There’s ongoing discussion about whether it’s ethical or appropriate to diagnose Trump, after several mental health professionals asserted that he’s a classic case of narcissistic personality disorder. I shared a post to that effect on Facebook, but on reflection realized I was approving of a practice I find profoundly suspect: psychiatric diagnosis.
The root of the problem is attempting to treat psychological distress as if it’s just like physical illness. If you have measles, any competent doctor can make a definitive diagnosis. There’s clear and unequivocal evidence of a specific illness. But if you’re suffering from mental distress, you might get a different diagnosis from one professional to another. I knew of one case where a woman had been variously diagnosed with depression, schizophrenia and borderline personality disorder. However you labelled her, she was still suffering.
The ‘Diagnostic and Statistical Manual of Mental Disorders’ is the bible of American psychiatry. It’s now in its 5th edition, so we refer to ‘DSM-5’. DSM-5 offers nearly 1000 pages of guidance on how to diagnose ‘mental illness’. Before considering the current edition, let’s step back to to 1973, when, literally overnight, millions of people suddenly ceased to be ‘mentally ill’. I wish I could say there’d been a miracle cure, but the fact is that the American Psychiatric Association had simply removed the diagnosis of ‘homosexuality’ from the DSM.
Is some psychiatric diagnosis just labelling behaviour that society finds challenging? I was in my teens when my father, diagnosed as ‘manic depressive’, told me that psychiatrists had ‘stuck a label’ on his back. His behaviour was sometimes challenging, but was he mentally ill? I started reading Thomas Szasz’s books on anti-psychiatry and began my lifelong fascination with psychological distress.
Debate continues: In 2012 Allen J Frances, who chaired the task force that produced DSM 4, described the latest edition as “deeply flawed” (Frances). He claimed that DSM-5 threatened to “expand the territory of mental disorder and thin the ranks of the normal” (Frances, 2010).
Thomas Insel of the National Institute of Mental Health agreed that DSM-5 lacked “validity” and proposed that we draw on genetic, imaging, physiologic, and cognitive data to create a new diagnostic system (2013). Thomas’s proposal doesn’t question the fundamental validity of psychiatric diagnosis and if the complexity of human being could really be reduced to biology, it might even work. But this technological paradigm ignores relationships, meanings and values. I’ve commented elsewhere on the complexity of human existence and conclude that importing the concept of diagnosis from physical medicine into discussions of mental distress is doomed to fail. As Bracken et al succinctly put it, psychiatry “will never have a biomedical science that is similar to hepatology or respiratory medicine, not because we are bad doctors, but because the issues we deal with are of a different nature”.
In my work as a psychotherapist I’ve had clients bring a diagnosis with them; “psychopath”, “schizophrenic” or “clinically depressed”. Sometimes that label is meaningful for them; sometimes not. In every case it’s the person I work with, not the psychiatric diagnosis. Perhaps we need to do the same with Donald Trump.