Like a bulging medical file for a chronically hospitalized ICU patient, every week sees new additions to the folders of evidence for Donald Trump’s diseased mind and his mental unfitness for the presidency. This past week, in the “History of Present Illness” section, it was his lack of empathy and blame shifting for the abominable response to hurricane-ravaged Puerto Rico. For “Past Medical History,” it was the unearthed recording of a conversation with trashmaster Howard Stern, wherein Trump appallingly described his neglect and disgust towards an elderly man bleeding on Mar-A-Lago’s floor. (Just as appalling is Trump’s unawareness that his response should be cause for shame.)
So, what exactly is psychologically wrong with this man, and what makes him dangerously unfit for public office? In this time of Trump-induced peril, is it still ethical for the American Psychiatric Association (APA) to gag its members’ speech against the president, under their Goldwater Rule of 1973? And more broadly, what are the psychological effects of a Trump presidency, and what does Trump’s rise to power say about this country?
For answers to these questions, there is no better place to turn than The Dangerous Case of Donald Trump: 27 Psychiatrists and Mental Health Experts Assess a President. Edited and brought together by Bandy Lee, the psychiatrist who organized Yale’s “Duty to Warn” conference earlier this year, the responses contained in this book’s 360 pages are detailed, insight-rich, and well-reasoned.
Lee has assembled a dugout full of power hitters for this volume, with experts coming from esteemed institutions such as Harvard, Hopkins, NYU, UNC-Chapel Hill, and UCSF. Among the contributing psychiatrists, psychologists, and psychotherapists are leaders in the field like Judith Herman, the psychiatrist author of a seminal work on PTSD, Trauma and Recovery; Philip Zimbardo, the psychologist who conducted the Stanford prison experiment; and Robert Lifton, the psychiatrist famed for his studies of Nazi doctors and Hiroshima survivors. (If only Trump’s cabinet contained such luminous talent, we could feel much safer.)
A precise and elegant prologue by Lee and Herman lays the ground rules for the three sections that follow. In it, the authors admit the impossibility of giving Trump a definitive diagnosis in the absence of clinical interviews and testing. They also posit that the APA’s Goldwater Rule should only be broken in the event of an emergency, and this is one such time. Lest there be any doubt, they conclude with the 27 authors’ unanimous conviction that “anyone as mentally unstable as Mr. Trump simply should not be entrusted with the life-and-death powers of the presidency.”
Part One (The Trump Phenomenon) focuses upon the symptoms and behaviors that render the president imminently dangerous. The various authors in this section argue that Trump exhibits impairments consistent with multiple diagnoses, including Narcissistic Personality Disorder, Antisocial Personality Disorder (or sociopathy), paranoia, hypomania, and possibly dementia.
The clinicians do an excellent job, assembling a greatest hits collection and several B-sides of Trump’s deranged statements and abhorrent behaviors to make their cases. Their assessments span the president’s entire lifetime, though with emphasis primarily upon his words and deeds while campaigning and now as president. Their summation is a horrifying trek down Memory Lane and utterly damning in its totality.
The only chapter that I found unpersuasive was psychologist Michael Tansey’s discussion of Delusional Disorder, a rare condition by comparison to those already mentioned. To use a time-worn clinical aphorism, when you hear hoof beats outside your window, it’s usually a horse and not a zebra.
Far more compelling is psychologist John Gartner’s overview of malignant narcissism, which appears to tidily encapsulate the Man in the Red Cap. A diagnostic construct originally developed by the influential psychoanalysts Erich Fromm and Otto Kernberg (both refugees of Nazi Germany), malignant narcissism is comprised of four essential components: Narcissistic Personality Disorder, antisocial behavior, paranoid traits, and sadism.
Before I move along and discuss Part Two, I’ll go ahead and respond to what I anticipate will be a primary criticism of The Dangerous Case of Donald Trump. I expect that many reviewers and readers will argue that the multiplicity of possible diagnoses presented here weakens the case for Trump’s mental impairment.
To answer this, I’ll play my “psychiatrist with over 20 years of clinical experience” card, and offer a four-fold reply. First, just as often as not, patients meet the criteria for more than one diagnosis. Second, our main tool for diagnosis in psychiatry – the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) – is far from perfect, an overly reductionist approach to the diversity and malleability of human behavior. But as a former Secretary of Defense once said, we go to war with the army we have, not the army we wish we had.
Next, our president has not submitted to interviewing and testing, lending the discussion an inevitable imprecision. Therefore, it’s more accurate to consider the disorders explicated in the book as part of a differential diagnosis, rather than anything conclusive. And lastly, professional disagreement over exact diagnoses is the norm in our specialty, given (in most cases) the lack of blood tests and neuroimaging studies to furnish the greater certainty that comes with, say, diagnosing diabetes or a specific type of cancer.
In addition (and here’s a nice segue to Part Two), one of the core theses of Parts One and Two is that precise diagnoses are not the key to professional concern about Trump. Instead, the foremost worry is pathological dangerousness, because someone so evidently paranoid, impulsive, and aggressive should not have sole access to the nuclear codes.
The authors clearly don’t want to stigmatize sufferers of psychiatric illness in the general population, as most such folks are quite capable of high social function and lasting, meaningful relationships. Besides, a close reading of presidential biographies shows that many of Trump’s predecessors likely suffered from some form of mental illness that did not leave them unfit for public service, such as Lincoln’s well-known struggles with depression.
