Diagnosing Donald Trump

In his analysis of Donald Trump’s fitness for office, Brookings Institution fellow Robert Kagan recently wrote that “we can leave it to the professionals” to label with precision the relationship between Donald Trump’s behavior and what may be a clinically defined mental illness or personality disorder. Other commentators are less reluctant to diagnosis Mr. Trump. In his article “Donald Trump and Narcissistic Personality Disorder,” Daniel Wagner — who, to my knowledge, has no qualifications in psychology, medicine, or any related fields — makes clear his assessment. Putting it in blunt, colloquial terms, Eugene Robinson asked: “Is Donald Trump just plain crazy?”

But with a few notable exceptions, the medical community has been largely quiet on this question of genuine concern to the nation and the world. In light of his seemingly erratic, impulsive, and at times inexplicable and even menacing behavior, do mental health professionals have an ethical responsibility to weigh in?

Silence from Psychiatrists

The near-silence of psychiatrists and psychologists seems conspicuous, but they are constrained by an ethical code that grows directly out of a prior presidential election.

In 1964, Republican nominee Barry Goldwater went up against Democratic incumbent Lyndon Johnson. Fact magazine asked over 12,000 psychiatrists, “Do you believe Barry Goldwater is psychologically fit to serve as president of the United States?” Only 2,417 responded. Of those who did, 57 per cent declared him unfit.

That those 1,189 psychiatrists comprised less than 10 per cent of those surveyed was not the spin that Fact put on the story. Instead, the magazine pulled out damning diagnostic terminology used by respondents, including “paranoid,” “schizophrenic,” “obsessive,” and — a favorite of the current campaign — “narcissistic.” Those words packed a lot of punch when backed by professional credentials, especially in an era when mental health problems were shrouded in shame.

Perhaps the most scathing comments seemed to impugn Goldwater’s manhood. One anonymous psychiatrist described him as “inwardly a frightened person who sees himself as weak and threatened by strong virile power around him—and that his call for aggressiveness … is an attempt to defend himself against and to deny his feelings of weakness.” Even today, when gender roles are more fluid and expansive, this characterization of a presidential candidate would do damage — just think back to the suggestion that the windsurfing John Kerry was not just a waffler, but effete. In 1964, it was a bombshell.

Goldwater lost the election to Johnson, of course, but he did not let slide the accusations in Fact. He brought a libel suit for $2 million against the magazine’s publisher Ralph Ginzburg and editor Warren Boorson. At trial Ginzburg was asked directly if he had meant to suggest that Goldwater was homosexual. While his denial was emphatic, he asserted that Goldwater “identified with a masculine mother and a feminine father,” invoking Freudian theories of early psychosexual development and reiterating the implication that there was something abnormal in Goldwater’s psychological profile. Ultimately, however, Goldwater prevailed and won $75,000 in punitive damages.

His victory has had a lasting impact. When it first appeared, the American Medical Association (AMA) and the American Psychiatric Association (APA) immediately condemned the Fact article. In 1973, the APA issued a set of ethical guidelines that came to be known as the Goldwater Rule that govern comments to the media about the mental health of public figures. While psychiatrists can speak in broad terms about mental health questions, “it is unethical for a psychiatrist to offer a professional opinion unless he or she has conducted an examination and has been granted proper authorization for such a statement.” The American Psychological Association has a similar code of ethics.

Election 2016 and Beyond

The Goldwater Rule has been revisited perennially, but in recent months, as Trump marched toward the Republican Party’s presidential nomination, the question gained renewed urgency. In the June issue of the Journal of the American Academy of Psychiatry and the Law, Jerome Kroll and Claire Pouncey explore the history and ethical arguments for and against the Goldwater Rule.

[gpullquote]”This is a teachable moment to raise awareness and to further challenge the stigma of and beliefs about mental illness”[/gpullquote]

They argue that while it is certainly important to discourage injudicious speech against public figures, the Goldwater Rule muzzles psychiatrists who have legitimate, well-founded, and well-reasoned contributions to make to the public conversation about our political leaders. In its overzealous effort to protect the image of psychiatrists and psychiatry, the APA has silenced all psychiatrists. Kroll and Pouncey conclude that, on balance, there are “legitimate reasons for providing thoughtful education to the public and voicing psychiatric concerns as acts of conscience.”

Feeling duty bound to speak out, a handful of psychiatrists and psychologists have danced on the edge of their profession’s ethical standards. Harvard psychologist Howard Gardner described Trump as “remarkably narcissistic.” Northwestern psychologist Dan McAdams characterized Trump’s narcissism as “really way off on the extreme end,” even as he demurs to “argue that it’s a clinical condition.”

Whether or not one thinks Trump suffers from a condition that might disqualify him from the presidency, this is a teachable moment to raise awareness and to further challenge the stigma of and beliefs about mental illness. Crucially, our understanding of psychological disorders changes over time. Revelation of Democratic Vice-Presidential nominee Thomas Eagleton’s history of depression sank his candidacy in 1972; today, when our understanding of and treatment for depression has come a long way, it very well might be seen differently. When Fact implied that Goldwater might be gay, it was considered a mental disorder and a social taboo. In the medical profession and mainstream society, such beliefs are no longer held.

An understanding of where we as a society stand on the relationship between specific mental health challenges and their relationship to fitness for political office can only grow out of a frank and informed national conversation. In light of Trump’s public behavior and the lack of a psychiatric evaluation in his already questionable medical report, it is time for mental health professionals to weigh in with their professional opinions. Commentators bandying about words like “crazy” diminish what needs to be a serious and well-informed conversation. In this election and ones to come, the stakes are too high and the benefits too great to leave it to the amateurs.