Madness,virtue,and ecology: A classical Indian approach to psychiatric disturbance

The Caraka Saṃhitā

The text is traditionally located in the area of āyurveda, that is, a sacred text of knowledge (veda); of health (ārogya, freedom from disease); or of vigour (āyus), which is synonymous with long life (dīrghamjīvitīyam). ² ‘That is called āyurveda in which beneficial and detrimental, contented and sorrowful life, and what is beneficial and detrimental to it, its assessment, and [life] itself, are described’. ³ Very roughly, this text is presented by itself as a system taught by Agniveśa, who learnt it by being taught by the sage Ātreya. Caraka is mentioned at the end of each chapter as having only ‘edited’ (pratisaṃskṛta) the text. Circumstantial evidence leads contemporary scholarship to think that the earliest layers of the text were composed by the third or second century BCE. But around the fourth or fifth century CE, someone called Dṛḍhabala seems not only to have organized or reorganized it, but also to have added large sections, with his name mentioned in various chapter endings (Wujastyk, 2003: 4). So, when scholars speak of ‘Caraka’, they do not mean a single, specific author, since the compositional history of the text is poorly understood.

This complex compositional and redactive history must surely play a role in the considerations of the historian of ideas, as the text cannot have held the same ideas together in the centuries over which it took its final form. However, I want to make two interrelated points about why I do not attend to that temporal dimension of the text. The tradition itself takes the text, once formed, as a compositional whole, the task of the exegete becoming to interpret its parts in terms of that whole. And, in a sense, I do take myself to belong to that tradition, as someone developing a way of looking at a complex text as a whole, and not merely treating it text-critically. I am not wholly part of that tradition, of course: for one thing, I do not treat the text as a masterwork whose inconsistencies have to be explained away, and for another, I view certain ideas (and those alone) in the text as yielding conceptual inspiration for rethinking contemporary questions that the text itself did not take itself to be answering. In brief, I look at the text as a philosopher, and not as a historian of ideas.

The Caraka Saṃhitā, as it comes down from that time, has 120 chapters, divided into eight sections (sthāna). References will be to the section, the chapter, and the verse or prose passage.

Sūtra (rules, Sū): 30 chapters on drugs and their uses, food, diet, the duties of a physician, and other topics, including some philosophical discussions.

I will look at the different places in which the text talks about ‘illness of mind’ (mānasa roga) and ‘madness’ (unmāda) – primarily in the Sūtra section for the former, and the Nidāna and Cikitsā sections for the latter – while also looking at the Śārīra section (as well as the Sūtra) for larger, philosophical conceptualizations of the human being.

The Caraka Saṃhitā lays out its purpose thus:

Mind, self and body – these three are like a disciplining triple staff [tridaṇḍa]. ⁴ Through their unified combination the world is fixed, they are the point of fixity for all things. This [unified combination] is the human being; it is sentient, it is the subject of this sacred text. ⁵

The category of the ‘psychiatric’ as used in this article

In this article, I want to look specifically at one aspect of this text’s delineation of the human being as patient, namely, the phenomenological situation of certain forms of subjective disturbance (vibhrama). There are two broad areas of interest in the Caraka Saṃhitā’s depiction of the human being as patient, when it comes to the category of the mental. The first is to do with how the text offers a philosophical anthropology of the human being as a composite entity whose being should be understood through its location within an ecology of affect, attention, social interaction, and phenomenal content. This view of the human, I have argued previously, offers ways of thinking about illness that, while permitting analytic distinctions between different categories (physical, mental), are not based on the familiar dialectic between dualism and materialism that continues to trouble the modern philosophy of psychiatry with its Western roots (Ram-Prasad, 2018: 34–45).

This first area is not directly about disturbances of subjectivity that came within the domain of the ancient Indian physician, but more about how the mind is conceived within the text’s programme of the diagnosis and treatment of the human being quite generally. The second area of interest is specifically about this topic. The text’s approach, concerned not only with diagnosis and intervention (pharmacological, palliative, etc.), but also the restoration and maintenance of health, takes on a particularly sharp focus when it comes to what we would think of today as the ‘psychiatric’.

This is because the Caraka Saṃhitā tries repeatedly to tackle, although seldom in a thematically explicit way, the problem of the relationship between why someone falls ill psychiatrically and what ought to be done to help and possibly restore them. This problem is articulated in two ways. One is about the moral relationship between the virtuous and the well life, or the moral and the medical dimensions of a patient’s subjectivity. The other is about the phenomenological relationship between the patient and the ecology within which the patient’s disturbance occurs. The aetiology of and responses to such disturbances help us think more carefully about the very contours of subjectivity, about who we are and how we should understand ourselves. These two issues provide the focus of this article.

Let me begin with a clarification about terms of usage. I do not use ‘psychiatric’ in the sense of the specific clinical science that arose in the 19th century. I am mindful of Dominik Wujastyk’s caution that we should ‘avoid reading back into the ancient and medieval Sanskrit texts ideas and terms from the post scientific-revolution period’ (Wujastyk, 2003: xlv). As we will see, the Caraka Saṃhitā uses two terms: mānasa roga, which translates exactly as ‘mental illness’, and unmāda, which draws on the same Indo-European root as ‘madness’ and can be translated that way. Part of this article’s objective is to explore how these two terms relate and what the differences are in how this compendium uses them. To anticipate myself, what we see is that the text offers a twofold classification of somatic and mental illness in one section, and the concept of ‘madness’ in another section, without explicitly identifying one with the other, while offering overlapping yet distinct analyses of the aetiology of and treatment for each. Moreover, all of this is complicated, in comparative context, by what the Compendium means by manas (mind), as is the case with classical Indian thought. This represents a different history than the Western one with regard to these forms of illness, and it does not suffice to use only the term madness in the less historically situated way, following Foucault.

