"Who in the world am I? Ah, that’s the great puzzle."

―Lewis Carroll, Alice in Wonderland

Mental illness has always been a controversial topic and although neurobiological research in the last 2-3 decades has given us a better understanding, many aspects of it remain shrouded in mystery. The foremost among these is the basic question: what is sanity? Of course, this is allied to another philosophical query: what is reality?

It may not surprise readers to learn that psychology, the study of the mind (and psychiatry, its close cousin) are relatively young disciplines and less than 150 years ago, the questions which are now a purview of these sciences in fact belonged to philosophy. The word ‘psyche’ itself from which ‘psychology’ and ‘psychiatry’ are derived refers in its original Greek meaning to ‘soul’, sometimes also referred to as ‘spirit’ or ‘breath’.

While in past millennia, the various manifestations of the mind and its disorders were attributed to malevolent, metaphysical forces, today we understand that what we call the ‘mind’ is a manifestation of the brain, the organ which sits inside our skulls and is the ‘command center’ of our bodies. If brain activity ceases, mental processes also cease. What happens to the ‘soul’ in that case is no longer the purview of scientific inquiry but that of religion.

Back to our original question though: What is sanity? Who is sane and who is not? And importantly, who decides? The question has more than just academic value. Once the first ‘psychiatric hospitals’ (then called ‘lunatic asylums’) were established in the West in the late 18th and early 19th centuries (the very first ones were built by Muslim rulers in the 7th and 8th century under the Umayyad caliphs), angry husbands would frequently bring their rebellious wives to the asylums and leave them there in lieu of divorce and perhaps avoid paying alimony or child support.

African American slaves in the American South would frequently be declared mentally ill if they tried to escape slavery and would be beaten and brutalised as ‘treatment’. In the former Soviet Union, political dissidents would sometimes be declared mentally ill if they refused to toe the party line and even in today’s America, the prison system is the largest repository of the mentally ill.

In Pakistan today, it is not unusual for husbands to divorce their wives and claim custody of children citing mental illness and many recent cases of blasphemy have featured mentally ill defendants being deprived of their properties and even their lives.

One reason that the mentally ill can be subjected to such abuse is because the mind is an abstract concept. It does not have an existence independent of the brain that produces it and thus is not objectively verifiable. I often tell my students to think of it this way: your brain is the slide projector which you can touch, feel and pick up in your hands. The slide projector makes an image onto a screen and that is your mind. The mind is real but you cannot touch it or smell or taste it. Yet, there it is. If you switch off the projector, the image disappears confirming its existence as secondary to the projector.

Our mind is basically a collection of feelings and thoughts, both internal (about ourselves) and external (about the world around us including the other people in it). Those feelings and thoughts drive our actions which is the third aspect of our mind: our behaviour. Sanity, in turn, is basically just an agreement amongst ourselves about appropriate actions and behaviours and is very much temporally and culturally based.

Read also: We’re all mad here -- I

A hundred years ago, many customs and acts which were considered perfectly normal and sane would be considered abhorrent and unacceptable today. Something you might do on a beach in France would be considered totally unacceptable in Saudi Arabia and vice versa.

But in the end, sanity is basically mass agreement on what is correct and acceptable and what is not. This means, of course, that anyone who deviates from the socially acceptable definition of ‘normal’ is liable to be labelled ‘mad’ (or today’s more polite version ‘mentally ill’).

A seminal experiment done at Stanford University in the early 1970s showed just how tenuous the concept of sanity really is. Stanford psychologist David Rosenhan conducted his experiment in two parts. In the first part, Rosenhan himself along with seven of his associates (with no history of mental illness) presented themselves to a psychiatric hospital feigning a symptom of mental illness (hallucinations). The hospital staff were unaware of the experiment. All of them reported vague symptoms of hearing ‘voices’ saying things like ‘empty’ or ‘hollow’. None of them reported any other symptoms. All were admitted to psychiatric hospitals across the country ranging from poorly funded public hospitals to excellent, well funded private clinics and university hospitals. They were all instructed to deny any symptoms after admission and to behave normally.

Despite this, all of them received diagnosis of serious psychiatric illnesses such as schizophrenia or bipolar disorder and most ended up staying in the hospital for several weeks, forced to take medicines, despite reporting no symptoms of any illness. Their normal behaviours while in the hospital were interpreted as signs of mental illness. All were discharged with the same diagnoses.

Rosenhan and his colleagues also reported on the overwhelming sense of dehumanisation, loneliness and boredom inside the hospitals as well as occasional verbal and physical abuse. Most saw their doctors on average for a little over five minutes each day. Later, Rosenhan pointed out that the only way to get out of the hospital was to affirm the psychiatrists’ view that they were, in fact, insane.

In the second part of the experiment, Rosenhan agreed to send pseudo-patients (normal people pretending to be patients) to a hospital whose administration challenged him that they could identify them. In the following weeks, out of 193 patients, hospital staff identified 41 patients as pseudo-patients when, in fact, Rosenhan had sent no one to the hospital.

In his famous paper about his experiment titled ‘On being sane in insane places’, Rosenhan argued that one could not distinguish the sane from the insane on the basis of currently accepted criteria and that the idea of psychiatric ‘diagnosis’ was flawed. His paper was also a strident critique of the dehumanisation and labeling inherent in diagnosing someone as mentally ill.

So where does that leave us with regard to our original question? Who is sane and who is not? And who decides?

In the case of severe mental illness, the answer is somewhat easier. Acute disorganisation of thoughts and behaviour usually lead to actions which would be considered unacceptable in any society, at any time. Someone who is agitated, assaultive, suicidal or homicidal would be restrained and brought to the attention of appropriate authorities no matter where or when they lived.

Should they be compelled to undergo treatment? Yes, because leaving them to their own devices will result in harm to the person themselves and/or society at large. The problem becomes trickier in milder cases where the person is perhaps a concern to their families or loved ones but not overtly agitated. In that case, the best course of action is probably to encourage them to get the help they need but not to force the issue. Just because someone refuses to fit into the straitjacket designed for them by society does not mean they are mad. If that were the case, people like Albert Einstein, Mozart, Leonardo da Vinci and in our part of the world Ghalib and Manto would all have been labelled mad.

We should remember what Alice told the Mad Hatter when he asked her if he had gone mad. "I’m afraid so, you’re entirely bonkers, but shall I tell you a secret? The best people usually are". (Concluded)