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|Year : 2011
: 53 | Issue : 2 | Page
|A utilitarian concept of manas and mental health
Department of Psychiatry, SRM Medical College Hospital and Research Center, Chennai, Tamil Nadu, India
Click here for correspondence address and
|Date of Web Publication||30-Jun-2011|
|How to cite this article:|
Thirunavukarasu M. A utilitarian concept of manas and mental health. Indian J Psychiatry 2011;53:99-110
| Introduction|| |
We, the generation living in the early years of the 21st century, occupy a special position in human history, in that we have witnessed unprecedented and unparalleled growth in the understanding and knowledge about the world around us and life on this planet. While we bask in that glory, let us not forget that there are some important and large questions that remain embarrassingly unanswered. The most conspicuous of those questions is one that is central to the field of psychiatry - "What is the mind?" Nevertheless, psychiatrists have brazenly avoided or ignored this question due to a learned lack of enthusiasm, given the historical inability to achieve a consensus about anything pertaining to the mind. Not to mention the inevitable criticism and/or possible ostracism that relentlessly pursues anyone who takes a stand on this controversial issue. Psychiatrists did not just want to open that can of worms! We simply hoped that if we managed to keep the can closed, the worms would suffocate and die and we would never have to face that uncomfortable question again. We believed that just like we managed to evade the exact definition of mental illness, we would be similarly successful in evading the definition of the mind. However, in the last several decades, human life has transformed so much that we are now faced with a relatively new concept - mental health, which too remains to be defined. The list keeps growing and our silence has been deafening. While our understanding of the human brain, human behaviour, and neurosciences has grown exponentially, the task of describing or defining the mind has also become increasingly difficult. Our wilful indifference or tactical retreat from confronting these tough questions is not helping us, one bit. Increasingly, we are educating ourselves with an explanation that any definition of mind or mental health is not even a possibility, let alone plausibility. Let me highlight the importance of this issue by discussing the well-known, controversial, yet insightful Rosenhan experiment.
| The Rosenhan Experiment|| |
In 1973, American psychologist David L. Rosenhan published the findings of his controversial study, 'On being sane in insane places' in the journal Science, stirring up a lot of reactions and criticisms among the psychiatric community.  It was a two-part experiment exploring the consistency and validity of traditional methods of psychiatric diagnoses. For the first experiment, Rosenhan arranged a group of 8 normal individuals called 'pseudopatients' who were known to have no psychological or psychiatric pathology. They included a psychology graduate student, 3 psychologists, a pediatrician, a psychiatrist, a painter and a housewife. Three of them were women and five of them men. Rosenhan was one among them. These pseudopatients appeared at 12 different psychiatric hospitals (11 university or state hospitals and 1 private hospital), reporting a false complaint of repeatedly hearing something such as "thud", or "hollow" or "empty" and gaining secret admission. They used pseudonyms (false names) to feign their real identity. However, other than this fabricated complaint of auditory hallucination, they reported no other problems and behaved completely normal, i.e., as they would usually behave. Rosenhan conducted this experiment to see if psychiatrists could correctly identify the pseudopatients with one fabricated symptom, as sane. To everyone's embarrassment, all these patients were diagnosed with schizophrenia, except the one who appeared at the private institution who was diagnosed with manic-depressive psychosis. All of them were admitted into inpatient wards, with stay ranging between 7 and 52 days and averaging at 19 days. As instructed and planned prior to the study, these pseudopatients stopped complaining of the initial complaint soon after admission. They observed the condition and happenings inside the psychiatric hospitals keenly and took notes diligently. Initially, their note-taking was secretive and discrete, but as soon they realized that no one else was paying attention, they started taking notes openly. They were cooperative, friendly, and pleasant, and were also recorded in the hospital records as being so. Despite all this, none of them were identified as sane during the hospital stay. They were prescribed psychotropic drugs, which they reportedly discarded without the knowledge of the hospital staff. They were released with a discharge diagnosis of 'schizophrenia in remission', after they admitted to being insane but feeling improvement. Some of the results of Rosenhan's experiment came to be known to the staff of a certain teaching psychiatric hospital, which claimed that such errors would not happen at their institution. This claim formed the basis for the second part of the experiment. Rosenhan made an arrangement with this hospital, letting them know that he would send one or more pseudopatients (i.e., sane individuals) to their hospital in the next three month period to gain secret admission. Each staff (including attendants, nurses, psychiatrists, physicians, and psychologists) were asked to rate each patient presenting for admission based on their suspicion of being a pseudopatient and thereby identify the impostors. During the three month period, 193 patients were judged and of these, 41 patients (~21%) were identified as pseudopatients by at least one staff member, while 23 patients (~12%) were identified as pseudopatients by at least one psychiatrist. Nineteen patients (~10%) were identified aspseudopatients by one psychiatrist and one other staff member. The results of this second part of the experiment were more embarrassing than the first - Rosenhan reported that he had sent no pseudopatients to this hospital during that period.
From both these experiments, it can be suggested that traditional methods of diagnosis of mental illness were incapable of identifying, at least uniformly and consistently, even within one nation and one culture, sanity from insanity, and abnormality from normality. In the first experiment, psychiatrists committed a false positive diagnosis of a sane person as insane, i.e., what statisticians would call a Type 2 error. That is to say, the psychiatrists erred on the side of caution by assuming disease in a healthy individual, rather than missing a serious diagnosis such as schizophrenia. This is understandable, given the style of training during medical education where assuming illness in a healthy person (in order to give the benefit of doubt and empiric beneficial treatment) is taught to be more acceptable than missing a diagnosis of a potentially serious illness. In the second part of the experiment, when the staff were consciously alerted of the possibility of faking insanity, they tended to make numerous false negative diagnoses, i.e., Type 1 errors. Due to a significant rate of Type 1 and Type 2 errors, the contemporary diagnostic method for mental illness was unreliable, Rosenhan concluded.
