PLEASE NOTE: This blog has now moved.
As of 7/11/15 all new posts will appear on
and comments on this site are closed.

Friday, 22 February 2013

Gazza, Lance and the difficulties of psychiatric diagnosis

John McGowan

What do you call someone who tells lies persistently? In recent weeks the answer is probably Chris Huhne, the latest in a line of hubristic politicians who have told a stream of big porkies to cover up a small one. You may have already forgotten that before the erstwhile next leader of the Lib Dems bowed out, the deceiver du jour was cycling champ (technically ex-champ) Lance Armstrong. I've written about the ethics of Armstrong’s fall from grace elsewhere, suggesting that, while his doping to win the Tour de France wasn't great, his unpopularity has far more to do with his deceit and with our disappointed expectations of a previously heroic figure.

Pinocchio. Worrying signs of psychopathy
in childhood! Picture:  Ropa-To.
However, what should we call him? Is he a ‘jerk’ (his own suggestion), or one of many more colourful names suggested on various comment threads of the web? As well as the stream of abuse, some of Lance’s ex-fans also seem eager to offer a more nuanced appraisal in the form of psychiatric labels. Is he a psychopath or a sociopath or, as an article in the Atlantic a couple of weeks back suggested, an ‘aggressive narcissist’? What, I wonder, do these labels tell us about him that conventional monikers do not?

Psychiatric diagnosis is a hot topic right now. The forthcoming Diagnostic and Statistical Manual of Mental Disorders (DSM-5) is to offer a vastly expanded range of medical labels for our emotions and behaviour, raising a range of complicated questions. For starters, how real are these illnesses? Is having bipolar disorder as tangible as having a broken leg? Problems arise over the broad and often inconsistent range of problems covered by a label such as schizophrenia. What is apparently the same psychiatric diagnosis will capture a far more variable range of symptoms than the diagnosis of a broken limb.

There is also the issue of whether these labels simply reflect the prevailing attitudes of our era. Behaviour apparently outside the norm (often a pretty subjective decision itself) has attracted many interpretations, from imbalances of the humours and possession of the soul, through to our current, mainly biological, ideas. As the writer Sarah Vowell commented when reminiscing about her Montana childhood:

‘my grandmother Ma Parson lost her mind one day and couldn't remember my name, though she could remember all the words to "Bringing in the Sheaves." And today we call this Alzheimer's, but back then we called it "God's will."’

Sometimes labels tell us as much about ourselves as about the people we apply them to.

Beyond these complications though, the issue remains of whether classifying problems in this way is useful or not. Is the increasing use of diagnosis a medicalisation of everyday life? Or a recognition of conditions that are under-diagnosed and under-treated?

Debates on the utility question may go on forever, but thinking about how we apply labels to public figures may be informative. In one way calling Lance Armstrong a psychopath is simply another insult. Something to freshen things up when bully, bastard and thug are getting a bit tired. In a similar spirit, service user and author Louise Pembroke has commented that personality disorder ‘is the clinical term for arsehole’. I’d argue, though, that wheeling out psychiatric language is often more than simply a new set of insults. The use of psychopath is also an attempt to capture a particular quality of disregard for others. Still abuse then, but of a precise sort.

However, there is also the very different possibility that an illness label can open up the opportunity for compassion towards someone who has behaved badly. Whether you think an attempt at compassionate understanding for such a person is worth your effort is another matter. The Atlantic piece goes further than simply slapping a label on Lance. Rather the author makes some sort of effort to understand the tough formative experiences and inner life of someone who seems to have been consumed by a fear of not succeeding and who was willing to go to extreme lengths to preserve his primacy.

Liking a drink. Are you glad, bad, mad or sad?
Photo:  Ben Chilada
OK it’s quite possible that a psychiatric label is unnecessary to understand someone else. Sometimes though, it seems to be the key that opens us up to compassion when we can’t get there by any other route. Perhaps this shouldn't be so, but often that seems to be the world we’re in. We can see it in the coverage of the latest instalment of the Paul Gascoigne saga. Back in the day I remember Gazza being simply an exceptional footballer who became a domestic abuser. Discussion of him now is saturated with pity and I've lost count of the number of times I've read about the illness of alcoholism. As someone who grew up in a family where a much-loved uncle was a boozer, this feels very familiar. Alcoholism was a disease and we should be sympathetic to him rather than condemnatory, in spite of the many consequences it had for my cousins. Looking back, for my family the label of an illness (and the attendant perception that my uncle’s behaviour was beyond his control) was the only way sympathy for him was possible. Bad or sick: those were the options and on balance sick seemed the more helpful.

One wonders if there is room for some nuance in between. The trouble is that the question of whether or not to use these labels is complicated. For all its flaws we hang onto psychiatric diagnosis because it seems useful. But, as my colleague and contributor to this site Anne Cooke has argued, this has its limits. For instance, there may be negativity and stigma associated with a diagnosis. It’s important to acknowledge that this is not always the case though. I've worked with plenty of service users over the years who have been quite attached to their diagnosis. Perhaps that’s partly because seeing yourself through the lens of illness can be quite forgiving. In my uncle’s case being ‘sick’ was quite convenient in exonerating those involved, such as an abusive father or my uncle himself, from responsibility or blame. A no-blame position may be beneficial if you’re feeling guilty about your inability to struggle on, but perhaps there are downsides. Having a label of alcoholism or autism or dyslexia may be very helpful but what if all your behaviour becomes the responsibility of your illness rather than of yourself? What chance the stimulation of your own resources to change?

