by Bandy X. Lee
Conclusion
Donald Trump’s presidency confronts the psychiatric profession and, much more important, our country with the challenge of dealing with an elected leader whose psychological style (marked by impulsivity, insistence on his own infallibility, vengeful retaliation, and unwarranted certainty in uncertain circumstances) is a profound impediment to sound decision making and presages the erratic and ill-considered exercise of enormous power.
Leonard L. Glass, M.D., M.P.H. is a psychiatrist and psychoanalyst in Newton, Massachusetts. He is an associate professor of psychiatry (part time) at Harvard Medical School and a senior attending psychiatrist at McLean Hospital. Dr. Glass was president of the Boston Psychoanalytic Society and Institute and was a Distinguished Life Fellow of the American Psychiatric Association until he resigned in protest of the Goldwater rule in April 2017. He has written professionally about ethics, the psychology of men, psychiatric risks of large groups, and boundary issues in psychotherapy. He has also authored popular articles about road rage and spectator violence at sporting events.
ON SEEING WHAT YOU SEE AND SAYING WHAT YOU KNOW
A Psychiatrist’s Responsibility
HENRY J. FRIEDMAN, M.D.
Can experienced psychiatrists well trained in both psychiatry and psychoanalysis and seasoned by decades of clinical work actually turn off their powers of observation? And if they could, why would they choose to do so? As important, why should the public be deprived of our expertise? These are relevant and necessary questions to ask before exploring the question of how to process the experience of being exposed to President Donald Trump in the media. Such a series of questions and concerns would be entirely unnecessary were it not for the position taken by the American Psychiatric Association that insists it is unethical for psychiatrists to comment on or diagnose a public figure such as President Trump unless you have seen him in your office. There is a certain irony in this position because if, as a psychiatrist, you examined him in person, you would be prohibited, by ethical standards of confidentiality, from revealing anything about his diagnosis without his permission to do so, even if you had concluded that he was in some way unfit for office.
The American Psychiatric Association came to the Goldwater rule after Fact Magazine had surveyed psychiatrists, asking them to diagnose Barry Goldwater, who was running for the presidency against Lyndon Johnson in 1964. A majority of those responding felt that Goldwater’s endorsement of the use of nuclear weapons in the Cold War with the Soviet Union justified giving him a diagnosis of paranoia (even paranoid schizophrenia) in some form or another. This fact alone was felt to be sufficient for many to use this diagnosis in responding to the question asked by the magazine. Goldwater successfully sued the magazine for libel; the resulting panic and concern expressed in the APA’s adoption of the Goldwater rule was understandable at the time but would certainly have been expected to be modified in response to the very different world that has evolved since the early 1970s. Changes in the world of media, such as the presence of cable news with its 24/7 cycle of reporting and broadcasting visual images of events and leaders, should have led, in my opinion, to the abandonment of the Goldwater rule. Instead, the Ethics Committee of the APA decided, without polling the members, to double down on the Goldwater rule by extending it beyond the realm of diagnosis to include any and all comments on the mental functioning of this or any president or prominent public figure.
In addition to changes in the availability of coverage on TV, there has been an evolving use of phone and Skype in the distant treatment of patients in both psychotherapy and psychoanalysis. Many contemporary psychiatrists no longer feel that their patient must be present in the consulting room with them. While clinicians vary in their comfort and experience with phone and Skype therapies, there is a definite trend toward these modalities as essential if one is to conduct a full-time practice and extend treatment into underserved areas. This shift in attitude toward “remote” treatment conducted through previously untried communication methods is relevant to why commenting on President Trump’s mental function feels not only comfortable but necessary.
Because of the constant exposure to Donald Trump on TV news and his open expression of his thinking in rapidly expressed tweets and a multitude of other extemporaneous, unscripted remarks, a trained observer cannot avoid noting the style of his thinking and his reaction to the existence of frustrating realities that challenge his version of events. In this regard, observations about President Trump require some professional clarification concerning the concepts of paranoid thinking and character. The applicability of these concepts to the president can be considered by the nonclinical observer, thus facilitating a more enlightened, critical-thinking public better capable of acting in its interest.
Paranoid thinking, when persistent, is indicative of a paranoid character structure. This means that an individual with such a basic character will consistently produce ideas and responses that find exaggerated danger and malevolent intent in others and in the situations he encounters. The major totalitarian leaders of the twentieth century have all manifested paranoid thinking. Their destructive behavior has been an enactment of their disturbed ideation. Inevitably we have watched as such individuals have taken over entire countries, always acting to increase their power by suppressing freedom of the press and media, jailing or killing the political opposition, and militarizing their political power. Hence, the resemblance between Hitler and Stalin with regard to the senseless murder of millions of people for reasons of pure paranoid-based ruthlessness once they had entered the leader’s mind as “enemies of the people.”
