Sunday, 29 January 2017

Diagnosing Donald

(note: more than is usually the case, credit must go to my wife for formulating many of the substantive ideas in this post)

Since he lurched into the Republican primaries last year, There seem to have been more published diagnostic impressions of Donald Trump than for any public figure. Perhaps someone with interests in both mental health and politics can't avoid seeing such pieces doing the rounds, but I suspect it is not just me.

We should all know better. The Guardian's Hannah Jane Parkinson wrote a well thought out piece about the issue back in November, when the Donald's combination of prominence and unpleasantness had reached its latest peak. Distance diagnosis, she reminded us, can be inaccurate, undermine confidentiality, and perpetuate stigma. It didn't seem to change very much. 

Sometimes I see what purport to be knock down arguments against diagnosing Trump. He doesn't have a mental disorder, he's just a bad person. He doesn't have a mental disorder, he has a flawed character. But however small the overlap might be on the Venn diagram of "bad people" and "diagnosable people," it is not non-existent. These arguments don't hold water and are a red herring. There are other more pressing reasons not to diagnose Trump.

If diagnosis is to have any place at all in mental health care (and I have argued frequently that it inevitably does and will), it can only be as a beneficent way of re-conceiving the difficulties that bring people to mental health services. Even if you oppose diagnoses and resolutely refuse to use them in practice, a referral to a particular EST, the use of particular therapeutic style, or medication all indicate a particular diagnostic formulation; the use of categories as a reference class to guide decision making. Users of mental health services are not stupid; people can infer diagnoses, ask for information about them, or even explicitly ask for one to be given. Professionals have to make peace with how they use that information and how they frame it.

Let's focus on personality disorder diagnoses, as this is type that most frequently gets applied to Trump. I don't like "personality disorder" as a way of talking, and am inclined to see that cluster of problems as having to do with what David Shapiro called "styles." Life is a weird and difficult thing, and we all have styles that help us get through it. My own style, for example, might be framed as a sort of cautious, ruminating introversion. My temperament and my lifetime's reinforcement schedule have helped pushed me into acting in a particular way. Sometimes it works well, and sometimes less so.

Sometimes our styles get us into trouble. When that trouble is of a particular sort, our styles can get called personality disorders. If you want to help people examine and adapt their style, you have to first create a situation in which you aren't just some hostile outsider telling them they're doing things wrong. You have to try to understand what the style feels like to inhabit, what it is helping someone to achieve, and how it might look different. Help for someone with a diagnosis like "borderline personality disorder" can only come with honest communication about what such a term is supposed to denote.

Herein lies the problem with diagnosing Trump. It's not that he is in principle un-diagnosable, but that the people diagnosing him are doing it for all the wrong reasons. Opponents of diagnosis sometimes say they are insults, and that they perpetuate an uncomfortable power imbalance between clinician and service user. Is that not exactly what we see in the bandying around of "narcissism" as a word to describe Trump? 

When Deborah Orr called Trump "King Narcissist," she deployed the formal sounding acronym "NPD," but went on to frankly insult him in less clinical terms:
"In the world beyond psychiatric jargon, narcissists are usually known by the more colloquial terms of “bully” or “abuser.”
And when journalists, psychologists and psychiatrists wade in and offer diagnoses, are they not trying (rather desperately) to pull back some power from the man who now arguably holds more of it than any single other person? Trump is a whirl of aggression, authoritarianism and petty nativism. Like all politicians, he is a human with a mind. It is appropriate, even imperative, to wonder about his reasons and emotions. One day (if we survive) someone will probably write a fascinating biography that explores why Trump came to be the sort of president he's turning out to be. But unless he elects to see a mental health professional, or falls so far foul of the law that he can't avoid it, diagnosing him serves no purpose.

A mental health diagnosis can only have value if it takes place in a formal compact, usually between two people who want to work on a problem. We know that diagnoses can be stigmatising and insulting. We know that they map uncomfortably onto what can be a pernicious power dynamic. We know that many people find they make matters worse. Trump's would be analysts seem to believe they are casting light on his behaviour, and helping to predict his presidency, but they are engaged only in power play and sophisticated insult throwing. If you're the kind of clinician who thinks they can help anyone by diagnosing a public figure from arm's length, you're mistaken.

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