For the philosophical purposes of this article, I need an analytic concept to cover both these terms, while also indicating that the implied metaphysical mind-body problem that still informs the modern Western usage of mental illness does not quite apply to this very different context. The text talks of ‘disturbance’ or ‘perturbation’ (samudbhrama) as the nature of what happens to the patient whom, in other sections, it describes as ‘mentally ill’ and ‘mad’. So I will talk of ‘psychiatric disturbance’ when dealing quite generally with both ‘mental illness’ and ‘madness’ in Caraka, with the emphatic disavowal that this in no way implies a mapping of a modern clinical scientific term back on to the diagnostic toolbox of the ancient Indian physicians: there is no term in the text that is being translated this way.

Ecological phenomenology: Outline of the argument

My exploration of the Caraka Saṃhitā’s approach to psychiatric disturbance is guided by the concept of ecological phenomenology that Maria Heim and I have developed and written on elsewhere (Heim, 2018; Heim and Ram-Prasad, 2018; Ram-Prasad, 2018). We use the metaphor of ecology to draw attention to how, in any complex and dynamic system (taking the environment as the literal realization of an ecology), the focus of our investigation determines what salience we pay attention to and, consequently, what elements of the system we define and study. A tree on a river bank becomes a focus of analysis in very different ways depending on whether one is thinking about soil erosion, water management, wildlife habitat, changes in climate patterns, conservation of a nature reserve, material for furniture, or an imaginary castle. Not only is the same thing looked at in different ways, but, more fundamentally, what that thing is – a single living organism, a habitat for multiple organisms, or a part of a larger entity like a forest – itself changes with the focus of attention. The metaphor helps with the suggestion that we should do the same with the human subject and its being-in-the-world.

Ecological phenomenology should be understood in two complimentary ways. One is as a hermeneutic methodology for approaching descriptions of experience, in which the context always matters and determines the way we can absorb a particular set of descriptions. ‘Context’ in this methodological sense includes: the genre of the text, with its literary conventions and lexical registers; the stated purposes of the text; and the narrative or other locating devices by which the significance of the textual passages in question is foregrounded. This permits shifts of scope and constitution in our hermeneutic understanding. By seeing the thematization of experience thus – that is to say, as always coming to our attention in terms of the contexts of the text (and the genre) in which it occurs – we are not bound to think of each account as a fundamentally incompatible theory of reality but as covering different aspects of experience in accordance with the concerns and modes of expression of a text or genre.

The other interpretation of ecological phenomenology views it as a philosophy of the nature of experience. Here, ecological phenomenology argues that the analysis of the structures and implications of experience is always dependent on context. ‘Context’ in this philosophical sense includes: material constituents of the objective body; whose boundaries and features vary; ambient features of the sensory range; affective artefacts in the environment; the very conception of what count as the constituents and dynamics of the environment; norms of conduct within which experience is articulated; and the dynamics of social identity.

Ecological phenomenology is methodologically meant to enable us to think of the treatment of the human being in different expressive contexts (what I have called ‘texts’ in a broad sense) as thick and analytic descriptions of being human that need not be seen as offering competing ontological claims. (This is not at all to deny the possibility of ontological projects seeking to determine the context-independent metaphysics of subjectivity, of which there are as many in classical Indian thought as in the classical, medieval, and modern West.) In the Caraka Saṃhitā, the conception of what the human being is and what it is to experience illness as a patient is located within an account of epistemic interaction, modes of treatment, and the cultivation of a virtuous life (and the conception of such a life) that is ecological.

