One of the biggest reasons that mental health treatment has been hampered in the attempts by advocates to put it on parity with physical health treatment is the stigma associated with mental illness. The trouble is, that stigma is empowered by silence. Until we can talk as openly about depression as we do about the flu, that won’t change.
We are now witnessing how that silencing works on a massive scale as we see the attempts to shut down any conversation about Donald Trump’s mental health. We are hearing talk of professional and journalistic ethics that continue to shroud mental illness in a cloak of mystery. Lee Siegal provides an interesting analogy:
We don’t need to be told by a doctor that the guy who is coughing and sneezing at the other end of the train car is probably sick, though we don’t know if it is a cold, the flu, bronchitis, pneumonia, or an allergy. All we know is that the safe thing to do is to stay away from him. When someone is compulsively lying, continuously contradicting himself, imploring the approval of people even as he is attacking them, exalting people one day and abusing and vilifying them the next, then the question of his mental state is moot. The safe thing to do is not just to stay away from him, but to keep him away from situations where he can do harm.
For too many people, the basics of what we need to know in order to have an informed conversation about mental health get lost in that shroud of secrecy. So perhaps a few basic points would be in order to clarify some of the misinformation that is currently being circulated.
First of all, the so-called “Goldwater Rule” that prohibits psychiatrists (not psychologists) from diagnosing unless they’ve conducted an individual in-person assessment was crafted before the Diagnostic and Statistics Manual of Mental Disorders (DSM) took mental illness out of the realm of a Freudian focus on motivation and into the realm of observable behavior.
While it will be lovely when technology is able to tell us what disorder someone is suffering from based on a blood test or a brain scan, we’re not there yet. Most mental health issues are diagnosed by behavioral self-reports, direct observations, and information from those who spend time with the patient (i.e., spouse, parent, etc.) As I outlined after Trump’s last press conference, that usually means meeting a certain number of behavioral criteria that are associated with a particular disorder.
Take a look at how John Gartner, former professor of psychiatry at John Hopkins, and Lance Dodes, MD, Harvard Medical School Professor of Psychiatry, discuss and demonstrate this with Lawrence O’Donnell.
When it comes to Trump, it might also be helpful to know that there are major differences between personality disorders and clinical syndromes. The latter includes a whole host of diagnoses from depression to schizophrenia, but Trump is often associated with personality disorders. While many of the lines can be blurred with certain conditions, here is a critical distinction:
Clinical syndromes have an underlying biomedical cause which the treatment can compensate for, whereas personality disorders are thought to underlie dysfunctional personality traits developed early in the life course. A biomedical cause is not (necessarily) considered to be involved in personality disorders.
Moreover, personality disorders are often associated with extremes on a continuum. That is why there is a distinction between “narcissism” and “Narcissistic Personality Disorder,” between “aggression” and “Antisocial Personality Disorder” or between “paranoia” and “Paranoid Personality Disorder.”
Because personality disorders are not necessarily associated with a biomedical cause, they are not amenable to the kind of drug therapy that is critical for patients suffering from clinical syndromes. While drugs may be used to mitigate symptomatic behavior, the disorder itself is not treatable. So unlike Bipolar Disorder, for example, personality disorders cannot be controlled via medication.
These factors are important to keep in mind when you hear someone say that almost all politicians are narcissists. That may be true. But that is very different than one who has NPD. And while no one wants to further stigmatize people with mental illnesses, it is especially important to distinguish between those that can be controlled via medication and those that are more dependent on enlightenment via talk therapy on the part of the patient, especially when choosing a leader of the free world. My main objection to Dick Cheney and Newt Gingrich — other than their political positions – was that they are sociopaths (another personality disorder).
Finally, as someone who was once a licensed mental health professional (I discontinued renewal when I no longer provided therapy) and trained in systems theory, I can say that I agree with what psychiatrist Allen Francis said:
There is sickness, Frances contends, but he believes it is in society in general. “We are ignoring real existential threats—of overpopulation, of climate, of inequality.” The cure for this illness, he believes is political activism and electing officials who can be trusted to face “the real problems.”
The distinction I would make is that the illness he describes doesn’t obviate the election of a president with a mental health disorder. In fact, it increases the chances of that happening unless we all engage in the cure he describes.
I think it is important to have this conversation for two reasons. Not only do we need to address the political and psychological concerns of having someone like Donald Trump in the White House. Perhaps we can also bring the topic of mental illness out of the shadows and deal with the stigma under which it has been shrouded for too long.