Medical Examiner

How to Talk About Mental Illness Without Relying on Strength

Donald Trump’s comments on mental illness are awful, but not unusual.

Republican presidential nominee Donald Trump speaks at a campaign rally on October 27, 2016 in Springfield, Ohio.
Unlike much of what comes out of Donald Trump’s mouth, the equation of mental health issues with personal weakness is an error that many of us make, even if we mean well.

Maddie McGarvey/Getty Images

Earlier this month, Donald Trump stood in front of a crowd of veterans and suggested that soldiers who take their own lives are not “strong” and that they “can’t handle it.” The precise words of the man who evaded military service by invoking the “bone spurs” in his feet were:

When you talk about the mental health problems, when people come back from war and combat, they see things that maybe a lot of the folks in this room have seen many times over and you’re strong and can handle it, but a lot of people can’t handle it. … We are losing so many great people that could be taken care of if they had proper care.

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His remarks were quickly shoveled atop a heap of disqualifying gaffes (a Valley of Ashes where “Miss Housekeeping” and “I like people who weren’t captured” waft eerily through the air). But this was a rare case in which Trump actually seemed concerned about human suffering.

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Unfortunately, his comments were also uninformed: For one thing, the majority of veteran suicides don’t seem to stem from post-traumatic stress disorder—a syndrome that affects about 7 percent of soldiers. Far more of these deaths appear to correlate with the stress of transitioning from military to civilian life—from an environment charged with meaning and danger to, say, an eight-hour shift ringing up groceries or drafting memos—without adequate support. This misunderstanding suggests we might be misallocating our resources; at any rate, Trump is right that we should provide better care for all our veterans.

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But the implication that suicide arises from personal weakness is troubling. And unlike much of what comes out of the candidate’s mouth, this particular verbal error is one many of us make, even if we mean well. We wince when physical maladies are set in martial frames, when people are said to “battle” cancer or Lance Armstrong identifies the paths forward after a scary diagnosis as “give up or fight like hell.” But stigma continues to envelop mental illness, leaving those who suffer from psychological disorders ashamed of their “frailty” and reluctant to seek help. A Canadian survey of more than 1,500 adults this year found that 42 percent of respondents had experienced feelings of anxiety and depression yet were too embarrassed to tell anyone.

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Statements like Trump’s reinforce the idea that we can fight mental illness if we just put our mind to it. We can’t: Post-traumatic stress disorder and depression are no more amenable to the brute application of will than are physical diseases such as diabetes.

“To make wild assumptions about who’s strong and who’s not when you have no idea what you’re talking about is not just inappropriate but immoral,” George Bonanno, a professor of clinical psychology at Columbia University’s Teachers College and the leader of the Loss, Trauma, and Emotion lab, told me.

It is a mistake to blame mental illness on a lack of grit or hardiness, or to suggest that failing to get better reveals anything about a person’s identity. Psychiatric pain is not a character flaw. Alleviating it is not a matter of spitting on your hands, connecting with your inner Wonder Woman, and getting down to business. Disorders such as schizophrenia, anxiety, and depression emanate from an intricate mesh of genetic, biological, and environmental causes, none of which melt away in the glow of a can-do attitude.

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Luckily, Trump’s gaffe arrived at a malleable moment in the culture’s understanding of mental health. Shows like You’re the Worst, Lady Dynamite, and Crazy Ex-Girlfriend are beginning to normalize our tousled psyches. Celebrities regularly “come clean” about their addictions, mutinous brain chemistry, and eating disorders. One day after Trump addressed veterans in Virginia, rapper Kid Cudi published a Facebook post describing his “depression and suicidal urges.” As Aisha Harris noted at the time, “rappers are often treated like superheroes, and hearing that even they sometimes struggle with depression might help others to not feel ashamed.”

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But the depression conversation (or the PTSD one, or the addiction one, or the schizophrenia one) remains a rickety bridge. That Trump has demolished much sturdier structures in his public speaking rampages shouldn’t prevent us from acknowledging how hard it can be to talk accurately and humanely about psychological health. We want to be sensitive to the challenges of mental illness, using language that illuminates those challenges without stigmatizing them. We want to identify qualities and methods that can help people cope without appearing to fault those who continue to struggle.

This is infinitely complicated by the fact that the medical literature does recognize both “strength” and “resilience” as legitimate concepts in mental well-being. Is there a way to acknowledge the significance of these psychic resources, and to promote their development, without sounding like Trump?

Resilience has acquired multiple meanings since George Bonanno began to study bereavement and trauma 25 years ago. Often, it’s understood as a type of outcome: a flourishing in the face of adversity due to a tangle of factors, including character traits and environmental supports. Bonanno’s work has looked at when resilience occurs: In a series of transformative experiments, he and his colleagues tracked people who had lost their spouses, survived traumatic injuries, witnessed Sept. 11 firsthand, suffered heart attacks, endured sexual abuse, and more. Prevailing wisdom held that anyone unfortunate enough to experience such stressors would suffer tremendously through a prolonged and thorny grieving process (though that’s not to say trauma always leads to mental illness, or that mental illness always results from trauma). But Bonanno demonstrated that, quite to the contrary, “the ability to rebound remains the norm throughout adult life,” as Scientific American summarized his findings in 2011.

