In a stunning ruling that attracted national attention this week, Pakistan’s Supreme Court declared that schizophrenia does not qualify as a mental disorder under the country’s criminal law definition. As a result, the court rejected the death sentence appeal of Imdad Ali, a 50-year old man diagnosed with paranoid schizophrenia who was convicted of murder in 2012, and concluded that his execution by hanging would proceed on November 2, 2016.
According to the human rights group Reprieve, the execution of a mentally ill prisoner in Pakistan violates both “international agreements which prohibit the execution of mentally ill prisoners” as well as Pakistani law itself:
"A statement issued by 14 of Pakistan’s leading psychiatrists also warns that executing Mr. Ali would run contrary to Pakistani law. The experts, including Malik Hussain Mubbasshar, Professor Emeritus at Lahore’s University of Health Sciences, said that: '[The] Law does not allow such execution of prisoners suffering from this nature of mental disorder in which the prisoner is having a psychotic illness and is unable to know why is he being executed and what will be the consequence of this punishment.'"1
Amnesty International notes that Pakistan is the “third most prolific [state] executioner second to China and Iran” and that:
"...in Pakistan many death sentences are handed down after trials that do not meet international fair trial standards and violate Article 10(A) of Pakistan’s constitution, which calls for a fair trial and due process for the determination of a person’s civil rights and obligations in any criminal charge."2
It therefore appears that by declaring that schizophrenia is not a mental illness, the Pakistani Supreme Court bypassed its own laws and international agreements in order to proceed with Mr. Ali's state execution. According to various sources, the declaration was based on the convoluted rationale that since schizophrenia represents an “imbalance” that can be exacerbated by stress and treated with medications and psychosocial interventions, it is a “recoverable disease,” not "permament condition," and therefore not a mental disorder. The complete court decision also cited the following quotation from psychiatrist Karl Menninger in 1962: "I do not use the word 'schizophrenia' because I do not think that any such disease exists."
While that might, or should, seem ridiculous, the claim that schizophrenia isn't a mental illness or a brain-based disorder, or that schizophrenia doesn’t exist, or that there’s no such thing as mental illness at all is hardly idiosyncratic to Pakistan. These claims have been rallying cries for the "anti-psychiatry movement" in the English-speaking world for years. Their argument goes something like this:
1. Despite years of investigation, researchers have never found a unifying biochemical or anatomical abnormality that provides a tidy explanation of “what’s wrong” in schizophrenia. Diseases have pathophysiologic explanations, schizophrenia doesn’t; therefore it can't be a disease.
2. “Symptoms” of schizophrenia like auditory hallucinations or "voice-hearing" can seemingly be “caused” by traumatic life events, not biological events. Diseases aren’t things that happen to you in response to “social” causes; therefore schizophrenia is not a disease or an illness.
3. Some people with symptoms of schizophrenia don’t get better on medications, some do get better without them, and some experience "voice-hearing" while otherwise appearing completely normal. Therefore, "pathologizing" or "medicalizing" the symptoms of schizophrenia doesn't make sense.
4. “Schizophrenia” is just a label that authoritarian entities use to control deviant or unwanted behavior.
By way of brief response, let me address the first three claims, before coming around to the last one at the end of this blogpost:
1. From its inception, schizophrenia has always been regarded as a constellation of different conditions, with many potential biological pathways leading to the expression of its symptoms. Therefore, researchers don’t expect to ever find some single abnormality in a gene, brain structure, or neurotransmitter to account for schizophrenia. However, there is extensive evidence of a broad range of genetic and anatomical abnormalities in people with schizophrenia, which I referenced in a previous blogpost called “Schizophrenia Doesn’t Exist?! What That Means and Doesn’t Mean” (see references 3 and 4 for more information).
