Revealing Weaknesses of Mental Health Professionals & Diagnoses

The other morning I was enjoying my morning routine of coffee and news when I came upon Dr. Frances‘ (psychiatrist and former chair of the DSM-IV Task Force) comments on Trump.  If you don’t know, there’s been a ton of debate among psychiatrists, psychologists and other therapists on whether or not we have a duty to comment upon the perceived mental health of public figures who are in positions of power.  Frances’ comments addressed this topic as it relates to Trump and I found two sources.  The first was a short piece he wrote in Psychology Today months ago and the other is from an interview with the Verge, which was what I found on this particular morning.  As a regular person and as a Clinical Psychologist, I was frustrated but more disturbed than anything.  I’ve witnessed many mental health professionals that are in leadership positions get a lot wrong, and in some big ways.  Frances’ comments are concerning to me because he’s been heavily involved in the development of the DSM.  While this article focuses primarily on Frances, I also want to raise issues related to therapists needing to improve their level of psychological insight and health regarding themselves, and also point out that the DSM does not diagnose relationships.  I find both of these extremely problematic and upsetting.

1 |  Rejecting a Diagnosis is to Diagnose Someone

Those who use the DSM are advised to not diagnose at random, not to diagnose people whom they have not met, not to diagnose people who are not their clients, and that a diagnosis should not be publicly made unless it is the client disclosing this information.  When a diagnosis occurs, a process called “Ruling Out” happens at the same time.  “Ruling Out” is when a clinician (e.g., psychologist, psychiatrist) determines that a client does not meet the criteria for a specific diagnosis.  In order to do this the clinician has to know the person well enough or have enough information about them in order to say, for certain, that the diagnostic criteria are definitely not met.  In this way, to say that someone does not have a diagnosis is to diagnose them, which is exactly what Frances did.

Frances said, “The psychiatrists and psychologists who are now publicly diagnosing Trump feel compelled by the higher call of national interest to break any restrictions against diagnosis at a distance.  But the argument fails because their diagnosis is poorly informed and simply wrong.”  Yet, Frances says directly that Trump does not meet the criteria for Narcissistic Personality Disorder.  How can he say that when he’s not supposed to diagnose anyone publicly, from a distance and without adequate information about the person?  He can’t but does so anyway.  As a result, Frances contradicts himself and has grossly misled the public.  But this isn’t the most concerning thing about Frances’ statements.  But before I continue picking apart his comments I think it’s important to note that he has some good points in these two publications.  Given the outrage, they could go unnoticed.

2 |  Not All Bad

First, Frances’ comments seem to be complex and nuanced, which is what I would hope to see from any clinician.  As much as the human brain wants to over-simplify facts or reality, it’s always infinitely nuanced.  Consequently, not all of Frances’ statements are bad or without merit.  From my perspective, about half of what he says is worth considering, is accurate or possibly helpful.

First, diagnosing from afar is dangerous and our egos often have more to do with this than a desire to protect others (though Trump may be a very real exception to this for some clinicians).  The average person generally doesn’t understand the many layers of thought that go into the process for diagnosing.  This isn’t because people are dumb but rather, they just haven’t gone through the extensive education and training that it takes to adequately consider a diagnosis.  No amount of personal reading or Google searches can equal this training.  This is why diagnosing should be left to the professionals.  Everyone should know that such an exercise, though seemingly simple, can be very complex.  Professionals can also have different opinions or diagnoses that are often valid, and this can confuse the average person but for the professional it makes perfect sense.  While Frances is right that clinicians should avoid diagnosing from afar, he violates this himself.  I’m interested to know how he didn’t catch that or if he did, did he think that the rest of us wouldn’t notice it?  Obviously I’m just guessing here in an attempt to understand his large error.  Regardless, I think that there’s also something to be said for professionals to taking action when someone is acting in abusive and manipulative ways.  As I see it, Trump (like many other politicians) is abusing the American people and manipulating them in so many different ways.  If there isn’t something unhealthy or diagnosable about these behaviors then I think that there’s something very wrong with the DSM and those who support it.

