The Dangerous Case of Donald Trump: 27 Psychiatrists and Mental Health Experts Assess a President
=================================================================================================

* Jerome L. Kroll

Edited by Bandy X. Lee, MD, MDiv. New York: Thomas Dunne Books, St. Martin's Press, 2017. 384 pp. $27.99 hardcover.

Just between the time that an email request from the book review editor of the *Journal* arrived (November 28, 2017) to the time of sitting down to begin writing a first draft of this review (January 14, 2018), there was a flood of print and electronic media opinions on the interrelated topics of President Donald Trump's mental health and perceived dangerousness. Further, elucidated during this discussion has been the controversy about the American Psychiatric Association's (APA's) position on the Goldwater Rule, which declares unethical and forbids all public opinions by psychiatrists about diagnoses and mental health status of public figures whom the opining party has not directly examined according to accepted standards for psychiatric evaluation.1

Keeping up with the media and print publications about President Trump seriously hampered writing this review, as events of each day threatened to overrun whatever I had written. This experience reminded me of occurrences during the presidential campaign. Mr. Trump the candidate presented himself as embodying several traits that many thought of as incompatible with the task of serving as the president of our country. All of this was brought out publicly and repeatedly during the long campaign. With each howler, liberals and moderates were convinced that surely this latest gaff would be the candidate's undoing; U.S. citizens would never stand for it. With each such attack, his supporters grew more certain that he was their man; even women supporters defended this man who demeaned and made nasty sexual comments about women. His base did not reject him as the liberals expected or hoped. In late January 2018, President Trump made some of his most offensive statements when referring to Haiti and other African nations in derogatory terms.2 While nations around the world and many of us at home were outraged, his approval rating climbed to almost 40 percent on domestic polls, higher than it had been in months.

To many psychiatrists, President Trump's statements and behaviors were patently symptomatic of one or several mental disorders. The facts of the case and the serious risks of erosion of our constitutional democracy and possible nuclear annihilation of the world demanded that psychiatrists warn the public. The analogy to the silence of Germany's educated and professional classes during Hitler's ascendancy to power was too obvious to ignore; but roughly 40 percent of the country does not agree that the president is evil or dangerous.

Bandy Lee's edited book, a compilation stemming from the presentations at a similarly themed conference that took place in New Haven, CT, in April 2017, is a sincere act of conscience. The authors of the 28 chapters (including Prologue, Introduction, and Epilogue) are not in full agreement as to the details of what they believe ails President Trump, but all concur that he is mentally ill or dangerous (by virtue of being president) or both. There is discordance as to the nature or the diagnosis of the mental illness that makes him dangerous, and the various authors take their shots as to which descriptive terms and which diagnoses fit best. Along the way, the authors acknowledge the heavy presence of the Goldwater Rule and the intimidation to silence psychiatrists that the APA leadership and Ethics Committee have imposed.3,4 I think that the critically important question taken up in this volume is Mr. Trump's fitness to serve as president and that the furor over the Goldwater Rule will become a footnote in the history of this presidency and this era.

It is clear that the president's dangerousness is the most important concern to our country, especially to those poor and disenfranchised persons who will be most damaged by his policies5 and to the global environment that may be irrevocably affected. I was also interested to see how deeply the authors would take on and debate the Goldwater Rule. One could assume that the authors' willingness to make public diagnostic, descriptive, or psychological statements about a public figure of whom they have not personally conducted a formal diagnostic assessment serves to challenge the APA's long-held principle. This notwithstanding, I was also hoping to read a thoughtful debate in which the Goldwater Rule was placed in broader social and intellectual context. I hoped to see a dissection of the arguments given by the APA considering the common experience that the community standard for doing psychiatric assessments in the trenches of a community health center, a homeless shelter or an emergency room differs substantially from the ideal of an extended personal interview: particularly as this idealized version is often complete with medical records and a rational subject who can provide a linear life history. Further, I hoped there would be discussion of why a personal psychiatric interview is considered more trustworthy than, say, watching hours of videotapes of a subject engaged in a range of activities.