Rosenhan began this article in Science, with an open question, "If sanity and insanity exist, how shall we know them?" Its been more than 35 years since this article was published. Do we have an answer for Rosenhan? No. Currently, each mental illness is identified by a set of presenting symptoms or elicited signs. This assembled set of clinical information invariably lends itself to variations arising from culture, language, geography, religion, country, etc. from the view points of both the subject and the psychiatrists; not to mention the wide interpersonal variations and even temporal changes within the same person. Such variations are often resolved by a process of voting or consensus by a select group of experts. Criteria for diagnosis of mental illnesses are then statistically derived, most often by some sort of scoring system on a list of enumerated symptoms for each diagnosis. The lack of these mental illnesses is then understood to be mental health, by principle of diagnostic exclusion. Even the so-called positive definitions of mental health seem to be constructed indirectly from exclusivity of what constitutes mental illness. Mind, on the other hand, is commonly described as a conglomeration or array of a variety of psychological functions such as memory, learning, perception, consciousness, emotions, thought, reasoning, imagination, problem-solving, etc.
In my experience as a clinical and teaching psychiatrist for the last 30 years, I have found these definitions of mind and mental health minimally beneficial in educating medical students, psychiatry residents and fellows, mental health nurses, and paramedics. These definitions are too broad and loose for educating mental health professionals, who are often left without any working definition of mind or mental health necessary for them to understand psychiatric patients and approach them in a comprehensive manner. They are also unable to understand the scientific literature and interpret them properly. Conversely, authors of scientific manuscripts also use terms interchangeably, adding to the confusion. The existing definitions give room for too much interpretation, misunderstanding, and misspeaking of terms. Inevitably, it allows personal bias to creep into science, allowing for exploitation of the field by ideologies operating towards non-medical objectives. Psychiatrists are also unable to explain to patients and the common public alike (especially in popular media) about mind or mental health without confusing the listeners. Worse is that psychiatrists often offer different, sometimes contrasting, and rarely, even contradicting explanations, leaving the public to assume that psychiatrists do not know any more than the others about the mind. Such attitudes are widely prevalent, contributing to the pre-existing stigma in psychiatry. This also stalls progress in the attempts to increase mental health awareness. In essence, our delay in defining the core operating entity of our profession - the mind or the psyche, has not been beneficial. We have to act, and act now.
| Is it Possible to Identify Sanity from Insanity?|| |
Rosenhan's experiment has left us with a bad taste in the mouth as psychiatrists demonstrated practical inabilities to identify sanity from insanity. If experts themselves were not able to do so, does it not give credence to the philosophical point of view that sanity and insanity are indistinguishable, signalling a dead-end in our road to define mental health? I do not believe so. I see that Rosenhan's experiment could actually constitute proof that sanity can in fact be identified from insanity. At one point, Rosenhan argues that the inability of the staff to correctly identify the pseudopatients could not have been because the pseudopatients did not act sanely enough. To provide evidence for this argument, he states "During the first three hospitalizations, when accurate counts were kept, 35 of a total of 118 patients on the admissions ward voiced their suspicions, some vigorously. "You're not crazy. You're a journalist, or a professor (referring to the continual note-taking). You're checking up on the hospital." While most of the patients were reassured by the pseudopatient's insistence that he had been sick before he came in but was fine now, some continued to believe that the pseudopatient was sane throughout his hospitalization. The fact that the patients often recognized normality when staff did not raises important questions." Clearly, the other inpatients in the psychiatric wards were able to identify these pseudopatients correctly as being sane. While 35 inpatients, i.e., ~30%, of supposedly insane patients could identify a sane individual (i.e., pseudopatient) amongst them, 100% of sane psychiatrists could not do it! In short, Rosenhan's experiment implied that insane laymen could identify sanity more often than sane people who were qualified experts in the field of insanity. While note-taking by the pseudopatients lead other inpatients to suspect sanity, psychiatric staff recorded it as 'writing behavior'. Rosenhan concluded that this was because once a patient was labelled with a psychiatric diagnosis, every behavior is shaded with that label obscuring any possibility of seeing sanity, even if it existed. I would like to extend on Rosenhan's conclusion, while also trying to zero-in on the root cause of this problem. My contention is that the psychiatrist, while evaluating a pseudopatient (or any patient, for that matter) was probably continuously asking him / herself, "Is this patient schizophrenic?" or "Is this patient mentally ill?" The complaint of auditory hallucinations presented by the pseudopatients made the psychiatrist conclude 'yes' to the above questions, thereby arriving at a diagnosis of mental illness. Instead, if the psychiatrists had been asking themselves "Is this person mentally healthy?" or "Does hearing 'thud' make this person not mentally healthy?", they would have chosen to ignore that single complaint or at least become suspicious of it, thereby identifying sanity correctly at some point during the patient-doctor contact - if not during admission, during the stay or at least at the time of discharge. That is, the line of thinking was rooted in identifying mental illness, not mental health. So, it is critically important that clinical evaluation, and hence training and education in psychiatry should start with mental health moving to mental illness and not the other way around.
But to define mental health, we would first have to define mind, which has been a historically daunting undertaking. Before I propose my concept of mind, let us take a look at the history and evolution of the concept of the mind and how it has influenced the present day understanding of the same.
| Concept of the Mind|| |
Maxwell Bennett's recent review "Development of the concept of the mind"  provided an elaborate and comprehensive account of the historical ideologies relating to the mind. Nearly 6000 years ago, man began explaining his experiences of the self, especially intrigued by the experiences during sleep and dreams. He believed them to be wandering, shadow-like entities, which in Shamanism came to be known as 'spirits'. This idea of a wandering spirit capable of ethereal travel into and outside the body continued to exist among cultures, until 8 th -5 th century BC when in Greece, Homer identified this spirit as the "soul," which he believed was located in the head. , However, he identified two types of soul. The first type was a sort of a body soul, which in turn was constituted by three entities namely, thymos, noos, and menos. The thymos was considered as the driving force of the body propelling motion and consisted of emotions such as joy, grief, fear, pity, etc. Noos consisted of the rational and intellectual component, responsible for thinking. Menos, on the other hand was to signify an inner rage that is experienced in fierce battle. Menos was considered to be located somewhere in the chest and it is probably the linguistic root for the English word "mind."  The second type of soul was an impersonal immortal soul, capable of ethereal travel. This was called as the "psyche," a terminology that is popular till date and becoming the root of several words related to the mind. It is quite interesting to note that Homer was aware of psychological attributes such as emotions, thought, etc. but attributed them to an immortal substance, the soul. During this time, it was believed that the psyche lived in a mystical place called Hades. During the next few centuries, the idea of a personalized immortalized soul for each person began to become consolidated.
