from candid reflections on his own sometimes provovative conduct. Indeed when he had completed his manuscript he sent a copy to William James. James wrote back:
You were doubtless a pretty intolerable character when the maniacal condition came on and you were bossing the universe.
But as a man who was viewed by his treaters as "insane," the onus was not on Beers to maintain the highest standards of conduct. The repeated failure of his custodians to avoid reflexive and punitive reactions to unusual behavior is a problem that still runs shamefully through mental health treatment today. Bringing it to light will stand as one of Beers' greatest legacies. He is at his most heartbreaking when describing the treatment of others:
Of all the patients known to me, the one who was assaulted with the greatest frequency was an incoherent and irresponsible man of sixty years. This patient was restless and forever talking or shouting, as any man might if oppressed by such delusions as his. He was profoundly convinced that one of the patients had stolen his stomach—an idea inspired perhaps by the remarkable corpulency of the person he accused. His loss he would woefully voice even while eating. Of course, argument to the contrary had no effect; and his monotonous recital of his imaginary troubles made him unpopular with those whose business it was to care for him. They showed him no mercy. Each day—including the hours of the night, when the night watch took a hand—he was belabored with fists, broom handles, and frequently with the heavy bunch of keys which attendants usually carry on a long chain. He was also kicked and choked, and his suffering was aggravated by his almost continuous confinement in the Bull Pen. An exception to the general rule (for such continued abuse often causes death), this man lived a long time—five years, as I learned later. 
A Mind That Found Itself-p.139

A Mind That Found Itself is also fascinating psychologically, for its reflections on the thinking and reasoning involved in what we might now describe as an affective psychosis:
They thought I was stubborn. In the strict sense of the word there is no such thing as a stubborn insane person. The truly stubborn men and women in the world are sane; and the fortunate prevalence of sanity may be approximately estimated by the preponderance of stubbornness in society at large. When one possessed of the power of recognizing his own errors continues to hold an unreasonable belief—that is stubbornness. But for a man bereft of reason to adhere to an idea which to him seems absolutely correct and true because he has been deprived of the means of detecting his error—that is not stubbornness. It is a symptom of his disease, and merits the indulgence of forbearance, if not genuine sympathy. Certainly the afflicted one deserves no punishment. As well punish with a blow the cheek that is disfigured by the mumps. 
A Mind That Found Itself-p.42

And this, along with Beers' experience of a Capgras-style delusion, may be part of why William James found the book so compelling. He wrote to Beers:
The most striking thing in it to my mind is the sudden conversion of you from a delusional subject to a maniacal one—how the whole delusional system disintegrated the moment one pin was drawn out by your proving your brother to be genuine. I never heard of so rapid a change in a mental system.
When he was discharged from the state asylum, Beers became an energetic advocate for the rights of people receiving psychiatric treatment. Among other things, Beers went on to found an outpatient clinic in New Haven, which just happens to be at the bottom of the road I currently live on:

But not everyone was impressed with Beers' book. Shortly after its publication, the superintendent of the Connecticut state asylum, Alfred Noble, felt moved to write a defensive response in one of his regular reports. Irritably and awkwardly, Dr. Noble blames the victim, saying "insane people do not always manifest the angelic temperament which some would have us believe," before going on to indulge some egregious character assassination:

(I am indebted to a librarian at the Connecticut Valley Hospital library for making this available)

But Beers has the last laugh. The grounds of the old asylum house the campus of what is now called Connecticut Valley Hospital. Dotted around the grounds are buildings named for various esteemed former superintendents. Noble Hall stands in abandoned disrepair, but at the crest of the hill overlooking the eponymous valley stands a building still in use. Its name? Beers Hall.


You can read more about Beers' reform work here
A Mind That Found Itself is available online in its entirety courtesy of Project Gutenberg

Thursday, 6 April 2017

The ethics of fascination

Much as I can get fed up with the glibness and superficiality of Twitter, it occasionally throws up some sustaining gems. Thankyou to Neassa Conneally (@neasaconneally) for posting this gut-punching extract from the Oxford Handbook of Clinical Medicine:

It somehow chimed with a remarkable piece I read recently by Kate Davies, who reflects on reading books about the brain while she prepares her own personal work about a stroke she suffered. Davies is somewhat critical of the genre, and takes to task in particular one widely respected author:
I know that [Oliver] Sacks is much beloved as a sort of avuncular figure in the field of popular science, and that many of you find his writing humane and amusing and insightful. Perhaps I too might once have felt that way, but from the perspective of a person who has experienced brain injury he really is “the doctor who mistook his patients for a literary career” in the memorable words of one reviewer. He may be a fantastically able writer with an undeniable facility of communicating the way that brain deficits might hold a key to the mysterious operations of our grey matter to a general audience, but his early work is so deeply exploitative of his patients, their complex conditions, their lives and their experiences, that I find myself unable to reconcile myself to anything of potential worth in his output. 
That section hit me in particular because I am probably one of those who have lionised Sacks. Davies' post made me think about a more general tendency alive in psychology and neuropsychology, and probably in all caring professions; the tendency toward fascination with people and their problems.

