June 23, 2021

There’s a thing in the ethics of psychology called the Goldwater Rule. It states, in essence, that mental health professionals should not diagnose people from afar. It arose in the 1964 US presidential election, after the magazine Fact published an article quoting various psychiatrists saying that Barry Goldwater, the Republican candidate, was “psychologically unfit” to be president.

Reasonably and inevitably enough, Goldwater then sued the heck out of Fact. The American Psychiatric Association then made it a principle of their code of ethics that “it is unethical for a psychiatrist to offer a professional opinion unless he or she has conducted an examination and has been granted proper authorisation for such a statement”. In the UK, the Royal College of Psychiatrists “strongly supports” the rule.

I’m not a mental health professional. Nonetheless I think it’s a broadly useful principle to live by, especially if — as I do — you write a lot about mental health. Suggesting that some political opponent or other is mentally ill is often easier than wondering why a sane person in command of their faculties might believe something you disagree with.

But there’s an opposite mistake to the one the Goldwater Rule guards against: acting as though mental health issues have no relevance to our political and cultural lives.

Last week, the novelist Chimamanda Ngozi Adichie published a blog post called “It Is Obscene”. It referred to her experiences since she did an interview with Channel 4, in which she said that “trans women are trans women” — that is, she did not say that she thought that trans women are women, without caveats, although she has been a longtime campaigner on LGBT issues. Two young writers who she knew personally, she said, had accused her publicly of transphobia. One had called for people to “pick up machetes” to defend trans people from the “harm” she caused. 

For Adichie, this was a story about the “sanctimony” and “emotional aridity” of the online Left, and the “ideological orthodoxy” which requires people to denounce their friends and toe unwavering political lines in order to remain part of a “chosen puritan class”. I think this is undoubtedly part of the story, but not the whole.

Adichie did not identify the writers; I will follow her lead, although it was not difficult to identify them from her text. But one of them had publicly declared a few months earlier that they have “dissociative identity disorder”, DID. That is: they have multiple personalities within one body; they refer to themselves as a “system” of personalities rather than a single person.

This is where I bump up somewhat against the Goldwater Rule. DID is a personality disorder which often presents with, or is confused with, another disorder called borderline personality disorder (BPD). About 70% of DID patients are also diagnosed with BPD, and the two conditions are often considered part of the same spectrum. The diagnostic criteria for BPD include “identity disturbance with markedly or persistently unstable self-image or sense of self,” and “severe dissociative symptoms”. Goldwater notwithstanding, I think it’s OK to draw lessons across from one to the other; diagnoses of the various kinds of personality disorder are very fuzzy — often people are in several categories, or don’t fit neatly into any of them. Both BPD and DID are marked by extreme emotional volatility and a lack of a stable sense of self.

This is a marvellous, sympathetic piece on BPD; the metaphor it uses is that people with BPD are cognitively “lighter” than neurotypical people. That is: if you are heavy, it takes a lot to move you. So when something quite nice happens to a neurotypical person, it makes them slightly happier: the wind only moves them a little bit. When something quite unpleasant happens, it makes them slightly sadder.

But if you are cognitively light, then the same events will move you much further. A small victory will make you thrill with joy; a small problem can make you suicidal (and BPD patients have a tragically high suicide risk in their younger years). It also applies to people’s opinions of others: “Either a relationship is perfect and that person is wonderful, or the relationship is doomed and that person is terrible,” as the NHS page on BPD puts it. This is called “splitting”, and again, it’s easy to think of it as someone being light, rather than heavy: being blown on the wind of events.

People with these conditions feel emotions much more strongly. But they also have difficulty forming a strong self-image, and often take on very visible identities, such as being a Goth or a fan of a particular band, dyeing their hair or getting tattoos, in order to give themselves something solid to cling to.

This piece written by a BPD patient discusses how she would change her entire personality, and with it her wardrobe, with each new relationship or phase in her life: “In my ‘Premier League’ days, it’d be athletic and gym gear; when dating a hipster, I mimicked their use of rings and hats. My wardrobe was like the skin of a chameleon, physically embodying the changes in my personality.” This one talks about “waking up and trying to be a new person every day. Go vegan, go goth, go hipster, go glamour, cut your hair, change your makeup, gain weight, lose weight, and never feel quite there.”