In this article, after introducing the structure of the text, I will begin with an outline of the human being as a ‘composite’ (rāśi). The significance of this account of the complex compositional nature of Caraka’s conception of the human being lies in the fact that it implies a phenomenology of being human (what it is to undergo experience). Then, within this account of the composite person, I will foreground a cluster of ideas around the text’s conception of ‘mind’, ‘intellect’ and ‘judgement’, focusing on the text’s functional depiction of mind within the bodily composite, and judgement as reasoned response by the intellectual faculty of the mind. Through applying a pervasive if elusive concept in ancient India, called ‘guṇa’, or the qualitative valence of an entity, the Compendium presents maladies of mind as shifts in the nature of the human being. We then see that two typologies, those of (i) ‘mental illness’ and (ii) ‘madness’ occur at different points in the text, with somewhat different orientations, to explain such maladies. Despite these differences, in common they are seen as being about ‘disturbances’ or ‘perturbations’ of the mind. This will enable us to begin thinking more carefully about the phenomenology of the psychiatric patient that is the text’s concern in these sections. I will look more specifically at the text’s schematic definition of ‘perturbation of mind’. Caraka describes the result in terms of a disturbed phenomenology: fundamental changes to how a person experiences himself or herself and the world, and interacts with that world. Caraka does not distinguish between chosen and unchosen errors of judgement in a psychiatrically disturbed life. The text takes there to be an intrinsic moral dimension to the onset, experience, and treatment of disturbed phenomenology, but does not itself pass moral judgement on why the patient came to be this way. Rather, it presents the therapeutic necessity of a virtuous life as the response to such a disordered life, a life whose minutiae it presents through the ideal social, ritual, and psychological disciplines of early first millennium thought in the culture of the Sanskrit language-using elite of South Asia. The ecological conception of the psychiatric patient’s way of being shows itself first in the relationship between other modes of treatment (such as herbs, drugs, rituals, and talismans) and the role of the virtuous life in the aetiology and therapy of disturbed phenomenology. Subsequently, it shows itself in how the virtuous life is presented as a grounding of the patient in disciplined modes of engagement with his or her world. Together, this result is an ecological phenomenology of psychiatric illness: the aetiology and therapy of disturbed subjectivity of a compositely conceived person is found in the warp and weft of a skein of relationships running between the medical and the moral, which constitutes the affective existence of the person as patient. Furthermore, the moral therapy for the return of a patient’s subjectivity to order is the following of a virtuous life, which in turn is constituted through a complex environment of psychological, bodily, and social practices of moral discipline. In the concluding section, I locate my ecological interpretation of this ancient medical text’s treatment of illnesses of the mind in relation to recent uses of the idea of ‘ecology’ in the philosophy of psychiatry.

‘Mind’ and the person: A compositional account ⁶

It would be worthwhile to locate the Caraka Saṃhitā’s outline of the ‘ordinary person’ (that is to say, the patient as opposed to some rarefied or spiritual entity) against the backdrop of the notion of the human being with which we are familiarly confronted in Western modernity. Drew Leder’s summary puts the case succinctly:

It is not the ‘mind’ per se that is the scene of illness, nor the ‘brain’, but the life-world of the individual, constituted by the play and solicitations of the embodied self with its environs. Illness is triggered, and can be treated, on the levels of neurobiology; cognitive ideation; life motives and goals; habits of diet, exercise, meditation, and creativity; family structures; social relations; religious systems; dominant institutions; cultural norms and pressures; along with the interactions and synergies taking place between these different levels. (Leder, 2005: 112)

The Caraka Saṃhitā shows a certain fluidity over the conception of bodily nature, depending on objective and context. At some times, it can be the material body that yields the text’s physiology; at others, it concerns various aspects of the phenomenological body that justifies the need for a physiological understanding in the first place. (Hailing from a time long before technological tools, without a regime of regular checks, possibly based on statistical risk assessments, that might detect dangerous diseases of which the patient is not aware, ancient medical texts tend to focus on people feeling ill or being in pain, or other negative states. Obstetrics – to which the Compendium devotes considerable attention – is an exception to the extent that the pregnant woman, in principle, need not feel ill in order to come under the purview of the physician, but the text is quite mindful of pain.) The phenomenological body – the living subject with its agency and goals, and its illnesses and suffering – is itself determined in different ways, depending on the concerns of the text at any particular point. This fluidity is synergistic in various ways that anticipate Leder’s call to treat the person and the illness in terms of a larger environment.

At different points, the Compendium offers a variety of lists on the constituent elements of a person, apparently drawing on philosophical concepts available at that time (Maas, 2008: 139–40). However, for my purposes, the typological explanation in the first chapter of the Section on Body (Śārīra Sthāna) is the most relevant because of the way this typology then fits into various formulations of the nature of the human being, together forming what can be called a philosophical anthropology for medical ends.

At 1.16, the text notes that the subject (puruṣa) is by tradition (sṃrti) said to be constituted by the five material elements (mahābhūtas), together with sentience (cetanā); these six are the constitutive elements (dhātus). (In its more physiological sections, the text uses dhātu specifically in the sense of ‘body tissue’, i.e. the constitutive material of the different organs and structures of the body.) But the very next verse tries out an alternative schema:

Or yet again, it is said to consist of twenty-four constitutive elements: the mind, the ten [sensory and motor] organs, the five objects [of the senses] and the functional entities made up of the eight constitutive elements (the five forms of matter, the ‘I’-sense, the faculty of judgement, and the primordial base of these). ⁷

My aim here is not to investigate the philosophical arguments for this ‘compositional’ account; as a text for diagnosis and therapy, the Caraka Saṃhitā does not seek to argue for a metaphysics. ⁸ Rather, I want to note that howsoever it seeks to deal with the human being as patient, the Caraka Saṃhitā works with a picture of that being as composed of various categories, rather than in a dualist or reductively physicalist manner. The problems it confronts with the concept of ‘mind’ when trying to deal with psychiatric illness need to be understood on their own terms. It has a practical yet analytic approach to the maladies of what it in the Śarīra Sthāna calls the ‘ordinary person’ (katidhāpuruṣa): it talks of the mental and the somatic without being compelled to provide a metaphysical reduction. In this, its approach accords well with those who argue (obviously with no knowledge of the Caraka Saṃhitā) that there is no need to wrestle with dualist implications in the philosophy of psychiatry (Schaffner, 2013).

