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Online and Other Distance Diagnosis of Mental Illnesses

April 5, 2011

Go online on any given day and it is easy to find laypeople and worse, even licensed mental health professionals who should know better attempting to run to the media and proclaim that some celebrity or even some ordinary person who did something they did not like, has a mental illness. The most recent popular target is Charlie Sheen. Mental health professionals who have never even met, much less examined him are piling on, running to any media gossip maven who will provide them a forum and declaring that he is bipolar, narcissistic and whatever else they can come up with. I’m not saying that he is or he isn’t…that’s just the point: since I have never met, nor examined Charlie Sheen, the only responsible thing for me to say is I have no idea whether or not he has a diagnosis. That is for a mental health professional conducting an in-person assessment to decide, should Mr. Sheen decide he desires treatment and he has every right to refuse such treatment. I also would not presume to judge whether he is fit to be a parent. Again, that is up to licensed social workers conducting an in-home evaluation to decide, not an online observer who has never been in his home.

While it is understandable that a layperson could engage in this bogus practice out of sheer ignorance, thinking they can learn all they need to do by watching Oprah or reading pop psychology books, for mental health professionals that are doing so, shame on you. Just because someone is engaging in behavior you do not like, does not mean that they are mentally ill. If you don’t like the behavior you are seeing and find it disgusting, then fine, speak up. It’s your First Amendment right and for public figures, you have a great deal of leeway in what you say, as long as you do not engage in malicious fabrication. However, if you attempt to diagnose, then you are crossing a line — not necessarily legally actionable, but a line, nevertheless. If you are not a licensed mental health professional, you are not qualified to do so and if you are, that is even worse as you would be engaging in bogus practice.

Contrary to misinformation to the contrary, I actually have done quite extensive coursework at both the doctoral and masters level in diagnosis and assessment of mental illness. One of the first things we learned in our professional training is that we can take any diagnosis, especially personality disorders and we can find those characteristics to one degree or another in just about any human being if we look for them. That is called confirmation bias. If we are looking to notice something, we will. This is why students who are being trained to be mental health professionals (and also medical students) have a tendency to believe that they, themselves have every condition that they read about. However, simply having some of the diagnostic criteria does not mean that the person would be necessarily have that particular mental illness or personality disorder. Confirmation bias is compounded when someone has a particular bias or agenda against the person being distance diagnosed. It is all too easy to focus on public behaviors and jump to completely unwarranted conclusions.

As the Harvard psychologist Richard J. McNally repeatedly pointed out in his new book, What is Mental Illness, when it comes to mental health diagnosis, context is crucial. The only way to determine context (background, setting, circumstances) is to do a competent, in-person mental health assessment using standardized, reliable and valid assessment measures.

Anyone, when put in a stressful enough life situation, can appear to be “crazy” when actually they are a sane person having a response to an insane situation. That person is not necessarily mentally ill; they are just responding to a high demand situation and may be behaving in ways that resemble a mentally ill person, but are not. A classic example of this is recently, someone (likely Scientologists) videotaped the Scientology defector Marty Rathbun sitting in an airport. He appeared extremely on edge, restless, looking furtively around and appeared to be talking to himself at times. Several times he even looked on his wrist as if he was looking at the time but was not wearing a watch — several people concluded he was hallucinating. What nonsense. Have you ever, after having regularly worn a watch, lost the watch and then looked at your bare wrist, forgetting that you were no longer wearing the watch? Good grief. There’s nothing necessarily pathological about that. It’s a common experience.

Given the harassment that he has been exposed to for having gone very public against Scientology, this is not surprising and by no means indicates that he is mentally ill. All that can be said about that video is that this is an individual who is under a great deal of stress. Again, a competent mental health assessment would have to be conducted to determine if he was mentally ill. People watching that video have no business diagnosing him, but of course, whoever made that video was obviously intent on making him look as if he was mentally unstable. That video has made me watch my own back when I am in airports.

In contrast, valid, professional diagnosis is done in-person after taking a careful, detailed history of the person. Diagnosing people who are not present in the room is a hallmark indicator of a bogus therapist. For instance one popular therapy fad is to “diagnose” a parent who is not present and perhaps even deceased, as having been a “narcissistic parent”. It is impossible to give a valid diagnosis to someone when all we have is the secondhand report of a family member based on memories of events that occurred decades earlier which are hardly reliable. This is even worse, when the therapist already has an agenda or belief that just about everyone who walks in the door of the therapy office, has a multitude of issues that were “caused” by a “narcissistic parent”. That is a setup that makes it easy for the therapist to find exactly what she expects to with just about any patient. Unfortunately, celebrities like Jane Fonda have become poster children for this, witness her most recent appearance on Oprah where she declared she had narcissistic parents to whom she attributes some of her difficulties as an adult. I don’t blame Jane Fonda, who was just trying to get some help and improve her life, but I do say shame on her therapists. The memory of her poor deceased parents will now have to forever bear the stigma of being labeled narcissists when no one ever did any kind of formal assessment or diagnosis of them, as far as I know.