Frances made another good point and it had to do with scapegoating.  He said that we need to be cautious about pointing the finger at one person, Trump, who is supposedly the source of all of our problems.  On this point I definitely agree.  Humans prefer simple answers and when things go bad, they (we) want something and someone to blame.  Interestingly enough, this is our own narcissism at play because by dumping the blame onto someone else allows us to walk away from the situation squeaky clean.  So when Frances says that Trump isn’t causing the world’s problems, I believe he’s partially right.  Where he’s wrong is that Trump is causing some major problems and making a variety of social issues much worse.  The fact that there were enough people to put Trump into office shows us that there are much bigger societal issues at play.

These involve the dominant societal definitions and approaches to mental, physical, social and environmental health.  Right now I would say that our definitions and approaches are weak, often misguided and that our country has always struggled with excessive arrogance and narcissism.  Unfortunately, doing what is healthy for us, on an individual and collective level, is generally not very popular (unless it increases our narcissism) and as a result, the rate of improvement in these areas is painfully slow.  Trump seems to be the ultimate expression and symbol of the selfie, our social media tendencies, our greed, our abuse of others, our racism, our ignorance, our misogyny, our admiration of narcissists and abusive people, and the privilege of white men, Christians, the wealthy and conservative people, and so on.  So yes, let’s not scapegoat Trump.  He’s one problem and then we have all of the problems that I just mentioned.  These are the sicknesses that are present in each of us and throughout our society.

3 |  Politics Over Truth, Mental Health & Public Welfare

For me, the most disturbing thing that Frances says to the Verge is, “We [made] the decision to introduce narcissistic personality disorder in DSM-III and I wrote the version that’s still used now.  The decision to include it was purely for clinical purposes and we never dreamed it would result in the diagnosis of NPD being used in political warfare now.  I think that if we’d had that thought along the way, we would have thought twice about including it.”  Wow.  Those who meet the criteria for NPD and hold leadership positions cause so many of the problems in the world, in our communities and in our families.  They can take advantage of others, they belittle them, they disregard anything that others say, they’re greedy, they’re manipulative, they destroy, they’re without regret or remorse, they lack empathy, they distort reality, they destroy the environment and they are deeply, deeply troubled.  Yes, there are problems with the misuse of diagnoses within the general population but this DOES NOT mean that we should prioritize politics over accurate diagnoses.  We shouldn’t hold back from labeling an unhealthy behavior because people in the public eye might be slandered.  We should work to counter slander but we shouldn’t sacrifice truth for it.  Yet, if this is truly what Frances believes then what about all of the other disorders that are tossed around or slapped on so many?  NPD is much more prevalent in men and he didn’t make any comments about those disorders that are overused and misused for women and children.  Does he wish to change all of them to avoid possible slander, public misperception and consequently degrade the validity of a diagnostic label?  Or is his particular focus on NPD revealing his privilege, bias or blindspot?

4 | Privilege Revealed

Another sizeable problem with Frances’ comments is that he seems to approach the subject of mental health as though he has the final word on the subject and its definitions.  His statements are presented in a way that seem to suggest that he has or believes he has the absolute right to define mental health…for all of us.  For me, it comes across as a bit self-aggrandizing and this is quite ironic given the topic of conversation.  To say that someone is not disordered “because these traits don’t cause him distress” is absolutely absurd.  From the looks of it, many serial killers and criminals aren’t distressed by their actions.  Does this mean that they don’t have serious mental health issues?  Of course not.  So how can Frances, someone who’s influenced the DSM significantly, maintain these views and expect us (psychologists and other clinicians) to use his definitions and diagnositic book?  Why wouldn’t we begin to question the whole system to ensure that there aren’t more distorted influences on the core resources that other clinicians use?  Regardless of whether or not Trump’s public personna is real or not, I believe that a person who chooses to conduct themselves as he has should not be considered mentally and emotionally sound.

