"The issue that we are raising is not whether Trump is mentally ill. It is whether he is dangerous. Dangerousness is not a psychiatric diagnosis." So writes psychiatrist James Gilligan in his contribution to the new book, "The Dangerous Case of Donald Trump: 27 Psychiatrists and Mental Health Experts Assess a President," edited and introduced by Dr. Bandy Lee, a professor of law and psychiatry at Yale School of Medicine.
The book grew out of the Yale "Duty to Warn" Conference, which Lee organized in April, after which she was contacted by almost a thousand mental health practitioners. (See Salon interview with Lee here.)
Gilligan's distinction is crucial in at least two important ways: first, in how it directs our attention and second, in how it defines our concerns. Rather than focusing attention on Trump personally, in isolation, it highlights the situation of his presidency and how he got there. That focus includes those who are endangered and the nature of the dangers involved, as well as those who actively support Trump or passively enable him. Rather than concerning itself with diagnosing the president at a distance, the primary concern here is public health.
At the close of her introduction, Lee makes this point explicitly, "In spite of its title," she writes, "I would like to emphasize that the main point of this book is not about Mr. Trump. It is about the larger context that has given rise to his presidency, and the greater population that he affects by virtue of his position." In a similar spirit, I want to write about this book — choosing a few selective examples — to situate within a larger process of how we cope with Trump, and with the forces that have made his rise to power possible.
As Lee explains, the book is divided into three parts. The first is devoted to describing Trump, "with an understanding that no definitive diagnoses will be possible," the second "addresses the dilemmas that mental health professionals face in observing what they do and speaking out when they feel they must," and the third speaks to the societal effects Trump has already caused "and could cause in the future."
In fact, all three parts of "Dangerous Case" inevitably touch on the full range of concerns. Trump could not be described — nor would many be interested — absent his public role, and the power he wields. Concerns about how professionals should respond make no sense without reference to Trump himself and those he threatens. Trump's societal effects can't be separated from his behavior, nor can mental health experts write about them coherently, without considering the ethical imperatives as well as the challenges involved.
The stage is set in the foreword, "Our Witness to Malignant Normality," by renowned psychiatrist, psychohistorian and author Robert Jay Lifton, whose numerous books include "The Nazi Doctors: Medical Killing and the Psychology of Genocide," "Death in Life: Survivors of Hiroshima" and "Home From the War: Vietnam Veterans — Neither Victims nor Executioners." Lifton frames the task of psychological professionals in terms of two themes: First, what he calls "malignant normality, which has to do with the social actuality with which we are presented as normal, all-encompassing, and unalterable; and second, our potential and crucial sense of ourselves as witnessing professionals."
Malignant normality was an idea Lifton developed in his study of Nazi doctors. "Some were upset, even horrified" at what was required of them, he notes. "Yet, with a certain amount of counseling — one can call it perverse psychotherapy — offered by more experienced hands, a process that included drinking heavily together and giving assurance of help and support, the great majority could overcome their anxiety sufficiently to carry through their murderous assignment." This adaptation to and normalization of evil was an extreme example but has echoes closer to home, he notes, pointing to the torture protocols engaged in by psychiatrists and psychologists under the rubric of “enhanced interrogation” during the Bush administration.
"I am not equating this American behavior with the Nazi example," he writes, "but, rather, suggesting that malignant normality can take different forms. And nothing does more to sustain malignant normality than its support from a large organization of professionals." That's why it's important for mental health professionals to speak out, to act as witnessing professionals. It's also important for journalists to inform themselves of these mental health issues in order to act as witnessing professionals themselves, rather than being complicit in the spread of malignant normality.
The "Goldwater rule": Largely beside the point
Psychiatrists are constrained by the American Psychiatric Association's 1973 "Goldwater rule," which essentially gags its members from publicly diagnosing someone without having professionally interviewed them and gained their permission. Discussions of the Goldwater rule figure prominently in part 2 of "Dangerous Case." One contributor suggests possibly suspending the rule, but there's a broad consensus that it shouldn't be allowed to silence professionals, especially since there's an equally compelling contrasting piece of guidance, the "duty to warn" from the 1976 Tarasoff decision by the California State Supreme Court. The American Psychoanalytic Association, by the way, has no such rule, as affirmed in a letter in July stating that the group "does not consider political commentary by its individual members an ethical matter."
