|US President Donald Trump (Photo: Quartz)|
I'm no fan of Mr Trump or his policies. I find him genuinely frightening. However, as someone who's spent most of their adult life working in NHS mental health services, I am uneasy to see so many people commenting in public forums on his mental health - usually in reference to whether he has Narcissistic Personality Disorder (NPD).
I'm very uncomfortable with armchair psychology, but especially when it is reduced to some throw-away lines on twitter.
I'm also very worried about the scope for using mental health terminology as a form of abuse.
Of course, it's perfectly acceptable to look to make sense of someone's behaviour. Historians often do this retrospectively, using evidence from a different time to suggest someone may have had a condition we now recognise as a medical problem. From Henry VI to Nicolae Ceausescu, historical figures have had their lives and achievements revisited to take account of likely mental health issues. Relatively recently David Owen wrote a book, considering world leaders including Tony Blair and George W Bush as potentially suffering from a "hubris syndrome". He brought both political and medical expertise to his work, and while I felt it unfairly judgmental in some respects, ultimately he was merely putting forward a medical theory. Should that be allowed? Should historians be permitted to speculate about physical health problems, while mental health is off-limits? I'm not sure I would support a "don't ask, don't talk" approach towards mental health, as if it should somehow be taboo.
But it is difficult - especially when mental health isn't so black and white and a great deal of stigma remains - and how we do it is of enormous importance. I'm reasonably comfortable with people questioning whether someone's behaviour is narcissistic, etc in general terms - I have more of a problem with people arriving at their own (public) diagnoses, however consistent a presentation may appear with the diagnostic criteria. We reduce both humanity and psychiatry when we do that. Those who make diagnoses about public figures can do more damage than they know.
I worked in both acute and forensic mental health services over 16 years, and have some experience of working with people with NPD. What I would say is that NPD is notoriously difficult to diagnose, and is rarer than people imagine.
It's not only on social media. This week a number of prominent psychologists have stated their belief that Mr Trump suffers from a "malignant narcissism". John Gartner described him as being "dangerously mentally ill and temperamentally incapable of being president"; Dr Julie Futrell believes “Narcissism impairs his ability to see reality so you can't use logic to persuade someone like that". While these people are undoubtedly expert clinicians, their public statements give fuel to others who use them as ammunition for their own insults on social media and elsewhere. So while their views may be informed, we should ask: are they helpful?
Added to this, yesterday House minority leader Nancy Pelosi has publicly stated she would support legislation requiring the President to undertake a mental health assessment. It should be obvious to anyone why that would be a terrible idea.
Equally unhappy at the NPD-focused conversations on twitter and in the wider media, psychiatrist Allen Francis has hit back in a series of tweets. Some of these raise very valid points, and are definitely worth repeating. For example, he warns that "instead of misdiagnosing Trump, we must analyze the societal sickness that gave someone so flawed the power to determine fate of the world", and observes that "calling Trump crazy also insults people who suffer from mental illness, most of whom are well meaning & well mannered. Trump is neither." So far, so good.
But he goes further, and insists that Trump has no psychiatric condition: "Constantly saying Trump's crazy wrong & misses point. He doesn't meet DSM Narcisssistic criteria (I wrote them). It's worse-he's bad, not mad".
So for Dr Frances it's open and shut. A closed case. Trump is pretty nasty. He's bad, not mad. All based, presumably, on his public appearances and statements.
The news article in Refinery 29, a US online lifestyle magazine, states that Dr Frances "wrote the diagnostic criteria for narcissism" - it's not quite true; he has never defined narcissism. He was part of the task force that helped to revise the framework for defining NPD (which has undergone several revisions). That's a significant distinction. No doubt it's possible to be narcissistic without having NPD, just as it's possible to be anti-social without experiencing Antisocial Personality Disorder.
I'm concerned about his response. Just as I am troubled about the kind of armchair psychiatry that positively diagnoses from a distance, and uses mental health related terms to insult and abuse, so too am I concerned that an eminent psychiatrist has weighed in, presumably without ever having met Mr Trump, to assert an absence of NPD. As he should know, NPD is notoriously difficult to diagnose. I have no doubts about his expertise and experience, but isn't he too guilty of making diagnoses from afar? Isn't this undermining psychiatry? Should health professionals be making any kinds of diagnosis of public figures on twitter?
I accept a lot of the points Frances is making, especially in relation to society, but did he need to go so far as to make a negative diagnosis? I don't know whether Trump has a mental health problem; he may have, he may not. He may need help, he may not. Bad guys can have mental health issues too. Ultimately, I think Frances is guilty of a similar "well meaning, but misguided" approach he accuses others of following - namely, of trying to destigmatise mental illness by public declaring that the objectionable Mr Trump doesn't have one. But at best it's an unprofessional approach - unless you sit down with someone and undertake a proper and full mental health assessment you have absolutely no right to speculate (publicly or otherwise) on their mental health, let alone make an unequivocal diagnosis.
For me, two wrongs don't make a right.
Ultimately, I think the problem here is how we view mental ill health. It is with dismay I see the words "personality disorder" used to insult and demean - or, even worse, used in a politically partisan way to depict someone as somehow less than human. That it's often liberals doing this, who honestly should know better, is equally worrying.
If we can strip away the stigma and it is seen as a health problem like any other, perhaps the idea of suffering from it will seem less offensive. A positive flip side would be fewer people using mental ill-health to abuse and insult others. We need to work to create a society - and health system - in which mental well-being is given parity with physical well-being, and in which stigma and discrimination towards mental ill-health are eradicated. In the meantime can we concentrate on resisting the President's destructive policy direction, rather than allow ourselves to be distracted by the question of his mental health?