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TheProblemOfDefiningSanity

The subject of this article is Bruce Hamilton's views on the problem of defining sanity.  (Probably, in our opinion, it should be moved to BruceHamiltonOnDefiningSanity.)  To write a review of what is known, from medical, psychological, and philosophical points of view about this topic, please see SanIty.

Medicine and psychiatry have self-admitted difficulties defining sanity. Bruce Hamilton, who orginated this article, is a layman who has read some psychology books and who thinks he has this stuff figured out.  Bruce hopes to explore some of the possible reasons for this and pose this question: could a definition be developed upon which most would agree?

"SanIty" is defined in ordinary dictionaries in such vague terms as the following: the quality of a sound or healthy mind, rationality, the ability to discern right and wrong, etc.  Some such definitions have probably been advanced in the interest of political expediency (on which, more later).  Of course, we realize that ordinary dictionary definitions of difficult concepts such as sanity are far from adequate.  In fact, we aren't quite sure why we're quoting a dictionary at this juncture.

The word itself comes from the root adjective "sane," which stems from Latin "sanus," or "healthy." This etymology, which by itself means rather little, nonetheless would seem to imply that a sane mind is a healthy mind. This is, in fact, part of most medical definitions--at least insofar as there ''are'' any medical definitions of the term.  We're not too sure about that.

Sanity is also defined, by someone we are not willing to identify at this juncture, as being mentally "normal."  But enough about ''that'' definition.  Maybe it'll come up later in this article, maybe not.  We're not sure why we're mentioning it at this point.

Some people (again, we don't know who; maybe your Aunt Ethel) equate sanity with mental health.  Health, in general, denotes strength, soundness, proper functioning, especially of biological systems. As the mind is generally regarded as the seat of awareness and reasoning, Bruce Hamilton posits that its proper function might be said to entail clarity of awareness and accuracy of reasoning. If this thesis holds, one might expect to find these qualities in a sane individual.  We'll put off exploring more historically and medically important conceptions of sanity until we have indulged Bruce--why not?  After all, Bruce's opinions on these subjects, about which medically-trained psychiatrists spend their entire lives, are very important.

Of course, to make sense of this thesis, we will have to explore in greater detail exactly what "clarity of awareness and accuracy of reasoning" means.  Further, it may be helpful to understand to what degree errancy must intrude into mental function before one can reasonably be determined to no longer be sane.  Whether we will actually do these things remains to be seen.

There are a number of objective criteria whereby one may assess the workings of a mind and determine their accuracy, but by and large, one sees testing for such criteria used more frequently in determining IntelliGence than sanity. While a degree of IntelliGence may be implicit in the concept of sanity, this would not be the only measure.  One's ability to perform mathematical computations, identify shapes, find the next in a series of deductive steps, identify patterns in data, all are related to mental accuracy, but may be poor indicators of sanity.  And, of course, no reputable psychologist holds that IntelliGence is by itself a good indicator of sanity; which might make one wonder why we're even considering the notion that IntelliGence is an indicator of sanity, but no matter.

An instance of a broadly accepted test in English speaking areas of the world which is thought to address issues of mental and emotional health would be the Minnesota Multiphasic Personality Inventory (MMPI).  This test has no right or wrong answers, and the evaluee is advised of this fact.  He answers dozens of questions about how he feels and thinks regarding certain issues, and the way in which his answers relate to each other and pre-determined baseline critera determines whether the person adminstering or evaluating the test finds his attitudes more or less healthy in given areas.  If his environmental factors include the recent loss of a loved one and various of his answers reveal a depressed mood, the evaluator may declare this "appropriate."  Labels such as "normal" or "abnormal" with regard to test results are avoided.  The kinds of tasks which one performs accurately, then, and how "accuracy" is defined, may have an impact on the perception of one as sane or not. 

