Who has not experienced this before: We have been hurt and the person hurting us exclaims in a mixture of surprise and justification that they only meant well! The invocation of the good intention seems to them like an absolution of their responsibility for their action (or inaction) and thus our pain. Having worked as a psychotherapist for many years now with people on the receiving end of all kinds of well intentions (of parents, partners, siblings, classmates, teachers, religious leaders), it is clear to me that this not a sufficient ingredient for good outcome. Really, and I mean here even the truly well intentioned efforts of some parents have at times caused havoc on the lives of their children, that it is heart wrenching to behold, how all sides have lost and suffered in these situations. Why is this so?

Preventing Action

It seems that the good intentions my give some a sense of having fulfilled their aim already, thus preventing them to move to action. Like the good intention to ourselves to stop some bad habit of ours and paradoxically the more honest the intention meant at the time the more problematic it may turn out: it thus can better fulfill the very function of calming our worries and anxieties or doubts of being a bad parent, partner or person. Thus good intentions can prove to ourselves that we are not the bad person we may fear we are. To give an example I am very familiar with is procrastinating to study for an exam by repeatedly telling myself, very seriously, that I am going to study “for real” first thing tomorrow, thus feeling at ease today and therefore being able to continue with my not-studying at that very moment, only to have the same pattern repeated the next day. It is the same pattern I see with people struggling with major dependency issues (of any substance and their often futile change efforts), who often will profess with great sincerity that they will stop. It calms them, and often their very afflicted family members as all can sense the honesty of the intent, but thus taking away the force that the suffering provides that is needed to overcome the problem. Good intentions thus can prevent action by removing the psychological motivation that is created by the normal self-doubt, concern about the future (exam, financial situation, you name it …) or suffering that some undesired state creates, and thus turn against us or the people around us.

Mismatch of Gift and Need

Then there is the situation where we do move to action but it fails to meet the need of the recipient. I think this is captured well in the bible when Jesus talks about the ones on the right who have feed him when he was hungry, gave drink when he was thirsty. The gift matches the actual need of the recipient. But at times we give water when the person is hungry. This is especially confusing because the receiver may even feel an obligation to be thankful as the other went through the effort of bringing him a gift (albeit one he does not need)! I am not sure if it is possible to capture all the reasons this goes awry (still assuming truly good intentions), but what seems relevant is that the feedback about this mismatch does not reach the giver, for one because the recipient out of the above mentioned conflict does not give it. The second is that the giver will not hear or accept the signs and or direct feedback of the recipient. Why, because he meant well, which is sufficient in their minds to prove they are not the enemy and thus they can discount the other. This is where tragedies start.

Unintended Consequences of Our Limited Knowledge

To stay in the above analogy, I may know you are hungry and bring you a juicy burger not knowing you are a vegan! It is in the end a variation of the mismatch of gift and need, and in the end suffers from the same break down, a failure to connect and the giver to hear the correcting information he would need. In all of these situations there is no getting around the issue that the giver should be invested not only in meaning well but also in achieving good outcomes, as that will ultimately prove their professed intention true. It is that simple if I am truly concerned about the other I will want not only to intend good but to actually do well.

Veiled Bad Intentions

Finally there is a cluster of behaviours that is so obviously damaging to the intended recipient that the expressed good intentions have to be seriously questioned. They rather are attempts of the perpetrators to hide their self-serving needs behind that mask of well intention. To be clear in all the above mentioned situations there is a self-serving motive present as well (who does not want to be a good person, after all!), but the main difference is that in those situations there is also a real intention to do good to the other, that is clearly not present in these cases.

So professionally I am sold on the concept. Personally, it took me quite some growing up myself to see that even my good efforts were missing the mark at times and that they needed correcting and still do, it’s an never ending quest. It takes all our attention and awareness to notice signs of the people around us for feedback on how we are doing and it its dam hard to not let our feeble self’s come in the way of that.

So does this mean that every time you are hurt, the one who so offended you is then responsible for that? What are your thoughts?

Depression can take on many forms, from just feeling nothing at all to being very irritated, deeply hopeless or just wanting to withdraw from the world. As varied as the symptoms of depression are, so are its causes. One of the causes I often see in my practice is what I have come to term “a lost sadness”. What do I mean by that?

