Allen Frances Letter to the NYT Editor

[psychstudent5]

posted without comment...

https://www.nytimes.com/2017/02/14/...trumps-mental-state.html?ref=todayspaper&_r=0

An Eminent Psychiatrist Demurs on Trump’s Mental State

FEB. 14, 2017

To the Editor:

Fevered media speculation about Donald Trump’s psychological motivations and psychiatric diagnosis has recently encouraged mental health professionals to disregard the usual ethical constraints against diagnosing public figures at a distance. They have sponsored several petitions and a Feb. 14 letter to The New York Times suggesting that Mr. Trump is incapable, on psychiatric grounds, of serving as president.

Most amateur diagnosticians have mislabeled President Trump with the diagnosis of narcissistic personality disorder. I wrote the criteria that define this disorder, and Mr. Trump doesn’t meet them. He may be a world-class narcissist, but this doesn’t make him mentally ill, because he does not suffer from the distress and impairment required to diagnose mental disorder.

Mr. Trump causes severe distress rather than experiencing it and has been richly rewarded, rather than punished, for his grandiosity, self-absorption and lack of empathy. It is a stigmatizing insult to the mentally ill (who are mostly well behaved and well meaning) to be lumped with Mr. Trump (who is neither).

Bad behavior is rarely a sign of mental illness, and the mentally ill behave badly only rarely. Psychiatric name-calling is a misguided way of countering Mr. Trump’s attack on democracy. He can, and should, be appropriately denounced for his ignorance, incompetence, impulsivity and pursuit of dictatorial powers.

His psychological motivations are too obvious to be interesting, and analyzing them will not halt his headlong power grab. The antidote to a dystopic Trumpean dark age is political, not psychological.

ALLEN FRANCES

Coronado, Calif.

The writer, professor emeritus of psychiatry and behavioral sciences at Duke University Medical College, was chairman of the task force that wrote the Diagnostic and Statistical Manual of Mental Disorders IV (D.S.M.-IV).

---

Members don't see this ad.

 

[Fan_of_Meehl]

"Most amateur diagnosticians have..."

Says the 'professional' diagnostician who throws out sweeping negative claims about the guy's personality organization (world-class narcissist, grandiosity, self-absorption, lack of empathy) without reviewing his medical record, conducting a clinical interview, and/or psychological testing.

This is some pretty sophisticated double-speak.

But, hey, this guy 'discovered/invented/owns' the diagnostic construct of narcissistic personality disorder since it clearly wasn't known or recognized in the field prior to his work on the 'list of features' that he and other colleagues picked out over bagels and coffee one day.

 

[CheetahGirl]

Many can definitely get behind the statement that he's been "richly rewarded, rather than punished" for his bad behavior.

No comment on anything else.

 

[singasongofjoy]

More general question. Personality disorders aren't my thing, but my understanding is you don't necessarily have to report significant distress with your pattern of behavior to be diagnosed with NPD- is this wrong? Also, +1 to @CheetahGirl. Related to my question, he probably would experience significant distress if he'd been met with less reward and more punishment for bad behavior. Kinda hard to be distressed when the rewards outweigh the other possibilities.

 

[CheetahGirl]

There are personality 'features' (we all possess these, in various types, intensity, degrees) which are long-standing (i.e., our personality structures are based on these characteristics), then there is the disorders that stem from those features (those are our 'axis II' diagnoses that are non-billable under the former DSM) that take a longer therapeutic relationship and more assessment to determine extent and severity (and under the Goldwater Rule, we can't speak about indivs' diagnoses without meeting them multiple times and without their consent). Yes, there is a difference between personality disorder and personality features, and you wouldn't call it NPD in the diagnostic sense if you are determining the person's self-perceived distress is absent

 

[singasongofjoy]

There are personality 'features' (we all possess these, in various types, intensity, degrees) which are long-standing (i.e., our personality structures are based on these characteristics), then there is the disorders that stem from those features (those are our 'axis II' diagnoses that are non-billable under the former DSM) that take a longer therapeutic relationship and more assessment to determine extent and severity (and under the Goldwater Rule, we can't speak about indivs' diagnoses without meeting them multiple times and without their consent). Yes, there is a difference between personality disorder and personality features, and you wouldn't call it NPD in the diagnostic sense if you are determining the person's self-perceived distress is absent

Thank you for the diagnostic clarification - I'll stick with kids and IDD

 

[smalltownpsych]

Saying that I wrote the book on narcissistic personality disorder sounds a little narcissistic. I do agree with his basic premise that we should not be diagnosing public figures and feeding the misperception about bad behavior = mental illness.

 

[CheetahGirl]

@singasongofjoy - that 'self-perceived' distress in NPD is what makes it so tricky...wouldn't you say?

 

[deleted343839]

I was wondering when Allen Frances was going to jump in with his $0.02.

Trump is far from the first raging narcissist to occupy the White House. It's interesting that this is what people have chosen to focus on.

 

[Fan_of_Meehl]

I was wondering when Allen Frances was going to jump in with his $0.02.

Trump is far from the first raging narcissist to occupy the White House. It's interesting that this is what people have chosen to focus on.

This is so true.

Someone should write a rebuttal to Dr. Francis chiding him for ignoring the 'base rates' of personality disorders (especially narcissism) in prominent politicians. Spending one's life in pursuit of political power in order to obtain a position of writing rules and laws governing other people's behavior (because you know best, of course) seems a pretty efficient filter to 'pan for Axis II gold' out of the general population.

My main issue with the editorial is that it trivializes what we do and possibly would dissuade veterans (the population I treat) who may personally have a more conservative political ideology from seeking help in the form of psychotherapy/medication from a profession that appears to strongly (and inherently) favor the opposing political party in a nation as divided as we are currently. I would hope that we could all cleave to our professional role as psychologists/psychiatrists first, political ideologues second (and in our private, not professional, lives).