When attention is called to the resemblance between Hitler and Trump, it tends to elicit a veritable storm of objection. Those who object so strongly are, in effect, calling attention to Hitler’s actions in immediately taking over the press and arresting or killing his opposition. While it is true that the restraints operating in our country have prevented Trump from moving as swiftly as Hitler did, this can be attributed to the balance of powers and the greater strength of our democratic traditions rather than to any sense that Trump’s patterns of emotional thinking are greatly different from those that motivated Hitler.
The totalitarian mind is remarkably reproducible because it depends upon paranoid ideation presented in a dramatic fashion designed to mobilize both fear and hate, particularly in the less well-educated citizens. Trump, like Hitler, began with his insistence on identifying the United States as in decline, a decline, in Trump’s case, caused by our first African American president, who, according to Trump, had left our country in a mess, an “American carnage.” This, despite the actual spectacular record of President Obama in saving the economy after the crash of 2008, preventing the worst recession from becoming another Great Depression, the extension of health care to the poor and middle class, and the general spreading of enlightened attitudes toward minorities and women.
The insistence that grave danger exists in reality because it exists in one’s mind is the hallmark of the dictator. For Hitler, the Jews represented an existential threat; for Trump, it is illegal immigrants and Mexicans in particular. Also, the disregard for facts, the denial that “factualization” is a necessity before making an assertion of danger or insisting on the nefarious intent of a large group (i.e., the Jews for Hitler, the Muslims for Trump) is typical of paranoid characters who need an enemy against whom to focus group hate.
Many critics of Trump, particularly journalists but also those in the mental health field, have focused on his so-called narcissism, his need to be constantly approved of, the childlike nature of his character. In this they are minimizing the significance of his paranoid beliefs and, in so doing, are relegating his psychological dysfunction to a much higher level than is actually the case. This is also true of those who believe he is simply using his attack on illegal immigrants and Muslims to feed his base. In doing so, they are suggesting that he himself knows better, that he knows that he is merely using these ideas because
they will appeal to the white working-class men who make up the bulk of his voters. Yet, this overlooks and minimizes the more ominous probability: that he actually is paranoid and that there is an overlap of his personal hatreds and those of his followers. Together, they represent a desire to undo the impact of all that has changed since Franklin Delano Roosevelt, the New Deal, and the general liberalization of society and life in the United States.
Progress within our liberal democracy can hardly be said to have been rapid. Rather, it has been slow, coming in bursts of activity followed by the integration of the change, but that integration has always been opposed by those who found the particular change unacceptable. The civil rights movement established a new identity for African Americans, one in which they refused to accept a designation as inferior individuals expected to be treated as second-class or lesser citizens. Their ability to use passive resistance and marching to achieve recognition of their right to equal status was furthered by the registration of black voters against local resistance and the establishment of their votes as a powerful determinant in both state and national elections. The combined power of African American, women, and liberal voters resulted in the election of the first African American president, a result that led many liberals, including President Obama, to believe that the United States had at last arrived at a postracial position as a society. Unfortunately, this proved to be anything but the case. Instead of proving to be the sign of decreased racism, the very fact of a black man in the White House appeared to generate a degree of hatred and resistance to President Obama that was, if anything, a grim reminder of the legacy of slavery and the split in the United States between the North and the South that has never come close to actually healing or even scarring over.
In his successful campaign to capture the Republican Party nomination, candidate Trump used the racism of the white working class to engage their enthusiastic support by attacking each of the other Republican candidates in terms never seen before in such a competition. Mostly, however, he depended upon his populist appeal to his followers’ discontent and disdain for the establishment. What tended to get lost even in the process of securing the nomination was his ability to make things up and, at the same time, to believe them himself. Trump managed a variation on Descartes’s “I think, therefore I am”: “I think it, therefore it is.” This reckless relationship to reality on Trump’s part has continued to represent a reliably occurring part of his character; no fact that he believes to be true, often after reading it on some alt-right website, is fact-checked or questioned. This form of grandiosity is part of the paranoia that clearly dominates Trump’s thinking.
Am I making a diagnosis of President Trump? Well, yes and no—and even maybe—but whatever it is I am doing, there is one thing that I am refusing to do: to deny what I am hearing and seeing coming from Trump himself on the TV news and in the printed reliable press. The effort on the part of CNN, MSNBC, the New York Times, and the Washington Post to keep the public informed about Trump and his administration has undoubtedly been a crucial element in preventing him from doing more harm, from going the really radical route of Hitler. Hence, his attack on the press, accusing real reporting of facts as being “fake news,” is an attenuated version of the more extreme takeover of the media that is usual in totalitarian governments. Trump hasn’t been able or willing to seize the news media and close them down, but he has tried by insisting that those who question his campaign’s involvement with the Russian interference with our election are refusing to accept that there is no basis for investigating this possibility. Some reporters, such as Thomas Friedman, Rachel Maddow, and Lawrence O’Donnell, have suggested that Trump is “crazy.” Recently, in relationship to his firing of FBI director James Comey, many have made the observation that President Trump is “unhinged.” These descriptions are made by intelligent nonpsychiatrists who are limited in using such terms to describe their impression of the man and his thinking. Donny Deutsch on Morning Joe actually spoke out against the Goldwater rule and asked when the psychiatrists were going to comment on what they see in watching President Trump. Deutsch emphasized the need to ignore the Goldwater rule in favor of supporting those who correctly doubt that Trump’s mental state is compatible with the office he currently inhabits.
