The resurgent debate about President Trump’s mental health prompts me to update a piece I wrote for THCB last June. That piece drew lively comments and debate.
It’s also the one-year mark of the Trump presidency.
As The New York Times editorial page recently asked, bluntly, on Jan. 11: “Is Mr. Trump Nuts?”
Since last summer, that question has gained more traction and spurred more earnest debate. The results from Trump’s medical and “cognitive” exam on Jan 12 are unlikely to quell concern. (More about those results below.)
Nearly every major newspaper and magazine has run stories. Print media columnists and TV commentators dwell on it constantly. It’s catnip for late night comedians. It’s been a trending topic on social media for months. And, of course, it’s a topic of discussion and banter almost everywhere you go.
Lawmakers have finally joined in, too, after reluctance for the better part of 2017. Some even render an opinion publicly.
Articles have begun to pop up in medical journals, too—most recently Dr. Claire Pouncey’s piece in the New England Journal of Medicine (Dec. 27, 2017).
And then there’s the book, which sparked Dr. Pouncey’s piece as well other articles and reviews since it came out last fall. I’m not talking about Fire and Fury: Inside the Trump White House by Michael Wolff—although that book is certainly relevant in this context.
Rather, I’m talking about The Dangerous Case of Donald Trump: 27 Psychiatrists and Mental Health Experts Assess a President, edited by Dr. Bandy X. Lee, a specialist in law and psychiatry at the Yale School of Medicine.
The Dangerous Case will almost certainly go down in history as a breakthrough academic book in the field of presidential psychology and medical ethics and law. It also represents a breakthrough because it bucks the Goldwater Rule.
That’s the American Psychiatric Association (APA) policy—dating back to 1973—that strongly recommends mental health professionals not render diagnoses of people they have not personally treated, especially public figures. It’s called the Goldwater Rule because it was prompted by publication in 1964 of a magazine article arguing that conservative Republican nominee Barry Goldwater was unfit to be president. The article was based in large part on the results of a survey sent to 12,356 psychiatrists. Of 2,417 responses to the survey, 1,189 said Goldwater was “mentally incapable” of being president. The other 1,228 psychiatrists declined to make a judgment.
Goldwater sued the now-defunct magazine for $50,000 and won. Thus, while the Goldwater Rule is meant to apply only to mental health professionals, it de facto extended for decades to the media.
No longer. The media is clearly not going to play along anymore—with Trump and likely any president that follows him. And, now, a growing number of mental health professionals concur. The book’s authors assert that they have a duty to apply their knowledge and skills for the greater public good. This duty, at this time, surpasses (trumps) the Goldwater Rule, they say.
The Dangerous Case is a no-holds-barred indictment of the president’s mental health, character, and boorish behavior. The book’s 28 essays put scholarly and academic meat on the bones of the speculative psychoanalyzing and character assessment (some would say assassination) that has grown in intensity since Trump announced his candidacy in 2015.
The authors examine almost every angle of Trump’s character and behavior, and present a portrait of a man with a somewhat unique confluence of dysfunctions and personality traits.
Many diagnoses—labels—are applied. You’ve heard some. But you may not be familiar with others, such as: malignant narcissistic personality disorder and “extreme present hedonism.”
Malignant narcissism consists of antisocial behavior, paranoia, and, most notably, sadism—in addition to the usual narcissistic traits of (a) persistent exaggeration and grandiose statements about one’s self and achievements, (b) the belief that one is superior to other people, (c) needing and expecting constant praise from others, (e) ever-present defensiveness.
“Extreme present hedonism” is characterized by living in the present moment in a way that denies, negates or dismisses what has happened in the past (even perhaps just the day before or hours before) or what consequences one’s statements and actions might have for the future. People with this condition seem to lack the ability to track their behavior or statements over time, or simply don’t care; they say and do what they want “in the moment” to get what they want in the moment. They also display marked impulsiveness.
Both these diagnoses seem spot on for Trump. His flaming and frightening narcissism can’t really be disputed at this point, and the paranoia and sadism have become more evident over the past year. Accusing Obama of wiretapping him, for example. Or the constant tweets with shocking personal attacks, even on people who are highly regarded public figures (like Meryl Streep).