One can arguably observe both responsibilities — which is exactly what this book tries to do. Trump's behavior patterns are discussed, even characterized, but that stops well short of a formal diagnosis. As contributor John Gartner notes, "Trump’s is a genuinely complex case," and multiple different behavior patterns can be observed, drawing on different conceptual frameworks. None claims to offer a clinical diagnosis. The patterns they describe help make sense of the president's public actions, which have so often involved threatening or dangerous behavior.
But plenty of experts are not bound by the Goldwater rule, and cannot be expected to abide by it, because it simply makes no sense for their roles and responsibilities. As one contributor, Craig Malkin, notes, some people are "already trained to provide functional and risk assessments based entirely on observation — forensic psychiatrists and psychologists as well as 'profilers' groomed by the CIA, the FBI, and various law enforcement agencies. They spend their whole lives learning to predict how people behave." The Goldwater rule would be nonsensical applied to them, if not completely incapacitating.
Such professionals may interview subjects (or observe them being interviewed) on occassion, but this is clearly an ancillary part of what they do, and they are never in a privileged therapeutic relationship with those they assess. There are also guardianship attorneys, such as James Herb, who explains that part of his job is "to come to a preliminary conclusion about the mental incapacity of a person before I file a petition to determine incapacity." There are also those who perform such evaluations under court order, such as Diane Jhueck, who begins by noting that mental illness in a president "is not necessarily something that is dangerous for the citizenry," and may even be common — nearly half of all presidents through the 1970s showed some signs, according to one study. But dangerousness is an entirely different standard, one Jhueck and others are particularly qualified to address.
Then there those who work with victims, whose work necessarily entails developing knowledge of dangerous perpetrators in order to assist their clients. They, too, are represented in this volume, most notably Betty Teng, a trauma therapist in a Manhattan hospital. Therapists often help clients deal with abusive, destructive individuals in ways that require understanding, description and prediction without the benefit of interviews, or even first-hand observation. Several more of those are represented as well.
In short, there are many different ways in which expert psychological knowledge can help us gain a better understanding of an individual such as Trump that have nothing to do with the assumptions that gave rise to the Goldwater rule in 1973.
Gilligan notes that long before the Goldwater rule, in his 1917 essay, "Science as a Vocation," Max Weber propounded a similar view, separating social science from politics. Gilligan believes this helped create a dangerous vacuum:
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. ... Our current president does not have to be a literal reincarnation of Hitler — and I am not suggesting that he is—in order for the same principles to apply to us today. ...
One does not need to have fifty years of professional experience in assessing the dangerousness of violent criminals to recognize the dangerousness of a president who:
Asks what the point of having thermonuclear weapons is if we cannot use them ...
Urges our government to use torture or worse against our prisoners of war. ...
Urged that five innocent African American youths be given the death penalty for a sexual assault even years after it had been proven beyond a reasonable doubt to have been committed by someone else. ...
Boasts about his ability to get away with sexually assaulting women because of his celebrity and power. ...
Urges his followers at political rallies to punch protesters in the face and beat them up so badly that they have to be taken out on stretchers. ...
Suggests that his followers could always assasinate his political rival, Hillary Clinton, if she were elected president, or at the very least, throw her in prison. ...
Believes he can always get away with whatever violence he does commit....("I could stand in the middle of Fifth Avenue and shoot somebody and I wouldn't lose any voters.")
In short, it requires no expertise to see Trump's dangerousness, but experts can help us respond more wisely, more coherently and more effectively — but only if we hold up our own end. Most of the things that pundits puzzle over in Trump's behavior are not puzzles for trained psychiatrists, clinical psychologists and other related professionals. It's only a mystery if we stubbornly refuse to learn what's actually going on. Let's consider some examples.