Part Two (The Trump Dilemma) mostly revolves around the ethics of the Goldwater Rule vis-à-vis our other obligations as mental health professionals. I found this section to be argued flawlessly.
Highlights include a pointed ethical analysis by Leonard Glass (a Distinguished Life Fellow of the APA, until he resigned in protest earlier this year) demonstrating that in its current flawed execution, Emperor Goldwater has no clothes. Glass writes that the Goldwater Rule bespeaks the APA’s “profound lack of respect for and confidence in the maturity and judgment of its members.” He proceeds to say that the rule is mortally weakened in its failure to distinguish between a confidential clinical assessment of a patient and a professional opinion offered in the public square. Ironically, too, the Goldwater Rule runs countercurrent to one of the APA’s core missions (reiterated in a 2013 publication) to educate the public.
In his chapter, Harvard psychiatrist Henry Friedman compellingly claims that the APA’s telling its members to turn off their powers of observation plays directly into the Trumpian technique of doubling and tripling down on his lies until the listener doubts their own critical faculties. Fellow psychiatrist James Gilligan builds upon Friedman’s condemnation of the APA, describing it as Trump’s “passive enabler.”
In one of many apt Nazi Germany analogies found throughout this book, Gilligan utters what may be the understatement of the year: “It does not seem to me that the German Psychiatric Association of the 1930s deserves any honor or credit for remaining silent during Hitler’s rise to power.” Family therapist William Doherty nicely puts the finishing touches on this part, rounding out earlier statements about the public health obligations of mental health professionals, to introduce the concept of the citizen therapist.
Part Three (The Trump Effect) contemplates the societal import of the Donald’s rise to the presidency. The section begins strongly with a chapter by Betty Teng, a New York City therapist and trauma specialist. Teng discusses the triggering effects of our president’s ceaseless emesis of aggressive statements and erratic behavior. While some may argue that labelling Trump’s misconduct as traumatic devalues the experiences of PTSD sufferers, I was persuaded by her contention that our Pussy Grabber in Chief is re-traumatizing those who’ve suffered domestic abuse and other forms of violence.
Unfortunately, the middle portion of Part Three sags a bit. Your mileage may vary, but I found the chapters on “Trump Anxiety Disorder” and “Other-blaming” to be too self-helpy for comfort. Additionally, chapters on Trump’s daddy issues and his promotion of birtherism were interesting but came across as digressions from the key theses of Lee’s book.
Happily, this section finishes robustly with some of the most eloquent and affecting writing in The Dangerous Case of Donald Trump. Jungian analyst Thomas Singer potently considers the interface between Trump and the collective American psyche. I found echoes of James Baldwin’s prophetic essays as Singer discussed Trump as the apotheosis of America’s narcissism and sociopathy, exposing the barrenness of our celebrity culture, our worship of “success,” and our denial-laden fixation on America’s mythic innocence.
Polish-born therapist Elizabeth Mika chilled me with her meditation upon tyranny as a narcissistic collusion among the tyrant, his followers, and their broader society. I’m guessing she writes from personal experience of living under dictatorship, as she points out that modern tyrants have inevitably been malignant narcissists. A “we are so screwed” dread rose in me, in reading Mika’s essay, as it kills any residual fantasies that tyranny can’t happen here. (This chapter would be usefully complemented by perusing that other must-read of 2017, Holocaust historian Timothy Snyder’s On Tyranny.)
Offering a bulwark against fatalistic despair, Part Three concludes with a pragmatic, action-oriented essay by psychiatrists Nanette Gantrell and Dee Mosbacher. With lawyerly exactitude, they make their argument for Trump’s grave danger to national security, requesting Congress to act immediately upon Section 4 of the 25th Amendment, to formally convene an impartial panel to assess the president’s mental fitness for duty. I can only hope that some of our representatives will read this.
Though The Dangerous Case of Donald Trump is not exactly a brisk beach read, I’m convinced that anyone who is psychologically curious will find it accessible, profiting from time spent with it. With the omnipresent gaslighting by Trump and his morally dead sycophants, there is immense benefit to conceptualizing and therefore understanding the psychopathology at the core of this administration. Where the APA is AWOL on its commitment to America’s public health at this dire juncture, Lee and others like her have taken up the necessary slack. And just as countless patients have thanked me for defining their ailments and course of treatment, naming the trauma and distress inflicted by Trump will be therapeutic for many.
With its condemnation of the cowardice of the APA leadership – accurately labelling them as Trump enablers and comparing them to Nazi physicians – it’s doubtful this book will win any converts among the cravens currently atop the APA hierarchy. Instead, it is my hope that rank-and-file APA members who still feel intimidated by the Goldwater Rule will be persuaded to act on the more pressing ethical obligation to use their specialized knowledge and warn the American public of the growing danger posed by Trump’s psychological instability.*
*Public service announcement: If mental health professionals reading this have not yet affixed their names to the Duty to Warn petition (now with over 63,000 signatures), please do so here. And please attend a Duty to Warn Town Hall on October 14th (open to all); I’ll be speaking at the one in Chattanooga.
Photo attribution: “Donald Trump” by Gage Skidmore, licensed under the Creative Commons Attribution-Share Alike 3.0 Unported license.