‘Mind’ and ‘judgement’

The notion of ‘mind’ (manas) in the Caraka Saṃhitā is mainly functional, talking more about what it does rather than what it is. The functional list is recognizably what one would expect of an entity called ‘mind’ in English, so it is not the case that the text has some alternative set of features attached to the same Indo-European root word. It wrestles in the same way as other traditions of thought with the intractable mystery that it is like something to think, yet without the possibility of isolating that organ by which there is that occurrence (as opposed to, say, that organ by which it like something to breathe).

I set aside here the more fundamental problem of how like-somethingness is itself possible, the very possibility of subjectivity. Tackling the clever and indirect way in which the Caraka Saṃhitā deals with consciousness itself is a different task, and does not contribute directly to the issue of psychiatric illness in this article (Ram-Prasad, 2018: 40–5). Here, I want only to outline how the Caraka Saṃhitā speaks of manas, because it becomes important to its accounts of psychiatric illness.

The Caraka Saṃhitā is concerned with the human being as the natural and naturalistic subject of the physician’s attention; and it therefore includes aspects of subjective human nature in its classification in the Śarīra Sthāna at 1.17. The ‘mind’, although it is not physically evident like the five sensory organs for the perception of various states and aspects of objects, is still conceived as a further sensing organ whose contact with the other senses is required before there can be cognition (jñāna):

The characteristic of mind is that while with it there might be right or wrong cognition, without it there is no cognition at all, even when there is contact between self, senses and their objects; and right cognition is accomplished only when the mind is in conjunction with them. Furthermore, it is said that the mind has two features: it is subtle, and it is singular. ⁹

Along with the mind, the Compendium also speaks, again using a traditional concept, of the intellect (mahān or buddhi). The intellect is an important constituent aspect of the person for the Caraka Saṃhitā:

Thought, investigation, consideration, imaginative meditation and determination, and whatever else can be known by means of the mind, all those are its objects of understanding. Mental action is the control of sense organs, self-regulation, examination, and investigation; after that is the operation of the intellect. ¹⁰

Since the text takes the intellect’s operation as the outcome of mental activity, it does not treat the two separately; the term buddhi can therefore also be translated as ‘mental faculty’: ‘The intellect of creatures functions on the basis of the appropriate sense organs’. ¹³

From this outline of what is meant by ‘mind’ and ‘intellect’, it is clear that the Caraka Saṃhitā is not making the distinction between ‘mind’ and ‘body’ with which we are familiar in our contemporary folk language, whose roots lie in the popular reception of so-called Cartesian dualism. ¹⁴ The whole bodily human being is itself not a monadic entity fitted into an environment. In this article, I hope to draw out how the Caraka Saṃhitā sees the human as discernible in different ways, according to diagnostic and therapeutic purposes, as an ecologically enmeshed assemblage of functional constituents and phenomenological affect.

Mind, qualitative valence, and malady

Within this larger picture, we can now pay more attention to how the text thinks of ‘mind’ and ‘intellect’ in relation to illness:

The body and the essence of reasoned understanding are taken to be the seat of illness. So too, of wellness. Their balanced use is the cause of wellness. ¹⁵

As we dig deeper, we find that while the text talks specifically of mind and its illness, this does not necessarily mean that it is talking of non-material states of being. This can be seen in its use of one of the most pervasive but elusive and polysemic classificatory tropes of classical Indian thought, the ‘three qualities’ (triguṇas):

‘Wind’, ‘bile’ and ‘phlegm’ are said to be combinatory factors for humoural maladies of the body; while ‘passion’ and ‘inertia’ are specified as the ones for the mental. ¹⁶

In fact, the Caraka Saṃhitā is not exactly making a distinction between material and non-material sources of malady. It is adverting to its reading of the three guṇas or ‘qualities’ from its contemporary philosophical system of Sāṃkhya: ‘lucidity’ (or ‘essence’, sattva), ‘passion’ (rajas), and ‘inertia’ (tamas). They are the ‘operational forms’ of the primordial stuff of reality (prakṛti). ¹⁷ Reading them as parts of primordial nature suggests a whole/part relationship with primordiality that is misleading (Ramakrishna Rao, 1963: 63). Ramakrishna Rao suggests that the three should be seen as the modes of working of the stuff of the world, or ‘primal nature’ (prakṛti): sattva (purity or lucidity) is the being of things, rajas (passion) is their changingness, and tamas (inertia) is their resistance to change (ibid.: 67). Mikel Burley, while still preferring to think of guṇas as parts, also calls them ‘strands’ (Burley, 2012: 51). These strands seem to be ways in which nature shows up phenomenologically, as in the gloss the great ninth-century commentator Vācaspati gives them, ‘as “delight” (sukha), “distress” (duḥkha), and “dullness” (moha) respectively’. ¹⁸ So the guṇas are aspects of the stuff of nature. At the same time, they are valences of its modes of manifestation; and this can be at various systemic levels, be it in the conduct of states or the behaviour of a person, the virtues and shortcomings of a book, or the successes and failures of a performance. Any of these can be characterized as possessing these guṇas. Their functioning as they are meant to is their demonstrating sattva. The organic normality of a person is nothing other than the functioning of the qualitative valence of sattva; it would seem (although there is clearly no single interpretation of them across genres and contexts) that the malfunctioning of any system is due to the combinations of the other two, resulting in the vitiating of lucidity.

