As difficult as it may be, try to set aside the Trumpian focus here for a moment, and let’s just talk about the DSM diagnostics–the criteria set by the American Psychiatric Association that are used widely in many parts of the world to diagnose mental illnesses. What you see there in Dr. Frances’ tweets are wonderful examples of the failings of the DSM. Let’s go through some of them:
You can find the “distress clause” in numerous DSM IV and DSM 5 diagnoses. It basically says: if the patient is not distressed by the symptoms, they don’t have the illness. Dr. Frances cites that clause in his tweets.
This is particularly absurd when we’re talking about narcissists. Have you ever been in relationship with a narcissist? They aren’t distressed by what they do to you. That’s the point.
One of my favourite quotes about narcissism is that: “Narcissism is the one mental illness for which only the victim gets therapy.” I don’t know the original source for that other than EVERY PERSON THAT’S BEEN IN A RELATIONSHIP WITH A NARCISSIST.
The mention of “impairment” also points out a serious flaw in many DSM diagnoses. They fail to factor in privilege and social determinants of health. A rich white guy isn’t going to be impaired by his compulsions in the same way that a marginalized person would be. The rich guy has the social or financial capital as well as the leniency in the systems with which he interacts to get away with compulsions to an extent that others can’t. Many a good lawyer can buy you out of “impairment”.
This focus on impairment in the DSM can just as easily lead to over-diagnoses of mental illnesses when people are actually struggling with social or environmental barriers. Somebody who’s struggling with financial, housing, or food insecurity will be far more likely to get stuck with the additional burden of an illness label, when they’d actually be far more capable of handling the stuff in their head if they had support in other areas of their lives.
Even a “healthy” person that can’t access food gets impaired pretty damn quickly.
The idea that we don’t get rewarded for mental illness symptoms is often a barrier when it comes to getting started on recovery. From years of practicing mental illness, we’ve often come to conflate our identities with our symptoms. Other people know us for them. We get rewarded for them. With OCD, for instance, sufferers can always clearly point to moments in the past when being particularly obsessive about work got them good grades or a promotion. They were the dedicated one, the one that spotted the problems! The fear of giving that up can interfere with getting help.
Celebrities get rewarded all of the time for self-destructive behaviours. They get more attention. They get their own reality TV show empires. And, sadly, we love our self-deprecating, self-destructing comedians.
The idea that people don’t get rewarded in business for their mental illness compulsions is just not accurate. Books like the “Psychopath Test” and “Snakes in Suits” have all explored how psychopaths gravitate to leadership positions. Sure, a lot of the time psychopaths end up in prison, but on the way there, they’re doing a lot of damage and they’re getting rewarded.
I agree with the general sentiment that we don’t need to stick mental illness labels on people. Saying that somebody has a mental illness definitely shouldn’t be an excuse to harm others. There are so many people, every day, all over the world, who are doing the incredibly tough work to experience the stuff in their heads–intrusive thoughts urging them to hurt others or themselves–and they’re choosing not to listen to that stuff. They’ve had mental illness labels stuck on them but those labels don’t control their lives and they’re making healthy decisions for themselves and their communities. If a leader has a mental illness, that doesn’t have to stop them from making healthy decisions for the people they serve. That’s what we need to be talking about here. What’s the healthy way to govern? How do we want our leaders to treat others? What kind of world do we want to live in?
There are forces in this world that have a long history of oppressing marginalized people, that view the world from a narrow, stunted cultural perspective, that stigmatize those with disabilities, that prop up and encourage institutionalized violence… and that’s just the DSM. So when we’re having this conversation about how to govern and lead in a healthy way, let’s set aside that weapon that inspires a vomiting reflex in so many people that have had it used against them. It’s literally made a lot of people mad and it’s, frankly, quite bad.
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