The most prominent aspects of accurate mental function which have been used by ordinary people as indicators of sanity over the centuries appear to have related to the areas of interpersonal relations and bodily safety of self and others. These criteria are frequently examined by courts in commitment proceedings, determination of fitness to stand trial, hearings on competency and other such undertakings.  More recently, especially in medically related fields, personal mental composure has come to be included, as well.  One sees diagnoses based on subjective mood, and drugs advertised to improve outlook.   

Criteria other than accuracy of function have been also employed as determinants of sanity. Conformance and agreement with societal norms have played as great a role in the determination of sanity historically as any other criteria. In some contexts, societal norms loom large. For example, in WesternCivilization?, one would generally find it unsettling if a friend began to speak of voices telling him things, of demons tormenting him, or how he was cured by someone burning incense, shaking rattles, and chanting. Modern psychiatry lists such reported experiences among the symptoms of SchizoPhrenia? - a serious mental disorder. In many regions of the ThirdWorld?, however, shamanistic tradition accepts and reinforces such experience. One who declared to the members of such a culture that these subjective experiences were invalid might find his sanity called into question by the local chief or medicine man. 

The impact of a culture or cultures are evident when one examines what the modern western medical (psychiatric) community uses as a measure of sanity. In a medical/psychiatric context, the most general means of identifying sanity is that a person's mentality is "normal."  A search of the meaning of "normal" leads us to a definition by exclusion - that is, absence of functional mental illness, defect or disorder. The word "functional" (denoting abnormality in function, but not in form) is important, as dysfunction which is traced to a uniformly remediable or replicable physical cause generally is reclassified as a medical problem rather than a mental one, with concomitant change in diagnosis and approach to treatment. Such medical issues are removed from the criteria for judging "sanity." Conversely, when one displays an apparent symptom or limitation for which no physiological cause is indicated, doctors refer to the problem as "functional."  That is, it is not related to a physical problem, but rather a mental one.  The medical/psychiatric definition just stated will seldom be satisfied in the absolute, as will be seen below. 

The problem of identifying a concise,positive, functional definition for sanity, a key element in the more general issue of MentalHealth, is perhaps best illustrated by comparison. In identifying "sanity" with "health," one invites comparison with known standards of health in other organs and systems. A contrast is immediately apparent between the certainty and objectivity with which one can identify physical health, as opposed to mental health. One may examine, for example, a liver. Its normal role and functions, uniform from one person to the next, can be determined through the methods of physical science. It can be x-rayed or biopsied. Liver enzymes in blood samples can be measured. Hepatitis antibodies can be tested for. In the extreme, exploratory surgery may be performed. The proper functioning of a liver can be quantatively measured. While the mind is usually associated with a body organ, the brain, science to date has been unsuccessful in attempting to develop brain testing protocols which are definitive in predicting or measuring sanity. Part of the reason for this is that "normal" mental function may vary from person to person and from one context to another. Therefore, contextual observations, tests and measurements remain the standards of choice. 

The standard for mental diagnosis in psychiatry is the Diagnostic and Statistical Manual (DSM) of the American Psychiatric Association. It has undergone a substantial evolution in the last half-century. From the few mental disorders defined in Freud's time, the number of psychiatric determinations of aberrant human behavior has expanded. When the DSM was first published in 1952, it listed 112 mental illnesses or disorders. The 1994 issue of DSM (IV) specifies more than 370 disorders. And the psychiatric community has not always agreed on how these should be classified. For example, concerning "schizophrenia," DSM-II states, "Even if it had tried, the Committee could not establish agreement about what this disorder is; it could only agree on what to call it." DSM-III says "there is no satisfactory definition that specifies precise boundaries for the concept 'mental disorder'.... For most of the DSM-III disorders... the etiology [cause] is unknown. A variety of theories have been advanced... not always convincing, to explain how these disorders come about." DSM-IV states that the term "mental disorder" continues to appear in the volume "because we have not found an appropriate substitute." Diagnoses which appear in the manual were developed, in part, by a majority vote of those attending DSM conferences. As a result, short attention span, questions about one's spirituality, difficulty with writing or mathematics, defiance of one's parents, fidgeting, excessive neatness, all have found a place in the manual among symptoms and diagnoses. In contrast, homosexuality or the unreasonable desire of a slave to escape, once defined as mental defects (the former in early editions of the DSM), do not appear in today's DSM. 

