UNKNOWABLE

Armchair diagnosing Donald Trump with mental illness does a terrible disservice to psychology

In 1964, after Fact magazine polled more than 12,000 psychiatrists and wrote a cover story on the 1,189 who considered Republican Barry Goldwater mentally unfit for presidency, the American Psychiatric Association officially banned its members from commenting on a public figure’s mental health without examining them. With this policy, known as the Goldwater rule, the APA made clear that passing such judgement from afar was morally reprehensible and unethical.

Yet there has been an unrestrained rush to offer armchair diagnoses of US president Donald Trump.

Critics of the president and opposition politicians are openly discussing whether the president is mentally well, and there are dozens of articles on whether Trump fits the profile of a psychopath or narcissist. “Goldwater, schmoldwater,” wrote Zoe Williams in her Guardian article, in which she argued that Trump “has the classic stamp of the high narcissist.”

Trump’s behavior—his aggression, erratic policies, and willingness to twist the truth—are clearly concerning. Members of the public have every right to criticize his actions and mannerisms, and it’s even valid to support proposals that presidents should have a psychiatric evaluation before taking office. (Though, as Quartz has reported previously, that proposal is fraught with complications.) But pointing at unpleasant actions or disagreeable policies and labelling them psychotic is foolish—and worse, it uses mental illness as an insult.

The same is true for all those faux-concerned comments about Melania Trump, with speculation—seemingly founded on the occasional glum photograph—that she’s depressed or in an abusive relationship. Though photographs’ ability to misrepresent reality has been widely discussed in recent weeks, many seem to believe that studying the first lady’s face gives insight into her health.

Steve Hyman, director of the Stanley Center for psychiatric research at Broad Institute of MIT and Harvard, says such diagnoses are empty. “It’s fine to say that a person who you’ve seen videos of looks sad,” he says. “But depression is a diagnosis that requires you knowing about their sleep and appetite and energy and thinking. Those things are not shared in these brief snippets.”

Let’s be clear: statistically speaking, every single person reading this article likely knows someone going through mental health struggles such as depression. True empathy for mental health issues can be expressed by supporting those you know personally—not with a glib #FreeMelania hashtag.

Judgments on Trump’s mental health are even more concerning when they come not from unqualified amateurs, but professionals who should know better. Again, it’s one thing to comment on Trump’s behavior specifically, and express concern about his bad temper and inability to empathize, as several health professionals have done. But going further and attempting to proffer a diagnosis definitively crosses the line. After all, Hyman points out, coming up with a diagnosis (or ruling one out), requires knowing about the patient’s medical history, full list of symptoms, what medication they take, whether they’ve experienced head trauma, and whether they drink or use drugs.

Yet one psychotherapist argues that Trump has “malignant narcissism” and he’s confident that “we can make this diagnosis indisputably.” Another strongly suggested that Trump fits the profile of a psychopath.

This week Allen Frances, psychiatry and behavioral sciences professor at Duke University Medical College, went the opposite but equally problematic route and stated definitively that Trump is not suffering from mental illness.

Frances argued that Trump is “bad, not mad,” on Twitter, and then went beyond 140 characters in a widely shared letter to the New York Times.

He definitely states that Trump “causes severe distress rather than experiencing it,” while providing absolutely no evidence for his assertion that Trump does not, in fact, suffer distress.

Frances confidently argues that Trump cannot have narcissistic personality disorder because “I wrote the criteria that define this disorder.” Well, he may have written the criteria for the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders, but that manual is since out of date, following the publication of the fifth edition. Plus, the manual itself and its methods of diagnosing mental illness are highly controversial.

Currently, mental illness is formally diagnosed using a method developed in the 1960s that mimicked the model of diagnosing infectious disease. It’s an approach that gives rise to the false confidence that it’s possible to diagnose mental illness from afar based on checklist criteria.

Hyman points out that, contrary to what the manual suggests, there’s no “bright line” between health and psychiatric illness. The methods of the diagnostic manual encourages a “mad versus bad” discussion, he says, when “in fact we know better than that.”

“These [disorders] are continuous and the idea that if you meet certain criteria you’re ‘mad’ and if you don’t meet them you’re ‘bad’ is wrong on many counts,” he says.

Mental health is in fact a gradient, much like many other medical conditions. “There are some infectious diseases where categories really work. You either have Ebola or you don’t, you have have smallpox or you don’t. But most chronic human ills have this continuity with health. So hypertension, diabetes, atherosclerosis,” says Hyman. “Setting thresholds of illness has a certain arbitrariness to it.”

Mental health, in other words, is highly nuanced. Even with a personal examination and all the relevant information, the current methods of diagnosing mental illness fail to acknowledge grey zones and are subject to debate. Attempting to pass judgement on someone’s mental health without this personal insight is, quite simply, ridiculous.

President Trump has shown signs of racism, anger, grandiosity, and erraticism. But as for his mental health, I simply don’t know. And neither do you.

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