Later on, Plato revolutionized the then existing philosophy by now identifying only one soul for each person, called the 'psyche'. This psyche was now constituted of three parts, namely the thymos, the logos, and the pathos. The thymos was similar to the thymos of Homer and was believed to be located somewhere in the chest.  The logos was the part concerned with reasoning and it was this part that Plato called the "'mind." Plato believed that the logos (or the mind) existed in the head.  The pathos, otherwise called the id, was attributed to bodily appetites of food and drink, and was believed to be located in the liver. It is quite interesting to note that Plato had identified the various psychological attributes of man that he now attributed to the soul, which was located inside the body in multiple places.  However, Plato committed that the thymos and the pathos were composed of a corporeal or mortal substance, whereas the logos, i.e., the mind which was concerned with reasoning was incorporeal and immortal, existing even after the death of the individuals. That is, according to Plato, mind (or logos) was the part of the soul (or psyche) that was immortal. Since the capacity to reason was attributed to the soul and considered immortal, morality became to be associated with the soul. Plato's idea, as old as 4 th -3 rd century BC has dominated Western thought, extending up to this very day. This idea of dualism of the psyche, being composed of a bodily component and an immortal component, i.e. mind was quite attractive for future Christian theology and philosophy, which argued that the bodily mortal components of the soul, namely the emotions (thymos) and appetites (id) existed in all, but the capacity to reason and act (the logos) was immortal and subject to divinity or the supernatural God. Since a part of the soul was immortal, the soul was in general considered to be immortal. Plato, with his concept of dualism made himself and his theory vulnerable to a perennial logical attack of how an incorporeal immortal soul interacted continuously with a mortal corporeal soul! This laid the invisible seeds of what would centuries later transform into the mind-body problem, which is unsolved till date. It is important to note that throughout this time, the soul was continued to be thought of as an "entity" or supernatural "substance," akin to the ghosts or shadows or spirits.
However, Plato's disciple, Aristotle came up with a revolutionary idea departing sharply from his guru's philosophy. He advocated that there were three different types of soul influencing a person - a rational soul (concerned with thinking and analyzing), a sensitive soul (concerned with passions and desires), and a nutritive soul (concerned with appetites and drives). In a way, this classification was similar to the thymos-logos-pathos classification of Plato, but the genius of Aristotle rested in the tenet that none of these were incorporeal substances but merely powers or characteristics or traits of the mortal person. He said that the mind could not be located anywhere inside the body, and was simply an attribute of the body and considered the word "mind" only as a figure of speech. Hence, the recalcitrant problem of solving how the mind interacted with the body (or the brain) became a non-issue.
In Aristotelian terms, interaction of the mind with the body is as absurd as asking how the wood of a table (body) would interact with the shape of the table (mind) or as asking how the pupil of the eye (body) would interact with the vision (mind). Clearly, Aristotle was ahead of his times and in retrospect, I believe that he is still ahead of us too, as this philosophy is not popular in the current system of medicine, which is still dualistic. After Aristotle, the dualism introduced by Plato, adopted and nourished by Christian theology regained momentum as Neoplatonism. However, the central problem of how a mortal corporeal soul could interact with an immortal soul, influencing the life of a mortal man remained painfully unanswered by dualism.
In the 16 th century, Rene Descartes introduced a paradigm shift in the philosophy of the mind, by theorizing that emotional soul (or thymos) and the nutritive soul (or the id) were functions of the body, and not of the soul. In essence, Descartes removed thymos and the id from the soul and displaced it to the body. Hence, the logos (or the rational or reasoning entity) came to be the lone constituent of the soul, i.e., the psyche. Descartes maintained that this psyche is immortal and incorporeal. He believed that by doing so, he was solving the problem of dualism, but in essence he merely converted the problem of an incorporeal soul interacting with a corporeal soul, to the problem of a mortal body interacting with an incorporeal psyche. Semantically, one could say that the seeds laid by Platonic dualism blossomed with Cartesian dualism. It is important to note that it is with Descartes, that logos (or mind), which was entrusted with reasoning (and hence morality) came to be synonymous with the immortal soul or psyche. Descartes also introduced the concept of awareness of one's own self, i.e., consciousness to the immortal psyche. This explains why people often conjure up mind, soul, consciousness, morality, and divinity together, using words interchangeably and blurring the differences between them. The current system of medicine and medical education are deeply rooted in the Cartesian doctrine, where the body (identified by a set of physical attributes such as height, weight, locomotion, color, heart rate, blood pressure, etc) is seen as one entity that continuously interacts with another entity called the mind (identified by psychological attributes such as perception, emotions, imagination, etc). The mind is not considered as a part of a body like the heart or lungs, but instead an entity that interacts with the body and vice versa. Since the time of Descartes, there have been several remarkable advances in medicine that not only failed to shake the Cartesian system, but instead became absorbed in it. For example, in the 19th century, Ivan Pavlov demonstrated that learning (which is often regarded as a "mental" capacity) was an involuntary process, suggesting the existence of a machinery in the brain that enables learning. During the same time, Charcot demonstrated that clinical symptomatology in multiple sclerosis patients were correlated to pathological changes in the central nervous system.