Mental illness is the result of combinations of material self-expression in bodily being. It certainly pertains to existential states that are not reducible to physiological ones like the humours, but their possession of valence – values or disvalues attached to the phenomenology of the patient – is not due to their being of a different order of existence: it should be remembered that the humours and the valences are equally part of the stuff of nature (prakṛti). The Caraka Saṃhitā is reaching for some intuitive distinction between somatic and mental illness, but is at the same time working within a conceptual framework that treats their aetiology as lying within the same order of being. For example, we will see how its aetiology of what it calls endogamous madness slices across the somatic and the mental, preserving the analytic distinction and yet not treating that distinction as metaphysically constitutive of the human being. What the text wants to do is draw attention to the categorial differences within these aetiologies, while keeping its attention on the type of illness with which it is concerned:

Thinking is the purpose of the mind. Then, the proper usage, and excessive, non- or wrong usage of the mind and its judgement are [respectively] the reasons for normal functioning and malfunctioning of the mind. ¹⁹

Typologies

Bad judgement, virtue, and implications for therapy

‘Judgement’ is the common point of focus for the Caraka Saṃhitā in its depiction of both ‘mental illness’ and ‘madness’, even if the aetiological classifications, as we have seen, are slightly different.

When talking of ‘mental illness’ as the malfunctioning of the mind through imbalances in its qualitative valences, the text introduces a key notion in its description of psychiatric disorder:

Three-fold action [relating to speech, mind and body] with the three alternatives (of excessive, non- or wrong usage) constitute bad judgement. ²³

Bad judgement is to be understood as provoking all maladies. ²⁴

With this concept, the Caraka Saṃhitā squarely confronts the relationship between psychiatric disturbance and the virtues of the patient. What we would call choices of lifestyle are implied in the view that bad judgements are involved in making worse – provoking (prakopaṇa) – maladies. This perspective prompts the Caraka Saṃhitā to set out a rigorous programme for the virtuous life, to be followed both to remain well and to regain wellness (Ram-Prasad, 2018: 50–4).

Bad judgement is generated as mental action, and is expressed more generally in behaviour. Both reasoning with inconstant intelligence (viṣamavijñāna) and inconstant conduct (viṣamapravartana) constitute bad judgement, and both come within the ambit (gocara) of the mind (Śa.1.109).

Despite presenting the trope of ‘madness’ with a somewhat different aetiology than ‘mental illness’, the Caraka Saṃhitā nevertheless ties them together by returning to the larger question of the compositional aspects of the human being that are related to ‘bad judgement’ (prajñāparādha). (With this focus on ‘judgement’, the text at this point seems to ignore the emotions, but as we will see in the next section, it in fact has quite a lot to say about particular emotions, especially in relation to their impact on attitudes towards oneself and the world.)

Madness is taken to be disturbance of mind, intellect, understanding, knowledge, memory, devotion, virtue, manner of living, and proper conduct. ²⁵

Madness is perturbation of intellect, mind and memory, and is said to be exogenous or endogenous. ²⁶

The Caraka Saṃhitā demonstrates an attitude to the therapy of psychiatric disturbance that resembles discussions in recent Western philosophy of psychiatry. Eric Matthews argues that we must think of at least some mental disorders as ‘unchosen’: they are just the things people feel, think, or do that make for divergence from satisfactory life under some moral conception of that life (Matthews, 1999: 308–9). For the Caraka Saṃhitā too, treatment of psychiatric disturbance is about developing a virtuous life. The text says that a wise person (buddhimat) ‘even if seized by mental illness’ (mānasavyādhiparītenāpi) – in other words, what befalls the patient unchosen – should consider what is beneficial (hita) and what is not:

So one should try to accomplish the following: one should try to serve those who are knowledgeable [in the treatment of diseases], and acquire knowledge of the self, place, family, time, strength and energy. ²⁸

It should be emphasized that the Caraka Saṃhitā is not saying here that the illness is the fault of the patient who has a particular qualitative valence (guṇa) to his or her nature, or who responds to life events in ways that result in that illness. The Caraka Saṃhitā is astonishingly humane in that, even as it describes what people do in marked deviation from virtue, it soberly traces back the manifestation of moral misconduct to the aetiology of illness, that is to say, to what is unchosen.

Without doubt, the Caraka Saṃhitā offers moral cultivation to correct the consequences of the bad judgements that mark psychiatric disorder. At the same time, it not only locates moral cultivation within a wider notion of therapy for the (re)attainment of the life towards which health should tend, but also locates bad judgement within a wider notion of a patient’s phenomenology. To anticipate my conclusion, the text’s depiction of disturbed subjectivity and its therapy locates that subjectivity within an ecology, which helps us think about being a human subject in a certain way. But first we must see how even the accounting of the types of psychiatric disturbance is ecological. To do this, we trace affect through different aspects of the perturbed subject, the ill being, being ill. The text implicitly deals with the patient as an organic, composite being, with a complex and phenomenological being-in-the-world.

The ecology of psychiatric disturbance: Endogenous and exogenous aetiologies

‘Madness’, as we have seen, is classified as endogenous or exogenous, and the classification stretches from triggers through symptoms and therapy. Whereas we have seen that the Caraka Saṃhitā talks about ‘mental illness’ as a distinct illness separate from those caused by imbalances in the three humours, here it talks of one type of ‘madness’ as in fact being triggered by such imbalances.

