Before diagnosing Trump as mentally ill, let’s ask what that actually means

Onlookers the world over are trying to understand Trump’s behaviour. Joseph Sohm/Shutterstock

The notion that Donald Trump is “mentally ill” is circulating more frantically than ever, with various mental health practitioners voicing unusually public concerns that someone with an unsound or disordered mind is in high office. One such figure is John Gartner, a psychologist with 20 years’ worth of experience at Johns Hopkins Medical School, who has now garnered almost 30,000 signatures on a Change.org petition:

We, the undersigned mental health professionals … believe in our professional judgement that Donald Trump manifests a serious mental illness that renders him psychologically incapable of competently discharging the duties of President of the United States. And we respectfully request he be removed from office, according to article three of the 25th amendment to the US Constitution, which states that the president will be replaced if he is “unable to discharge the powers and duties of his office”.

It’s not been confirmed that all Gartner’s signatories are in fact mental health professionals, and the petition’s statement is not uncontroversial. Many or even most psychiatrists agree that mental illnesses cannot be diagnosed without close formal observation and access to a patient’s medical, family and personal history. But Gartner apparently disagrees; he insists that “we have tons of information about his behaviour, his words, people who know him well, who have observed his behaviour … we have so much information that it is screamingly obvious.” Trump, he says, has “malignant narcissism”.

Allen Frances, a renowned psychiatrist and the chair of the team that produced the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV, 1994), disagrees:

Most amateur diagnosticians have mislabelled President Trump with the diagnosis of narcissistic personality disorder. I wrote the criteria that define this disorder, and Mr Trump doesn’t meet them. He may be a world-class narcissist, but this doesn’t make him mentally ill because he does not suffer from the stress and impairment required to diagnose mental disorder.

This is a tricky debate to navigate – and a good place to start is to interrogate our ideas about what mental illness even is.

Defining disorder

There are two main systems for classifying and defining mental disorders: the DSM, now on its fifth edition and the International Classification of Diseases – Classification of Mental and Behavioural Disorders manual, 10th edition (ICD-10), published by the World Health Organisation in 1992. Both focus on distress and disablity but the latter pithily defines “mental disorder” as “the existence of a clinically recognisable set of symptoms or behaviours associated in most cases with distress and with interference of personal functions”.

This definition has a central problem: unlike many “physical” illnesses, mental illness as generally conceived of in the West has both biological and social components. Many people deemed mentally ill engage in behaviours that are socially defined as deviant or beyond the scope of social and cultural norms. The sociologist Thomas Scheff famously wrote that “symptoms” of persons with mental illness can often be viewed as “offences against implicit understandings of particular cultures”.

Clearly, Donald Trump’s statements and behaviour are being counted as just such violations.

Clinical definitions and diagnoses rely on subjective psychiatric observation and judgement rather than identification of specific disease pathways. More confusingly still, there is no uniform psychiatric view of mental disorder – and practitioners hotly dispute not only its causes but what it is.

Most definitions focus on deviations from “normal” behaviour, but that raises the question of what standard of normality should apply. The statistical frequency of how most people behave maybe one way of identifying “normal” behaviour – but as scholars Marshall Clinard and Robert Meier put it: “Statistical conceptions of mental illness can indicate only what most people do, not what they ought to do.”

So a mental illness, then, is what a psychiatrist says it is. If we go by Karl Menninger’s classic definition of mental health, which he describes as “the ability to maintain an even temper, an alert intelligence, socially considerate behaviour, and a happy disposition”, we might as well accept we’re all mentally ill at least some of the time.

Why mental illness?

The messiness of these definitions leaves them open to social and political abuse. When people are extremely violent or incompetent without an obvious explanation, labelling them “mentally ill” for their behaviour justifies treating them in particular ways, including ridicule or coercion.

Perhaps psychiatric thinking’s most famous critic was Thomas Szasz, a renowned psychiatrist himself. Szasz insisted that mental illness is a myth, designed to “disguise and thus render more palatable the bitter pill of moral conflicts in human relations”. In his 1970 book The Manufacture of Madness, he famously wrote that “in the past, men created witches: now they create mental patients”.

The debate over Trump is a chance to reflect on how deeply ingrained this myopia is. Many unappealing human behaviours are still dismissed as behaviours of the mentally ill; too often, we seem incapable of distinguishing between a disorder of mind and a disorder of character. Trump’s impulsivity, vulgarity, personal attacks, recklessness and fondness for misinformation are not necessarily symptoms of mental illness.

Equally, treating all unpleasant or shocking behaviour as a form of mental illness does nothing to help those who are legitimately suffering. As Allen Frances himself puts it:

Most mentally ill people are nice, they’re well mannered, they are decent, they are unselfish, they are good people. Trump is none of these. When you lump someone who is bad with people who have mental illness, it stigmatises the mentally ill population. Less an insult to him and more an insult to them.

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