At this point, in the interest of transparency and declaration of possible conflict of interest, I have to say that I have serious misgivings about Donald Trump's fitness to serve as President of the United States and also that I have been strongly opposed to the Goldwater Rule since well before his candidacy and election. Claire Pouncey and I co-chaired a symposium at the 2008 APA meeting debating the Goldwater Rule6 and subsequently published a related article in the *Journal* in June 2016 that did not have Mr. Trump in mind, but benefitted from the relevance that his campaign behavior lent to our article.7

In reading the book, I hoped to find a process of reflection about the history and context of diagnostic practices in psychiatry, including the tentative nature of psychiatric diagnoses which are often considered a work in progress. Further, it is critical to consider the sociohistorical, political, and scientific contexts in which diagnostic systems are developed, discarded, or altered based on considerations less scientific than political, or opportunistic, or prejudicial, or accepted, pending the next rewriting of the Diagnostic and Statistical Manual of Mental Disorders (DSM). The list of formal and informal diagnoses that have fallen by the wayside (homosexuality, pseudoneurotic schizophrenia, sluggish schizophrenia, inadequate personality, hysterical neurosis, and neurasthenia) or of those that have made belated appearances (posttraumatic stress disorder, tobacco use disorder, and narcissistic personality disorder) is sufficient to lend some humility to the diagnostic process or to diagnostic pronouncements in psychiatry. I also hoped to find discussion of various neurological and medicinal possibilities suggested by President Trump's apparently declining cognitive skills and lack of impulse control, although the latter may be less a case of frontal lobe disinhibition than lifelong asocial habits.

Moreover, I hoped to find an in-depth discussion of the controversies attached to attempts by a governing board or administrative managers to regulate important moral positions that are core to one's personal identity and being in the world. Ethics-related matters should not be decided by a vote of our peers, let alone by committee members who, by virtue of their medical degrees or their election to important posts in a professional organization, have no special claims or expertise in moral theory. It seemed to me that the present Goldwater Rule controversy came about because the APA leadership misunderstood that an admonitory statement reflecting disapproval of offering diagnoses of a public figure in the absence of a personal interview is a technical rule, not an ethics-based one. It relates to the empirical question of the best method for making a valid diagnosis. Alasdair MacIntyre, in discussing the role in modern society of the “manager, the bureaucratic expert,” whose status is based upon a claim of effectiveness in controlling certain aspects of social reality, states that this claimed effectiveness is not a morally neutral value. The manager's claim of effectiveness is “inseparable from a mode of human existence in which the contrivance of means is in central part the manipulation of human beings into compliant patterns of behavior” (Ref. 8, p 74).

The first thing one notices about the text itself is the title *The Dangerous Case of Donald Trump*. It is ambiguous but not innocent. When a doctor speaks of a case, the term references a clinical case in which a person becomes a patient, with a history, symptoms, laboratory findings, medical conditions, and a life lived in a community, but here in the title of the book sits one of the key disputed points: the psychiatrist has to deny that Mr. Trump's case is one of a patient while simultaneously providing a diagnosis that is claimed not to be a diagnosis; otherwise, all the Hippocratic and legal, medical, and ethics-related problems arise: confidentiality, privacy, respect, beneficence, nonmaleficence, and some sort of mutual contract. So, if he is not a patient, which he is not, in what sense is he a “case,” and why is the term used in the title of the book? It is left unclear, purposely, I assume. If there was any doubt that convening a conference that assesses the mental health of a president and publishing a book of the papers given at the conference sticks a finger in the eye of the APA leadership, then the labeling of President Trump as a case throws down the gauntlet.

There are three sections to this book. The first, entitled “The Trump Phenomenon,” takes up questions of diagnoses. The second section, entitled “The Trump Dilemma,” should really be titled “The Psychiatrists' Dilemma.” Trump has no dilemma; psychiatry does. This section discusses the problem that psychiatry has in deciding what stance to take about his dangerousness, especially in light of the Goldwater Rule. The third section, “The Trump Effect,” examines the impact of his personality and policies on various segments of the population (often white middle-class citizens in therapy) and on the psychiatric profession.