 

[PsyDr]

Looks like Dr Frances is desperately trying to skirt the Goldwater rule...

And the Apa ethics people have already publicly stated this applies to psychologists.

 

[WisNeuro]

He's an MD.

 

[Pragma]

I hate this kind of crap.

 

[psych.meout]

I hate this kind of crap.

Me, too. It's just unfounded speculation, almost as bad as criminal "profiling."

How do we know that Trump does or doesn't experience distress related to narcissism? Frances hasn't spoken to him about this, so all we have to go on is behavior, which could easily be interpreted either depending on one's a priori intent. E.g. Him lashing out at any perceived criticism could be a sign of distress from his narcissism or he could just be a jerk.

 

[WisNeuro]

Well, from a more theoretical basis, it's an interesting argument. Yes, distress and/or impairment are included criteria to pretty much any disorder. But, inarguably, distress and/or impairment are related to available resources. Someone who does not have a trust fund and low education may have a similar level of Axis II traits and have significant occupational/social/etc functioning. At what point do we draw the line with those criteria irrespective of moderating forces, while disregarding observable symptoms of mental disorders?

Think about it in a more broad sense. Did anyone else have like an entire semester in definitions of "abnormality" and taxonomy, replete with dense Meehl readings?

 

[PsyDr]

He's an MD.

I'm very aware of who he is.


The Goldwater rule originated in psychiatry, was codified into their ethical guidelines, and then adopted by psychology. From the Barry Goldwater presidential campaign. Goldwater sued and won based upon an article about him. Apa (psychology) has specifically discussed this in the most recent election. Applies to both professions.

 

[cara susanna]

Couldn't we make an argument about impairment? I mean, he's had multiple law suits and I would imagine that he's experiencing some interpersonal conflicts...

WisNeuro: Your post reminds me of why Millon disliked the anti-social personality disorder diagnosis. He said that it would never apply to white collar criminals because they get away with it.

 

[PsyDr]

@cara susanna et al:

"The American Psychological Association wholeheartedly agrees with Dr. Robert Klitzman that neither psychiatrists nor psychologists should offer diagnoses of candidates or any other living public figure they have never examined. Our association has declined requests from several reporters seeking referrals to psychologists who would make such speculations.

Similar to the psychiatrists' Goldwater Rule, our code of ethics exhorts psychologists to "take precautions" that any statements they make to the media "are based on their professional knowledge, training or experience in accord with appropriate psychological literature and practice" and "do not indicate that a professional relationship has been established" with people in the public eye, including political candidates.

When providing opinions of psychological characteristics, psychologists must conduct an examination "adequate to support statements or conclusions." In other words, our ethical code states that psychologists should not offer a diagnosis in the media of a living public figure they have not examined.

Susan H. McDaniel
President
American Psychological Association
Washington"

 

[erg923]

I'm not sure what the point of all this is. We get what we deserve because we elected him. Think about that.

Protest all you want, but if this is what we want and what we value??? We need to look as why this is???

I'm more concerned that his election victory spoke to two VERY different types of citizens/people. A troubling divide. A divide in the populous that existed way before he was in the news. What does that mean? How can we live in the same place (literally next door) and feel so different about such basic elements of life, freedom, economics, democracy...our fellow man, etc..

Personality exists on a continuum, and he clearly has a style/features that are counter to many of our personal and professional values. So did Kennedy, Nixon, Clinton, and host of others.

He will likely do a mix of good and bad things--and likely some pretty bad "bad" things. He was legitimately elected, and it is the will of the people... even if "the people" don't fully understand how these features have the potential to be dangerous to them. I don't like using "diagnoses" as a political weapon.

 

[CheetahGirl]

We get what we deserve because we elected him.

I didn't vote for him. Geeeez.

In fact, I'm going to protest on President's Day (Federal) Holiday, by going to work!

Ha! That'll show 'em.

Seriously, though...I agree with your other points, erg.

 

[cara susanna]

@cara susanna et al:

"The American Psychological Association wholeheartedly agrees with Dr. Robert Klitzman that neither psychiatrists nor psychologists should offer diagnoses of candidates or any other living public figure they have never examined. Our association has declined requests from several reporters seeking referrals to psychologists who would make such speculations.

Similar to the psychiatrists' Goldwater Rule, our code of ethics exhorts psychologists to "take precautions" that any statements they make to the media "are based on their professional knowledge, training or experience in accord with appropriate psychological literature and practice" and "do not indicate that a professional relationship has been established" with people in the public eye, including political candidates.

When providing opinions of psychological characteristics, psychologists must conduct an examination "adequate to support statements or conclusions." In other words, our ethical code states that psychologists should not offer a diagnosis in the media of a living public figure they have not examined.

Susan H. McDaniel
President
American Psychological Association
Washington"

Yeah, I know. I was just curious about how Francis is defining impairment.

 

[Sanman]

I have to agree with ERG for the most part about what is troubling in this situation. I have my thoughts on why this divide exists, but will keep that to myself as this is not a political forum, but a professional one.

Regarding Dr. Frances,

While I am not for diagnosing or not diagnosing the president. The broader implication of his statements that others are rewarding Trump for his behavior and that this more of a reflection of society rather than President Trump himself is an important point. However, the perception of whether Trump's grandiosity has hurt him or not, is a personal one that cannot be determined (or ruled out) without a conversation with "The Donald" himself. While he may appear to be benefiting completely from his behavior, a string of divorces and lack of clarity about how it has affected other social relationships means that only Trump can answer if there have been negative impacts in his life.