There’s a simmering debate going on in American mass media about US President Donald Trump’s psychiatric state, one which resonates in the Philippines with such questions as: “Can long-distance psychiatric diagnoses be made about politicians?” and “Should the fitness to serve in public office include psychiatric considerations?”
For medical anthropologists like myself, the debate has brought out the many gray areas around psychiatry, including definitions of what a disorder is and the possibilities of cultural differences affecting the way a “sound mind” and, conversely, a “sick mind,” is perceived.
Before I go on, let me just quickly differentiate psychologists and psychiatrists as I will be using both terms. Both are professions which, in the Philippines, require passing a board examination to be able to practice. To take the board exam for psychology, you only need an undergraduate degree in psychology from an accredited school. To practice psychiatry, you need to be a medical doctor, pass the board exam for medicine, and go through residency training in psychiatry.
Both psychologists and psychiatrists are referred to as “mental health professionals,” helping people to maintain mental health and to respond to illnesses and disorders of the mind. But psychologists are not allowed to prescribe drugs as part of the treatment. Psychologists like to say they are less “medical” in their approaches to mental health and illness, but psychiatrists also use a lot of “talk therapy” and counseling.
Narcissism
Back to the debate in the American mass media, in June 2016 a group calling themselves “Citizen Therapists for Democracy” was established with a website, and with their founder, William Doherty, warning about “Trumpism” characterized by “reinventing history, never apologizing, demeaning critics and inciting violence.” The group issued a manifesto which has now been signed by more than 3,000 “citizen therapists.”
A few scattered articles appeared over the last few months, including a psychiatrist’s, describing Trump as suffering from “malignant narcissism” (US News and World Report, January).
Earlier this month, a group of 35 mental health practitioners signed a letter to the New York Times suggesting that Trump suffered from “grave emotional instability,” making him incapable of “serving safely as president.” The psychologists and psychiatrists noted that Trump’s “speech and actions demonstrate an inability to tolerate views different from his own, leading to rage reactions.” The group said that Trump’s “words and behavior suggest a profound inability to empathize” and that “individuals with these traits distort reality to suit their psychological state, attacking facts and those who convey them (journalists, scientists).” The group also worried that Trump’s attacks were likely to increase because of his position of power.
A few days after that “manifesto” appeared, Dr. Allen Frances, a prominent psychiatrist, wrote in to express his disagreement with the group. Although the earlier letter did not use the term “narcissistic personality disorder,” Frances said that there has been a tendency among “amateur diagnosticians” to use the term on Trump.
Frances explained that he was the one who wrote the criteria defining that disorder, which appeared in the Diagnostic and Statistical Manual of Disorders, the “bible” of mental health professionals.
Here’s what’s so interesting: Frances said that while Trump “may be a world-class narcissist, (but) this doesn’t make him mentally ill, because he does not suffer from the distress and impairment required to diagnose mental disorder.”
Frances therefore recognized Trump’s “grandiosity, self-absorption and lack of empathy” but noted, too, that Trump has been “richly rewarded, rather than punished” for this behavior and is, therefore, not suffering from narcissistic personality disorder!
In so many words—knowing people similar to Trump in our families and offices, and among our colleagues and political leaders, many of us can relate to this—such people may be narcissists but not necessarily people suffering from narcissistic personality disorder. To be classified as having a disorder, they have to suffer because of their condition, as in those who get upset because they don’t get the adulation they want, a severe form of “KSP” (kulang sa pansin).
So, narcissists might make others suffer because they’re so full of themselves, demanding constant attention and not tolerating any disagreement or dissent, but they are not “mentally ill.” Frances went on to say that “bad behavior is rarely a sign of mental illness, and the mentally ill behave badly only rarely.”
Frances said Trump should be “appropriately denounced for his ignorance, incompetence, impulsivity and pursuit of dictatorial powers,” but “psychiatric name-calling” is a “misguided” response.
The debate in the New York Times did not end with Frances’ letter. Others have jumped into the fray, reminding mental health professionals about the 1960s, when the Republican presidential candidate Barry Goldwater was labeled as “psychotic” “megalomaniac,” “schizophrenic” and having “narcissistic personality disorder.”
In 1973, the American Psychiatric Association ruled that their members may discuss psychiatric disorders with media, but not actually diagnose a person without having seen the “patient.” That ruling is now called the “Goldwater rule.”
And Duterte?
All this resonates for Filipinos. As early as 2015, even before Duterte had formally declared his candidacy, there were already articles in the media quoting a psychologist, Dr. Natividad Dayan, who had issued her opinion on Duterte as part of expert testimony to get his marriage to Elizabeth Zimmerman annulled. Dayan’s report concluded that Duterte suffered from “antisocial narcissistic personality disorder,” characterized by “gross indifference, insensitivity and self-centeredness,” “grandiose sense of self-entitlement and manipulative behaviors” and “pervasive tendency to demean, humiliate others and violate their rights and feelings.”
We’ll probably see more of this debate in the weeks ahead. I don’t think Trump and Duterte will care, but for many of us, it’s time to study these definitions of “narcissists” and “narcissistic personality disorder.” As an anthropologist, I actually think that many cultures, in Asia especially, tolerate or even encourage narcissism, seeing it as something powerful men (and, occasionally, women) are entitled to. Just think of all the sycophants (sipsip) who encourage such behavior among the powerful.
And while it is true that narcissists, the very powerful ones in particular, may in fact be quite “healthy” in the sense that they don’t suffer any distress, they do cause much distress and harm to people, especially to their own immediate family or work colleagues.
As for the nation suffering, perhaps there is good sense in Frances’ argument: “The antidote to a dystopic Trumpean dark age is political, not psychological.” I sort of agree because really, you can’t propose psychological or psychiatric interventions to powerful presidents.
What we need is political action.
mtan@inquirer.com.ph