What’s Wrong With Trying to Figure out What’s Wrong With Trump: Responding to Shane Snow
Allen Frances, the chairman of the task force that produced DSM IV, recently published a short, wonderfully pugnacious letter in response to the Change.org petition Shane writes about in this article, and I think everyone has a duty to read it.
I think that so strongly, in fact, I’m going to post it here in full, because — again — the thing is short, and very, very good:
To the Editor:
Fevered media speculation about Donald Trump’s psychological motivations and psychiatric diagnosis has recently encouraged mental health professionals to disregard the usual ethical constraints against diagnosing public figures at a distance. They have sponsored several petitions and a Feb. 14 letter to The New York Times suggesting that Mr. Trump is incapable, on psychiatric grounds, of serving as president.
Most amateur diagnosticians have mislabeled President Trump with the diagnosis of narcissistic personality disorder. I wrote the criteria that define this disorder, and Mr. Trump doesn’t meet them. He may be a world-class narcissist, but this doesn’t make him mentally ill, because he does not suffer from the distress and impairment required to diagnose mental disorder.
Mr. Trump causes severe distress rather than experiencing it and has been richly rewarded, rather than punished, for his grandiosity, self-absorption and lack of empathy. It is a stigmatizing insult to the mentally ill (who are mostly well behaved and well meaning) to be lumped with Mr. Trump (who is neither).
Bad behavior is rarely a sign of mental illness, and the mentally ill behave badly only rarely. Psychiatric name-calling is a misguided way of countering Mr. Trump’s attack on democracy. He can, and should, be appropriately denounced for his ignorance, incompetence, impulsivity and pursuit of dictatorial powers.
His psychological motivations are too obvious to be interesting, and analyzing them will not halt his headlong power grab. The antidote to a dystopic Trumpean dark age is political, not psychological.
ALLEN FRANCES
Now, per usual, I’m not exactly the first person to write about this difference in opinion. Vox.com has, true to form, already published a crisp, well-researched article about Frances’ letter and how its been received by his colleagues, specifically the colleagues who penned the original statement about Trump’s mental health.
As the author of that article understands things, the basic disagreement between Frances and John Gartner (the most outspoken contributor to the original letter) is about whether or not a diagnosis of narcissistic personality disorder requires the person diagnosed to be in some kind of suffering as a result of their symptoms. Frances says Trump seems to be fine, happy, — monsterously successful, even — which in his view disqualifies him. Garten says that, on the contrary, not being distressed about one’s disorder is a primary feature of the disorder itself — indeed, it’s what makes things like Malignant Narcissism so potentially harmful: the afflicted don’t recognize that anything is wrong with themselves or their actions.
And while this very well may be one of the primary features of the miniature debate surrounding this issue, I think that there are much deeper problems with diagnosing trump in this way.
For starters: the diagnosis process itself.
Setting aside the fact that none of these mental health professionals have had any actual clinical contact with Trump — setting aside the fact that none of them have had the opportunity to administer a validated measure of personality to Trump — and setting aside the fact that the APA, as noted, has had a longstanding ethical sanction against just this type of behavior, because of the obvious biases and confounds that must cloud any clinical judgement of a public figure from afar — setting aside all of these things, I say, — we’re still left with the more basic problem: Categorical diagnosis is on its way out.
The neat little checkboxs, the easy-to-understand scoring (“Exhibits 4 or more of the following:”) — these easy ideas about how we can diagnose personality disorders have been questioned for years and are even now being actively argued against by personality and clinical psychologists around the world.
To make things brief: the method of diagnosis Shane is writing about here is, again, called ‘categorical diagnosis,’ and it’s been with clinical psychology almost since the beginning — back when psychology and psychiatry were still just special branches of physiology. Indeed, that’s where the method originally comes from: the science of physical medicine.
Emil Kraepelin, the person who helped more than anyone else to give us the categorical method, was originally trained in medicine and neurology, and this couldn’t have helped but to influence his thinking.
In clinical practice, after all, someone either has a disease like emphysema or they don’t; someone is either pregnant or they’re not; you either had a stroke or you didn’t, etc. etc. The early psychiatrists and neurologists who helped found the field of clinical psychology wanted to bring the apparent rigor and precision of this kind of thinking to their new science; they thought a trained clinician should be able to say, in just as definitive a way, that someone had manic depression — or that they didn’t — or that they were a histrionic — or that they weren’t.
The problem with this approach, however, is that it doesn’t handle gray-areas very well. What happens when someone only meets 5 out of the 6 criteria needed to be diagnosed with unipolar depression? According to the categorical approach, they can’t be given an official diagnosis — but clearly something is wrong with them, causing them suffering. And what to do about all of the symptoms that overlap between syndromes? With this all-or-nothing approach, it’s also difficult to say when, say, generalized social anxiety disorder stops and agoraphobia begins.
More than that, it seems to sacrifice a great degree of precision for simplicity. There’s no hierarchy or prioritization of symptoms, really, — maybe a DSM listing will say that one or another behavior is required for a diagnosis, but that’s it . This means that two people who both meet the requirements for a diagnosis of, say, Borderline Personality Disorder can actually present markedly different clinical profiles, with different symptoms and different levels of severity for each symptom — none of which is captured by the actual diagnosis.
This is why clinicians are increasingly calling for something called ‘dimensional assessment,’ which views mental disorders — and especially personality disorders — less as a collection of either-present-or-not symptoms, and more as a ‘spectrum,’ so to speak, of personality traits.
But I’ve been talking enough about psychology.
The main reason I’m needling on about all of this is twofold.
First, I’m writing about it because the way Shane presents information in his article makes diagnosing someone with a mental disorder seem much more straightforward or easy than it actually is, and I think this is a generally pernicious idea.
Mental disorders — and especially personality disorders — are things which stand in a much more intimate relation to us than disorders with our body do, because in a way it seems like its our actual person, our self which is afflicted by these diseases. The distinction between ‘healthy’ and ‘ill’ in this area is something that’s a lot murkier than most people would like to believe, and it’s a failure to recognize this — to instead view mental illness as something which is simple or obvious — which helps contribute to the stigma around mental disorder.
The other reason I’m talking about all of this is because of something Frances says in his letter:
Bad behavior is rarely a sign of mental illness, and the mentally ill behave badly only rarely. Psychiatric name-calling is a misguided way of countering Mr. Trump’s attack on democracy. He can, and should, be appropriately denounced for his ignorance, incompetence, impulsivity and pursuit of dictatorial powers.
His psychological motivations are too obvious to be interesting, and analyzing them will not halt his headlong power grab. The antidote to a dystopic Trumpean dark age is political, not psychological.
Even if Gartner and his colleagues diagnosis was correct, it would tell us precisely nothing new about Trump. We already know that he’s thin-skinned, we already know he is a seemingly compulsive liar, we already know that he’s a danger to himself, those around him, and the multitudes he is now responsible for.
Collecting this obvious information under some new clinical heading doesn’t help us understand it any better, and it doesn’t help us change it.
Those tasks, as Frances says, are wholly political in character — we won’t find the answers to them in any edition of the DSM coming out any time soon.
