We’re no different. Neither are they.

There was a time when I thought Americans were above this, that we were special. I thought what happened in WWII Germany could never happen here. “We’re not that naive,” I thought, “Not that dispassionate.”

As an American Jew, I grew up learning about the Holocaust: this is what happens when “good men do nothing.” I learned, if Jews wanted cultural acceptance, we’d have to stand up for it. If we wanted to survive in a hostile world, we’d have to create our own safe haven.

A common story among Jews: my maternal grandfather escaped Poland and moved in with extended family in NYC. At some point, he stopped receiving letters from his parents and siblings. He never saw them again. After the war, he tried desperately to find out what happened, but never could.

My grandfather was a very religious man. As a child, I had mixed feelings about his visits. On the one hand, my mom bought special “treats,” like bagels, lox and cream cheese, halvah and wafer cookies – you know. the kind that taste like cardboard on the outside but has that sugary pink cream in between? It was always the same items.

On the other hand, I was not allowed to watch TV or be driven anywhere Friday through Saturday. My mom had to leave one gas burner on at all times to cook, and lights were kept either on or off. Once my grandfather scolded me for using scissors.

This was how my mother was brought up. Even though she lived in Brighton Beach, she was not allowed to go swimming on a Saturday. She recalled walking past children on her way to shul enjoying the beach. But my mom was very proud of her Jewish heritage and even worked as a Hebrew school teacher early in her career.

As was common of his generation, my grandfather worked with his hands, making leather goods. My mom went on to become one of the first female attorneys of her generation. Nevertheless, she stayed home with my brother, sister and I until I was in school. For most of her career, my mom worked for the US Department of Interior, retiring at the age of 79.

She did not live to see her daughter join the Army, (which was probably for the best.) Like most moms, she was worried about me being in harms way. Our last discussion on the matter, we agreed-to-disagree. While my siblings and I held vigil at the hospital, I was going through the process of commissioning. I was 42-years-old.

Once I joined the Army, I learned many Soldiers did so for the same idealistic reasons as I: to make a difference and be part of something bigger than themselves. (Imagine my surprise when I heard those exact words on an Army commercial!) I also learned what it felt like to be taken for granted while, at the same time, regarding this as a luxury military men and women fought for. Its not unlike being a parent: a child has little awareness of a parent’s sacrifices, but we make these sacrifices so children have the opportunity to be children.

It’s human nature to get caught up in the day-to-day routine of life, but that sense of civic duty is essential for more than national security. It’s necessary for democracy and a cohesive society. America was not designed for a passive, reactionary citizenry. As Thomas Jefferson said, “If we are to guard against ignorance and remain free, it’s the responsibility of every American to be informed,” and, I would add, be involved.

All of my family’s history, hard work and potential would not have been evident to the Nazi’s. They did not give Jews the opportunity. They wanted an easy “solution” and a place to put their anger. So they had to treat us as subhuman.

Ive been a Clinical Social Worker for 26 years. In that time, I’ve learned people have good reasons for making bad decisions. Ive also learned people rarely feel one way about something (or someone). The problem is people have a tendency to ignore some of their feelings.

Why? It’s easier – less messy, less complicated and less anxiety-provoking. Responding individually to each situation (or person) takes effort. It requires insight and a variety of coping skills, which most people don’t have. This is the cost of a society that stigmatizes mental health: you can’t expect people to make good decisions if they haven’t learned how.

There is no simple solution for how to instill a sense of civic duty and emotional functioning, but rethinking school curriculum – emphasizing life skills and civic activism over complex math, science and literature – is a start. Another would be programs that bring together off-duty police officers and residents working together on projects to improve their communities.

We may be Americans, but we’re human beings first. So whether it be post WWII Germany or the United States today, you can expect people to respond the same way, until they learn to internalize the differences.

The Media’s Missed Opportunity

Trump-Media-Reporters-After his sterling performance at the 75th Commemoration of D-Day, the news media pondered if Trump really meant what he read from the teleprompter. When asked about this, one legislator even suggested Trump seemed emotionally moved by the experience.

