Unexamined bias and privilege play massive roles in not only who gets to diagnose mental health disorders, but who defines their criteria.
I grew up in a household full of people who were emotionally volatile and abusive. At any time, for no particular reason, I could be screamed at, guilted, shamed, or bullied — sometimes all four at once. I survived this by adapting, as humans do, to my environment, becoming hyper-vigilant, avoidant, and very anxious. I walked on eggshells at all times, constantly analyzing every slight change in a person’s facial expression, body language, and tone of voice. My alert level was always at orange.
Now, in adulthood—and generally surrounded by people who are not terrible—these habits and impulses still interfere with my attempts to build a happy life. Unfortunately, they’re very hard to break, and my alert level can’t just be turned down. I am, officially, mentally ill.
If this all sounds familiar to you, I’m not surprised. I’ve met many people who have had very similar experiences and now suffer from anxiety and/or depressive disorders. It’s to the point that the people in my life who don’t struggle with mental illness are out of the norm.
Speaking of “out of the norm”… Donald Trump is president of the United States.
For the past few months, nothing has seemed normal. He breaks well-established political norms on a regular basis. He says terrible and blatantly cruel things. He lies all the time. He puts completely incompetent people into positions of power.
In short, he’s not behaving at all like he should.Speaking of “out of the norm”… Donald Trump is president of the United States. Click To Tweet
And as a result, since his rise to leading Republican presidential candidate, the thinkpieces and compulsive conjecturing on his mental health have been published with increasing frequency and alarm. Paul Krugman has called Trump “obviously mentally ill” on Twitter, #DiagnoseTrump campaigns and petitions have gone viral, and last month California congressman Ted Lieu made news when he pushed for legislation requiring a psychiatrist in the White House.
In attempts to make sense of Trump’s abnormal behavior, journalists and assorted other media figures have scrambled to ask any and every person with any kind of background in psychology what they thought about Trump’s mental state. Such inquiries and articles have only intensified since Trump took over the country’s helm.
To a point, I get it. The United States appears to be in chaos and human beings have a need to make sense of things. Further, mental illness has a long history of being used as a handy scapegoat to explain Bad Things. In particular, it’s been increasingly used to explain away the mass shootings committed overwhelmingly by white men. Before that, it was routinely used to describe anybody who committed a heinous enough violent act to get in the news.
The president is behaving in a way that lies far outside the boundaries of what we conceive of as “normal,” particularly for a person holding the highest office in the land. His actions are scary, and collectively as a society we are attempting to make sense of something that seems to make little recognizable sense.
Around Inauguration Day, speculation that Trump has Narcissistic Personality Disorder seemed to reach a fever pitch. But Dr. Allen Frances, M.D.—who contributed to developing the criteria for the disorder in the the Diagnostic and Statistical Manual of Mental Disorders — weighed in, tweeting that Trump does not fit the criteria for the illness as he is not impaired. Highlighting his expertise in this area, Frances claimed that Trump was “bad, not mad.”
Indeed, it is difficult to say that someone is impaired when they can reach one of the greatest achievements in the world.
This got me thinking. What is mental illness in a society where someone like Donald Trump could become the U.S. president? How can someone who behaves so badly—so consistently inappropriately and erratically—be considered mentally healthy, or at least mentally competent enough to become the leader of the world’s biggest superpower?It is difficult to say that someone is impaired when they can reach one of the greatest achievements in the world. Click To Tweet
I posed these questions to Dr. Allen Frances himself over email. His response smacked me right out of the bad path I was going down of framing Trump’s behavior in terms of mental health.
“It is a great, and frequently made, error to equate bad behavior with mental illness. The mentally ill only rarely behave badly and people who behave badly are rarely mentally ill. And as many people have pointed out, talking about bad behavior as though it’s an inevitable quality of the mentally ill does us a lot of harm.”
This was certainly true in my experience. As a kid and as a teen, I was so terrified of getting in trouble that I never so much as shoplifted a candy bar, I didn’t try weed or alcohol until I was in college, and I drove myself into the ground to get nearly all A’s throughout middle and high school.
Still, concerning Trump, my initial question hadn’t been answered. What does “mental illness” even mean in a society that elected Donald Trump to the presidency? What is it in a society that’s sick enough to have put an administration into power that ticked off most of the hallmarks of fascism off in less than a month?
New research into stress and trauma is leading a number of psychologists to believe that many incidents of mental illness are the result of behaviors and stress responses learned during traumatic incidents and/or abusive or highly stressful environments that are maladaptive in one’s larger society.
Again, this resonates with my own experience. I now work in a place where I have never been treated badly or screamed at or even scolded, yet I still feel like I have to walk on eggshells. Despite all evidence that it’s a safe place, I have trouble asking for help or admitting to making any kind of mistake, which impedes my ability to work.