In 1995, Dr. Rex Cowdry, then director of The National Institutes of Mental Health, stated to a U. S. House of Representatives appropriations subcommittee hearing that, regarding mental illness, "We do not know the causes. We don’t have methods of ‘curing’ these illnesses yet." This should not be surprising. It has been without doubt a cultural process, within the fairly limited culture of psychiatry and psychology, which has taken place in an effort to define the boundaries of sanity. Diseases with cultural definitions may not respond to medical science. 

And defining sane behavior must always be done, at least in part, in the context of the subject's culture. If one is raised in a given cultural environment, educated in a given fashion, and exposed to certain norms, then behavior which is inconsistent with these factors may well indicate some defect in the capacity to accurately process the information available to the mind. 

In recent times, more recognition has been given to the concept of sanity as a subjective manifestation, evidenced by mental quietude, peace of mind, and resiliancy - an ability to survive the vicissitudes of life without such mental discomfort that one's ability to function is impaired. 

In the legal community, a culture unto itself, an entirely different effort has been undertaken to define sanity. Generally speaking, the most broadly known and publicly accepted standard for sanity under law is "the ability to discern right and wrong." This has been broadened, extended, shaped and colored in widely scattered juristictions internationally in an effort to establish standards which will punish the guilty and forgive those whose temporary or permanent mental state deprived them of the requisite ability to form intent, or "mens rea" (guilty mind) under the law. 

Defenses based on various findings of mental defect by medical professionals have been offered by criminal defendants with varying levels of success, in an effort to avoid being found sane, and thus escape a death penalty or any form of punishment at all. Multiple personality disorder, sugar addiction, somnambulance, amnesia, excitement or passion, obsessive-compulsive behavior of varying kinds, all have been pled as defenses before the bar of justice. 

Finally, various governments, particularly authoritarian ones, have undertaken to use political or public policy standards to define sanity, and have underwritten psychiatric efforts to restore sanity under such definitions by remedying behaviors which betray a mindset declared unacceptable by the state. The treatments employed toward this end are typically aversive, punitive, and/or coercive. The working definition for sanity in such cases, usually implicit rather than explicit, would seem to be, "believing and thinking as one is authorized to believe and think."  The argument supporting such a definition of sanity and resulting efforts to restore same is generally this: "The state functions for the good of the people. Proper functioning of the state requires conformance and compliance with state aims and policies. Fomenting disagreement with state aims and policies interferes with the proper functioning of the state. Any sane person would desire the good of the people and would therefore not foment disagreement." As experience quickly reveals that talking therapies fail to restore the sanity of a person who openly disagrees with the state and encourages others to do so, the therapies employed necessarily become those that a deviant citizen, given his choice, would avoid. Failing this, state hospitals may resort to treatments which nullify the patient's ability to engage in unauthorized expression. Thus sanity by political definition may be restored. 

Political definitions of sanity have not been confined to openly authoritarian governments. In otherwise putatively democratice countries which have a history of democratic elections and peaceful transfer of power, state-sanctioned and state-funded mental treatement has been imposed upon political dissidents and upon members of racial and ethnic minorities whose activities and efforts to achieve equal treatment and equal rights to those enjoyed by favored elements of these societies have been felt to be a threat to civil order or state security. 

