In her article “The President’s Fitness: Can Professionals Help Decide?“ Dr. Paula Caplan cautions us about using psychiatric diagnoses to make decisions regarding people, including our “narcissistic” president. If that sentence sounds like I tacked on a diagnosis of sorts at the end, that’s because I did. In fact, I think Dr. Caplan also diagnoses him. The point is that, though I agree wholeheartedly with Dr. Caplan, the issue about labeling folks requires a great deal of nuance. And though I believe that Dr. Caplan is quite aware of the issues involved, I thought it might be helpful to spell them out in the context of our current political situation.
First of all, categorizing and labeling the world enables us to communicate. Dr. Caplan’s article itself is full of labels. Indeed, Dr. Caplan appears to have created her own diagnostic system when she noted that one must “distinguish between two kinds of ‘mental impairment.’” The first kind is “emotional impairment” such as “believing oneself to be Jesus Christ [if one is not].” Sounds like a diagnosis to me: Emotional Impairment, delusions of Jesus type.
The problem isn’t labeling per se. It’s what labels are used for. And by whom, how, and why. In addition to the fact that labeling our world is necessary for any communication at all to occur, labels are especially useful to the human, social animal when attempting to obtain power and control over others. In fact, isn’t that what Dr. Caplan was attempting to do? By entertaining the notion that Trump might have a mental impairment of the second type (“cognitive impairment”), she was suggesting that there might be a valid, diagnostic procedure to be used when considering the removal of a president from office.
Diagnostic labels become especially pernicious, however, when (1) folks in power apply them to others who are much less powerful and/or are having problems elucidating their own perspective and being heard, (2) the labelers derive significant advantage from getting others to agree with their labels (their view of the world), and (3) the labels present a fundamentally false view of the world, which with psychiatric diagnoses almost always includes the claim that the labels have a high degree of validity. In fact, all three are true in the extreme when psychiatric labels are typically employed. And, as I explored elsewhere in more detail (“A Phenomenological View of Madness and Medicine”), the damage thus created is also extreme.
If this comment sounds critical of Dr. Caplan, it is important to reiterate that I agree with her. When making social decisions, labels should focus on problematic behaviors and impairments in functioning that, to the greatest extent possible (there is always some bias in human perspectives), can be assessed by folks with or without credentials, titles, and their associated pseudo-expertise. Consider the following for an example of how diagnoses can contribute to the obliteration of justice and reason when dealing with emotionally troubling social issues.
In Massachusetts, a man who has committed a sexual offense can be civilly committed for the rest of his life as a “sexually dangerous person” after he has finished serving his criminal sentence, that is, after having undergone the “punishment that fit the crime.” Though a sexually dangerous person can have his commitment reviewed by a court about once every three to four years, the typical one-day-to-life, civil commitment consists of 10 to 25 years of additional imprisonment. If the criminal sentence he received was a harsh sentence—which occurs quite frequently—we evaluate, diagnose, and then predict the offender’s future behavior often many, many years after any sexual misconduct. I recently testified in a commitment review of a 71-year-old man who had been in prison for 45 years for a crime he committed when he was 26.
At the initial commitment and each of the reviews, one of the elements that must be proved “beyond a reasonable doubt” is that the man suffers from a mental abnormality that impairs his ability to control his sexual behavior and makes it likely that he will commit another sexual offense. Given what we know about diagnoses, can you imagine that? That is, can you imagine being able to prove beyond a reasonable doubt that a psychiatric label not only validly applies to a man but that, by dint of the diagnosis we can know (almost for sure) how he is likely to behave in the future long, long after the last incidence of the problematic behavior?
In fact, in a recent article, I proved conclusively that the degree of hubris inherent in such an enterprise is seriously delusional, i.e., that the “sexperts” who make these predictions under oath are either quite delusional or lying. (Pardon me for diagnosing and labeling them, but as you can see in my two-part article—Part I and Part II—the evidence is in.)
I believe that evaluative labels—including diagnoses—can facilitate both communication and good decision making when (1) the labeled parties are able and allowed to present their own world views, (2) the conflicts of self-interest inherent in the use of the labels are transparent and are carefully assessed and taken into consideration, and (3) all parties have access to the evidence that can be used to assess the validity of the labels for themselves (i.e., they are not forced to rely on caliginous “expertise”). In the typical use of psychiatric labels when treatment (e.g., medication) and control (e.g., commitment) decisions are made, these conditions are rarely present.
And though none of these conditions is ever completely present, when they are mostly true, I believe that Dr. Caplan would agree with this view. At least that is my understanding of her warnings about the typical use of psychiatric labels followed by her call for the application of transparent, common sense when describing the actions and behaviors of President Trump.
Indeed, I believe that some psychiatric diagnoses with a modest degree of validity could be used to describe our president in a manner that enhances our understanding of our current political situation. My colleagues and I presented just such an example of the application of diagnostic labels. We carefully avoided violating the aforementioned rules for using descriptive terms in a manner that facilitates understanding and prevents an abuse of power.
First, the party we labeled has had an unparalleled ability to present his own view of reality. It might be fair to say that no one in all human history has had more attention paid to his worldview. So, in labeling, we certainly did not engage in an abusive use of a power imbalance.
Second, the conflicts of interest were quite transparent; indeed, they have been rendering the United States of America so divided as to be dysfunctional. Because of this, the inherent conflicts have received virtually endless acknowledgment and discussion. The audience of our diagnostic claim should themselves have the ability to weigh our words in light of the inevitable bias that, like all human viewpoints, ours possesses.
And third, we presented links to the research that offers the empirical basis for our understanding as well as, for an example, our beliefs about our subject’s behavior.
Thus, though we felt that our claims were transparent, fair, as well as helpful in developing a better understanding of our terribly troubled world, our readers had the information necessary to make their own judgments.
Above, I suggested that such use of diagnostic labels is rare in the field of mental health. That was an understatement. I have been involved in hundreds of commitment hearings in which psychiatric diagnoses were crucial. In that context, I have never witnessed the presence of all three factors: (1) the transparent (honest) use of diagnostic labels (which includes the acknowledgment of the inherent biases built into the labels as well as their highly limited validity), (2) allowing full voice to and full acknowledgment of the labeled person’s view of reality, and (3) using the labels in a manner that produces a useful understanding, which in standard mental health practice would require that the understanding produced by the use of the labels be significantly more beneficial to the labeled person rather than the labeler.
Ultimately, it’s that very last part that is so troubling in its absence when psychiatric diagnoses are typically utilized.
Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.