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Between 55 and 85 percent of the thousands of people Bonanno has surveyed over the past several decades reported signs of healthy functioning after experiencing trauma, sometimes in a matter of weeks or months. (The ratios depend in part on the inciting event: 60 percent of bereaved spouses exhibited resilience, for instance, compared with 75 percent of divorced spouses.) These men and women could forge social connections, fulfill their professional and personal duties, and discover happiness and meaning in their lives.

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Resilience, which Bonanno defined over the phone as “a stable trajectory of health despite having been through a highly aversive event,” seems to be our most common and natural response to loss. It allows us to work and love in the wake of misfortune.

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So how can we draw on our inner resilience? According to Bonanno, the factors that might predict the quality are diverse and a bit ethereal, each one having only a small effect in isolation. Researchers have just begun to unravel the complicated relationships between resilience and, for instance, personality traits like optimism and high emotional regulation. Other components may be demographic: Older people seem to be more resilient than younger people. Women are thought to be less resilient than men. (In the most striking study to bear this out, female survivors of an earthquake in California reported that the tremors lasted longer than they did while the male survivors accurately estimated the duration of the shaking.) Unsurprisingly, resources may play a role: financial savings, education, skills, social support, good physical health, and access to care all buoy resilience. Stress—both the neurotically drummed up kind and the kind the world inflicts on us—depletes our minds and bodies, likely leaving us less equipped to rise to various challenges.

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Again, the nascent body of research that attempts to understand resilience’s causes is far from prescriptive. And as of yet we have no formula for taking a less resilient person and making her more resilient. Bonanno calls his work “mostly theoretical,” noting that scientists haven’t reached a consensus on what to do with the patterns of coping (or not) that they’ve observed.

In the murkiness of our minds, we realize resilience has some connection to whether a person facing a traumatic life event will eventually get better. But that flicker is all we grasp—we don’t know enough about resilience to quantify it as a lump sum or to adjudicate when some poor soul doesn’t have enough. We certainly don’t know enough to tease out the connections between resilience and mental illness, as Trump appeared to do when he implied that veterans with PTSD needed to discover their inner strength.

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Eventually, Bonanno predicts, instilling or conserving this elusive quality will mean drilling down into its component parts. Next steps, he says, will likely involve “assessing people, identifying where they may be lacking and then enhancing in those areas.” For instance, a service member without close family members might be encouraged to join a support group. A vet treading water in the job market might pursue a degree that confers a competitive advantage in his field. And conversation should emphasize not resilience but the building blocks that promote and constitute it. Rather than declare an individual resilient or not resilient, the point is to pinpoint things that help—a sunny disposition, an active lifestyle, a nurturing parent—and encourage people to access them.

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Trump’s remarks to the Virginia veterans summon another word for questioning: strength. The GOP nominee presumes that if you are strong, you “can handle it.” But he misunderstands the particular valence this term carries in psychology. In the mid-1980s, a team of social workers and researchers at the University of Kansas pioneered what they characterized as a “strength-based approach” to treating mental illness. Shifting focus from pathologies and deficits to assets, the method deployed each patient’s unique blend of traits, skills, resources, and aspirations to aid in her “recovery and empowerment.” In other words, it’s not that individuals either have enough strength to deal with something or don’t—it’s that their treatment plan attempts to activate specific aspects of themselves that could aid them in the face of illness.

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“Strength-based practice is not about ignoring or papering over challenges,” Rick Goscha, a professor at the University of Kansas School of Social Welfare, explained. He and his colleague Ally Mabry, a case management and shared decision-making consultant and trainer at the school, were spinning out therapeutic scenarios with me over the phone. “But it puts the challenges in the context of what’s meaningful to a person,” Goscha said. Take, for example, a man dealing with schizophrenia who suffers from poor hygiene. Instead of treating dirtiness as a symptom to be resolved for its own sake, Goscha and Mabry might ascertain that the man fervently wants an office job. Their treatment plan, staked to that positive goal, would reframe clean clothes and showers as rational steps in the right direction, not externally imposed wellness markers.

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Underscoring what an individual has going for him can help overturn the self-fulfilling narrative that declares him eternally sick or broken. It can motivate him to change in ways that shame cannot. It is also very different from calling him strong—a strategy that Mabry claims can backfire. “That’s empty cheerleading,” she told me, referring to Trump’s flattery of the veterans who could “handle” what they had seen. “It’s the sort of thing that falls flat on people because it comes across as ignoring what their struggles are. They don’t feel validated.”

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Instead, she says, doctors should build patients up by reminding them of their specific aptitudes. They should invoke strength not as a static property, but as an attainable kit of skills, resources, and mental habits. (In the same way, praising children for innate talents hampers their success, and praising them for hard work promotes it.) Rather than rhapsodize about abstract psychological toughness, a therapist might draw attention to the way a career goal keeps a patient on track or note how she “finds strength” in her relationships with friends. Maybe, instead of urging an acquaintance to “be strong,” we can encourage him to relax by playing the guitar or get energized via a trip to the gym.

Part of what made Trump’s comments so awful was the hint—of a piece with his distressing genetic determinism—that some people are simply born with superior fortitude while others are irremediably flawed. Luckily, psychological strength admits more fluidity than that. So should our language.

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