The label may of course, like a broken leg, imply a particular treatment. But, certainly as far as medication is concerned, there is precious little evidence that psychiatric drugs address coherent biological causes in most diagnostic categories. Drugs may mess with your head, sometimes in helpful ways, but they are not the same as a cast on that leg. When it comes to psychological therapies a rather brisk debate is currently taking place as to how much diagnostic labels help focus treatment, a loaded word itself, and how much it’s really about the individual and their particular history and difficulties. And where does locating the problem in the individual leave the other factors contributing to human misery? What about poverty and inequality? Or unemployment, debt and homelessness? Ah well you’re obviously depressed. A nice pill and some CBT should sort you.

Though many of my psychologist colleagues would disagree, I'm prepared to argue that diagnosis has some value. Sort of. But perhaps only up to the point where it blocks thinking more broadly about people as individuals. Though the piece about Lance Armstrong’s aggressive narcissism was helpful in understanding him, it got stuck on this very issue. In fact it reminded me of how I've often seen diagnosis used in clinical settings. The background, troubles, vulnerability factors and social circumstances are considered, but all marshalled to explain how someone got depressed. Or psychotic. Or anxious. And that’s sort of it. You've got your label so job done. No further sense of the person’s humanity, little to distinguish them from others with the same label, and often not much of a clue what to do next.

Rather weirdly one of the more nuanced assessments of Gazza’s difficulties comes from an unlikely source: Jimmy Greaves in the Daily Mirror. Of course Greavsie had something of a drinking problem himself at the end of his playing days and, while he still considers alcoholism an illness, he acknowledges both the complexity inherent in it and the difficulties on the road to meaningful recovery. Even with Chris Evans in your corner. Does thinking of Gazza as an alcoholic help us open up to his troubles? Or close down our thinking so he’s simply an illness and a bunch of symptoms? The tricky bit is that it can do both. Like football, diagnosis is a funny old game.


  1. Greavsie turns out be more subtle analyst than the writers of the DSM! A little ironic perhaps but painfully true.

  2. I'd agree that the use of a diagnosis might be helpful in garnering compassion up to a point. Beyond that, it is spectacularly negative in its impact. Psychiatric labelling has the power to ruin lives. Once someone has gained a label they cannot shake it off and the mere mention of it will invite others to view that person through a certain lens - usually a very dark and negative one. I look forward to the day when it might be possible to sue a profession for defamation. Perhaps psychiatrists would then be a lot more cautious about the glib application of of diagnostic criteria that can have catastrophic consequences.

  3. I agree with Ignacio Martin-Baro when he advocated for psychologists to be more occupied with the work of changing the World than measuring or defining it! So does it even matter what label we give mental distress, so long as we are working WITH people to bring about change that will be beneficual to them, sadly for many in so called mental "health" services once diagnosed this is often where the intervention ends and they are left to fend for themselves with only a pill packet for company as community services are squeezed ever tighter in the name of austerity which for so many now means misery, social isolation, deprivation and poverty, so who cares what your diagnosis is if you are living a miserable life and have no-one with whom to share your troubles!

  4. Hi John
    This is excellent. I really like the way both you and Anne have brought this debate into the real world. I agree that diagnosis is Janus faced. It can help remove feelings of self blame but can also undermine personal responsibility and lifestyle choice. However, there is also a sense in which the impetus to create new labels is also perniciously interpolative in an ontological sense that is the power to name brings into being (but never exactly) that which is hailed into being.

    One of the functions of the DSM is to classify what is normative and non normative humanity and of course this is good for business because the more non normative states one posits the more treatments one can manufacture. It is also helpful to have some way of recognising whether a person is in need of help. Arguments for the widening of the DSM include very socially minded practitioners who see this as a way of widening funding for mental health care. This is particularly relevant in the US as people cannot get payment for treatment on their insurance without inclusion in the DSM.

    However, it is also ontologically normative in so far as what it means to be human is increasingly described in the language of sickness. Some may say that this sickness is part of the human condition (I believe Nietzsche had a good deal to say about that). But the bottom line is that the DSM narrows the perimeters of normative humanity, I believe it is Peter Beresford who suggests that the authors of the last DSM could be counter diagnosed as having middle of the roadism personality disorder and a reality obsession. So there is a politics of diagnosis in terms of whose understanding of what it means to be a person gets the upper hand. Having experienced a wide range of extreme psychological states, psychosis anxiety etc, I am inclined to agree. I would not be without their affective range as they are part of my tonality of soul. The trick for me is always to manage maximum emotional range without tipping off the edge. Further when I do tip off the edge or wander to close towards it to manage the art of getting up again with as little intervention as possible.

    If I could do it all again I would have much proffered some helpful help to achieve this capacity to self manage rather than a long and difficult struggle on my own. I am not an advocate of survival of the toughest on this as some of the places I have been to in mind I would not wish on anyone else and everyone should have the right to decide how much distress they feel they can or can not cope with in terms of the affective range that is right for them. But having got to a good place by accident, surely the emphasis of psychological treatment should be about supporting people to become all they can be rather than narrowing the perimeters for what it means to be a normal human in the first place?

  5. Thanks Ruth,
    I like the phrase 'Narrowing the perimeters of what it means to be a normal human'. Very much the downside for me. 'Janus faced' indeed.

    John McGowan


Note: only a member of this blog may post a comment.