Wednesday, June 7, 2017

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

Clinical and moral language serve different functions. The clinician's diagnosis of Narcissistic Personality Disorder is the disliked neighbor you think is an entitled, self-absorbed asshole. Both fit our current president. 

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; his condition severe enough to render him dangerously unfit for office. I have no doubt his desperate self-centered hunger impairs his judgment. Who in their right mind trusts his honesty and leadership? I don't, and the statistics suggest you do not, either.

Regardless of the accuracy of this diagnosis, and setting aside my concern with the Goldwater rule, I need moral language to adequately describe Trump. His condition may be psychiatric but it's clearly a moral pathology.  

There is a literature detailing past president's depressive grief and alcoholism. We know about Nixon's paranoia and Reagan's Alzheimer's.  Some presidents have been intellectually unsuited for the job, incurious, prone to the other's sway. The second Bush is a prime example. But pointing out that 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, call them sicknesses if you like, are morally problematic.  In particular, the Personality Disorders, the so-called Axis 2 pathologies of the old Diagnostic and Statistical Manual.  Among clinicians, it's usually pejorative to comment that someone is "an Axis 2".  And for good reason. These are disturbances where the bearer of the diagnosis locates their problems not so much within themselves as with the faults of those around them.  They have been wronged, hurt, and let down. They become sullen and belligerent when their vulnerability is exposed. 

Trumps's narcissism is a malignancy on the American body politic. Narcissists of his ilk indulge in fantasies of greatness and require an admiring audience to confirm it. When challenged, their claims of greatness have clinical and moral consequences. All presidents probably think they are grander than the rest of us. They almost have to. Some even had the stuff to back it up, but not our current one. Trump is not like other presidents. Trump is profoundly different. Even at his most paranoid, Nixon was far more competent. Trump's threatened narcissism severely warps his judgment. I don't know if he aches in the early morning when he tweets, but I wouldn't be surprised. His boasts, his fragmented attempts to shore up his entitlement and grandiosity 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, their knee-jerk reaction to failed attempts to hold admiring attention, is defended through escalating claims and 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, undoubtably real, obscures the most important point. It misses the importance that political leadership requires accountability and authentic service to the citizenry. Trump serves himself.  Suggesting he's sick rather than bad, clinical language lets him off the hook. Given Trump's 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. He may be a sad little man, but he's a danger to us all.