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Paula Joan Caplan's Authors Guild Blog

The Truth About Trump and Psychiatric Diagnosis — The Lightbulb Has to Want to Change

Originally published 02/20/2017 10:34 pm ET @ http://www.huffingtonpost.com/entry/58abb3b0e4b0417c4066c22b

Once you know a crucial fact about what gets called mental illness, the debate about whether or not President Donald J. Trump is mentally ill disappears, and what is left is what really matters. What really matters is that President Trump apparently has no desire to change behavior that has been described as totally self-absorbed, self-referential, misogynist, racist, xenophobic, and otherwise abusive.

It’s ironic that the arguments on both sides of the debate about whether or not Trump is mentally ill are based on the one “alternative fact”: that deciding who is mentally ill is a science. That could not be farther from the truth.

Those who are arguably the world’s most powerful psychiatrists — those who periodically create and publish a new edition of the psychiatric handbook called the Diagnostic and Statistical Manual of Mental Disorders (DSM) — typically acknowledge that the foundational premise of the entire book, that it is possible to define “mental illness” in an adequate, appropriate, and useful way, is wrong. In each edition of the DSM, the new set of arbiters tries to create a definition of “mental illness,” since the book consists of hundreds of alleged categories and subcategories of mental illness and thus depends on their getting that primary definition right. Each time, they have acknowledged their failure to do so. Even Allen Frances, who oversaw creation of the DSM edition that held sway from 1994 to 2013, famously called psychiatric diagnosis “bullshit” (cited in Gary Greenberg’s excellent Book of Woe from his article in Wired based on his interview with the psychiatrist).

As far as I can tell, no one else weighing in on the debate about the President has served on a DSM Task Force...and then felt they had to withdraw because of what they had learned. I spent two years as an insider on Allen Frances’s Task Force, where I learned that — despite what is widely assumed to be true — psychiatric diagnostic categories are not scientifically derived but are constructed, made up by the handful of people with the most power in the DSM hierarchy. When Frances in various media currently gives the impression that he is uniquely qualified to judge President Trump because he wrote the criteria for Narcissistic Personality Disorder (NPD), the label that many therapists have recently applied to him, Frances neglected to note that the criteria for NPD change with every edition. Frances changed them somewhat from the DSM edition that came before his, and the NPD criteria in the edition subsequent to his — the currently in use DSM-5 — differ from his. These changes reflect the moving-target nature of this label.

The changes over time in how NPD is defined are important, because to debate about whether or not the President has NPD is to reify misguidedly and harmfully the notion that there is a scientific way to find out. I resigned from the DSM-IV Task Force because I could not participate in the creation of a book that would be marketed as scientific when I knew that it was not — and that would garner more than $100 million for its publisher, the American Psychiatric Association, and help Big Pharma earn billions of dollars for psychiatric drugs marketed as curing the ever-growing number of manufactured categories.

Some people try to prove that Trump does not have NPD on the grounds that his self-centeredness and so on do not cause him to suffer; but even that argument is irrelevant, because no version of NPD has specified that in order to “qualify” for this label, one has to be suffering because of its features.

Do people suffer and deserve help to alleviate that suffering? Of course, they do, and that is the subject of many books and other articles. But the research about how that is best done — what behavior, feelings, and/or thoughts can be changed — and what cannot is a side issue for our purposes here, because there is not a shred of evidence that President Trump wants to change. Remember that old joke: “How many therapists does it take to change a light bulb?” “One. But the lightbulb really has to want to change.”

There is great debate among therapists about whether or not any personality disorders belong in the manual of mental illnesses, since it is an arbitrary decision left to each individual therapist whether or not a particular patient’s personality is extreme enough to qualify as a disorder. To engage in the attempt to decide whether or not President Trump has NPD is to act as though that label is clearly a description of a mental illness, however one defines “mental illness.”

Some believe that if they were to prove that the President is mentally ill, it would be easier to turf him out of office. But it was morally wrong that Senator Thomas Eagleton was removed as George McGovern’s vice presidential running mate in 1972 when it became publicly known that he had suffered from bouts of depression and had been hospitalized for that reason, because what should have mattered for him and should matter for all elected officials is how well they can do their jobs. Eagleton had been a great Senator. Whether or not one believes that Trump is doing his current job well depends partly on whether or not you share his views of the world, partly on whether or not he is truthful with the people of this nation (many Presidents have not been), and partly on how he manages his various tasks.

At this crucial time in our nation’s history, the last thing we need is to let debates about whether or not the President is mentally ill divert us from deciding whether or not he is doing his job, whether or not we like what he is doing, and whether or not what he is doing is dangerous or evil.

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Author’s note: I am the author of They Say You’re Crazy: How the World’s Most Powerful Psychiatrists Decide Who’s Normal, which is my insider’s description of the process of creating the book that is called the psychiatrist’s “Bible” and is used to determine who is mentally ill. I am editor of Bias in Psychiatric Diagnosis and have written many articles and book chapters about psychiatric diagnosis, which I would be happy for people to read.

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