As well, even casual followers of the news and Trump’s policy and political flip-flops can’t have failed to notice the jarring disinterest he and the White House have in consistency and coherence over time.
Trump’s supporters chalk this up to his management style of “creative chaos” and keeping staff off-balance and competing. But there’s now ample evidence after a year that whatever such chaos did for him in real estate and reality TV does not work in politics and world affairs. (Witness the current debate over DACA and see Evan Osnos’ Jan. 8, 2018 New Yorker piece—“Making China Great Again”—on how China’s leaders are exploiting Trumpian and White House chaos.)
The book’s authors also raise the specter of sociopathy and psychopathy, although less convincingly. The common elements of a sociopathic personality ring true for Trump: lack of empathy; remorse and guilt (never apologizes); restrained affect or emotional expression (except anger and rage); chronic lying; ignoring social norms, and persistent manipulative behavior.
Trump best fits the mold of a “high-functioning” sociopath, one essay says: someone who is aware he is different from others but who sees that as a strength and seeks to exploit that for his gain in terms of power over others.
Time will tell if Trump’s sociopathic traits bleed into psychopathy. Psychopaths are essentially sociopaths and then some. They are people whose sociopathy becomes more dangerous (to themselves and others) for reasons not always well understood. More dangerous in the sense that, when triggered by social or environmental factors, they are willing to take bolder actions that could harm others. Whatever inhibitions they had seem to fall away.
In fairness, Trump seems at times genuinely empathic. Most recently, he has expressed support on numerous occasions for allowing the DACA population to gain permanent residence in the U.S. And throughout the debate over the ACA, he expressed support for legislation that was compassionate. Example: Trump called the House ACA repeal bill “mean.”
But then political expediency would quickly and easily overrun those sentiments, with no clear explanation for the change.
Then there are the cognitive issues. My initial (June 2017) post focused on those so I won’t repeat the points here. But the evidence has only mounted in the past year that Trump suffers from some form of cognitive decline, most notably in his language skills. He is often unable to string together 5 sentences without repeating himself, going off on a tangent, or using the same simple and often clunky phrases and/or words multiple times.
His supporters say he’s “plain spoken” and that this is an asset. But it’s become clear from media reports that he’s often (but not always) inarticulate and incoherent in private political meetings even when he knows the substance.
Trump’s judgment also exhibits impairment, several of the book’s essays say. While poor judgment is not by itself a sign of mental illness, impaired judgment is a common symptom of cognitive decline, emotional turmoil, stress, and many neurological or mental health problems.
Is Trump’s poor judgment tied to his personality and character, whether you consider that disordered or not? Or is it independent? That is, contrary to Trump’s claims to be a “stabile genius” who acts intuitively and “smartly” in his decision–making, is he as a person who’s actually really bad at making solid judgments about things—policy or people?
There’s certainly strong anecdotal evidence that his judgment regarding people is poor—Steven Bannon, General Michael Flynn, the Mooch, Spicey, Jared Kushner as a policy advisor. From Trump’s and the White House’s POV, allowing Michael Wolff open access to staff seems pretty stupid.
Speaking of stupid (see also “moron”), Trump’s intelligence has, of course, also been called into question. The book does not probe this. My own layman’s take is that concern and questions about his brain power, IQ or whatever devolve to his possible cognitive decline. He’s certainly not an idiot per se. He is often poorly informed—and never seems to care about that. Which is poor judgment.
The medical exam
So, what was that cognitive test all about at Trump’s medical check-up last week?
Not being a doc, I can’t render an informed medical opinion about the scope and validity of the test. But initial reports in the media indicate the test is not a detailed probe of the many forms of cognitive decline that can occur with aging. It’s more of a simple initial screening test.
As for White House physician Ronald Jackson’s performance—and it was that—I’ll wager there’ll be criticism from many quarters regarding the cognitive assessment in the days and weeks to come.
Jackson’s statements that he found: (a) “no reason whatsoever to think the president has any issues with his thought processes;” and (b) that the president is “very sharp” and “very articulate when he speaks to me and “absolutely fit for duty,” have already come in for ridicule.
