‘[I]n evaluating any given person,’ Allen Frances writes in his book Saving Normal, ‘we lack a general definition of mental disorder to help us decide whether he is normal or a patient, mad or bad.’ The admittedly porous, but nonetheless vitally important line between mental illness and mental health has been one of the threads in my academic work for the last couple of years, so it is with growing wariness and frustration that I have been watching the debate on Donald Trump’s mental health play out.
Criticism of the focus on Trump’s mental health appears to be few and far between. Where it exists, it tends to concentrate on debating the ethical responsibilities of mental health professionals (in particular whether they are violating the Goldwater Rule) or pointing out the danger and difficulty of making a diagnosis from a distance. Political commentators have tended to focus on the inappropriateness and ‘unseemliness’ of calling into question the mental health of a head of state.
Criticism of psychiatric nosology – the classification and demarcation of mental illness – has a long history. Queer and feminist scholars have been active in pointing out that psychiatry has a dangerous tendency to ensconce prevailing morality in their classification of mental illness. For instance, homosexuality was not removed from the Diagnostic and Statistical Manual of Mental Disorders (DSM) until the 1970s. These concerns are not merely historical embarrassments; controversially, gender dysphoria continues to be included in the latest edition of the manual.
Frances has made his distaste for the armchair diagnoses of Trump abundantly clear, arguing that they lead to the unnecessary stigmatisation of the mentally ill, and are further evidence of psychiatry’s tendency to medicalise and pathologise perfectly ordinary behaviour and individuals. For instance, the most recent version of the DSM was heavily criticised for blurring the line between depression and grief, particularly where bereavement was concerned. Another arguably more serious consequence of this pathologising is the potential for overprescription of psychopharmaceuticals, particularly for children.
I fear that the danger raised by the debate raging on Trump’s mental health is not the danger of stigmatising ‘the mad’ when we lump them in with ‘the bad’, but rather what we give up when we label the bad as the mad.
The predilection for appealing to medicalised terminology crops up in interesting and unexpected places. As a compulsive reader of advice columns, I have also been a longtime lurker in online communities that offer relationship advice and support for interpersonal troubles. Over the last couple of years, I have been intrigued to find that people seem increasingly eager to diagnose their tormentors with various mental illnesses, in particular Narcissistic Personality Disorder (currently a popular diagnosis for Trump himself). Descriptors such as ‘narc’ ‘NPD’ or ‘borderline’ (in reference to Borderline Personality Disorder) appear to be increasing in prevalence.
This growing tendency towards pathologisation can be seen not only in the growing use of specialist terminology in wider society and in academic debates about the classification of mental illness, but also in the increased ‘mainstreaming’ of specialised therapeutic ideas and techniques. Therapeutic interventions and theories that were originally used to treat specific mental illnesses are now being offered to the public without requiring a diagnosis – and often without any indication that they are associated with mental illness. (For instance, the techniques of Mindfulness Based Stress Reduction programs, initially developed to treat chronic pain and severe anxiety are currently readily available on the internet.)
I became interested in the relationship between pathologising and the problems with making therapeutic tools more accessible when, at the ripe age of twenty-seven, I became heartbroken for the first time. Veterans of the state will know that heartbreak can be associated with intense levels of misery and a proclivity for melodramatic thoughts. As a novice, I was horrified. I couldn’t understand what felt to me like the brick wall of sadness that I kept hurling myself against, nor the wailing thoughts of a teenager that had taken up residence in my head.
Alarmed, I searched the internet and learned two things: first, that all of this was fairly typical of heartbreak; second, most of my melodramatic thoughts fit the pattern of distorted thinking, as described by cognitive behavioural therapy. My thoughts were both typical and pathological. Indeed not just typical, but characteristic of what many of us would consider an important and formative life experience. The blurring of the line between mental illness and mental health that critics of nosology point to has parallels in psychotherapy – consider how this example is strikingly similar to the DSM’s failure to demarcate grief from depression.
Obviously, making therapeutic techniques available more widely is not wholly bad. Indeed, self-service avenues such as internet resources, apps or self-help books are one way of addressing the scarcity of mental health resources, which remain difficult to access even for those with diagnosed conditions. These resources also provide valuable tools for improving the quality of everyday life even where someone does not have a mental illness. Take, for instance, mindfulness-based meditation and breathing exercises, which seem to be effective at relieving stress regardless of whether someone has been diagnosed with a mental illness. Still, there is a pattern here – an increasing proclivity towards pathologisation, which in addition to some of the issues already mentioned, comes with particular costs in the case of Trump.
Allow me to illustrate by circling back to the pathologising happening in the online communities dealing with interpersonal conflict. It is not clear what to make of the trend. Is it an attempt to delegitimise the person that has caused the hurt? The incidents described in these communities range from small disagreements to full-blown instances of verbal and physical abuse. In the latter case, victims often find it difficult to have others believe their version of events, so perhaps the diagnosis helps to provide legitimacy to their perspective. Or perhaps it is an attempt to understand and explain how someone that purported to love you, such as one’s parents or partner, could hurt you so badly.
Obviously these are all understandable motivations, but what the pathologising ultimately results in is a failure to properly hold someone accountable for their wrongdoing.
As an undergrad, one of my lecturers posed the following series of questions: ‘When you stub your toe on your couch, do you get angry at the couch? Do you blame the couch for your pain? What about when someone steps on your toe?’ This question backfired spectacularly as he suddenly had on his hands a room full of people confessing that they did in fact get angry at the various objects that they had stubbed their toe on. But in the end we understood the lesson. We tend to get angry and apportion blame mainly when we believe that someone could have reasonably acted otherwise. This is the difference between someone accidentally stepping on your toe and wilfully stomping on your foot. This is also the difference that the line between mental illness and mental health makes.
Where someone is mentally ill, we are prepared to believe that they could not have acted otherwise. Naturally, the extent to which this is the case depends on the wrongdoing and the mental illness in question, but our feelings of anger and blame are generally attenuated when we learn that someone has a mental illness (for the philosophers in the audience: yes, this is the point Strawson makes in ‘Freedom and Resentment’). Our anger and willingness to hold Trump accountable is the cost of diagnosing him with a mental illness. This is what we lose when we deem him mad rather than bad.
It is certainly tempting to declare that Trump is mentally ill. If this is the case he could be declared unfit for office and this particular nightmare would end. But such an easy solution mitigates our ability to call out the harms the US president has caused. I believe Trump could have reasonably acted otherwise in many situations, and as such should be held responsible for his actions. Focusing on his mental health lets us avoid the onerous task of carefully unpicking how such a state of affairs came to be and other unpalatable worries, such as what we are to make of the people who embraced and voted for Trump. We should particularly be wary of easy solutions when they seem to have had a large part to play in why Trump got elected in the first place.
At the moment, most debates about mental health tend to focus on the scarcity of mental health resources and rightly so. It is appalling that those in need do not get the assistance and support they require. But barring the efforts of those such as Frances, there has been an overwhelming tendency to let mental health discourse and its inclination to pathologise run unchecked. The obsession with Trump’s mental health is but one example of this trend, and the associated costs demonstrate why we should be more scrupulous about such discourse.