Around the same time, Alois Alzheimer showed that the condition called General Paralysis of the Insane (GPI, a complication of tertiary syphilis) was associated with histological changes in the brain, thereby showing that what was termed "insanity" could be related to brain pathology. Despite these advances, which suggested that a change in brain state paralleled a change in the mental state, the Cartesian system remained unquestioned. Instead, this simply formed the basis of explaining the mind-body problem within the Cartesian system, thereby strengthening it. This paradox became more visible when Alzheimer demonstrated that the loss of memory (which was considered to be a psychological capacity) was shown to be associated with the deposition of amyloid plaques and Nissil's granules in the brain. This was the first time that a mental disorder was shown to be associated with a neurological pathology. The Cartesian system assimilated the paradox by shifting the disease of Alzheimer's dementia from the arena of psychiatry to neurology. This forms the central issue of the problem - if changes in brain states are understood to be causal in the mental states, then psychiatry is no different than neurology. The Cartesian system will continue to see psychiatry and neurology as different, as its doctrine dictates that mind and body are different yet interacting entities. Steven D Edwards in his article, 'The body as object versus the body as subject: The case of disability'  highlights this problem as follows, "....... more recent theorists can be charged with Cartesianism of a related kind in which the brain plays the role of Descartes' disembodied soul. From either of these perspectives, the self is to be defined in ways which make no reference to the body. The traditional Cartesian recruits mental properties which are detachable from the body. The modern Cartesian also recruits mental properties but typically claims these to be identical with brain states." However, this unnoticed problem of the Cartesian system unearthed by Alzheimer's findings received serious attention when Emil Kraepelin suggested that mental illness has a biological basis, rooted in both environmental and genetic factors. By doing so, Kraepelin was able to explain the biological basis of psychiatric illness using neurosciences, while at the same time maintaining psychiatric illness distinct from neurological illness, thereby introducing "neuropsychiatry." Nevertheless, the Cartesian system of dualistic approach to the mind and body is still widely prevalent among the medical community, medical education system and the common public alike. It is important to come to the realization that the mind-body problem and the concomitant burden of explaining how the psyche (regardless of how it is defined) interacts with the body (or brain) is simply an artificial by-product of the Cartesian system of medicine, which we have chosen to accept by default. Hence, it is not incumbent upon me to explain mind-body interaction, if I choose to discard the Cartesian system, and adopt an Aristotelian-like method of thinking.
All the above refer only to the ideas prevalent in the Western world. The Eastern world ideas of the soul are quite different, although there have been strikingly similar parallels. The soul is called the "aatman" in Sanskrit (like "atmen" in German, signifying a common Indo-Germanic origin). There is a school of thought that distinguished a mortal personal life-soul called the jeevatma, which interacts with an immortal divine impersonal soul called the paramatma. This ideology called the Dvaita (meaning "two") philosophy is akin to the Platonic-Cartesian dualism of the Western world. However, unlike the western world the non-dualistic schools of philosophy that mortal personal soul is simply the manifestation of the supreme all-pervading immortal soul such as the Advaita (meaning "non-dual") and Vishistadvaita (meaning "non-duality with uniqueness") and hence cannot be distinguished apart from each other (akin to Aristotelian philosophy) constitute a much more popular stream of thought than the Dvaita philosophy in India. Interestingly, these Indian philosophies do not commonly regard the soul with psychological attributes such as emotions, memory, learning, etc unlike the Western systems. The Indian systems of medicine do refer to abnormalities in the body (as the irregularities of the humors) to underlie the mechanistic explanation of mental illness, while maintaining mental illnesses as a separate discipline, akin to the line of thought prevalent in the current post-Kraepelin era. However, since modern mainstream medicine is largely the contribution and extension of Western thought, dualism is more popular in modern medicine than Aristotelian ideas.
| The Liabilities of Psychiatry|| |
Why has it been so hard to define the mind? Why has there been no consensus with any concept? And why is this issue so controversial? There are several reasons. First, there are no animal models for studying the human mind or mental illnesses. Secondly, stringent research about the human mind has several human rights related and ethical limitations. Thirdly, the study of the human mind is invariably done by another human mind, and hence an unbiased objective interpretation of findings becomes difficult.  There is another very important reason too - any concept of the mind has far-reaching implications not just in medicine, but also outside it. This can be well understood by looking into the history of mental illnesses. Man has been concerned, bothered, and disturbed by deviant phenomena and human behavior, such as crime, violence, sexual deviations, mental illnesses, etc. Man has been trying to control, contain, and manipulate such deviant phenomena to his own ends. Such deviant phenomena have far reaching implications in multiple spheres of life. Initially, such deviant phenomena were thought to be an issue of morality and sin. Hence, it was historically dealt with by religions and faith systems which have come to dominate contemporary thinking. In due course, such deviant phenomena were also thought to be an issue of law and crime with legal implications, and hence law makers and law enforcement authorities have also come to influence concepts pertaining to these deviant phenomena. People of medicine, whose primary duty was to relieve human suffering have obviously been interested in these deviant human phenomena. Physicians tried to study that part of the self that was the reason for such deviant phenomena, and that study lead to the discipline of psychiatry. Over the course of the last few centuries, medicine has become streamlined by scientific methods. We live in the era of science, where faith- and religion-based claims are relentlessly contested by science. Drafting of legal policies also seem to need the support of science to move ahead without controversy. Hence, there is a huge incentive for non-scientific interests to influence scientific approach to such deviant phenomena, which is the title job of psychiatry and its allied disciplines. Scientists in this field are consciously and unconsciously influenced by personal and non-personal sources of bias and conflict, while investigating the nature of the mind. Today, all ideological battles and conflicts are fought in the proxy of science, and hence any definition of the mind by people of science is going to cost somebody a lot. Therefore, it is important to make clear that the proposed concept of mind is only meant to be a medical conceptualization of what appears to be the subject of interest and study in the field of psychiatry. Being physicians, in principle, we are interested in studying the mind only for the purpose of relieving human suffering, just like any other specialty. Our primary purpose is not to influence law or morality in a society by any means. Hence, I am apprehensive of using the word "mind" or "psyche" anymore to describe the subject of study in the field of psychiatry, as these words derive themselves from those which we would like to consciously distance ourselves from, such as divinity, immortality, soul, morality, etc. Through centuries of indoctrination and linguistic idiosyncrasies, we are hard-wired to think in a certain way when the words "mind" or "psyche" are used, consciously or unconsciously. Therefore, I would like to deliberately avoid using the terms "mind" or "psyche." If so, then what am I trying to conceptualize? Let me paraphrase my objective - I am not trying to conceptualize the mind or the psyche, as the world has known it. Instead, I am trying to conceptualize that part of the human self that is the subject of interest in the scientific study triggered by deviant human phenomena, only for the purpose of providing medical relief to human suffering. That is to say, I have identified what I am conceptualizing by the very purpose for which it is being scientifically studied by a health professional. I would baptize what I am conceptualizing by a term unused in contemporary western literature, in order to sever any connections or relations to what has already been philosophized for the mind/psyche and to wilfully exclude any pre-existing assumptions about it. I chose to use the word "manas" for this purpose. Hence, I would hereby attempt to conceptualize the "manas," not the mind or the psyche so as to stay away from the liabilities incumbent on conceptualizing an entity that has been philosophized in multiple different ways, without even being defined. In other words, manas is that part of the mind or psyche that we are concerned about as doctors, and nothing else.