Though we hold advanced degrees in our fields, Frances and I (or anyone else else for that matter) are not in the position to establish, absolutely for all people and cultures in the world, a definition of mental health and that of mental illness.  We are not the final authorities because we cannot speak for everyone, every culture, every country and every related field.  Yet, some of those is our field believe that they have the right to make such declarations.  Why?  Because of privilege.  Even though I believe that there are many issues of privilege present in Frances comments, I’d like to focus on his declaration.  This is because people could run with this and they have the potential to use his statements to support their own biases and perspectives.

While I don’t believe that any of us can claim something absolutely, I do believe that we should voice our views on a given subject matter, especially when its within our profession.  I think if we’ve studied and worked within a field for a long time that it’s important for us to throw our views out there for people to consider.  This is one of the primary ways in which we advance and mature as a species.  But we have to be careful when we toss things into the ring and this is where Frances went wrong; he didn’t “IMO” enough.  Though this phrase seems so overused, I believe it’s a good trend because it emphasizes that no one is the ultimate authority over a thing.  It recognizes that a person’s view is one of many.  If it is sincerely meant, then it is a humble acknowledgment of our collective or socially constructed reality.  Frances would have faired much better had his contributions embodied this philosophical and social position.  From my perspective (aka, IMO) and as a person who’s studied psychology for over 30 years, our individual level of mental health is largely determined by our ability to adapt, handle stress and how we conduct ourselves in relationship to the world (i.e., people, animals, environment).  And yet, this is where the weaknesses of the DSM are revealed because it has no diagnosis for relationship patterns.

5 | The DSM Lacks Relationship Diagnoses

This is probably where eyes will start to glaze over, if they haven’t already, but I’m going to make this short so hang in there with me.

The DSM is a narrow in its focus and extremely biased in its approach to diagnosing.  It’s based upon the conditions of an individual and a diagnosis is determined by observed behaviors or traits and statements the individual reports about how they feel about themselves, others, etc.  Simply put, a diagnosis from the DSM is viewed as medical diagnosis (though that’s in theory…but I won’t get into that).  One of its huge weaknesses is that it has failed to derive relationship-based diagnoses.  If an individual physically, sexually or psychologically abuses other people, there’s no diagnosis for this.  What a clinician will try to do is to give them an individual diagnosis such as Antia-Social Personality Disorder or something to that effect.  So if a person is an abusive predator of others but it never bothers them, disrupts their life or if it fails to meet existing criteria in the DSM, then they won’t have a diagnosis.  Of course, this is if we follow Frances’ example and his reasoning.  This would be like us saying that Jeffrey Dahmer wouldn’t have received a diagnosis until he went to prison because his behaviors finally disrupted his work-life balance.

We still have a lot of work to do in this field and despite issues such as these, I’m glad to be a part of it.  All of us, and I mean all of us, just need to work hard at being better for ourselves and others.  The culture in the U.S. rewards some of the most troubled people and even puts them on a pedastal.  I can only hope that Trump’s example will show all of us just how destructive, mean and hurtful such traits are and then we can alter this trend.  Who knows, being humble and psychologically healthy might actually become popular one day!  Well, I can always hope.

When Hope Feels Like Bullshit

When we’re down, especially when we’re really down, we have a hard time feeling hopeful, being optimistic, or seeing that things will get better.  It can be particularly frustrating, even infuriating, for someone who is very depressed to hear, “oh, it’ll get better,” “it’ll be okay,” or, “it’s not that bad.”  The person saying this probably means well, but to the person being told this may experience it as ridiculous, invalidating, ignorant, or belittling.   And no matter how true the statement might be, these reactions tend to occur.  But why?  How we communicate to someone who is really suffering can be tricky and expressing such things can be extremely unhelpful.  So let’s dig into this to figure out what’s going on.