The heart of the book is Section One, because it engages the descriptive and diagnostic issues head-on. In these chapters, the offerings are restricted to various combinations of narcissistic personality (sometimes combined with antisocial personality), malignant narcissism, bipolar disorder, paranoid personality and paranoid psychosis, and some form of cognitive impairment reflecting early dementia. Long behavioral lists of self-aggrandizing, lying, snarly criticizing, boasting, bullying, blaming others for troubles, and needing constant praise are paraded out to the readership. We are familiar with these lists; they have been exhibited in Mr. Trump's public rhetoric and are indicative of narcissistic personality traits if his public persona is to be taken at face value. In a few instances, authors of chapters create, in my view, a questionable link from narcissism to paranoia, not just to suspiciousness but to actual delusional thinking. This notion comes as close to junk science as I have seen and does not advance the credibility of the case for his mental illness or dangerousness.

Section Two, “Trump's Dilemma,” which I have renamed “The Psychiatrists' Dilemma,” takes up the subject of dangerousness. The focus is less on arguing for a diagnosis and more on Mr. Trump's own provocative statements across a wide arena, statements that have undermined U.S. intelligence communities and incited assaults upon political opponents and journalists, casual comments about use of nuclear weapons, insults directed toward leaders of friendly nations, and juvenile challenging taunts of leaders of less friendly ones. Some of the psychiatrists in this book invoke the *Tarasoff* duty to warn as justification for speaking out, but this seems to misrepresent the wording of *Tarasoff* and is a legalistic argument that sidesteps a direct confrontation with the Goldwater Rule. I think the Goldwater Rule is poorly conceived and deleterious to psychiatry and that *Tarasoff* is largely irrelevant to the types of dangers that President Trump represents. Leonard Glass, in commenting on *Tarasoff* in his chapter in this book, states that “Our duty to warn is an expression of our concern as *citizens* possessed of a particular expertise; not as *clinicians* who are responsible for preventing predictable violence from someone under our care [italics his].” (p 153).

Section Three, “The Trump Effect,” presents various chapters that discuss the effects of the president's rhetoric upon the collective psyche and individual psyches of those who are unhappy with him. Some of these chapters come very close to diagnosing half of the American population as victims of his hyperbolic and hectoring behaviors. I see this defeatist stance as very unfortunate, since the organized marches on Washington, DC, and state capitols are anything but the behavior of victims. Underlying some of these chapters are the unhappy attempts to explain or explain away Mr. Trump's election and the indigestible fact that a very vocal and sizable minority of Americans strongly supports his policies, including his anti-immigrant and racist stances. To this faction, he is the president who is doing what he promised to do in his campaign speeches and tweets.

Interspersed within these chapters are direct references to and indirect awareness of the looming Yeti, a.k.a. the Goldwater Rule. The Goldwater Rule controversy should be placed in proper perspective as related but secondary to the Trump phenomenon. There are timeless principles involved in the APA's insistence that it is within its rights to establish rules prohibiting public commentary on public figures by its membership and to justify such rules by categorizing breaches as unethical, rather than merely imprudent or misguided. Even if psychiatric opinion on Mr. Trump is unlikely to change the public outcome in this international high-stakes moment, the basic question of whether a professional organization such as the APA should move to curtail free speech of its membership under the aegis of an ethics mandate deserves scrutiny and, for some, resistance. Furthermore, it was the APA itself, in adopting DSM-III in 1980,9 that established a new standard for making diagnoses based primarily upon observable data (including speech content and patterns) rather than (unobservable) inner workings and psychodynamics. This emphasis on measurable and replicable behavioral observations downgrades the importance of the personal interview in making diagnoses. Now the APA seeks to resuscitate the legitimacy of looking inside the person for diagnostic purposes, but lacks the accompanying psychodynamic theory to support it.

Dr. Lee is to be commended both for hosting the conference in which these papers were presented and for the hard work of turning conference papers into finished chapters for a book, all in a short amount of time. It is not easy to persuade presenters at a conference to do the disciplined work of taking the rough outline of a paper and converting it into proper sentences, paragraphs, and coherent thoughts. The ongoing controversies that the book engages and, in turn further generates, are important to understanding the context of the book historically and in the present moment, including my own being swept up as a participant–observer and, now, reviewer.