I understand holding out hope Trump will change – just as I understand why a battered spouse keeps returning to her abuser. But to expect Trump to change after one event is like expecting a person w/ cancer to cure himself by sheer force of will. If it was that easy, Trump would have changed already.

I wish the news media understood how such untrained observations can discourage people from seeking help. Sadly, only 37% of people w/ a mental illness seek treatment. By suggesting that Trump could emotionally pivot in one day, insinuates he’s capable of change if only he tried harder. Many of my patients get accused of this, which leaves them feeling unsupported, misunderstood and inadequate. Then they start second-guessing their symptoms. The news media’s amateur psychoanalyses also feeds the misconception anyone can be a psychologist. If reporters with no medical training regularly hypothesized about Trump’s physical health, I expect they’d be fired.

The mental health field is constantly working against stigma and minimization to reach people. Silence and misinformation lead to increased isolation which leads to increased suffering. The consequences include a rise in teen suicides, a drug epidemic, increased violence and irresponsible policy.

Cluster B personality disorders, which includes Narcissistic Personality Disorder, develop over years of dysfunctional rearing (and, in many cases, trauma). Naturally, it takes years of therapy to unravel the effects. Plus, at his age, Trump’s brain is hard-wired to think the way he does. Often there is a comorbid diagnosis with a personality disorder. Some contribute to the formation of a personality disorder, such as ADHD or a learning disorder. Others can be a byproduct such as chronic depression, anxiety, or substance abuse.

Trump’s conduct over the last 2 years has provided ample opportunity to explain his behavior to the public. The news media could have brought in “panels of experts” in mental health just as they’ve done with lawyers and security analysts. These experts can differentiate between psychosis and maladaptive behavior, explain how psychiatric disorders are diagnosed and what treatments are effective with what diagnoses. They need not prognosticate, (which is less than many legal or security analysts do).

Rightly so, the news media takes its role of speaking truth-to-power very seriously. And there’s no doubt our democracy is safer for it. But shouldn’t that include the issue most responsible for our current state of affairs: Trumps mental instability? Don’t Americans deserve this information before returning to the voting booth?

By doing so, the news media will also legitimize and destigmatize mental illness for millions of Americans.

 

How Our Cultural Ignorance of Mental Health Helped Elect Donald Trump

mentally speaking trump flag

Leading up to the 2016 presidential election, I repeatedly heard politicians, pundits and voters predict or at least express hope that, if elected, Donald Trump would “rise to the occasion” or “surround himself with good people.” It infuriated me. As a mental health practitioner, I knew this would not happen. More than his policy or populist rhetoric, it was Donald Trump’s instability I feared. Most disturbing to me was how few people did.

People assume that psychiatric diagnosis is a subjective science open to interpretation, but this is far from the case. Human behavior operates on a continuum. In many cases (but certainly not all) it’s a matter of degree and frequency that separates abnormal from normal. When taking Abnormal Psychology in college, we were warned of psychiatry’s own version of “medical student syndrome.”

Perhaps this is why it’s easy to justify Trump’s deviances. It’s when you take into account the totality of his behavior that you see a troubling pattern. In the mental health field, practitioners rely on the Diagnostic & Statistical Manual (DSM) to differentiate normal from abnormal. The DSM, now in its fifth revision, outlines specific criteria which must be met before a diagnosis can be made.

After intake, a patient will sometimes ask, “So, do you think I’m crazy?” My usual response is, “If you were, you wouldn’t have asked that question.” I believe this fear is the main reason why the mental health field is so stigmatized. What most people call crazy, we call psychotic symptoms: auditory or visual hallucinations (hearing voices or seeing figures that aren’t there) or delusions (an unshakeable, and usually irrational, belief despite irrefutable evidence to the contrary). But psychotic symptoms apply to just a fraction of mental health disorders and are usually of neurological or pharmacological origin.

Most distorted thinking has nothing to do with psychosis. It is a maladaptive form of coping. One of my favorite mantras is, “People have good reasons for making bad decisions.” This is why people repeat the same self-defeating, and even self-destructive, behavior no matter how much you try to reason with them.

