Wednesday, June 7, 2017

The Personality Disorders are Different. A note on moral and clinical language and Presidential psychopathology.

Clinical and moral language serve different social functions. The clinician's diagnosis of Narcissistic Personality Disorder is the disliked neighbor you think is an entitled, self-centered asshole. 

I have mixed feeling regarding the psychiatric diagnosis of American Presidents, an indoor sport currently stimulated by the reasonable conjecture that Donald Trump manifests a Narcissistic Personality Disorder, and the reasonable concern that his condition is so severe it renders him dangerously unfit for office. I have little doubt that his desperate self-centered hunger impairs the sort of measured judgment required for weighing the complicated factors of governance and diplomacy. Who in their right mind now trusts his honesty and leadership?  I don't, and the statistics suggest you don't, either.

Regardless of the accuracy of these diagnoses, and setting aside my concern with the Goldwater rule, I prefer moral language for some of our Presidents' conditions. There is a literature detailing their depressive grief, alcoholism, Nixon's paranoia, and Reagan's Alzheimer's.  Some have been intellectually unsuited for the job, incurious, prone to the other's sway. The second Bush is an easy example. But saying many American presidents have been mentally ill offers a false equivalency and blurs an important distinction that moral language is better positioned to expose. Some conditions of the psyche are morally problematic, in particular the Personality Disorders (the so-called Axis 2 pathologies of the Diagnostic and Statistical Manual). It's pejorative to comment that someone is Axis 2. It is a moral condemnation, often as not.  And for good reason.  These are conditions where the bearer of the diagnosis locates their problem not so much within themselves as with the failures of their environment. They have been wronged, hurt, let down and can't tolerate their vulnerability exposed. 

Narcissists are prone to fantasies of greatness and require an admiring audience to confirm it. Claims of greatness have both clinical and moral consequences. All presidents probably think they are grander than you. They almost have to. Some even had the stuff to back it up, but clearly not our current one. Trump is not like other presidents. Trump is profoundly different. Even paranoid, Nixon was far more competent. Trump's threatened narcissism warps his judgment. I don't know that he suffers the early morning, but I wouldn't be surprised. There is considerable pain there, somewhere. His boasts, his fragmented attempts to shore up his failing entitlement, vulnerable grandiosity, and small hands are painful to read.  But his pain is our hazard. 

Psychiatric illness is awful, the carrier dreadfully suffers, but the character disorders of narcissism and paranoia target and harm the rest of us. The narcissist's pain is a knee-jerk reaction that comes from failed attempts at holding your attention, and is defended through escalating claims, demands, and a preoccupation with victimization and revenge.  The problem from the narcissist's perspective is you. You didn't appreciate their grandness. You got tired of their endless winning.

A focus on Trump's illness obscures an important point. It misses the importance of political leadership requiring accountability and reasoned service to the citizenry.  Clinical language attempts neutrality and lets him off the hook, suggests he's sick rather than bad. Considering his privilege and power, the moral language of blame and condemnation is a better fit. Maybe he is sick, but he's a very bad person. Trump may be a sad little man but he is a danger to us all.







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