Hope, The Unhelpful Kind – Blind hope or blind faith is not very helpful because it, generally, does not have a substantial foundation.  What I mean by this is that there’s no proof in the pudding and for the person who’s suffering, the proof that they’re seeing is all negative.  To emphasize blind faith or hope completely invalidates the person’s experience.  Furthermore, blind faith or hope can be based more in fantasy than reality and be symbolic of our own discomfort with the situation.  “It’ll get better,” the person says but, what happens when it doesn’t?

I’ve worked with many kids and adults who’ve experience various traumas and if I were to say this to them after they talked about being physically or sexually abused, they’d probably give me the finger and go elsewhere.  When a person is suffering and has suffered greatly, their challenge lies in both accepting (but not liking) the situation and learning how to work and improve their situation.  But right now, however, they have no hope and so they need some experiences where hope is valid and real.  From their perspective, life has shown them that everything sucks, that they’ll fail, that they’re not good enough, and being loved and accepted is not a possibility for them.  Lastly, we need to watch our own discomfort when we’re with a person who is suffering.  Are we saying, “just look on the bright-side” because we honestly don’t know what to say or do?  We might be, and it’s a very natural, albeit unhelpful, thing to say and do.  If this is the case, the best thing you could do is say something such as, “I really want to help but I just don’t know what I could do or say that would help you.  How can I help?”  Not knowing but staying with them, caring for them, but not trying to fix it for them, is the best possible thing you could do.

Hope, The Helpful Kind – Hope that’s based in reality is the most helpful.  We need to acknowledge the evidence or the proof that supports it.  For some of us, we’ve come to the realization that unwanted situations always change for the better, but we don’t know when or how this will happen.  In our lives, we’ve witnessed this truth.  Yet for the person who hasn’t witnessed this, they have to experience it for themselves before they know it.  In order for this to happen, they need to learn how to accept the situation (but they don’t have to like it) and develop the ability to figure out how to improve things.  In short, they need to develop strong problem-solving skills, while managing their emotional reactions.  They then have the opportunity to realize the type of hope that is substantial and real, given their situation.

But for the person who is completely overcome by emotion, reason may not be their strong suit, even when they’re in a calmer state.  Consequently, it can take time for the person to become more reasonable and rational.  We can help them along by listening to them, empathizing (not sympathizing), accepting their views (though not agreeing with), and even asking question about alternatives.  In essence, we’re giving them hope by offering our own rational thinking and by embodying the hope that they don’t presently have.  Of course, they may reject your perspective and this is where the line is drawn.  You’ve offered the possibility of real hope and now it’s up to them to use your support.  Yet, you can’t force them and it’s not helpful to push it on them.  This will only sour the relationship.

Communicating Hope and Possibility – There are times when we’re just not the right person to help and the other person may flat out reject your attempts to care and support them.  While this may sadden us a great deal, we can take our desire to help in order to find them someone who can, in a healthy way, help them.  Many parents are in this spot.  Their relationship with their child might be stressful and have a history of problems that get in the way of forming a supporting and collaborative relationship.  In order to help your child, they’ll need someone else like a therapist.  Then, one of the things that you can do is work to repair the relationship by working with a family systems therapist and/or to find your own therapist.  Over time you can repair the relationship where your child may start to accept your support.  Furthermore, by having your own therapist you can explore how your helping may not be so helpful.

Many of us have such good intentions but often aren’t taught how to work with very difficult, anxiety-provoking, and emotional situations.  We may have a very hard time relating to the other person for whom we care, but that doesn’t mean that we can’t get there.  In order to share and communicate real hope, we have to become real hope.  Meaning, we have to exude it and do so authentically with little to no reactivity (aka, enabling, minimizing, soothing, fixing, getting upset) in response to the person who’s suffering.  This way we are able to understand them (empathy), demonstrate that we accept where they’re at (validating), and support them as they, yes they, learn how to make their own changes.  If we try to take on their problems, we end up handicapping their ability to become master problem-solvers.  They need practice and we can’t practice for them.