To be a psychologist of any stripe is to be fascinated by people, almost by definition. The field is crowded with a canon of human intrigue. A considerable amount of what we know about our minds has come from famous case studies of people whose lives were disrupted by events of violence and tragedy (a not insignificant number of which were aggressive surgeries by optimistic doctors). That tragedy fades into the background when we focus on a striking loss of ability, change in personality, or new double dissociation. When neuropsychological case studies are presented as education or literature, the dominant response is generally meant to be "Wow, how interesting!" rather than a reflection on the depths of a tragedy.

What are the ethics of this fading? Let's put aside ethical issues about what and whether to publish about patients. That question has its own well trodden terrain. What are the ethics of simply being fascinated in the clinical encounter? Of regarding people's minds not just in terms of their private sorrow, but as phenomena that engage interest? How often do clinicians remark to their colleagues that someone they are working with is fascinating? What do they do to that person when they say such things?

On the positive side of the ledger, I have always been impressed by Sacks' evident enthusiasm for the subjectivity of his patients. His pursuit of their experiences doesn't just deepen the reader's theoretical understanding, it presumably intensified the quality of the care Sacks gave as a doctor. His books are always full of ingenious rehabilitative strategies that could only come from an intimate understanding of the what it's like-ness of neuology. In this sense then, fascination is an engine for the good. Think of Jimmy, The Last Hippie in An Anthropologist on Mars. Sacks' curiosity about the nature and extent of Jimmy's dense amnesia prompts him to organize an outing to Madison Square Garden to see The Grateful Dead.

But does this process of deep scrutiny itself have a clinical downside? If some patients problems are fascinating enough to be worked up into bestsellers, what of the more mundane cases whose neurological losses are patchy and banal? Might they be implicitly shunted further down the pecking order of intrigue? Such a hierarchy is disquieting enough in itself. What if it led to those less interesting patients being afforded less attention?

Fascination might also be a distraction or manic defense. The extract I started with draws our attention to an aspect of illness that it can be easy to avoid thinking about; the loneliness and despair it so often entails. These are the things that patients might be expected to care about. But professionals have the luxury of keeping their focus on what is intriguing. What does it mean for patient care when the novelty or peculiarity of a symptom comes to dominate the picture? More attention perhaps, but more attention to a symptom, which would seem to entail distraction from the humdrum daily struggle of being unwell. Even without tangible effects on the well-being of the patient, such distraction seems somehow inherently perverse.

I'll finish with a quote from the psychiatrist Elvin Semrad, drawn from a book of his aphorisms:
I don't have any more interest in hallucinations and delusions that I would in a fever. I don't care about the fever, but what's going on to cause it. Don't get me wrong, fever is interesting for people interested in research on fever. But what are you going to do with this guy, help him or make him an academic study? -p.164.

Monday, 20 February 2017

Agency in Madness

I have a piece in the March edition of The Psychologist on the history of thinking about agency in psychosis. It is meant to be a brief whisk through of some of the literature (fictional and psychiatric) on the issue.

However, there is an intriguing conundrum nearby that I don't really get into: the question of whether it is actually possible to think yourself into a psychosis. If, like me, you are tempted to answer "no," then it is worth wondering why. Two obvious thoughts: 1. Psychosis seems, at least in part, to be a matter of predisposition. 2. Most people experience psychosis as something that happens to them. But these are not knock down arguments

First, a predisposition needn't entail something's being entirely passive. Many talents are probably (partly) a matter of predisposition, but you can't express a talent without agency. Does it ever make sense to say that someone has a talent for psychosis? Second, experiencing something as though it were passive is not the same as its actually being so. We can be mistaken about mental agency, as psychologists well know.

Part of why this question is interesting is that the non-standard answer (the one that violates our traditional intuitions) would seem to vindicate some peoples' experiences. I once asked someone in the recent aftermath of a psychosis how they had found their antipsychotic medications. Did their thinking feel clearer? It certainly seemed (from the outside) as though it was. They agreed their thoughts were clearer, but disavowed a role for the medicine, saying they had done it themselves.