However, our appreciation for the courage and effort to take on the APA ethics police and the Trump lobby should not cause us to overlook some of the weaknesses in arguments, logic, perspective, and evidence. I recognize the pressures to get this book out in a timely fashion, but an index would have been helpful. It is difficult to go back and forth and see what several of the authors had to say about narcissism or dangerousness or the Goldwater Rule. On a more substantial note, there is too often a lack of critical thinking about concepts and causality, which seriously weakens the credibility of what the authors wish to get across. For example, there are too many outdated and simplistic assumptions about the psychodynamics of narcissism. The reader is told that persons are narcissistic to hide their shame or overcompensate for their inadequacies; they stifle their conscience and their compassion. I do not know if any of these generalizations are true of Mr. Trump, nor do I have confidence that if I asked him directly, I would get a trustworthy answer. It does not help the advancement of our field to proffer rote explanations, and it certainly does not help to use such arguments in trying to persuade anyone to view the situation differently.

Moving on, the lack of critical thinking and the presence of inexact comparisons are distressing. Is it helpful to call Presidents Clinton and Kennedy narcissists, because they are said by some to be womanizers? How many women does one have to be casually involved with to be a womanizer? Is it the number or quality of relationships that supports such a label? Would the APA come down on psychiatrists as heavily if they called a political figure they had not personally examined a womanizer rather than a narcissist? Are there reasons, other than narcissism, to consider why an individual might be a womanizer?

On a different but related note, the 2006 article by Davidson *et al.*10 on a survey of mental illnesses in U.S. presidents from 1776 to 1974 (George Washington began his first term in 1789) is cited without hesitation. However, when looking more closely, several concerns arise about its methodology, biases, historical context, the validity of secondary sources, and the pattern of using descriptions of character traits and stormy or moody incidents. Those concerns are related to establishing a firm basis for DSM diagnoses of illness. Davidson and colleagues are a little more circumspect in acknowledging levels of confidence in the jump from anecdote to diagnosis. However, by the time the reference appears in the tertiary literature (such as some chapters in the book under review), all nuances and subtleties are erased. We are left with the bald statistic that 49 percent of presidents met criteria for at least one mental illness. Based on my reading of the historical literature, I always thought Thomas Jefferson was shy and found public speaking difficult. He preferred the quiet of his study at Monticello to the raucous political environments of Philadelphia and Washington, DC (Ref. 11, pp 52–3). How does this morph into social phobia? Teddy Roosevelt was well known for extraordinary energy and stamina after a sickly childhood.12 Certainly, high energy and high activity are seen in some manic individuals, but in many nonmanic ones as well. To move into diagnosis while ignoring the diagnostic criteria of “marked impairment” and much else makes me wonder whether the Goldwater Rule has a point or people are uncritical historians, but since the chapters under consideration here relate to making diagnoses of presidents, the 49 percent statistic spuriously serves to support the case in doing so for Mr. Trump.

Finally, the lack of a scholarly discussion of the controversial relationship between personality disorders and major mental illnesses is noteworthy. As mentioned earlier, the quick slide from Mr. Trump's public displays of narcissism to a diagnosis of paranoia is almost a sleight of hand. There is some mention that he is a master of presentation management, a skilled presentation artist, such that one never quite knows what to make of any single outrageous or scary statement. This is not to scrub him of all psychiatric or psychological problems, but much of what he says is for public consumption. My point here is that he may be chameleon-like and therefore difficult to pigeonhole into a single category. The entire list of personality disorders is often hijacked as a way of expressing moral disapproval of a person. The noted German philosopher–psychiatrist Karl Jaspers, in discussing abnormal personalities, which he considers as variants of human nature and not indicative of sickness, describes one type of abnormal personality as craving “to appear, both to themselves and others, as more than they are and to experience more than they are ever capable of. The place of genuine experience and natural expression is usurped by a contrived stage-act, a forced kind of experience” (Ref. 13, p 443). Descriptive labels change over the decades, but the basic condition is recognizable.