Recommendations – If you can relate to what’s been described here and wish to move forward in a positive direction, a therapist will be invaluable for you and the other person.  Again, we’re generally not taught how to be psychologically-minded in our schools or in life.  To think that we should be highly self-aware from birth is similar to us thinking that we should all be amazing athletes without having ever trained.  We just doesn’t work like that.  A therapist is going to be able to help you reflect on the situation, yourself, and to help you make solid changes that are truly helpful over time.  So, the next step just might be working with a therapist to undergo training.

Locating the Cessation of Suffering in Its Cause

Some time ago, one of my dharma teachers suggested the phrase, I have everything I need, as a mantra of sorts to return to when caught up in feelings of anxiety. At the time it sounded a bit hokey to me–the idea of stopping in a moment of anxiousness to say to myself, “Laura, you have everything you need” brought to mind Saturday Night Live parodies of the affirmations said to one’s reflection in the mirror. However, in the last several years, this phrase, “I have everything I need,” has become an incredibly powerful one for me. It’s no cure-all, but I’ve come to feel that the importance of the pause it necessitates in the throes of emotional distress. Even if I only connect to its theoretical truth, I usually notice a gentle release of tension in my chest, a small expansion that reminds me my experience is not as narrow as it feels in that moment. However, recently I’ve noticed that, while I have trained myself quite well to mentally pause for my little mantra, I’ve had a harder time genuinely engaging with it, re-investigating its weight rather than intoning it to myself on autopilot, turning a familiar practice into a tired exercise. It wasn’t until I was rereading part of Mark Epstein’s book, Thoughts Without A Thinker, that it occurred to me that there’s a way in which I have perhaps allowed this helpful little mantra to let me off the hook in terms of getting to bottom of those feelings, treating the phrase like a soothing balm to spread over a wound without first stopping to gently locate and remove the bits of dirt so deeply ground in–no wonder its effectiveness reduces with each flare up of infection.
In Epstein’s opening chapter, he describes the Hell Realms, a set of purgatory states of suffering that humans may be born into as a reflection of their karma. In psychological terms, he refers to these realms as “vivid descriptions of aggressive and anxiety states.”  This time around, I was especially struck by his discussion of the Realm of the Hungry Ghosts, whose inhabitants are visually depicted in the Tibetan Wheel of LIfe as: “phantomlike creatures with withered limbs, grossly bloated bellies, and long, thin necks… [who] while impossibly thirsty, cannot drink or eat without causing themselves terrible pain or indigestion [and] the very attempts to satisfy themselves cause more pain.”
According to Epstein’s translation of the realms from a ‘place’ into a psychological state, the Realm of the Hungry Ghosts represents an attachment to the past, a state of “searching for gratification for old unfulfilled needs whose time has passed.” This assessment interested me greatly because, while I identify deeply with the compulsion to fill up the emptiness of ‘not enough’ by casting about myself for comfort–in exercise, affection, food, even my meditation practice–I have never considered myself to be someone particularly attached to the past. In fact, my experience of myself has almost always been a complete and utter preoccupation with the future, letting go of the past with a dismissive “I don’t believe in regrets.” And yet, what else could be at the root of this habitual rising of ‘not enough’ but “old unfulfilled needs whose time has passed”? What else could be behind such a hard, bright insistence on worrying over the future and staunch refusal to dwell on the past? 
Though I have some leads, I don’t have concrete answers to correspond to these abstract questions for myself as of yet. I have the sense that, as usual, a seed which was planted years before is finally, just now, beginning to sprout. Fundamental to the foundation of Buddhism is the recognition that suffering is our resistance to a direct experience of reality, and by extension, ourselves. As I do my best to nurture my curiosity despite the anxiety and fear clouding my view, I take comfort in the Buddhism’s notion of interdependent co-arising: “the causes of suffering are also the means of release; that is, the sufferer’s perspective determines whether a given realm is a vehicle for awakening or for bondage.” If this is true, then I do, in fact, have ‘everything I need’ to gently remind myself that I am not stuck with the burdens of my past so long as I aspire to look directly at my present, which includes acknowledging the origins of my habitual patterns.