I think this helps make sense of a lot of what was going on with the subject of Adichie’s essay. That person had been a worshipper of Adichie’s: later, they considered Adichie a transphobe and a bigot. A neurotypical person might have been disappointed that their hero was using what they considered insensitive language about trans people, but for someone whose emotions are more easily blown around, it made their opinion swing from 180° from love to hate. The relationship is perfect and the person is wonderful; then, the person is terrible and the relationship is doomed.

The identity aspect makes sense as well. In one Twitter post the author called for people to “pick up machetes to protect us from the harm transphobes like Adichie & Rowling seek to perpetuate”. Those machetes are presumably metaphorical, albeit an astonishingly vivid metaphor, but in other posts they abhor the “violence” of Adichie’s (to me mild-seeming) language towards trans women. This looks like straightforward hypocrisy, but to someone who struggles to form a coherent self-identity, and then finds one with the trans community, any criticism of that identity might well feel like a violent attack on the very core of one’s being.

The Adichie incident is a recent and high-profile one, but I think a disproportionate percentage of the problems with online discourse stem from similar problems. I won’t link to or identify any individuals — they would not benefit from it, and nor would anyone else — but I repeatedly see analogous situations, often from people who in other tweets openly declare their diagnosis.

I want to be very clear about some things I’m not saying. I’m not saying that all online bad behaviour is because of mental health issues or personality disorders: lots of people are just dickheads, and there’s no need to pathologise them. And I’m not saying that all or even most people with BPD or similar disorders end up attacking people online. And — while this example is lifted from the trans activism/gender-critical forever war — I’m certainly not saying that all trans people have personality disorders or that being trans is a mental illness. 

But one of the cries of our age is to be more sympathetic and understanding of mental health conditions. The trouble is, I find that when people say things like that, they are often thinking of the more acceptable manifestations of mental ill health; people being depressed or anxious, staying home and making cute posts about being introverts.

Sometimes, though, mental health issues cause people to behave badly and cause harm to others, in ways that are not cute or sympathetic or easily understandable. An old friend with a personality disorder once wanted to write about this, on Mental Health Awareness Day: that we’re all keen to be Aware of Mental Health when it means someone being anxious or unhappy. But when it’s about psychotic episodes — or even less sympathetic disorders, such as psychopathy or narcissistic personality disorder — we’re less keen. My friend never wrote the post, but I think it’s true.

For instance: Freddie de Boer, a brilliant and insightful writer on many issues, suffers from bipolar disorder. During a manic period he falsely accused a man of rape and sexual harassment of women, causing enormous harm to himself and the man accused. He holds himself accountable for it and does not blame his illness, but it is nonetheless the case that his mental health issues caused him and others much pain.

Or Johann Hari, a journalist who was fired from the Independent after using fake “sockpuppet” accounts to libel other writers as homophobes and racists and antisemites. He was suffering from depression and addiction at the time. Again, it is not absolving him of responsibility to say that his mental health issues were a factor in the disastrous decisions he took.

I don’t know what my proposed solution is here. But I do think there is a failure — an understandable failure, a failure born of a desire not to offend or stigmatise, but a failure nonetheless — to address the reality of how mental health issues interact with our online discourse. Online, it’s easy to find causes to join, to give you identity; it’s easy to find people who’ll cheer you on, even if whatever they’re cheering you on to do is self-destructive, or damaging to others — calling for people to “pick up machetes” to attack women, for instance, even if it is a metaphor.

In the case of BPD, apparently, the prognosis is generally a good one: we all grow more emotionally stable over the course of our lives (as children, we are very emotionally volatile, and settle down with age) and by middle age, most people with BPD are leading healthy and happy lives. One study followed up patients 27 years after diagnosis and found that 92% of them no longer met the diagnostic criteria.

But we shouldn’t pretend that these issues aren’t a factor in the sometimes toxic online environment. Puritan attitudes, ideological dogma, hypocrisy and cant are all part of it as well, but, Goldwater Rule notwithstanding, we’re missing a part of the story of online discourse if we don’t find a way of addressing, sensitively and without stigma, the role of mental health.

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