Welcome to my scientifically-informed, insider look at mental health topics. If you find this video to be interesting or helpful, please like it and subscribe to my channel. Hello, this is Dr. Grande. Today's question is: can mental health professionals diagnose public figures? And also we have some other questions kind of related to this topic. We see some recent controversy over individuals talking about Donald Trump and mentioning Narcissistic Personality Disorder and Antisocial Personality Disorder. And I'm also going to look at this video at the Goldwater Rule, which, of course, is tied in with this whole question. So, first I'll start here with Donald Trump and these recent things we've seen. So, we see that Kellyanne Conway's husband, - his name is George Conway - has been tweeting information and really been saying a few things about Narcissistic Personality Disorder and Antisocial Personality Disorder, referencing Donald Trump on Twitter. He took pictures of the DSM, the Diagnostic and Statistical Manual, of the symptom criteria for those disorders, put those on Twitter, and he's also said that Donald Trump is a liar. He said Donald Trump is the "worst kind of dumb" - that's a direct quote. And he's also accused him of having "word salad". This is when somebody kind of puts together words with no rhyme or reason. It's actually a symptom of a few different disorders, including schizophrenia, but either way nothing to do with NPD, Narcissistic Personality Disorder, or APD, Antisocial Personality Disorder. So, we know that George Conway is not a mental health professional - actually, he's a lawyer. But he's not the only one who's been doing this. We also see that some mental health professionals have been doing this. We see a book by Dr. Lee - Dr. Bandy Lee - called the "Dangerous Case of Donald Trump". And there are other psychiatrists that helped write that book, as well. So, we see kind of this group of psychiatrists that some people kind of refer to as a little "rebellious" because they are violating the Goldwater Rule, which is part of their Code of Ethics. I'll talk about that in a moment. But the reason they give for violating this rule is that their "duty to warn" is more important. So, this gets into a lot of complex issues, but either way we have a lot of individuals looking at Donald Trump and trying to diagnose him or trying to suggest a kind of... Maybe not so subtly, suggest that he has certain disorders. So, before I get too far into this discussion, let me quickly review what the symptom criteria for these disorders are. Right, let's just take a look at the symptom criteria. For NPD, we see a grandiose sense of self-importance, having fantasies of success, power, wealth, the ideal love... Feeling special or unique, requiring excessive admiration... Having a sense of entitlement... Tending to manipulate other people... Having a lack of empathy, being jealous of other people, and appearing to be arrogant. That's NPD, Narcissistic Personality Disorder. Moving over to Antisocial Personality Disorder, we see here somebody who violates society's norms. Someone who lies, someone who's impulsive... Being irritable or having aggression... Having a reckless disregard for your own safety or the safety of others... Being irresponsible and having a lack of remorse. Both of these are Cluster B personality disorders in the Diagnostic and Statistical Manual, so they're in the same cluster as Borderline Personality Disorder and Histrionic Personality Disorder. So, the question at this point might be: why do I care? Why does this matter if these individuals want to try to diagnose or to kind of strongly suggest the Donald Trump has some sort of diagnosis? Why does that matter? Well, to say that Trump has characteristics of narcissism is one thing. And I'm not saying that. I'm really staying out of this whole part of having an opinion about somebody else's mental health on this topic. But either way, that's one thing to say that that is one type of behavior. So, if we look at, like, the Five-Factor Model of Personality, for example. Openness to experience, conscientiousness, extraversion, agreeableness, and neuroticism. Remembered through the acronym OCEAN. If somebody wanted to comment on those personality traits, they want to look at a public figure and say, "well, they look very conscientious" or "they appear to be introverted low extraversion", that's all just personality. I don't necessarily recommend that, but again, that's one area that's different than applying a diagnostic label. And even within the realm of personality, I'd be more comfortable if a mental health counselor or mental health professional was taking a look at this as opposed to somebody with no qualifications. To assess somebody's personality or to consider what potential mental health symptoms might be present or not present. So this idea of casually commenting on someone's personality, this isn't what George Conway is saying. He's invoking the Diagnostic and Statistical Manual, essentially weaponizing the DSM. Diagnoses aren't intended for use in the political arena as weapons. Rather, they're used to help treat people for potentially serious disorders. Now, if you want to look at the psychiatrist and the other mental health professionals that are doing this... Well, okay, they are authorized to use the DSM, so that's a little different. But let me take a look at the rules of diagnosis here so we can kind of clear up who has the authority to do this - to diagnose - and under what circumstances. So, the rules for diagnosing can actually get a little bit complex, but to simplify it: First, somebody has to have legitimate authority to diagnose. George Conway is a lawyer, not a mental health professional. He has