Political definitions of sanity are a reflection of the earliest attempts by humans in a social setting to live in comfort, unmolested by disquieting behavior by those around them. As far back as history has been recorded, mentions of "lunatics" (for the Latin meaning "moon-touched," after the belief that undue exposure to the full moon could damage the mind) appear. These persons fail their compatriots' test for sanity grounds observed by others rather than experienced by self. Their bevavior is erratic, unpredictable, unsettling, and cannot be rationally understood by those around them. The discomfort that they impose upon the society around them disqualifies them from being considered sane. The very concept of "sanity," as a condition, may have developed first and foremost in contrast to these early observations of it apparent absence. This primary identification of a health issue by others than the affected person is somewhat unique. One may complain of a headache, sore stomach, excessive weariness or various aches, pains, or numbness. One may notice a rash or falling hair, or be unable to keep food down. One may even be unable to concentrate or attend the utterances of others with clarity. These subjective symptoms, reported by their sufferer, translate to bodily illness of one kind or another and drive the individual to seek relief. Absent social indoctrination, however, one seldom will complain of a defect in their own sanity.

"Doctor, I'm depressed," is a complaint of relatively recent origin.  In pre-Freudian times, an individual may have been "sad," "morose," "maudlin," or "pessimistic," even afflicted with "despair" to the point of suicide.  This would not have been viewed as a mental disorder, nor occasion for a diagnosis or treatment.  It would have been perceived that the person needed cheering up, or that he was responding appropriately to some event or condition of his life which cried out for remedy, or that he was constitutionally incapable of being cheerful - much after the manner that one might be short, or bald.  Modernly, radio, television and popular periodicals carry messages from doctors and drug companies that being too sad may be a sign of clinical depression, and that one ought to seek treatment or drugs.  Hence, "Doctor, I'm depressed."  Whether the older or more modern view is more appropriate is the subject of ongoing debate between professionals in the field.

A common thread runs through the foregoing. Sanity, or health of mind, as evidenced by proper functioning is measured in each case against the ability of the individual to successfully cope with the demands of life and his society in a manner which coexists harmoniously with that society. To the degree that one inputs data faithfully, processes it accurately, and assesses the impact on self and others of his actions and reactions so as to avoid unnecessary friction or harm, he could be called sane. One could go so far as to say that errant mental function in any or all of these fields does not move an idividual over the line from the "sane" category to the "not-sane" category as long as the incidence of errant function is incidental, minor or infrequent, and proper function is predominant. Add to this the element that proper functioning necessary to cope does not place undue stresses or demands on the individual, require undue effort, nor cause excessive discomfort, (as in that the person can experience and express emotions without being victimized by them) and both objective and subjective criteria for sanity are met.  This is still a very long definition, but it seems to satisfy the requirements of almost every context.

The words "unnecessary friction or harm" probably cannot be omitted, but they are the weakest point of the proposed definition.  What is seen as necessary by one may be seen as wholly unnecessary and undesirable by another.  The case of the political dissident is such an example.  He sees his friction with the society around him as entirely necessary, for it is his position that the society must be altered for the good of all.  That same society, in preserving its continued existence, views such a position as deviant and dangerous, and is likely to exert pressure to eliminate it.

There is lively debate as to whether physical intervention is necessary or effective to achieve, maintain or restore sanity in the absence of quantifiable biological damage or dysfunction. The three main schools of thought in this arena could be called the "healthy brain - healthy mind" school, the "healthy mind - healthy brain" school and the "spiritual" school. The first maintains that mental function is a product of biologial function, and that therefore brain health and biochemical balance determines sanity. At this writing, this school of thought enjoys majority support in the West.  The second holds that observed changes in the brain and biochemical status are the product of mental function, and that mental health can therefore be addressed without treating the brain. The third holds that the mind is independent of the physical existence of the brain, and that the brain merely permits the mind to be expressed in the body. Organic damage to the brain would necessarily impair this expression. Traditional Eastern philosophical and religious thought tend more in this direction.  Various practitioners and researchers may adhere to a combination of the foregoing schools. How a society approaches its effort to maintain viabililty and cohesiveness through the sanity of its members would be determined by which school of thought enjoys the broadest acceptance in that society. -- AyeSpy, with tongue-in-cheek comments inserted by LarrySanger

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See also SanityTalk.