Under Ni.7.3–4, the text gives the following as the circumstances under which endogenous madness occurs: a person being fearful (bhīru); the qualitative valence (guṇa) of lucidity (sattva) in a person being vitiated (upakliṣṭa; as described earlier in this article); the raising (utsanna) of the medical factors of malady (doṣas); the consumption of various types of bad food; inconstant (vaiṣamya) and inapt (ayukti) modes of living (vidhi); the extreme depletion (atyupakṣīna) of the body; the prior contraction of some other disease (vyādhi); the infliction of injury (abhighāta); and damage (upahata) to the mind (manas) through the violent perturbation (vegasamudbhrama) of passion (kāma), anger (krodha), greed (lobha), lust (harṣa), fear (bhaya), delusion (moha), exertion (ayāsa), grief (śoka), or anxiety (cintā). For my purposes, at least three points need noting.

While the text talks of endogenous illness, it does not restrict aetiology to what lies under the skin. Rather, it thinks of the human being as a subject whose life functions (or malfunctions) through feedback loops between somatic and environmental factors. So we do not have a fixed inner/outer distinction. In fact, we should be attentive to the fact that it is in our language that we make the analytic distinction between the somatic and the environmental. While clearly aware of the factors that constitute these domains, the text itself simply presents the aetiology of endogenous psychiatric disturbance through factors that vitiate life as such, for inconstancy of living may be found in anything from one’s food and one’s words to one’s behaviour towards others.

The text also seeks to understand psychiatric disturbance as an intensification of non-pathological aspects of moral psychology in a well person. The types of emotion and evaluative attitude listed are problematic in a virtuous life, but they do not in themselves cause an ill one. But if we begin with a life dominated by such a moral psychology, then it would seem that psychiatric disturbance results from one or more of these emotions and attitudes worsening in their effect on the mind. Note here that, for diagnostic purposes, the text does not make any easy delineation between agentive failures in a moral life and unchosen moral disorder: just as what food one has may be due to either choice or circumstance, greed may be within agentive control somewhat more than grief (while lust may or may not be pathological). The focus, instead, is on the possibility of moral cultivation as therapy, for these emotions and attitudes are held to be susceptible to treatment through the development of a virtuous life. The text reframes the concerns of philosophical analysis as those of medical therapy. It notices that the phenomenology of emotions and the moral psychology of attitudes that are the object of the former discipline (whether in contemporary Buddhist commentaries on the proper life or in the knotty dilemmas narrated in the epic Mahābhārata) become, in their devolution into disorder, the object of the latter, which is the proper subject matter of the Caraka Saṃhitā.

The importance of moral cultivation as therapy becomes urgent in exogenous madness. Exogenous madness is a matter of ‘bad judgement’, a concept we have already come across:

Its cause is bad judgement [according to Lord Punarvasu Ātreya]. Due to bad judgement, one behaves in a calamitous way towards the gods, sages, ancestors, celestials, heavenly attendants, demons, ghouls, teachers, elders, adepts, preceptors and others worthy of respect. He also takes up other blameworthy activities; because of his own resorting to such wretchedness, the gods and others make him mad. ²⁹

The text then lists the circumstances in which these outraged forces bring about madness. Here the text is inconsistent because, while many are demonstrations of bad judgement, others can hardly come within the realm of the patient’s moral situation at all. Ni.7.14 enumerates some 20 circumstances in which these unseen beings bring about madness. There is a cluster of transgressions of sexual and other norms of conduct, which are held to be deplorable (apraśasta) in the view of the text, and, being choices made by the patient, leave the patient responsible for the madness-inducing failure of virtuous life. Some others are health-threatening factors like sanitation (coming into contact with unclean objects and creatures), medical malpractice (such as the incorrect use of emesis, purgation, or bleeding), or difficulties during or after delivery. Obviously, there is no moral choice involved in these circumstances. The same is the case with a third cluster of triggers, which are traumatic experiences like battles and witnessing the destruction of communities and towns.

The text therefore seems to vacillate between holding the patient morally responsible for a class of psychiatric disorder and humanely listing exogenous factors that are traumatic but entirely beyond the control of the patient. It seems to be the very nature of endogenously triggered disturbance that there are blurred boundaries between what is systemic disorder and what is moral disorder, and between what is chosen and what is unchosen in moral disorder. By contrast, one would think that by their very nature, exogenous triggers are environmental factors that impinge upon the patient, but because here too the text wants to maintain the relationship between virtue and psychiatric disturbance, it posits that even exogenously wrought factors – in the form of actions by gods, demons, and various adepts with paranormal powers – must be triggered originally by moral failures, that is, the results of choices made by the patient.

Beyond the uncertainties of the patient’s moral responsibility for bringing on psychiatric disorders, what we should note is that such disorders are not confined to one aspect of a person’s nature. Even when ‘mind’ is what is damaged in madness, it is simply the node of the physician’s attention within a larger reality. In all its formulations and explanations, the Caraka Saṃhitā locates psychiatric disturbance as the perturbation of a subjectivity constituted by a web of material functions, dispositions of character, reasoning and error, social norms, patterns of interaction with other subjects and things, and an expansively construed world of events and forces. It is not only not ‘all in the mind’; it is not reducible to a set of metabolic failures either. In short, the subject is conceived ecologically, and so is the disturbance of its phenomenology.