| Scope of Conceptualizing the Manas|| |
In the last few decades, there have been remarkable advances made in the fields of psychology, evolutionary biology, genetics, cognitive neurosciences, psychopharmacology, and behavioural sciences. There are new psychological phenomena and brain mechanisms that are being uncovered continuously, most of which are still being studied in detail. The proposed concept of the manas is not intended to accommodate all existing ideas in these fields pertaining to it.
Instead, it would only include the core ideas in the field, essential for formulating a working definition. Let me explain what I mean by 'core' ideas. James Trefil has explained the dynamics in the arena of scientific knowledge by using three concentric circles [Figure 1].  The innermost circle is the "core," which consists of time-tested ideas, which are no longer disputed within the scientific community. They are ideas that are considered to be beyond reasonable doubt. For example, the idea that the earth is a globe, the idea that sun is at the center of the universe and evolution of man are some of the core ideas in science. It is possible that core ideas may be disproved in the future, but the likelihood of that happening is exceedingly rare. The next circle is the "frontier." which consists of current scientific research and new ideas. The scientific frontier is actively populated by new ideas, which continue to be debated and tested repeatedly. Most ideas in the frontier are expelled after repeated testing, while few which survive intense scientific inquiry are internalized into the core. The outermost circle of scientific knowledge, which is farthest from the core, is called the "fringe," which is populated by ideas that often make the average scientist uncomfortable about its claims. A lot of what is called pseudoscience, such as the claim that flying objects such as the UFOs exist are considered to be fringe ideas. A lot more evidence would be needed before they are internalized further. I would like to extrapolate Trefil's description to our conceptualization of the manas - the part of the human self that is the subject of interest to the scientific study triggered by human deviant phenomena and behavior. I would try to include only those ideas that have been internalized by the psychiatric scientific community as core ideas. This way, the concept is open to be modified further by the internalization of new ideas in the future.
|Figure 1: Scientific knowledge and areas - The three concentric circles (Reproduced with permission from James Trefil)|
Click here to view
| Objective of Conceptualizing the Manas|| |
The supreme objective of conceptualizing the manas is to provide a simple, working concept to medical students, psychiatry residents, nurses, paramedics, psychiatrists, students and professionals of all allied clinical disciplines, to enable them to understand mental illness and mental health in a uniform and consistent way so that they can navigate the health system better and provide more comprehensive care for those seeking psychiatric help. This would enable all mental health professionals to speak the same language, without room for personal bias or interpretation. The other objective is to enable the common public to understand the implications of mental health and illness without confusion, which would go a long way in avoiding unnecessary miscommunication and misconceptions and in reducing the stigma attached to mental illness and the seeking of psychiatric help. That is to say, I am attempting to model a utilitarian concept, using core ideas for medical purposes only.
| Manas - A Utilitarian Medical Concept|| |
Considering all of what has been said before, I would like to describe the concept of the manas as follows:
- Every human being has one, and only one personal indivisible manas
- Manas is not a substance or matter of any nature; nor is it an energy or force
- Manas is a neither an attribute nor a part of the body. Instead, manas is an attribute or part of the self, just as the body is an attribute or part of the self
- Manas is a utilitarian medical concept
- Manas is a functional concept, i.e., manas is evident only as long as the self functions
- Manas ceases to exist if the self ceases to function or exist. Manas is not immortal
- Manas has at least one basis that is biological, and hence can be affected by biological processes
- There is nothing supernatural about the manas; nor does it communicate or interact with anything that is supernatural
- Manas is not in anyway related to the soul
- Manas cannot travel outside the self or the body; nor does it have any powers, whatsoever
- Manas has no direct effect on anything else other than the self of which it forms a part
- Nothing can have a direct effect on the manas, except through the self of which it forms a part
- Manas can exist in a state of health or disease
- Manas is that part of the self that is primarily diseased in mental illness
- Manas is what that is healthy in mental health
- Manas is defined as the single indivisible amalgamation of three substituents namely
Mood, thought, and intellect always exists in a manas. There is no manas that has only one or two of these substituentsA change in any one of these substituents produces congruent changes in the othersThe interface between the manas and the self is a bodily function of awareness called consciousnessWithout manas, there is no behaviorIf the manas is not affected, then the condition is no longer psychiatric
- Thought and
Now, let me explain the above in further detail. Manas is a personal entity that is indivisible into further components that can independently exist. Here, manas is not considered as part of the body, as the body can exist without the manas. However, the manas cannot exist without the body. Body is an integral component of the self, and a functional concept of the self is the manas. In Aristotelian-like terms, the retina of the eye (body) can exist without sight (manas), but sight cannot exist without the retina. Nor can the sight exist if the retina is not functioning. The retina and the sight together constitute the visual system (self). Also, when the visual system ceases to exist (as in death or coma), sight ceases to exist, even if the retina exists. Another example is the analogy of a computational system or computer (self). The operating system software (manas) such as Windows, Macintosh, or Linux is an integral part of the computer (self), without which a computer is useless. This software cannot exist without a hardware (body) i.e., hard disk, RAM, CD-ROM, etc. However, the hardware can exist without the software. The operating system can then perform several functions like running a movie, playing or song, editing a photo, calculating a mathematical problem, etc (psychological attributes like learning, memory, emotions, etc). The operating software (manas) and its attributes are evident only as long as the computer system is functioning. For the operating system software (manas) to run on the computer system (self), electricity is needed by the hardware (body). Electricity does not power the system software, it powers the hardware - but that enables the software to run on the hardware, hence enabling the proper functioning of the computer system. That is, electricity (consciousness) enables the hardware to realize the software loaded into it, and at this point an assembly of hardware parts now becomes a computer. Similarly, consciousness is the bodily function of awareness that serves as the interface between the manas and the self. Consciousness is not the manas, and manas is not the consciousness, but consciousness is what that allows manas to make a body into the self. I hope that this clarifies the idea of a functional concept. Also, consciousness has a purely biological basis and anything that affects consciousness can affect the manas.