Decoding Trump's behavior patterns
In "Extreme Present Hedonism," Philip Zimbardo (best known for the Stanford Prison Experiment) and co-author Rosemary Sword write about Trump within the framework of time perspectives (past, present or future, viewed either as positive or negative). They have written previously about his narcissism, but here they advance a less familiar but extremely valuable perspective which helps make sense of his rapid, impulsive shifts:
"An extreme present hedonist will say whatever it takes to pump up his ego and to assuage his inherent low self-esteem, without any thought for past reality or for the potentially devastating future outcomes from off-the-cuff remarks or even major decisions." Trump is, they argue, "among the most extreme present hedonists we have ever witnessed." They go on to explain the basics of "time perspective analysis" and what it tells us about Trump. In non-extreme form, present hedonism is relatively common, and even healthy among children and adolescents, they explain. That's one of many examples of the ways Trump's behavior must be seen in context to be properly evaluated.
In "Pathological Narcissism and Politics: A Lethal Mix," Craig Malkin first explains that narcissism — the feeling that one is special — isn't a diagnosis, but, to varying degrees, a part of normal everyday life. That's especially true among children and teenagers, who need some degree of overconfidence to take on the challenges of development they face. Pathological narcissism comes about when one is so addicted to feeling special that all other considerations start to fade away, bringing us into the realm of narcissistic personality disorder (NPD), the heart of which involves what Malkin calls "Triple E." Stop me if this sounds familiar:
- Entitlement, acting as if the world and other people owe them and should bend to their will
- Exploitation, using the people around them to make themselves feel special, no matter what the emotional or even physical cost to others (battering away at their self-esteem or running them into the ground with late-night work projects)
- Empathy-impairment, neglecting and ignoring the needs and feelings of others, even of those closest to them, because their own need to feel special is all that matters.
As it intensifies, Malkin writes, NPD "often blends with psychopathy, a pattern of remorseless lies and manipulation," in which empathy isn't just impaired, it's completely absent. "When NPD and psychopathy combine, they form a pattern of behavior called malignant narcissism," a term coined by psychoanalyst Erich Fromm and refined by Otto Kernberg "to describe people so driven by feeling special that they essentially see other people as pawns in their game of kill or be killed, whether metaphorically or literally."
Echoing a constant theme of the book, Malkin notes, "When it comes to the question of whether or not someone who’s mentally ill can function, danger is the key — to self or others. This is where pathological narcissism and politics can indeed become a toxic, even lethal, mix." This danger becomes manifest in what he calls "the psychotic spiral," which includes increasing paranoia, impaired judgment, volatile decision making and gaslighting. Regarding the latter, he explains:
As people with NPD become increasingly psychotic, they’re determined to convince others that they’re the “crazy” ones who can’t see reality for what it is.
Gaslighting reassures pathological narcissists that their own grip on reality remains firm because they can’t bear to acknowledge their sanity is slipping away.
In the end, Malkin asks, "If pathological narcissists, in their reality-warping efforts to feed their addiction, bring themselves to the precipice of disaster, why should we, as nations, allow them to pull us into the abyss with them?" This is the ultimate, driving question behind the book. But it's not that simple to figure out how to stop that process, is it?.
For the most part, analyses of Trump in the book's first section differ in approach and structuring of ideas more than in their conclusions. Three entries that might seem to contradict this judgment concern the question of whether Trump is "bad" – a malignant narcissist who's "crazy like a fox" – or "mad" – suffering from a delusional disorder that makes him "crazy like a crazy."
In “Why ‘Crazy Like a Fox’ versus ‘Crazy Like a Crazy’ Really Matters,” Michael Tansey argues that Trump’s outrageous lies are best explained by delusional disorder, yet in the end he leaves it up to readers to make the call. But in "Donald Trump Is: A) Bad B) Mad C) All of the Above," Gartner argues for (C), writing that "a dog can have both ticks and fleas." he writes. In "Sociopathy," Lance Dodes poses the same question: "Crazy like a fox or just crazy?" and answers, emphatically, "Yes!'"
This all reflects slightly different ways of approaching the same complex problem. But there's no reason why anyone should have to choose between these alternatives. Each provides a way of distilling decades of struggle to make sense of some of the most slippery human behavior imaginable. We don't need a single diagnosis of what's wrong with Donald Trump. We're actually better served by an ongoing dialogue of different assessments, which shed light and raise questions at the same time. The point, Tansey writes, is "not to diagnose but to educate the general public so that each person can make up his or her own informed assessment."