The ecology of therapy: The cultivation of virtue and other treatments

Although I will not have much to say about the text’s description of the genesis of disorders, I will present two relevant passages to give a sense of how it sees psychiatric disturbance within what Francis Zimmerman has called an ‘economy’ of the body rather than an anatomy in a strict sense. Zimmerman observes, ‘There is no map nor topography of the body but only an economy, that is to say, fluids going in or coming out, residing in some āśraya, “recipient” (organs are conceived of as recipients), or flowing through some srotas, “channel”’ (Zimmermann, 1979: 15; emphasis in original). What he means by this is that we cannot treat the āyurvedic texts as mapping on to the anatomy and, even more importantly, the physiology of modern medicine. The āyurvedic tradition does not think in terms of organs and their functions. Rather, it thinks of the body in terms of the flow and exchange of fluids, physically identifiable organs treated as waypoints and junctions in that flow. Consequently, ill-being is the result of blocks and diversions of that flow:

There [where the relevant causes hold]…the mind is damaged and judgement confused. The medical factors of malady intensify, and aggravated, enter the heart and close the channels of the heart-mind’s vessel, leading to madness. ³⁰

In a man with only a little [of the natural qualitative valence (guṇa) of] lucidity, these causes aggravate the impurities that distress the heart in which resides judgement; and being located in the channels of the heart-mind’s vessel, they quickly befuddle his intelligence. ³¹

I should clarify that nothing in my analysis turns on the āyurvedic understanding of how the body works, although Zimmerman’s metaphor is a persuasive one. I aim simply to present briefly the ‘medical’ understanding of madness, while my main concern in this article is with the phenomenological representation of it.

The text also has a long list of symptoms, ranging from acute observations about postural and behavioural changes all the way to speculative explanations about supernatural factors.

But let us now look at the therapies that are offered, and note once more the complex interplay of different aspects of the patient’s being-in-the-world. Treatments for endogenous psychiatric disorders include a range of somatic therapies: based on oil; on a wide range of precisely calibrated and elaborately prepared plant-based decoctions mixed with ghee or honey; ³² and on poultice, massage, and fumigation. Carefully laid-out diets are also prescribed.

In severe cases, the text reluctantly advises what sounds like a straitjacket and padded cell:

For one who persists in rough behaviour, he must be securely but comfortably tied up with cloth and confined to a dark room devoid of iron or wood. ³³

By contrast, we already know that the text takes a rather different view of treatment for exogenous madness. Whether it considers the triggers to have been due to catastrophic events or the provocation of unseen forces by a badly lived life, the Caraka Saṃhitā definitely takes the cultivation of a virtuous life as the appropriate therapy for this category. In the two different places at which it gives the therapy for exogenous (āgantu) unmāda, the text offers overlapping lists of practices that it considers exemplary of the properly cultivated, socially responsible, ritually ethical life:

The means of treatment are: incantations, medicinal talismans, amulets, auspicious rites, propitiatory sacrifices, gifting, fire oblations, restraint, vow-keeping, expiatory rites, fasts, receiving benedictions, performing obeisance, and pilgrimage. ⁴⁰

Exogenous madness is cured by propitiatory sacrifices, auspicious rites, fire oblations, wearing medicinal talismans; truthfulness, good conduct, austerities, knowledge, charity, restraint, vow-keeping, honouring gods, cows, brahmins, and teachers; and the application of perfected sacred formulae and medicines. ⁴¹

The text, it should not be forgotten, recommends the adoption of these values and practices as medical treatment, intended to lead the patient towards what it considers the life that ought to be led, but also the life that will treat the disordered state of the patient. This attitude fits strikingly well with Duff Waring’s contemporary articulation of the relationship between virtue and psychiatric disorder:

The goal of treatment can…involve changing a patient’s emotional, cognitive, and behavioral dispositions in ways that significantly increase her chances of achieving a satisfactory life. This can imply a threshold state of being virtuous if the character faults are to be superseded by morally desirable character strengths. The goal would be to supplant the character faults with settled cognitive, emotional, and behavioral dispositions that with sufficient effort will become stable virtues over time.…[The] patient has to accept responsibility for working with, on, and for herself. The working through can involve cultivating affective, cognitive, and behavioral dispositions that would amount to morally desirable changes in the way the patient treats other people. (Waring, 2012: 27)

On ‘ecology’: Concluding comparative reflections

My analysis of conceptions of disturbed subjectivity in the Caraka Saṃhitā has been based on the idea of ‘ecological phenomenology’, which I developed previously with Maria Heim. The main point of this analysis has been to demonstrate that, despite making distinctions between mind and body at certain points, the text is best understood as situating the human being within a larger web of dynamic interactions. Seen in this way, the text’s idea of ‘madness’ is shown to be a complex one. The aetiologies and the therapies it provides for its own classification of types of madness, while often only protoscientific in detail, reveal a way of looking at the human patient that goes far beyond the inside/outside, material/mental divides that have characterized the language of the philosophy of psychiatry for much of modernity. This dynamic location of the subject in an ecological paradigm of the surrounding social world notably generates a nuanced account of the relationship between moral responsibility and therapeutic practices. This article has sought to show one way in which mental illness could be approached, from the resources of a text and tradition far removed from the philosophical origins of modern psychiatry.