It is important that this functional concept of the manas is not to be misunderstood to be the same as the popular philosophical concept of the mind, called "functionalism." The latter philosophy  understands mental states to have a functional role in converting inputs received by the brain into outputs (i.e., behavior). My concept differs from functionalism in two major ways.
First, my concept pertains to manas, whereas functionalism pertains to the mind which philosophers have defined variably. Second, manas does not exist primarily by virtue of having a function of performing a task for the self, instead manas itself is a function of the self, or the result of a functioning self. Also, I have mentioned that manas has at least one basis that is biological. This means that manas can be explained mechanistically by biological processes, such as neurochemistry and neural networks. In turn, the manas can be manipulated by the use of biologically active substances such as drugs. However, this basis is a mechanistic explanation for the manas, and does not imply causality. For example, electricity can be explained by the flow of electrons. This does not mean that flow of electrons causes electricity; it simply means that flow of electron is electricity. Similarly, biological processes such as the altered flow of neurotransmitters across a neural circuit are mental illness, and may not necessarily be the cause of mental illness. From literature, we do know that psychotherapy is beneficial in the clinical setting. ,,, Hence, manas in turn may affect the biological functioning too, which in turn may affect mental states. The latter, although strictly speaking biological, is not typically biological. Hence, the idea that manas has at least one basis that is biological is not to be interpreted that there is another supernatural or unscientific non biological basis. It simply means that the manas may in situations be the basis for other typical biological processes. Hence, the other basis for the manas if any is an atypical biological basis. Again, such convoluted explanation has become necessary only because in the Cartesian system, biological theory pertains to processes of the "body" and not the self. If we discarded the Cartesian system and think of biological theory as pertaining to the "self," then I could simply say that manas has a biological basis.
In the manas concept, the mood is all that constitutes "feeling." This includes what is traditionally considered as affect in psychiatric literature. It includes joy, sorrow, grief, jealousy, pity, fear, anger, anxiety, etc. The thought is all that constitutes "thinking." It includes beliefs, faiths, ideas, imagination, etc. The intellect is all that constitutes "analyzing" or "problem solving." The intellect does not merely refer to what is often called "higher functions." Rather, intellect encompasses all computational processes of the self, i.e., receiving information from the environment and from within the self, processing that information and delivering outputs. Such intellect is basic for survival. For example, if an organism receives input that it is in need of food or water (from internal sources like serum glucose or sodium concentration or from outside sources likewise), it is processed in a certain way and results in procuring of food. This is in essence a problem solving function, and can be attributed to the intellect.
In this concept of manas, it is important to note that although there are three identifiable substituents, none of them can exist alone and they never disappear. Mood, thought and intellect always exist in any manas. There is no manas that has only one or two of these substituents. They are identifiable in the manas, but not separable. Here is a good example - consider a wheel made of polished steel that is spinning fast. When it spins fast and steady, you will begin to see two or three different colors. But these colors, although identifiable separately, cannot be extracted separately from the spinning wheel. When the wheel stops spinning, none of these colors will be visible. At any given point, there is a certain mood, certain thought, and a certain intellect - continuously functioning and occurring [Figure 2]. All these function congruently, i.e., a change in one by an external or internal stimulus affects a change in the remaining two. For example, if I hear a good news (positive stimulus), such as winning a lottery ticket I feel happy (mood), have congruent thoughts such as buying a fancy car or a flat-screen TV (thought) and how I can allocate the money to make those purchases (intellect). Happy feelings beget positive thoughts and vice versa. On the other hand, if I hear a bad news (negative stimulus) such as the death of a loved one, I feel sad (mood), have congruent thoughts such as thoughts of being with the loved ones and how life would be without them (thought) and also decide how I would have to inform relatives and friends and arrange a funeral (intellect). All three components are intimately and inseparably intertwined and act synchronously, harmoniously, simultaneously and congruently - which is why I have used the words "single indivisible amalgamation." If this congruency or synchrony were to be affected, then the manas has become adversely affected, signalling abnormality. There may not be isolated abnormalities in any of the three substituents such as mood, thought or intellect but there may be abnormalities in the way they become amalgamated, thus affecting behavior, conduct, personality, preferences, orientation, etc. For all practical clinical purposes of psychiatric evaluation, diagnosis and treatment, everything pertaining to our field can be accommodated by this concept of manas and its substituents. Every psychological capacity or attribute has some extension or implication in all three substituents, although it may have more connections to one particular substituent, under which it can be classified for practical purposes. For example, learning is primarily an intellectual capacity, i.e., a computation capacity of the brain. However, learning is always associated with a mood and thought at some level. Similarly, emotions such as grief or rage are primarily mood, but they are associated with congruent thoughts at some level.
|Figure 2: Three constituents of the manas, operating simultaneously, synchronously and harmoniously|
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| Concept of Mental Health|| |
As mentioned above, manas is a medical concept, which automatically implies that the manas can be in one of two states - health or disease. Hence, it becomes important to conceptualize a healthy manas, i.e., mental health from a diseased manas. Mental health is a relatively new concept in Western systems of medicine. It has its origins in scientific literature only within the last century and its importance has not yet been recognized fully in mainstream psychiatry. But mental health has been a well recognized concept in Indian literature. In classical Tamil literature more than 2000 years ago, there is specific mention of the word "mana nalam," which literally means "mental health." In the Tamil literary work Thirukkural, Thiruvalluvar notes "mana nalam man uyir akkam", which means that mental health is the root source for a better world and better life. It is anything but stunning to see that the importance of mental health has been recognized a couple of millennia ago. Mental health professionals of the present day need to concentrate more on promoting mental health, rather than merely treating mental illness. As with any branch of medicine, prevention is better than cure and promoting well-being could be the first step in reducing the burden of illness. But to promote mental health, one must first define it. But does mental health even exist? Was Freud right when he said that mental health, i.e., a normal ego (in his language) is "an ideal fiction"? I think Freud was partly right and partly wrong. He was right in calling it an ideal state, but wrong in calling it fiction. Mental health can only be an ideal state, as health by itself is an ideal or utopian state. But the reason why Freud called it fiction was probably because it is commonly understood that mind, as interpreted by behavior is subject to a lot of variation at several levels - interpersonal, cultural, geographical, national, racial or ethnic, linguistic, religious, etc. The idea that parameters of mental health cannot be generalized across the entire population is almost ubiquitous. I think this is one place where there is a consensus about mental health - that no consensus is possible!