Medication in this instance looked like the most plausible proximal cause, but if psychosis is more likely to emerge under certain cognitive conditions, might it be that medications provide the conditions, and that the patient does the rest? Outcomes in psychosis are very variable. Could agency be an overlooked piece of the puzzle?

Sunday, 29 January 2017

Diagnosing Donald

(note: more than is usually the case, credit must go to my wife for formulating many of the substantive ideas in this post)

Since he lurched into the Republican primaries last year, There seem to have been more published diagnostic impressions of Donald Trump than for any public figure. Perhaps someone with interests in both mental health and politics can't avoid seeing such pieces doing the rounds, but I suspect it is not just me.

We should all know better. The Guardian's Hannah Jane Parkinson wrote a well thought out piece about the issue back in November, when the Donald's combination of prominence and unpleasantness had reached its latest peak. Distance diagnosis, she reminded us, can be inaccurate, undermine confidentiality, and perpetuate stigma. It didn't seem to change very much. 

Sometimes I see what purport to be knock down arguments against diagnosing Trump. He doesn't have a mental disorder, he's just a bad person. He doesn't have a mental disorder, he has a flawed character. But however small the overlap might be on the Venn diagram of "bad people" and "diagnosable people," it is not non-existent. These arguments don't hold water and are a red herring. There are other more pressing reasons not to diagnose Trump.

If diagnosis is to have any place at all in mental health care (and I have argued frequently that it inevitably does and will), it can only be as a beneficent way of re-conceiving the difficulties that bring people to mental health services. Even if you oppose diagnoses and resolutely refuse to use them in practice, a referral to a particular EST, the use of particular therapeutic style, or medication all indicate a particular diagnostic formulation; the use of categories as a reference class to guide decision making. Users of mental health services are not stupid; people can infer diagnoses, ask for information about them, or even explicitly ask for one to be given. Professionals have to make peace with how they use that information and how they frame it.

Let's focus on personality disorder diagnoses, as this is type that most frequently gets applied to Trump. I don't like "personality disorder" as a way of talking, and am inclined to see that cluster of problems as having to do with what David Shapiro called "styles." Life is a weird and difficult thing, and we all have styles that help us get through it. My own style, for example, might be framed as a sort of cautious, ruminating introversion. My temperament and my lifetime's reinforcement schedule have helped pushed me into acting in a particular way. Sometimes it works well, and sometimes less so.

Sometimes our styles get us into trouble. When that trouble is of a particular sort, our styles can get called personality disorders. If you want to help people examine and adapt their style, you have to first create a situation in which you aren't just some hostile outsider telling them they're doing things wrong. You have to try to understand what the style feels like to inhabit, what it is helping someone to achieve, and how it might look different. Help for someone with a diagnosis like "borderline personality disorder" can only come with honest communication about what such a term is supposed to denote.

Herein lies the problem with diagnosing Trump. It's not that he is in principle un-diagnosable, but that the people diagnosing him are doing it for all the wrong reasons. Opponents of diagnosis sometimes say they are insults, and that they perpetuate an uncomfortable power imbalance between clinician and service user. Is that not exactly what we see in the bandying around of "narcissism" as a word to describe Trump? 

When Deborah Orr called Trump "King Narcissist," she deployed the formal sounding acronym "NPD," but went on to frankly insult him in less clinical terms:
"In the world beyond psychiatric jargon, narcissists are usually known by the more colloquial terms of “bully” or “abuser.”
And when journalists, psychologists and psychiatrists wade in and offer diagnoses, are they not trying (rather desperately) to pull back some power from the man who now arguably holds more of it than any single other person? Trump is a whirl of aggression, authoritarianism and petty nativism. Like all politicians, he is a human with a mind. It is appropriate, even imperative, to wonder about his reasons and emotions. One day (if we survive) someone will probably write a fascinating biography that explores why Trump came to be the sort of president he's turning out to be. But unless he elects to see a mental health professional, or falls so far foul of the law that he can't avoid it, diagnosing him serves no purpose.

A mental health diagnosis can only have value if it takes place in a formal compact, usually between two people who want to work on a problem. We know that diagnoses can be stigmatising and insulting. We know that they map uncomfortably onto what can be a pernicious power dynamic. We know that many people find they make matters worse. Trump's would be analysts seem to believe they are casting light on his behaviour, and helping to predict his presidency, but they are engaged only in power play and sophisticated insult throwing. If you're the kind of clinician who thinks they can help anyone by diagnosing a public figure from arm's length, you're mistaken.

