A major part of my career as a practicing psychologist was diagnosing mental disorder. I assessed thousands of people, making recommendations for treatment or for security. I have, of course, followed with interest speculations in the media about the mental fitness of our president. His recent reiteration that he is a “stable genius” prompted me to comment.
In the 1964 presidential election, a number of mental health professionals expressed an opinion that Barry Goldwater was paranoid and possibly schizophrenic. Subsequently, the Goldwater Rule was imposed by the American Psychiatric Association, prohibiting public comment about a candidate’s mental status. For more than 50 years, until Donald Trump, that was accepted as appropriate ethically.
The primary issues were confidentiality and privacy to protect the mental health client. There is, however, another important principle, that of “duty to warn” the public if threatening information was revealed. That reasoning was extended to the danger presented to the country by a mentally unstable president. Many professionals spoke up, and Dr. Bandy Lee organized a conference and published a book on the subject, The Dangerous Case of Donald Trump. The focus changed from diagnosing a mental illness to assessing dangerousness.
It remains inappropriate to diagnose a mental illness without interview and testing information, but mental illness was never really the issue. Many politicians have functioned adequately despite having significant emotional problems. Dangerousness is assessed based on observable behavior.
Dr. Lee is a professor at Yale who studied dangerousness and developed violence-prevention programs for Riker’s Island jail in New York City. Along with an array of respected professionals, she concluded that Donald Trump meets the criteria for several personality disorders and may have Attention Deficit Hyperactivity Disorder as well as developing dementia.
The personality disorders can often be diagnosed based solely on personal history and behavioral observations. Most discussion centers on narcissism, and the president ticks all the boxes. It is called malignant or pathological narcissism, as opposed to the ordinary level seen in politicians, because of the severity. The severe narcissist does harm to himself and those around him. He feels entitled to special treatment, he exploits others, and he has no capacity for empathy.
He also meets the criteria for Antisocial Personality Disorder, the largest single category seen in prisons. He stands accused of numerous crimes, including sexual abuse, and displays characteristic behavior of lying and disregard for right and wrong.
Of perhaps more concern is the possibility of neurological impairment. People who know the president well say that he seems to be losing his ability to speak with subtlety and complexity. He is easily frustrated and angered. Staff report that he repeats the same stories endlessly. It is not possible to diagnose dementia without extensive interview and testing information, but he displays what may well be a progressive impairment.
Many in the mental health community feel an ethical obligation to provide this information to the public. However, there does not appear to be a political mechanism for dealing with it any time soon. The Cabinet is unlikely to pursue 25th Amendment measures, and the Senate will almost certainly not vote to remove the president from office.
Another view of Donald Trump is that most of what he does is an act. He is first of all a promoter. His bellowing, insulting style is very similar to the showmanship of professional wrestling. His incessant tweeting seems calculated to provoke distress and anxiety. Inside observers say he laughs about the outrage he provokes. Some question whether he is delusional, a potentially severe psychotic problem. Others say he is simply a very practiced liar and he enjoys it.
A diagnosis of Narcissistic or Antisocial Personality Disorder does not imply a treatable mental illness. These are descriptions of personality traits that a person learned throughout his life. Psychodynamic explanations focus on early developmental neglect or trauma. Armchair analysts speculate that Donald Trump felt pressured and unloved by his father and that his emotional development fixated in his early teenage years.
People with personality disorders can change, but most do not. Counseling or psychotherapy are of little help.Such people are usually too suspicious and manipulative to engage in therapy. Only when life circumstances crash into their belief systems do they begin to look at themselves as the problem. The term “antisocial burnout” refers to criminals who have finally given up on their fight with authority.
The warning from mental health professionals is not simply affronted liberalism. There is science to the study of dangerousness, and Donald Trump raises their concern. Narcissists can deteriorate to a psychotic level of impulsivity if sufficiently frustrated.
An interesting comparison is the case of Howard Stern, a disk jockey who built a career shocking sensibilities and challenging the system. He and Donald Trump had a bond over many years, and in fact had quite similar personal histories. Both became obsessed with gaining approval, and both used insults and bullying to accomplish that.
Recently Howard Stern says that he has changed. He came to realize that his behavior, although drawing huge ratings, alienated him from everyone close to him. He went to psychotherapy, and he now looks on his earlier antics as embarrassing.
In my work in prisons, I saw even the most dangerous people with severe personality disorders gain some level of personal insight and empathy. For Donald Trump to change will require a radical revision of his worldview. I hope, for his sake and ours, that he will.