no legitimate authority to diagnose somebody. Now, Dr. Lee, she does have a license - as far as I know - so she would have legitimate authority. Also, the person you're diagnosing has to be your client. So, this is where really everyone else runs into a problem. Even the professionals run into a problem here because none of them are treating Donald Trump as their client. So, consider this analogy: If I run into somebody on the street, and I just walk by them and I see that they're crying, And they're saying that they feel hopeless and worthless, and they're more sad than they've ever been... I might think to myself - or I might even say - "you look kind of depressed", "you appear to be depressed." But that's different than saying that somebody has Major Depressive Disorder, or Persistent Depressive Disorder, or any of the other disorders that may align with the symptoms they appear to have. Because those come with consequences. We know that those have other associated characteristics, and that's beyond the evidence I have available in that moment. I can certainly say, "well, you appear to be sad" or "you appear to be hopeless". You're saying you're hopeless. That's different than saying, "I'm going to give somebody an official diagnosis that's intended to help guide their treatment." Another problem here is... The truth is that mental health clinicians aren't really good at diagnosing, even when somebody is right in front of them. We have a scientific discipline, but it's not as scientific as we would like. Often people who come in to be diagnosed are misdiagnosed. Again, even when they're in front of the clinician, and they are that clinician's client, and that person does have a license. We're not really great at that under those circumstances, so what makes anybody believe that we would be great at diagnosing from afar? Just looking at somebody on television, or YouTube, or other sources and saying, "Well, I think they have this disorder because I'm viewing this behavior on the screen." I guess what I'm saying is, when you have a shaky foundation, and you want to build a house, that's one thing, but don't - don't go building a skyscraper, right? I think that's - I think that's the problem here. We have to look at how solid the science is in the first place with the DSM. I tend to like the DSM, but it's far from perfect. We have to look at that science, and what kind of evaluations - what kind of statements can we make - based on that science. What's safe within, you know, a degree of error? And what's not safe? Another consideration here - and I've talked about this before - is the difference between a person and a persona. Now, we know that public figures do have a persona and that persona may be equal to who they are as a person, or it may not be. For example, when I hit the record button on this camera, I know that I'm recording, and I probably act a little differently than I would act in real life. In my case, maybe not a lot different - it's hard to say. But, either way, who I am as a person is different than my persona. So, in the case of Donald Trump, the persona that we see may be different than the person that he is. A clinician just looking at these videos - or whatever they're looking at - has no way of knowing what the difference is between the persona and the person. Some other considerations here are around the nature of NPD and ASPD. It's convenient for a non-professional to kind of, again, take pictures of these in the DSM and say, "Oh look, I think this person has them; I think Donald Trump has them", or whatever. But you don't know the context, and the context is crucial. The years of training, specifically at how to diagnose and assess people, well, it turns out they actually matter! All that training and education and supervision and licensure means something. For example, again, it's expedient just to take those pictures and make statements, but Narcissistic Person Disorder, NPD, was almost dropped from the current version of the DSM because we're so unsure about whether it's a real disorder. It turns out that it seems to explain what happens on one side of narcissism - we call that Grandiose Narcissism - but it fails to explain or really talk about Vulnerable Narcissism. So, NPD isn't something you can really say, "Well, that's definitely a clustering of symptoms that we're going to see often and it has some sort of value in terms of treatment." It is including the DSM, so yes, technically, it can be diagnosed, but again, it doesn't hold together well. So, we have to be careful about just looking at something and saying, "because it's in the DSM, it must be valid, and we should go ahead and use that." Now, how about Antisocial Personality Disorder? Surely this one exists and everybody agrees that it exists. Well, we certainly have more agreement around APD than we do NPD, but here's some interesting things about APD that may kind of shed some light on this. First of all, to have APD, somebody would have had to have symptoms of another disorder, called Conduct Disorder, before the age of fifteen. So, you can't even worry about APD until you know that. This is why it's important to take a detailed history. This is why it's important that somebody actually be your client before you try to diagnose them. Now, this is interesting because George Conway specifically said that Donald Trump seemed fine years ago in other televised appearances that he made. He looked at him being interviewed and said, "he seemed fine then." Well, if he was fine then, and you're saying now he has Antisocial Personality Disorder, how does that make sense? There's no such thing as late-onset Antisocial Personality Disorder. Or for that matter, there's no such thing as late-onset NPD. Now, I