But, I beg to differ. I believe we are right in understanding that there are a lot of variations in mental health. But, we are too naive to assume that such variations cannot be accommodated into a unitary concept. The world is becoming increasingly globalized and nearly every society is pluralistic in one way or the other. Even societies that are not pluralistic are witnessing pluralism and living in it through the media. People of various religions, cultures, races, ethnicities, languages, nations, ideologies, etc have all learned to live with each other harmoniously for the most part. When people have learnt to resolve their mental differences and find common ground to live, why cannot we as doctors, find a common ground for identifying parameters for health? I believe that barring exceptions and extremes, we can for the most part find practical solutions to overcome this limitation in conceptualizing mental health. One way of conceptualizing mental health is as the absence of any of the mental illnesses listed in the Diagnostic and Statistical Manual of Mental disorders or any diagnostic manual, for that matter. This is probably the easiest solution, but it is undoubtedly useless. Mental health cannot be a diagnosis of exclusion, because such a concept defeats the whole purpose of conceptualizing it. The purpose is to promote mental health - not treat mental illness. That is to say, the clinical strategy to promote health is distinct from the strategy to treat illness. For example, the clinical approach to promote cardiac health and prevent coronary artery disease is completely different from the approach needed to treat angina or myocardial infarction. Hence, cardiac health cannot be diagnosed as an absence of myocardial infarction. Let us make one point clear - The presence of mental illness implies the absence of mental health, but the absence of mental illness does not imply the presence of mental health. This is why, in the Rosenhan experiment the pseudopatients were incorrectly identified as insane, as the diagnosis of sanity and insanity were both clinically approached with the same strategy.
Based on the concept of the manas, I would like to propose a concept of mental health as follows:
- The object of health in mental health is the manas (as delineated by the manas concept)
- Mental health is a medical and utilitarian concept
- The health status of the manas is a two-dimensional spectrum [Figure 3]
- The first dimension is a continuum of the negative impact of the health status of the manas on the self
- The second dimension is a continuum of the negative impact of the health status of the manas on others
- The entire space of the spectrum may be divided into four mental health statuses, namely
"Mentally healthy" is a mental health status that occupies a rather narrow space in the spectrum, with the least negative impact in both dimensions. Mentally healthy can be identified by the presence of all three of the following criteria [Figure 4].
- Mentally healthy
- Mentally not healthy
- Mentally unhealthy
- Mentally ill
"Mentally not healthy" is a mental health status that occupies a space defined by intermediate to high negative impact in the first dimension and least to intermediate impact in the second dimension. That is to say, mentally not healthy individuals suffer due to the condition of the manas, but others are affected relatively less"Mentally unhealthy" is a mental health status that occupies a space defined by variable impact in the first dimension but moderate to high impact in the second dimension. That is to say, mentally unhealthy individuals cause suffering to others due to the condition of the manas, but the self may or may not suffer seriously."Mentally ill" is a mental health status that occupies a space defined by maximal or most severe impact in the first dimension, with a variable impact in the second dimension. Depending on the environmental conditions such as access to medical care, response to management, social support system and awareness of mental illness, the second dimension becomes variable.The above mental health concept is applicable only in the assessment of individual people at clinical setting; it is not applicable in the non-clinical setting and not for any group of people identified by a certain denominating factor (such as religion, culture, geography, ethnicity, nation, etc)
- Awareness of one's own self
- Ability to relate well with others
- All of one's own actions are useful, or at least not detrimental to one's own self and others
Let me expand on the above ideas. First of all, let me reiterate that the object of health in the mental health concept is not the mind or psyche, as the world has known it before. It is the manas, as conceptualized earlier. Mental health is understood as a two dimensional spectrum, as a one-dimensional spectrum would imply that there is a gradual slope between mental health and mental illness. Rather, extensive clinical experience and evidence-based literature suggests otherwise. For example, obsession (a thought) may play a role of a trait, a personality disorder or as serious mental illness such as obssessive-compulsive disorder (OCD), i.e., in a wide spectrum of disorders.  However, if mental health is understood to be a unidirectional spectrum, then it could be misunderstood that obsessive personality is simply a midway in the pathophysiological process from obsessive trait to OCD. But evidence-based literature suggests that obsessive traits and obsessive personality disorders can be standalone conditions as well. It is to avoid such misconceptions from plaguing the concept that the mental health spectrum is understood as being two-dimensional. Next, the dimensions are chosen based on how the manas handles a certain insult to health. If the manas shields the self from the suffering using a compensatory mechanism, the suffering is often passed on to others. This is probably what happens with mentally unhealthy individuals. The manas has no insight of the abnormality, while there is a deviant behavior that causes suffering to others. Hence, the suffering to one's own self is minimal or variable. Personality disorders are the best example for this category. Other examples would be certain paraphilias (sexual disorders) such as voyeurism, pedophilia, etc and conduct disorders. On the other hand, when the manas has a ready insight into the abnormality, there is significant suffering to the self. In such cases, subjects try to contain their problems adjusting their lifestyles to accommodate their problems, which may or may not indirectly affect others. Regardless, the suffering is relatively more to the self than to others. This seems to be the case with mentally not healthy individuals. Best examples include alcoholism and drug abuse, deliberate self-harm, anxiety, phobia, and certain sexual disorders like fetishism.