It isn't just about Trump
This book has so many riches in it, I've barely begun to scratch the surface. But the urgent question of how to avoid disaster demands that we find ways to focus. One particularly helpful entry in this regard is "Who Goes Trump? Tyranny as a Triumph of Narcissisim," by Elizabeth Mika. Instead of focusing narrowly on Trump, she offers a much broader view. "Tyrannies are three-legged beasts," she writes: the tyrant, his supporters and the society as a whole. Her perspective underscores how mistaken it would be to simply focus on diagnosing Donald Trump's mental problems, even if doing so weren't problematic.
In her analysis, Mika first notes that "not all dictators are tyrants. Tyrants are dictators gone bad. A leader may start as a seemingly benevolent dictator but turn into a tyrant as his reign progresses." This harkens back to Malkin's discussion of the psychotic spiral. Multiple authors in this volume offer different perspectives on why it's foolish to keep on expecting Trump to become "presidential." In fact, we should expect the opposite instead: He will become less and less "normal" because his norm is that of other tyrants he has often professed to admire: Vladimir Putin, Recep Tayyip Erdogan, Rodrigo Duterte and even — at one time, not long ago — Kim Jong-un.
Mika's analysis of the tyrant is as compelling and nuanced as any other in this book, but she breaks new ground when moving on to the subject of his followers. "The narcissistic collusion between the tyrant and his supporters is also driven by the latter's need for revenge," she writes, "for the tyrant is always chosen to perform this psychically restorative function: to avenge the humiliations (narcissistic wounds) of his followers and punish those who inflicted them."
Of course Trump's supporters are bound to be disappointed, Mika argues:
However, as the wounds often date to the supporters' personal ancient past and more often than not are perceived rather than real, the choice of the object of this vengeful punishment is not based on reality. Rather, it is based on the displacement and projection characteristic of the scapegoating process that becomes an inextricable part of the narcissistic collusion between the tyrant and his followers.
But simply blaming Trump voters is also too easy. That ignores the third leg: society as a whole.
Tyrants do not arise in a vacuum. ... It takes years of cultivation of special conditions in a society for a tyranny to take over. Those conditions invariably include a growing and unbearably oppressive economic and social inequality ignored by the elites who benefit from it, at least for a time; fear, moral confusion, and chaos that come from that deepening inequality; a breakdown of social norms; and growing disregard for the humanity of a large portion of the population and for higher values.
A broader social science view
Although formed primarily in psychological terms, the picture Mika paints here is strikingly similar to that painted by Peter Turchin in "Ages of Discord: A Structural-Demographic Analysis of American History." (Salon review here.) Turchin's theory, modified from Jack Goldstone's original form, puts population trends in tension with social structures to explain how societies pass through alternative cycles of integration and disintegration, punctuated by ages of discord in which civil wars and revolutions are likely to break out, even threatening to destroy societies as functioning wholes.
Material forces are driving factors, but Turchin stresses that the erosion of cooperative values and the rise of unbridled, even violent competition — especially among elites — are key factors that lead to social disintegration. This creates conditions in which tyrants, as Mika describes them, find room to flourish where they could not have a mere generation earlier. She writes:
In effect, we could see that the pre-tyrannical societies, whether nominally democratic or based on other forms of political organization, exhibit signs of narcissistic pathology writ large. Those involve the inevitable split into their grandiose and devalued parts, including those of the society's self-image, and a denial of their shadow, which is projected outward onto Others.
As Turchin explains, rising economic inequality first inflates the wealth and power of elites, followed by a growth in numbers which dramatically intensifies competition. This is the material underpinning of the dynamic Mika describes. Trump in his tower, descending his golden escalator to denounce Mexican "rapists," encapsulates this larger historical dynamic perfectly.
History provides no simple solution for how to extricate ourselves from this situation. But we are rapidly gaining more insight into what is going on in our society today, and this book is living proof.
The danger is not simply Donald Trump, although he may be more dangerous than any president in American history. The danger is three-legged, as Mika argues, or even systemic. It threatens to swallow us all.