The role of trauma and stress in mental illness formation was further explored by psychology professors Bruce J. Ellis and Marco Del Giudice in the 2013 paper “Beyond allostatic load: Rethinking the role of stress in human development.” In it, they argue that the standard idea that the intense stress responses learned in a volatile childhood environment result in toxic and maladaptive behavior patterns in adulthood is too simplified. They explore the idea that what are considered to be “maladaptations” could instead be viewed as differences in skill types—and at times even represent advantages:
“…maltreated children score lower than comparison groups on standard tests of intelligence and executive functions. Yet such children may show enhanced ability to detect, learn, and remember stimuli that are ecologically relevant to them. This includes enhanced perceptual sensitivity to angry facial clues, increased anticipatory monitoring of the environment in the context of interpersonal hostility, greater accuracy in identifying facial expressions of anger based on degraded visual information, greater speed in accurately labeling fearful faces, enhanced recall of distracting aggressive stimuli, and greater accuracy in identifying an adult in a photo line-up with whom they previously had a stressful interaction.”
Sounds like me.
But, of course, not all stress is caused by family. What if all of society is a highly stressful environment for someone? What about, to name just a few groups, black Americans, trans people, and Latinx immigrants? Could they ever be considered “truly” mentally ill while living in a society that openly treats them far worse than my family treated me? If members of various marginalized populations are highly anxious, stressed, suspicious, or even hostile all the time, is that not a normal, adaptive response to the threats they’re under just by existing?
To glean more insight on the matter, I spoke with sociologist Dr. Nancy Heitzeg, author of The School-to-Prison Pipeline: Education, Discipline, and Racialized Double Standards, on how white privilege interacts with the diagnosis of mental illness. In her text, she demonstrates how white people tend to be “medicalized,” or diagnosed with some kind of illness that renders them not responsible for their actions — let us not forget the infamous case of “affluenza” in which a wealthy teen was sentenced to rehab after killing four people on a drunken joy ride — while people of color, particularly black individuals, are “criminalized.”
In the introduction of her book, she says:
“This trend toward criminalization for people of color and medicalization for whites provides the larger socio-political context for the school-to-prison pipeline as youth of color, particularly Black males, are increasingly ‘criminalized’ within the context of schools, while their white counterparts are ‘medicalized’ for the same disruptive behaviors.”
Dr. Heitzeg expanded on this in our conversation, explaining how even when black and other marginalized children are diagnosed with illnesses rather than being immediately funneled into the juvenile justice system, a diagnosis is more likely to function as a stigma than as a way to excuse behavior.
“When you look at black children, there’s a tendency to label them with learning disabilities and behavior disorders or disturbances,” she said. This kind of diagnosis only serves to label them as ‘problem children’ who should be given up on, rather than sick kids who just need some extra help. “The medical model is helpful for some but can be a double whammy for others.”
This further complicates things. If there’s so much bias in how people are diagnosed, how can we know who is ill and who is not? What about the fact that many of the people who do the diagnosing are privileged white people? How much privilege do the people writing the criteria for diagnosis have?
Dr. Heitzeg’s response to that question told me enough: “Don’t get me started.”If there’s so much bias in how people are diagnosed, how can we know who is ill and who is not? Click To Tweet
It’s not just about race, either. Women, for instance, are often misdiagnosed with personality disorders for being “overdramatic” (thanks to a generous dose of medical misogyny from the historically male-dominated field of psychiatry) and autistic kids are often initially misdiagnosed with mental illness. And it’s important to keep in mind that higher level mental illnesses such as personality disorders and schizophrenia are significantly more stigmatized than my mood disorders.
In the broader social justice community, talk of mental illness still seems to be fairly surface level, rarely taking these many nuances into account. Mental illness is considered to be an axis of oppression, and neurotypicals — people without mental illnesses, autism, or any kind of “intellectual” disability — are the oppressors. But I feel a bit weird talking about “those neurotypicals” because who actually is neurotypical when our system of diagnosing mental illness is so imprecise and so subject to prejudice?
Not only can you not tell if someone has a mental illness by looking at them or how they behave, they themselves may be mentally ill and not know it. And some of us who have been labeled with an illness may in fact not have one, either because we were misdiagnosed for being female and upset, because we’re actually autistic but present differently because we’re not white boys, or even because we’ve fully recovered but can’t shake the stigma.
So is Donald Trump mentally ill? That’s not the conversation we should be having.
We should be talking about his white-supremacist-backed bigot horror machine administration and how his policies threaten the lives and livelihood of millions of people globally. And while we’re at it, we also need to have a deeper conversation about what mental illness is, including how it’s defined, who gets to define it, and how that definition changes with privilege — or a lack thereof. It needs to be a lot more than just “don’t use words like cr*zy” and “don’t compare us to Donald Trump.”
Although seriously, please, stop doing that.