In summary, this book addresses two publicly noted deficits. One the lack of learned psychiatric commentary on the nature of Mr. Trump's dramatically unpresidential, mercurial, and troubling behaviors and his fitness to serve as president. The second is the lack of a substantial challenge to the APA's Goldwater Rule, which seems to stifle psychiatrists from publicly commenting on his mental state. There has been excellent and thoughtful commentary on Mr. Trump from a variety of journalists, public intellectuals both liberal and conservative, and others, but our profession has been largely silent as a result of the Goldwater Rule. Dr. Lee, in this edited book has moved psychiatry into the public forum and, in doing so, has issued a challenge to the APA to open these critically important questions to public debate.

## Footnotes

*   Disclosures of financial or other potential conflicts of interest: None.

*   © 2018 American Academy of Psychiatry and the Law

## References

1.  1.American Psychiatric Association: The Principles of Medical Ethics with Annotations Especially Applicable to Psychiatry. Washington, DC: American Psychiatric Association, 2009 Revised Edition
    
    

2.  2.Davis JH, Stolberg SG, Kaplan T: Trump alarms lawmakers with disparaging words for Haiti and Africa. New York Times, Thursday January 11, 2018, p 1
    
    

3.  3.Lieberman J: The dangerous case of psychiatrists writing about the POTUS's mental health. Psychiatr News. November 15, 2017. [Psychnews.psychiatryonline.org/doi/full/10.1176/appi.pn.2017.11b13/](http://Psychnews.psychiatryonline.org/doi/full/10.1176/appi.pn.2017.11b13/). Accessed December 11, 2017
    
    

4.  4.Moran M: AMA goes beyond ‘Goldwater Rule’ in ethics guidelines on media interaction. Psychiatr News December 15, 2017
    
    

5.  5.Ahmed A: A ban by any other name. J Am Acad Psychiatry Law 44:226–35, 2016
    
    [Abstract/FREE Full Text](http://jaapl.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6NToiamFhcGwiO3M6NToicmVzaWQiO3M6ODoiNDQvMi8yMjYiO3M6NDoiYXRvbSI7czoyMDoiL2phYXBsLzQ2LzIvMjY3LmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

6.  6.Kroll J: APA's Goldwater Rule: Ethics of Speaking Publicly about Public Figures. Annual Meeting of the Association for the Advancement of Philosophy and Psychiatry. Washington, DC, May 3, 2008
    
    

7.  7.Kroll J, Pouncey C: The ethics of APA's Goldwater Rule. J Am Acad Psychiatry Law 44:226–35, 2016
    
    [Abstract/FREE Full Text](http://jaapl.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6NToiamFhcGwiO3M6NToicmVzaWQiO3M6ODoiNDQvMi8yMjYiO3M6NDoiYXRvbSI7czoyMDoiL2phYXBsLzQ2LzIvMjY3LmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

8.  8.MacIntyre A: After Virtue. Notre Dame, IN: University of Notre Dame Press, 1984
    
    

9.  9.American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders. Third Edition. Washington, DC: American Psychiatric Association, 1980
    
    

10. 10.Davidson JRT, Connor KM, Swartz M: Mental illness in US Presidents between 1776 and 1974: a review of biographical sources. J Nerv Ment Dis 194:47–51, 2006
    
    [CrossRef](http://jaapl.org/lookup/external-ref?access_num=10.1097/01.nmd.0000195309.17887.f5&link_type=DOI) 
    
    [PubMed](http://jaapl.org/lookup/external-ref?access_num=16462555&link_type=MED&atom=%2Fjaapl%2F46%2F2%2F267.atom) 
    
    [Web of Science](http://jaapl.org/lookup/external-ref?access_num=000234610400008&link_type=ISI) 

11. 11.Ellis JJ: American Sphinx: The Character of Thomas Jefferson. New York, NY: Random House, 1997
    
    

12. 12.Morris E: Theodore Rex. New York, NY: Random House, 2002
    
    

13. 13.1.  Max Hamilton
    
    Jaspers K: General Psychopathology. Translated by Max Hamilton. Manchester, UK: Manchester University Press, 1913/1963