I tell my patients, “There are plenty of people out there happy to give you advice. I’m here to empower you to make your own decisions.” Until you understand a person’s motives, identify his ambivalence (conflicting thoughts and feelings), and help him develop new coping skills to replace old ones, he will not change.

So, when the same people who hoped Donald Trump would change now express bewilderment over his behavior, I am not surprised. You cannot make sense of Trump except in the context of a personality disorder.

The DSM-V defines a personality disorder as a long-term and rigid pattern of thinking, feeling and behaving that adversely affect all aspects of a person’s functioning. The most relevant aspect of a personality disorder is the consistency and pervasiveness of the person’s behavior. This is why I knew Donald Trump would not change.

Consider the DSM criteria for Narcissistic Personality Disorder (NPD), indicated by five or more of the following symptoms:

1. has a grandiose sense of self-importance (e.g., exaggerates achievements and talents, expects to be recognized as superior without commensurate achievements)
2. is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love
3. believes that he or she is “special” and unique and can only be understood by, or should associate with, other special or high-status people (or institutions)
4. requires excessive admiration
5. has a sense of entitlement, i.e., unreasonable expectations of especially favorable treatment or automatic compliance with his or her expectations
6. is interpersonally exploitative, i.e., takes advantage of others to achieve his or her own ends
7. lacks empathy: is unwilling to recognize or identify with the feelings and needs of others
8. is often envious of others or believes that others are envious of him or her
9. shows arrogant, haughty behaviors or attitudes

When a group of mental health professionals came out with the book, The Dangerous Case of Donald Trump, some questioned the ethics of attaching a diagnosis to a person they had never treated. But Donald Trump has provided more evidence than could ever be gleaned from weekly office visits.

Another relevant aspect of a personality disorder is that it can’t be treated with a pill. It requires long-term therapy. Sometimes it can be augmented by medication if a patient has comorbid symptoms such as depression or anxiety.

After outlining the criteria for NPD, a friend asked me about an interview she read with Dr. Allen Frances, the self-described “author” of Narcissistic Personality Disorder in the DSM. He claimed that Trump didn’t have it. I had to shake my head over the irony.

The Diagnostic Manual was created to provide clinicians with an objective and universal measurement of mental disorders. If I needed Dr. Frances’ or any other author’s interpretation, it would cease to be the stand-alone resource that it is.

Dr. Frances, who is a long-standing skeptic of the DSM, based his argument on his (apparent) impression that Trump does not experience distress. While Trump’s anger outbursts and paranoid rants tell a different story, this is beside the point. There is nothing in the DSM criteria for personality disorders that requires internal distress.

I wonder if Dr. Frances is referring to the fact that most people with personality disorders do not seek treatment unless distressed – usually due to a crisis in their personal or professional lives or to comorbidity (depression, anxiety or substance abuse). Otherwise, it is very difficult to convince a person with a personality disorder to seek treatment. Unfortunately, once the crisis is abated or the emotional discomfort wanes, they usually stop going.

To further justify his argument, Dr. Frances points out that Trump has been rewarded for his behavior. While Trump may not have reaped major negative consequences for his behavior – yet – lying, cheating and breaking the law, are dysfunctional behaviors, consequences or no consequences.

Lastly, Dr. Frances warns against generalizations. Rightly so, he argues that this should not disqualify someone from the Presidency. Abraham Lincoln and Winston Churchill are believed to have had mental illnesses (Major Depression and Bipolar Disorder, respectively). But this is my point.

If a Presidential candidate is diagnosed with high blood pressure, voters would not automatically deem him or her unfit as long as the condition is being treated. However, if a Presidential candidate was diagnosed with dementia, there would be valid cause for concern. The impact of mental illness on a person’s functioning is no different. Many are manageable with therapy and/or medication, and need not significantly interfere with a person’s performance or functioning. The degree of impairment depends on the diagnosis and prognosis.

Rather than shying away from labels, we should be talking about what the labels mean. You may accuse me of bias, but there is nothing more essential to human progress than mental wellness. How we behave is inextricably linked to how we think and feel. To paraphrase the Spanish philosopher, George Santayana, until we learn to understand this link, we are condemned to repeat our mistakes.