think he was talking about other symptoms. Like, he didn't directly say it, but he kind of indicated some symptoms of schizophrenia. I mentioned that before. Like, word salad is a symptom of schizophrenia. So again, just really highlights the need to have proper training before making all these statements. One thing that doesn't make sense here is making all these statements without understanding mental health diagnosing. Right? If you don't understand the context, you don't have the training, it makes sense to me that all these technical errors would be made. And these are actually really important. Just because an error is technical doesn't mean it's not important. Now I'm gonna switch gears a little bit to the ethics behind this. So you may be thinking, well, this guy George Conway, he's not a mental health professional, so he's not bound by ethics. And actually, that's true. But what about the professionals who are making these claims? They are bound by ethics, and we do see in several ethical codes that you can't diagnose somebody who's not your client. We see in the NBCC - that is one code of ethics that governs my profession, professional counseling. We see it in the American Psychiatric Association, and this is referred to as the Goldwater Rule. I mentioned I would talk about this before. And this says that psychiatrists can't share a public opinion on what's going on with somebody in terms of their mental health without conducting an examination and having proper authorization. And we see something sort of similar with the American Psychological Association. So, that Association would be looking at psychologists. So, we see various rules and various codes of ethics that make it clear that diagnosing somebody who's not your client is, in fact, unethical. So then the next question would be: why is it unethical, or should it even be unethical? So, again, it's important to note here that, with the Goldwater Rule and the psychiatrists, including Dr. Lee, that have kind of broken that rule, they've used the "duty to warn", another ethical mandate, to get around that. So, what they're really saying is that Donald Trump, in essence, poses some sort of danger, and they have an obligation to warn the public. So, they might not view themselves as really breaking the rule because they have another rule that they're prioritizing. That's kind of another issue - I won't get into that too much, but it is important to note that that is their position. That's how they're kind of getting around this. So, back to the question, though: why is it unethical? Why are these rules in place? Well, for one thing, of course the diagnosis would often be inaccurate. That's a real problem, again, if you're trying to diagnose from a distance. But another reason is the stigma that it creates. What people have said - essentially, I'm kind of simplifying this - But people have said, "Trump is bad". There's a lot of different other adjectives that can be used there, but that's what many people have said. They say Trump is bad. And now we see this idea that - people are saying Trump has MPD and APD. So what happens here when people kind of do the math, is that NPD and APD become bad. Trump is bad. He has these disorders. Therefore, these disorders are bad. Now, of course, that's faulty logic, but that's what people are doing. So, by trying to diagnose Trump from a distance, not only is there no way to know if that's valid, of course, but it ends up stigmatizing people who have the disorders. People who have NPD and APD are human beings. They go in to seek treatment. They want to recover. They want to meet their goals. Mental health professionals, including mental health counselors, help them to meet those goals. And now we have, because of this whole diagnosing from a distance situation, people being stigmatized. Now, Trump is a public figure, and public figures expose themselves to scrutiny, including opinions and speculation. What I'm saying here is that diagnosing takes it too far. Diagnosing moves past what we really know. It's beyond speculation. When you diagnose somebody, you're kind of saying they do have this grouping of symptoms. They have these symptoms that, again, tend to cluster together, and we simply don't know that. That's beyond what we can get to in terms of good practices and assessment. So to kind of further illustrate this, I'm going to use an example. I'm going to use a Person A, Person B example here. So, say that I'm walking down the street and I see two men, Person A and Person B, and Person A is punching Person B. What do I know based on that observation? Well, only that. I know that Person A is punching Person B. I don't know why. I don't know any of the circumstances except for what I can actually observe. So, if I were diagnose, if I were to say, "Okay, I think Person A has schizophrenia, and he has command hallucinations that are telling him to punch Person B." Well, schizophrenia comes with a lot of other associated characteristics, like I talked about before. So you're gonna see disorganized thinking, you might see visual hallucinations, not just auditory. There are a lot of characteristics that go with that disorder. So, I've taken my observation and I've converted it into a diagnosis of schizophrenia which now yields all kinds of other potential information. But this is not reasonable because I don't know that it's schizophrenia in the first place So you might say, well, "if schizophrenia isn't the logical conclusion to draw from that behavior, what is?" "Maybe something like intermittent explosive disorder?" "Would that be a better diagnosis?". But again, you run to the same problem. Even though that seems like a better explanation - I would agree - you still can't figure