In a Jan. 7 post on THCB, ethicists Art Caplan and Jonathan Moreno exhort us to remember that Trump and the White House control what results from the president’s exam are released, and that there is “a long history of prevarication, distortion, withholding and pretending when it comes to medical information generated when doctors examine a President.”
Examples: Wilson (serious stroke), Roosevelt (polio, cardiac disease), Eisenhower (massive heart attack), Kennedy (Addison’s disease), Johnson (bipolar disorder, heart attacks), Nixon (alcohol abuse, depression), Reagan (early signs of Alzheimer’s), and Clinton (high blood pressure and high cholesterol).
Will this president and White House go for full disclosure and transparency? Caplan and Morena doubt it and urged renewed consideration of President Jimmy Carter’s proposal in 1994 that a non-partisan panel of doctors monitor the president’s health. A chapter in The Dangerous Case, by Nanette Gartrell and Dee Mosbacher, recommends similar action.
It is, indeed, now very clear that current policies and rules are inadequate to the task of fully assessing, and then quickly removing, a president who may either be physically or mentally unable to do the job.
Debate will continue on professional ethics
Meanwhile, the Goldwater Rule debate is far from resolved. Pouncey’s main arguments, with which I agree, are these:
- Protecting public health and safety is part of the ethical commitment physicians make.
- Many of Trump’s behaviors and actions, so far, can be interpreted as presenting a threat and danger to public health and safety (on multiple levels).
- Standards of medical ethics and professionalism change with time and circumstance, and psychiatry’s reaction to one misstep in 1964 does not inform the situation in 2017-18.
The APA disagrees. In March 2017 the APA broadened the Goldwater rule to apply to “any opinion on the affect, behavior, speech, or other presentation of an individual that draws on the skills, training, expertise, and/or knowledge inherent in the practice of psychiatry.” That’s an expansion, notes Pouncey, that would further silence psychiatrists.
APA past president Jeffrey Lieberman, now at the Columbia University College of Physicians and Surgeons in New York, went further. In Psychiatric News, he wrote that The Dangerous Case is “not a serious, scholarly, civic-minded work, but simply tawdry, indulgent, fatuous tabloid psychiatry.” And in a letter to NEJM at the end of December, commenting in Pouncey’s piece, Lieberman wrote:
“Although moral and civic imperatives justify citizens’ speaking out against injustices of government and its leaders, that does not mean that psychiatrists can use their medical credentials to brand elected officials with neuropsychiatric diagnoses without sufficient evidence and appropriate circumstances. To do so undermines the profession’s integrity and credibility.”
He concluded in that letter: “I believe that Pouncey and Lee and her coauthors are acting in good faith and are convinced they are fulfilling a moral obligation. But I believe this is a misguided and dangerous morality.”
Two important final points. One—made in the book but also by The New York Times editorial board on Jan 11, and in other recent articles—is that Trump’s unfitness for office can and should be assessed independently of his mental health status. As the Times put it: that’s “beside the point.”
The presence of mental illness would not always be a reason to dislodge a president. (Nor should it ever be a reason to keep a president—dismissing his or her deeds using mental illness as an excuse.) The stakes are too high. That line of reasoning and decision-making only serves to add to the stigma that, sadly, remains attached to mental illness. Lincoln suffered from depression. Maybe Lyndon Johnson, too. Grant was an alcoholic and had bouts of depression.
As should be more obvious in today’s world, the presence of mental health problems does not dictate character or ability or the value of a person or a life. Hundreds of millions of people worldwide with mental health conditions lead productive lives, with and without treatment.
Rather, Trump’s behavior, actions (whatever their origin) and his effectiveness in office must be what we ultimately judge him by.
And a last point: One of the essays in The Dangerous Case, as well as another recent book—The Twilight of American Sanity-A Psychiatrist Analyzes the Age of Trump (by Allen Frances)—assert that Trump has had a profound and mostly negative impact on the nation’s psyche.
The essay calls it “Trump anxiety disorder.” You could also think of it as collective trauma. On the surface, it manifests in the free-floating angst and cynicism that’s almost palpable among the president’s detractors. But Frances also notes that Trump has the dictator’s gift of bringing out the worst in his followers, playing on their prejudices, exacerbating their anger and irrational thinking, and—yes—their racism and misogyny.
This impact on the public’s “mental health” should be a part of the conversation.