This kind of distance diagnosis also occurs in the anti-cult community where some self-proclaimed cult “expert” therapists believe it is therapeutic to have their ex-cult member clients “diagnose” their cult leader, usually with Narcissistic Personality Disorder. While it is, of course, entirely possible that the cult leader did suffer from such a diagnosis, it isn’t necessarily so. Some cult leaders could have Antisocial Personality Disorder and others might not have any kind of mental illness at all. Just because someone engages in reprehensible behavior does not mean that they are necessarily mentally ill. To assume this, puts a stigma on people who are actually mentally ill, most of whom have never engaged in such behavior.

And finally, there is online diagnosis, usually by amateurs who have been patients, perhaps of a therapist practicing questionable methods or involved in some for of self help such as that offered by self-proclaimed “experts” on narcissism who have websites but are not mental health professionals and use one diagnosis such as “narcissism” as a label for all that is wrong in the world. Such a person typically believes they have had some kind of epiphany that they then apply to anyone that strikes their whim. As the saying goes, if all you have is a hammer, everything looks like a nail. The typical scenario is that in the course of some online discussion, people get into a heated disagreement and rather than discuss the topic at hand and make any attempt to actually refute what the person is saying, the person then gets attacked for being a “narcissist”. That certainly does provide an easy “out” for someone who is unable to offer a substantive rebuttal.

This happened to me a few years back. Someone who posts under the pseudonym “Alert” who is an activist against Scientology became extremely irate at some criticism I had of certain people in the anti-cult movement. As a result, because I stood my ground and refused to back down in the face of his ad hominem attacks, he declared that I had Narcissistic Personality Disorder (NPD) and should get therapy for it. He also shared that he, himself had been formally diagnosed with NPD by a mental health professional (although he believes himself to be recovered). There’s no telling what part of this pseudonymous individual’s story is truth or fiction. On the internet, particularly with people who use pseudonyms, the entire story could have been concocted, but whatever the case may be, he seemed to feel that this qualified him to go on some kind of amateurish mission as an expert to make online diagnoses of anyone whose postings he did not like. A common error such online self-proclaimed “experts” make is to confuse healthy self-assertion such as a victim standing up to a bully, with narcissism.  Of course, someone defending self is going to refer to self a lot in postings, but to conclude that is narcissism is a classic example of pulling things out of context and jumping to unwarranted conclusions.

After not having encountered this “Alert” character for a few years, he just popped up again on alt.religion.scientology to attack me again, declaring that I had NPD simply because I am choosing to stand my ground against certain anonymous people who have been posted highly defamatory lies about me on the internet. Newsflash for “Alert”: You cannot tell if someone has a personality disorder by what they write in a posting.

Actually what this shows that in spite of his own allegedly self-admitted, reported diagnosis of NPD and belief he is recovered or whatever the case may be, he seems to know less than he thinks he does. The very last thing an actual narcissist would do is to place him/herself in the kind of position that I have placed myself. I do things on a regular basis such as challenging sacred cows, that don’t make me popular at all, to put it mildly and I am well aware of that, always have been and yet I persist.  That is the opposite of what a narcissist would do. Above all else, a narcissist is very concerned with public image and would only put him/herself in situations that make the person look good. My direct challenges and confrontation of my cyber stalkers certainly does not, by any means, put me in a position that makes me look good. It subjects me to attempts at shame and ridicule, both by the cyber stalkers and by people who want to blame the victims who are ignorant on the topic. A narcissist, placed in that situation would never post under his own name but rather, would post behind a pseudonym and hurl ad hominem attacks at critics who had the courage to use their real names.

Update: “Alert” is, as predicted, quite unhappy with this blog and continues to hurl profanities and post rants about me me and insist he is holding some kind of a “mirror” up to me [yes, I know, it sounds like a scene from some kind of cheesy 70s encounter group – I think he’s too young to have lived through that, but maybe he had a therapist who did]. It is so interesting that people who do not know other people presume to make assumptions such as this. Actually based on feedback I have received in student evaluations, it is precisely the opposite. I am not perceived that way at all by people who have actually interacted with me. One of the questions on the evaluation asked students if the instructor appeared to be arrogant and to rate it on a scale ranging from strongly agree to strongly disagree. 100% of my students disagreed or strongly disagreed with that statement. In other words, not even one student perceived me as arrogant. Seems I am an utter failure as a narcissist if I can’t even manage to appear arrogant to even one student.

Also interesting and rather puzzling to me that “Alert” who lacks the courage to put his name to these attacks on me, is now complaining about being mentioned on this blog, complaining that if he had used his real name I would have used it here. Interesting that it never occurred to “Alert” that it seems perfectly fine for him to initiate an attack on me by name along with a string of semi-literate obscenities, but then when I call him out on his attacks masquerading as online diagnosis, all of a sudden I am horrible for doing that.  Apparently my being accountable for what I post by putting my name to it is not okay, but it’s fine for “Alert” to anonymously attack me. Go figure. One thing is becoming quite clear, though. People with a cult-like mentality who cannot stand to have their pseudoscientific dogma challenged, don’t like me very much, to put it mildly.

Still, lay people who reportedly have been patients and been given a diagnosis are engaging in excusable behavior because they are simply not trained as mental health professionals and hence, ignorant. But for mental health professionals who engage in distance diagnosis, to me, that would be a major red flag that this would not be someone I would want to recommend to anybody I care about who has a problem for which they are seeking help.

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