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.