Friday, 9 December 2016

Illness, Authority, and the Burden of Proof

Psychiatry is beset by a chronic controversy around the world “illness”. Critics and opponents of the specialty have long been engaged in what the philosopher Ian Hacking called an “unveiling” project, questioning the authority of psychiatrists to label people as ill. This has generally worked by highlighting the lack of an unambiguous marker or validator to confirm the presence of illness. Arch critic Thomas Szasz noted the lack of a physical lesion to prove the existence of pathology, and declared mental illness a “myth”. In a famous early 1970s experiment, Rosenhan and colleagues demonstrated that a single malingered psychiatric symptom could, without confirmatory tests, lead to hospitalization.

Herein lay the unveiling Hacking describes; revealing that something supposedly real was in fact constructed. The broad narrative of these critics was that “psychiatric illness” was a term applied to behaviours and experiences that were not pathological. Unlike other medical specialists, who are experts in demonstrably physical disease process, psychiatrists lack an externally validating terrain. They thus lack the authority to say of their patients “this person is ill”.

Notice the form of the argument; without validating evidence that a physically demonstrable disease process is present, we ought not to use the word “illness”. Thus, in psychiatry, we seem to treat illness as being similar to criminal guilt. A person is healthy until proven otherwise; sane until proven insane. Maybe this is the right way for psychiatry to be organized. We all naturally seek to be recognized as autonomous, reasonable individuals, capable of deciding for ourselves. We recoil from the possibility that our vision of reality may be compromised. Putting the burden of proof on the psychiatrist protects us pre-emptively from the possibility our autonomy is compromised and our slant on the world is “off.”

But it is worth contrasting this state of affairs with other forms of medical complaint. In a recent book about psychosomatic illness, neurologist Suzanne O Sullivan reports on a series of patients with serious physical symptoms. In each case, she concludes the most important causal factor lies in emotional conflict or disavowed stress. Although she does not deny these patients are ill, she does deny that the illness is straightforwardly physical in the way they believe. It is interesting to observe that, contrary to the situation faced by many psychiatrists, Sullivan has to work hard to persuade her patients that they don't have a disease.

Here the burden of proof is somehow reversed. The patients approach the doctor claiming to have a physical disease. Only a complex diagnostic process is able to rule out its presence and allow the symptoms to be accounted for as “psychosomatic”. Even then, there is no disease, but the patient is still ill. How can this be? Doesn’t Sullivan lack the same medical authority as psychiatrists in these instances? Isn’t she, like them, forced to conclude that absence of a disease process entails absence of an illness?

Apparently Sullivan cannot observe her patients’ situations and fail to conclude that they are ill. This seems partly to be sympathetic, and partly intuitive. Sympathetic because Sullivan is clearly at pains to communicate to her patients that she takes their experiences seriously. They feel themselves to be ill. Intuitive because and to all intents and purposes, these patients simply seem to be ill. When an individual is unable to walk, or is subject to persistent and debilitating seizures, we readily concur that we are in the terrain of medicine. We havestrong intuitions about where illness is and where it is not present. How otherwise how could the arguments about disorders like ME/CFS could, get so heated and confused?

Somehow our intuitions about physical and psychiatric debilitation are different. We question psychiatrists’ authority to label their patients “ill” in way we don’t bother to with for other specialties. This is not just a question of objective markers, it is written into how we interpret different experiences. This may amount to a systematic bias against seeing illness in the psychiatric realm. Insofar as psychiatry can suffer from “mission creep” (into the medical-labelling of political dissenters for example) this bias may have its uses. However, despite a relatively vocal movement for the demedicalisation of mental health services, there is reason to suppose that a complete movement away from an “illness model” will not serve everyone.

“Illness” is not only a word imposed top down on people’s subjectivity by patrician doctors, it is also a way of giving form to experiences that are painful, disorienting, dangerous or overwhelming. The idea of experience as illness can make sense of it no less than a narrative about its social, traumatic or affective origins, and is in any case not necessarily in conflict with such a narrative.

It is worth wondering then, why we light so easily on the idea of illness in the case of some forms of overwhelm, and so reluctantly in the case of others. In either direction we run the risk of going wrong. We might reasonably ask who has the authority to say that someone else is ill, but we might also wonder who has the authority to decide who is not.

Thursday, 17 November 2016

What's our problem with genetics?