that out just from that behavior. What if it's all an act? What if Person B wanted Person A to punch them for some sort of insurance fraud? Or what if they're making some sort of video and this is, again, all just acting? How can I know the diagnosis and how can I even know their mental states? Well person a You might say, "Person A must be in a rage and Person B must be fearful." But if it's some sort of scam, then neither one of those mental states would necessarily be there. So, not only do we have to be careful about diagnosing, we have to be careful about saying that we understand what somebody's thinking. We don't know what's going through somebody's mind. We don't even know what they're feeling. It might be reasonable to say that Person A is angry and Person B is fearful based on just the evidence of the punching behavior. Okay. It's reasonable, but we don't know for sure, and certainly we can't extend that to some sort of diagnosis. Now, there are other opinions on this issue, of course, right? So, to kind of reflect both sides of what's going on here, some people say - in the case of Donald Trump, anyway... They say, "well, indirect observations of somebody's behavior may yield the same value in determining somebody's mental state." And what they're really saying here is that an in-person interview might not yield any more information, especially if somebody's been a public figure for a long time. Well, this can be argued both ways. I can see this point. If somebody's been watched by the media a long time, then it might be something to consider consider that an in-person interview may not yield a lot of information So, this is kind of an argument on the side of these people saying that Donald Trump could be diagnosed or it's fair to say something's going on there. I don't agree with what they're doing, but that is kind of one argument that's been made. The way I look at it is, we really have to make decisions based on evidence, and we have to weigh that evidence. Watching and commenting on behavior is certainly fair to do, and it's more useful than believing that we understand somebody's mental state and then labeling them with a diagnosis, and then, of course, potentially increasing stigma. This really doesn't help anybody. And also, there is kind of a structure in place. There's a system in place if mental health professionals do have a concern about Donald Trump. It's called the 25th Amendment. So if the 25th Amendment were enacted, then Trump would have a mental health evaluation, right? So, there is kind of a remedy in place for mental health professionals that're concerned. I don't think that diagnosing people outside of what we have in terms of ethics is the way to address any situation that may be going on. Now, something else that I think very few people consider in this whole situation... And this kind of strikes me as funny, that so many people were worried about mental disorders in Donald Trump, But many don't consider: what if he really does have these disorders? Does it matter? What happens to people who have MPD and APD? Again, they're human beings. I know a number of people have these disorders that simply get on with their lives. They simply go to work. They have a family life. They just do what people do. We're really kind of jumping to another conclusion by saying, "Well, if they have NPD or APD then they must automatically be dangerous." Where's the evidence to support that? Yes, Antisocial Personalities, who are much more so than NPD, is associated with criminal behavior, But that doesn't mean that everybody with the disorder is a criminal. That's just one of the symptom criteria. So this just goes back to what I was saying. What if they're right, right? Does it matter if somebody has a disorder like NPD or APD? What are we supposed to do if we believe that Donald Trump does have this disorder, other than follow the system that's already in place? Again, the 25th Amendmant. Right? There's no other remedy. Are we supposed to be fearful or panic? We're supposed to write letters and say "don't be president anymore"? I'm just not sure what the what the real remedy is other than what's available in the law. I guess, ultimately, what it comes down to is if somebody believes those disorders matter. I mean, if they believe those disorders make people do bad things, Then you would vote accordingly, right? That's the only thing that you can really do in the system that I can see. Right? You just base your vote on available evidence. So, I think this is kind of an interesting debate. I know people get all fired up about this debate. Some people are for Trump. Some people are against him. And of course, it does seem to me that more people that are for him think that nothing's going on with his mental health, and the more people that are against him believe something serious is going on with his mental health, right? So there is a political line and there's division there. But I can also see that a reasonable person who is trying to look at this situation in a fair way would say, "Okay. Some of the behave are worrisome." I can appreciate that, and I can similarly appreciate how some people would look at his behavior and say "I'm not worried". I try to appreciate both sides of this, but either way, it makes for an interesting debate. So, on that note, if you have any thoughts on this subject, I do think it could contribute to an interesting dialogue. So, if you agree with me or disagree with me, or agree or disagree with these other people who have made these different commentaries, please put those opinions and thoughts in the comments. As always, I hope you found this description of the controversy with diagnosing public figures to be interesting. Thanks for watching.