I have tried to explain how ecological phenomenology, as a general framework, helps me to read the text in a certain way, and contributes to contemporary discussions on psychiatric disturbances. Within the Western philosophy of psychiatry too, specifically from phenomenological perspectives, there have been fundamental reworkings of conventional ideas of the mental. There has, in fact, even been a conceptualization of the human mind in terms of the metaphor of ecology. In this concluding section, having delineated a Carakan view of psychiatric disturbance, I will engage with some of the current literature that I think is headed in the same direction as me, albeit via the distinctive pathway of moving on from intuitions informed by Cartesianism, a path, of course, that the Sanskritic material does not follow.

It is important to remember that the text itself does not thematize an ecological approach as a medical approach to therapy. It is not consciously thinking of how to overcome dualistic and individualistic ideas about the subject and its disorders so as to offer a clinical model with superior diagnostic capacity over those that schematize psychiatric problems as confined to the brain (and treatable purely through drugs) or imagined by the patient (and therefore ‘all in the mind’; not a biomedical problem, but fit only for a certain type of counselling – if not simply for ‘pulling it together’). It simply functions in a conceptual world in which it takes the human being to be constituted in a particular way, and proceeds to tackle that being’s ill health with the diagnostic and remedial capacities at its disposal. In arguing that its approach to the human being’s experience of (psychiatric) illness may be characterized as ecological, I am confining myself to the purely philosophical task of asking how we might understand of the human being who is presented in the Caraka Saṃhitā’s chapters on psychiatric disturbance. I am not suggesting anything about the text’s relevance to contemporary psychiatric treatment. This clarification is necessary in order to distinguish clearly my use of ecology from one that has periodically been at the forefront of a debate in the philosophy of psychiatry.

For example, Quinton Deeley has drawn on Geoffrey Samuel to argue for what he calls an ecological approach to narratives of psychiatric illness. He draws on Samuel’s claim that explanations of mind and behaviour have been split between collectivist approaches emphasizing public, communal activities (myths, rituals, rallies) and individualist approaches focusing on drives, needs, and wants. Deeley says,

An ecological approach entails that both collective and individual variables should be viewed as interrelated and reciprocally constraining aspects of a single environment or field of relationships. The emphasis in explanation is not on attempting to consistently isolate a particular kind of variable as being the key or preeminent constraint on the formation of mind, behaviour, or any collective phenomenon, but rather on elucidating the relationships between individual human beings and between individuals and the rest of the world. Reality is thus conceived as a ‘flow of relatedness’, and the task of the human sciences is to model how human beings orient themselves within this flow of relatedness, modifying it and being modified by it. (Deeley, 1999: 110)

The notion of the ‘ecological’ that we have seen debated in the works discussed above concerns the question of diagnoses that take into consideration the physical, mental, social, and cultural environment in any explanation of why a patient might present in a certain way, and how those around him or her might seek to explain their own understanding of why he or she presents in that way. The question then becomes whether there is a diagnostic technique that unifies in a single explanatory system the environmental features of a patient’s condition. Littlewood argues that obviously there are many intersecting features – cultural, social, and so on – but it is not clear that they can all be integrated into a single and unified system of analysis. My use of the term ecological here is quite different. It is not a psychiatric diagnostic tool but a philosophical metaphor to account for why illness – along with any other experiential state – is explicable through a multiplicity of saliences and perspectives that bring our attention to bear on different aspects of the phenomenology of psychiatric disturbance.

My application of the general approach of ecological phenomenology to psychiatric disturbance most resembles the work of Thomas Fuchs. Fuchs, like Leder, has long argued that psychiatrists should recognize the need for an ecological psychiatry, ‘to better grasp the interconnection of psychological, social, and pharmacologic approaches adequate for its subject. For this subject is not the brain, but the mentally ill patient’ (Fuchs, 2002: 264). As with Leder, and as I have argued in this article, Fuchs is emphatic about the importance of seeing ‘mind’ in a non-Cartesian way. In a manner uncannily similar to what we have seen Caraka say about the mind (manas), Fuchs (2005a: 95) argues, ‘The mind is not a transmundane asylum of pure subjectivity, but it is the integration of all these living bodily processes, which render themselves transparent to the world’. This leads him to make several careful analyses of various psychiatric disorders (which lay considerably beyond the ken of Caraka two millennia ago), before stating a general conclusion very much in keeping with what I have argued is the fundamental approach of Caraka:

We may ask why psychopathology has traditionally disregarded this bodily and intersubjective basis of depression and focused on individual psychological symptoms instead.…The main reason for this neglect might be seen in the fact that psychiatry still has no concept of the lived body, nor of the organic unity of the embodied person. The traditional dualism of mind and body has only been replaced by a reductionist monism which now regards the brain as the true heir of the soul – again disregarding the living unity of the organism. (Fuchs, 2013: 234)

My general treatment of the human being, both in this article and in previous work to which I have referred, is less interested in offering a specific response to mind/body dualism and more in delineating an entirely alternative history of how to think about the bodily human being. And certainly, even in this article, I have much less to say about the specifics of psychiatric conditions, and – bound by the nature of this classical text – nothing about the brain. ⁴³ But ecological phenomenology as a broad methodology goes beyond the specific concerns about mind/body problems towards a general approach to human experience, and it is this general approach that I have brought to bear upon the Caraka Saṃhitā in order to elucidate the conceptual issue of how to think about the human being under the condition of psychiatric disturbance, and its therapy.