2. Many people develop schizophrenia without any identifiable “social cause.” Regardless, the idea that social causes can be separated from biological causes is an outdated myth of dualism, the belief that mind and brain are two separate entities. When we talk to people or read a book, our brains respond by changing both physically and structurally – that’s how we experience emotion, learn, and form memories. Our brains likewise change when we’re exposed to trauma – it’s not an "either-or" of social vs. biological. Many medical conditions can be “caused” or exacerbated by stress – does that mean that migraines or peptic ulcers aren’t diseases, illnesses, disorders and should better be understood in social terms and only treated with social remedies? No, it doesn't.
3. It’s true that people who hear voices don’t necessarily have schizophrenia or need to be treated with medications (see my previous blogpost, “Is It Normal to ‘Hear Voices?’”). And it’s true that some people with schizophrenia don’t respond to medications and may be improperly diagnosed. But most patients with schizophrenia do experience significant improvement in their symptoms with medication, sometimes in life-saving ways. If schizophrenia isn’t a biological, brain-based disorder, how do we explain that? We can't, because schizophrenia is a biological, brain-based disorder.
Whether or not we call something a medical illness or a mental disorder admittedly has a level of subjectivity to it. Considerable debate often occurs before deciding whether to include or remove an entry in the Diagnostic and Statistical Manual of Mental Disorders (DSM). “Clinical utility,” that is, the usefulness for clinical work, has always been a guiding principle for that decision. In my academic work, I have highlighted the more complicated issue of “contextual utility” – the usefulness of a DSM diagnoses in areas in addition to clinical work, such as research and the law.5 Sometimes, if not frequently, such utilities come into conflict, resulting in disagreements about whether something should count as a mental disorder.
The Pakistan Supreme Court seems to acknowledge that there is such a thing as mental illness. They also seem to acknowledge that mental illness can be a mitigating factor that might make the death penalty an inappropriate punishment for crime. They even seem to acknowledge that Imdad Ali does in fact have schizophrenia (thought it's less clear that they believe that Mr. Ali has the capacity to understand the wrongness of his crime, which is a requirement for the so-called "insanity defense" in both Pakistan and the US). But in Mr. Ali's case, the diagnosis of schizophrenia seems to present an inconvenience that the court doesn’t find useful for its legal purpose. Based on this kind of analysis of contextual utility, the court seems to have decided to therefore simply disregard schizophrenia as a mental disorder. Case closed, prepare the gallows.
If schizophrenia doesn’t count as a mental illness, one wonders what, if anything, does count as a mental disorder according to the Pakistan Supreme Court. Perhaps it will prove convenient to do away with the concept of mental illness altogether.
Which brings us to the question of whether such like-minded, but wrong-headed, thinking in the English-speaking world could have similar repercussions. If schizophrenia isn’t a disease or if mental illness doesn’t exist as the "anti-psychiatrists" claim, does that mean that the insanity defense could go the way of the dodo? Will an increase in the capital punishment of the mentally ill become an unintended consequence of mental illness denialism? Or, looking beyond the legal into other contextual realms, could such denialism mean the end of funding for research and insurance coverage for clinical care?
I’m confident that wiser heads will prevail. Thinking about schizophrenia as a mental illness makes good clinical sense, identifying a condition that responds to treatment with both medications and psychotherapy. It has helped to guide research into both causes of and interventions for psychosis. And it has utility in service of the ethical treatment of those with mental illness who run afoul of the law. Schizophrenia therefore isn’t a label that’s used to oppress deviant behavior – on the contrary, denying that schizophrenia exists seems more likely to play that role.
[If you would like to more about the case of Imdad Ali and participate in Amnesty International’s call for action on his behalf, you can do so here]
3. Chen J1, Cao F, Liu L, Wang L, Chen X. Genetic studies of schizophrenia: an update. Neuroscience Bulletin 2015, 31:87-98. http://link.springer.com/article/10.1007%2Fs12264-014-1494-4
4. Wheeler AL, Voineskos AN. A review of structural neuroimaging in schizophrenia: from connectivity to connectomics. Frontiers in Human Neuroscience, August 25, 2014. http://journal.frontiersin.org/article/10.3389/fnhum.2014.00653/full
5. Pierre JM. Mental illness and mental health: is the glass half empty or half full?
Canadian Journal of Psychiatry 2012; 57:651-658.