In the field of mental health there is a distinct allergy to the question of genetic influences on cognition. At its most extreme, this allergy leads to a sort of anaphylactic reaction that has been called genetic denialism. A recent example of this (an example that prompted the epithet) is Oliver James’ book “Not in Your Genes”. However, a milder form of the allergy exists, and I call it genetic disavowalism. Genetic disavowalism is far more pervasive than genetic denialism, and finds its way into clinical psychological writing. 

Genetic Denialism has changed little in 30 years

Genetic disavowalism has valid historical roots. There are good reasons for horror when we examine the way that genetic theories have been distorted to promote policies of eugenics and even mass extermination. But as with other allergies, the responses that are mobilized against “gene talk” are out of proportion to the current level of threat. It is misguided to conclude that it is somehow desirable to steer clear of genetics, or “genetic explanations” altogether, or that the field as a whole is tainted by Nazism. As is the case with other allergies, these responses may be counterproductive, or even damaging.

When I talk about disavowalism, I am not referring to certain widely agreed upon facts about the limits of genetics in psychiatry. That is, I am not calling into question the idea that genes are only one part of the aetiological process giving rise to various mental health problems. I am not contesting that the heritability quotient is a limited form of information about the role genetic influences and leaves (for the time being) a “heritability gap” between rates of within-family concordance and accounted variance in molecular approaches to genetics. Neither am I questioning the limited practical application of genetics in many areas of psychiatry. What falls under the scope of genetic disavowalism- what I take to be intellectually unhealthy- is a detectable aversion to even considering psychiatric genetics as a reasonable field of enquiry for aetiology or therapeutics.

Genetic disavowalism can be associated with its own wrongs. I lose count of the number of times I have seen a psychologist descry genetic explanations on the grounds that they imply a person is “permanently flawed” or similar. Flawed? Let’s follow the reasoning. If a genetic explanation implies that someone is permanently flawed then presumably a theory which allows for a more transitory kind of experience (an environmentally determined, understandable “reaction”) only implies that they are temporarily flawed. The time frame changes, but the “flaw” remains. 

This is not a problem with genetics; it’s a problem with how some people (including apparently, critics of genetics) think about other people. The use of the word “flawed” is suggestive of a value judgment that has nothing to do with causes, and everything to do with how you regard a behavior or trait. If you come to the aetiological debate with the view that people with mental health problems are “flawed”, then your inclination to disavow genetics may be a defence against your own internal prejudice.

It can be helpful, in the face of genetic disavowalism, to probe intuitions about the morality of psychiatric genetic research and intervention. If genetic psychiatric research is inherently negatively morally valenced (or if it amounts to a “tedious obsession” as I have seen it said), we might ask whether it should be discontinued.

Here is a case study that bears on the question. In Steve Silberman’s Neurotribes, there is a wonderful description of the origins of our genetic understanding of Phenylketonuria (or PKU), a disorder which can result in profound cognitive and intellectual disabilities. The Norwegian researcher Ivar Følling had noticed a strong smell in the urine of a child who had developed intellectual disabilities. Further testing revealed this to be the result of high phenylpyruvic acid levels, indicative of a difficulty metabolising phenylalanine. Phenylalanine build up in the brain is what leads to the pervasive cognitive difficulties often seen in PKU. Følling showed that the underlying metabolic problem was determined by an inherited abnormality on a specific gene.

This was a serendipitous discovery that came out of a line of investigation that can easily seem hopeless; the search for genes for generalized cognitive disability. Nonetheless, its implications are extraordinary. Children with the gene can now be identified at birth and, with a simple dietary regimen, be prevented from developing the sort of pervasive cognitive difficulties that can make it impossible to live independently. Was this unexpected discovery a bad thing? Are we worryingly closes to a program of eugenics for knowing that there is a form of cognitive disability that is caused entirely by an inherited abnormality on the PAH gene? Is it morally wrong to stave off that disability by resorting to a preventative diet?

The story of PKU will not easily generalize to all areas of mental health, but it is foolish (and a form of ahistorical thinking) to suppose that unexpected shifts in our knowledge about the genetics of mental health can not now lead to other breakthroughs in treatment. In 2016, do we know all there is to know? Psychiatric genetics has been parodied by analogies to a “gene for homelessness or debt”, with the implication that it is conceptually wrong-headed to conduct genetic research in the domains of schizophrenia or depression. Maybe a gene for homelessness or schizophrenia will never be found, but genes or genetic mutations for some specific subtypes of cognitive problems are not out of the question. How to approach genetic research most fruitfully is one issue. Whether that research should take place at all is another one entirely.

Friday, 28 October 2016

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.