Mental health is a spectrum - which implies that the exact borders between the four mental health states could be blurry continuum. Clinical acumen is critical in such rare ambiguous situations. It is important to note that a certain disorder may exist in one or more mental health states. The best example would be sexual disorders, i.e., paraphilias. There are various sexual disorders, some in which the subject's action results in more suffering to others such as rape, pedophilia, voyeurism, and frotteurism. The subject himself may feel no suffering or remorse. Such sexual disorders need to be identified from other conditions in which there is no suffering directly intended or delivered to others, such as fetishism. However, the subjects may (or may not be) distressed and suffering from their conditions. I prefer to call the latter, sexual deviations and the former, sexual perversions; and place sexual deviations under the mentally not healthy category, while placing sexual perversions under the mentally unhealthy category. Thereby, the approach to sexual deviations would be distinct from the approach to sexual perversions. The latter is just one example of how a single group of disorders may be classified in a clinical utilitarian way.
The rationale underlying the two-dimensional spectral model of mental health is to emphasize that the clinical approach to promote mental health differs according to the mental health status of the manas. The algorithm [Figure 5] to navigate through the spectrum would be as follows -
|Figure 5: Algorithm for the clinical stratey for managing mental health problems using the mental health concept|
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First, it is identified if the subject is mentally healthy by analyzing the three criteria as mentioned above. If the criteria are satisfied, then the approach to a mentally healthy person would be to promote the existing wellbeing. If these criteria are not reasonably satisfied, then the subject is "not mentally healthy". The approach now completely differs - the next step would be to identify if the subject is mentally unhealthy or mentally not healthy or mentally ill, using the above mentioned two-dimensional approach. If the subject is mentally ill, the usual recommended treatment is pursued with the intention to treat mental illness. If the subject is mentally not healthy, the approach would be to minimize his or her suffering with the intention to promote mental health. Instead, if the subject is mentally unhealthy, the approach would be to first contain the suffering delivered to others, with an intention to promote mental health. Most importantly, this concept of mental health is applicable only to individual person in the clinical setting. It is not applicable to groups identified by any denomination. For example, this concept of mental health cannot be used to assess if Nazis were mentally healthy or not; or if people of a certain religion or culture are more mentally healthy than others. Such an application is unscientific as mental health pertains to the manas. Groups of people do not have a manas.
| Conclusion|| |
"Psyche" has been the name for a disembodied soul since the time of Descartes and even before. The Cartesian doctrine has deeply penetrated modern thought, which is the reason why disorders for which an organic biological (i.e., typically biological) cause could not be identified are often referred to psychiatrists. This is because, as mental health professionals, we have not filled the big gap of what constitutes the target of psychiatric practice. We have also not identified what constitutes the healthy state of that target - something that almost every other medical discipline has been able to achieve. Unless we identify the target of our practice and identify its healthy state, psychiatrists will continue to be called "shrinks," and skeptic meaningless anti-psychiatry propaganda will continue to find ground. In order to identify that target of our practice, we need to deliberately eliminate all pre-existing misconceptions attached to the words "mind", "psyche", "soul", etc. Also, psychiatrists are people of medicine and people of science. Hence, scientific methods of inquiry should be rigorously adopted to deliver progress. How can such scientific methods be adopted if we have not identified the target of our practice and the healthy state of that target?
As a first step, I have made an attempt to conceptualize the target as the manas - a concept that is quite different from other major theories of the mind philosophized before. Which of these concepts of the mind is the right one? I do not know. More importantly, I do not care! I do not care what the mind is; I only care about that part of the self that I am medically and scientifically concerned about. To differentiate what I am concerned about from what may or may not exist, I have used a different name, unused in western mainstream psychiatric literature before. Mind could be anything, for what it is worth but, I am only concerned about the manas!
A condition, medical or non-medical that does not have an identifiable biological cause cannot be, by default, placed under the jurisdiction of psychiatry. If there is no detectable problem with the manas (i.e., its substituents or its amalgamation) in that condition, it can safely be considered non-psychiatric, for all practical purposes. But regardless of whether a subject has a psychiatric condition or not, every person in the population can be individually assessed for his/her mental health status, and thereby public health measures to promote mental health can be undertaken. This will also allow us to study mental health (not just mental illness alone) from an epidemiological standpoint, which I believe is very important for expanding our idea of mental health. Most controversies around psychiatry are because we have practically only one diagnosis, at least from the standpoint of the common public. And that diagnosis is "mental illness" - a label that has humungous consequences for the subject in all spheres of life. This is the reason for the stigma in psychiatry and Rosenhan has pointed it out clearly. Placing all mental health states under this one label is what that invites controversy, scepticism, and dissent. Such dissent is understandable. For example, there is no reason why fetishism and schizophrenia should both be given the label "mental illness." There is also no reason why anxiety and pedophilia are both given the same label "mental illness." It is important to identify not just mental health, but the varying shades of it by the type of clinical strategy needed. Several disorders in diagnostic manuals of psychiatry may not be mental illnesses but merely mentally unhealthy or mentally not healthy states. This will allow for the elimination of stigma attached to psychiatry. Clearly, the above concepts are infantile and need to be fine-tuned further. These concepts are open to modification, given the appropriate reasons. Future directions would include reassembling all diagnostic categories in the Diagnostic and Statistical Manual (DSM) and/or International Classification of Diseases (ICD), according to mental health states of the manas. Another important future direction would be to conduct population-based epidemiological studies of the mental health states and their distributions. So manas can be defined as a functional concept constituted by mood, thought, and intellect, which are nicely amalgamated and synchronized and cannot function in isolation. They always function in unison. Mental health can be defined as the fulfilment of the following three characteristics: (a) awareness about one's own self, (b) ability to relate well with fellow human beings, and (c) all his or her deeds and activities are useful to one' own self as well as others, at least not detrimental to self as well as others.
| Acknowledgments|| |
I acknowledge the extensive contributions of Dr. Pragatheeshwar Thirunavukarasu, MD (Resident, General Surgery, University of Pittsburgh) in formulating the above concepts and drafting the script.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
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