Well do you know the experience of being lost? You don’t know your way anymore, wander around somewhat aimlessly, not knowing where you came from last, nor where you need to go. You’re stuck, unable to find your way out of the situation.

That is the kind of psychological state I sometimes encounter in my clients, who are struggling with depression. When I ask where their depression is coming from, they are mostly lost. Yet when I inquire about their life in more detail we often do end up finding some significant event that has instigated the break in well being, yet they have lost sight of it, or deemed this not important enough to have caused such impact. It is lost to them!

Once it is, having lost sight of the cause of our unhappiness, we are in danger to get really stuck with our sadness and from there it is no easy coming back. Now the “sadness” that normally “knows” why it makes us so, has turned into this diffuse, cloudy melancholy. Not only that, but even more damaging is that it is also not clear how to resolve this emotional state: which direction to take with our life seems now daunting a task. Sadness is lost and can’t find its way out.

That is why in these depressive episodes, there is often the experience of crying “for no reason”. The feeling is there but is disconnected from its roots. The work that needs to happen in therapy then is to discover that original context of the depressive state and work through the pain, thus helping the sadness to finish the course it began (sometimes a long time ago).

Yes, no. But let me explain.

When I am asking this question, of course I am not just asking whether the man is meeting the everyday definition of the term that is nowadays common usage, as the answer to that should be more than obvious. No, I am more interested in the fact that this question has taken on such an importance and why this may be so.

The recent debate on Trumps mental state started with the open letter to the New York Times signed by more than 35 prominent mental health professionals warning the public about what they perceived as clear signs of Trumps emotional inability to be president. Soon responses by other prominent professionals followed warning about a diagnosis from afar and more outspoken then that: "It is a stigmatizing insult to the mentally ill (who are mostly well behaved and well meaning) to be lumped with Mr. Trump (who is neither). Bad behavior is rarely a sign of mental illness, and the mentally ill behave badly only rarely. Psychiatric name-calling is a misguided way of countering Mr. Trump’s attack on democracy. He can, and should, be appropriately denounced for his ignorance, incompetence, impulsivity and pursuit of dictatorial powers." (Alan Frances, Letter to the NYT).

Alan Frances objection to a mental health diagnosis seems to mostly come from a concern on how to respond to Trump. What his objection clearly implies is that you have to get the first question correct (the diagnostic problem, on which I disagree with Alan Frances) in order to answer to the more pressing matter of how should we respond and react to such a man.

This problem "of how to deal with unusual behaviour" frankly is an old one in our field, and has been addressed prominently in a simple heuristic: "mad, sad or bad". By this simple rule we could organize every "out of the ordinary" behaviour into a one of these categories and it was clear how to respond and treat the person, once so done. The mad (like the psychotic or manic person) would be seen driven by mental states beyond his control, thus be excused from the general expectations of rationality and decent behaviour, they would be locked up. The sad (like the depressed and anxious) would receive our empathy and support to lift them up until feeling better. The bad, of course the firm consequences and punishments that bad behaviour deserves.

Yet while this is a useful rule of thumb, the relation of these three (mad, bad sad) to each other has not been reflected much in our field, as can been seen in the quote above by a professor in psychiatry and the implicit assumption that these are three wholly distinct categories. "Bad behaviour is rarely a sign of mental illness" Mr. Frances writes, true. But what is even more important here is the implicit admission that hides in the rarely, that there is some small overlap between the two categories. And if you have ever read the criteria for narcissistic or anti-social personality disorder it is clear that "bad" is part and parcel of these conditions.

So where in this classification do the personality disorders fall and by extension then what should our reaction be? Here it becomes even more messy as it is unclear where to put them, rightly so, because actually we as humans and our personality is more dimensional and complex. We are neither simply good or bad, sad or mad, we are all of it! That's one reason why the same person can often elicit very different reactions in us. So rather than putting people once and for all in a box of "mad", "bad" or "sad" (as a diagnosis seems to be doing!) I suggest we respond to the human in front of us, each moment!

In regards to Donald Trump this means if he shows bad behaviour, it actually does not matter whether while so behaving he meets the criteria of a narcissistic personality disorder or not, bad is bad. It is on these grounds that we should resist him. Deciding what is bad is not the core business of the mental health profession, and it would be a sad day when we would have come so far that we need experts to tell us if somebody is behaving bad. So, no it should not matter to us whether he has the diagnosis of narcissistic personality disorder or not.