A paranoid, hypersensitive, grandiose, ill-informed leader such as Donald Trump, who has surrounded himself with a Cabinet and a set of advisers who either are unable to bring him out of his paranoid suspicions and insistences or, worse, identify with his positions, represents a multidimensional threat to our country and the world. The most common concern I hear from my patients is that Trump’s impulsivity will result in a nuclear war with North Korea. The intensity of this concern tends to mask an awareness of what has already begun in the United States, namely, an erosion of the just and decent society that has been evolving since FDR’s New Deal. That society reached the pinnacle of decency under the presidency of Barack Obama, a leader who personified what it means to be a stable leader of a great and powerful nation. Trump’s need to destroy everything that Obama achieved derives from the paranoid character’s hatred of goodness in others whose achievements he cannot attain, understand, or tolerate. This degree of destructiveness in any individual makes him a poor candidate for therapy of any sort. The goodness of any therapist, his or her competence, and his or her ability to provide needed responsiveness can and will be targeted for destruction. Treating such individuals is always arduous and rarely effective, and yet they often present when in trouble as motivated to receive help. Once they have managed to solve the problem that has brought them to therapy, they quickly reveal a lack of investment in the therapy or the therapist.
This brings us to the question of analyzing President Trump from a distance; is it possible, is it ethical, and who is to decide this issue? In particular, does the stance of the APA, with its newly minted version of the Goldwater rule, prevent a psychiatrist-psychoanalyst from attempting such an analysis? A classical psychoanalyst would scoff at the idea that any psychoanalysis could be done from a distance, whether by telephone or by Skype. For such an analyst, both analyst and analysand must be present in the consulting room, so that observations of the patient who is practicing free association can be made continuously. The unconscious is to be found and interpreted to the patient at the moment of interaction. Judged by the criteria of classical psychoanalysis, no analysis of candidate or President Trump is possible. But taken from the perspective of an interpersonal or relational psychoanalyst, it is possible to think psychoanalytically about him only from a distance. Because of the unlikely possibility that Trump could form a significant attachment to a therapist, we need to see him as a fit subject for descriptive reflection rather than treatment of any kind; we need to believe what we see in all that he reveals to us without hesitation or inhibition. As important, we need to emphasize that these revelations cannot be normalized; nor will they change. Trump challenges us with the question “Are you going to believe me, or are you going to believe your lying eyes?”
Whatever Trump thinks at the moment is translated into tweets or speech with no regard for linking his idea with any previously stated idea or with any context that should be obviously relevant to what he is now asserting. He may be beyond the scope of even the most broadly defined idea of applied psychoanalysis, but what he does gives us ample access to is his characteristic style of responding to others who oppose him. His critics often treat him as if he were childish—that is, were merely acting like a child rather than a mature adult—suggesting that, as a child, he can still “grow up.” The problem with such an approach is that it is a manifestation of wishful thinking, and it is incorrect in that it grossly underestimates the importance of Trump’s adult paranoid character with its belief in an apocalyptic vision of a weak, diminished United States that only he can save from the liberal Democrats who oppose his authority. Any attempt to “understand” Trump from the perspective of his childhood or of what he is reenacting from the past is, i
n all probability, a hopeless and unnecessary task. Character formation of the paranoid typology becomes so autonomous that, once it has solidified, it is practically meaningless to try to find an explanation for its existence in a particular individual.
Ultimately, the response to the Trump administration will have to come from the electorate. All the policies that he wants to promote may not in themselves be absolutely ruinous to our country. The poor and disenfranchised will undoubtedly suffer, but the real danger will be from the president’s paranoid character, which will continue to be present and active for as long as he is in office. Perhaps the observations of this psychiatrist-psychoanalyst, and of others in the mental health field, will help clarify why the threat of President Trump exceeds the issue of his policies, and resides instead in his core paranoid personality. When, as a psychiatrist, I watch commentators and reporters struggling to understand or explain President Trump’s latest irrational position—as when he lies about when and why he decided to fire James Comey or the claimed details of his exchanges with Comey before the firing occurred—I wish that I could help them understand his paranoid character and why there should be no surprise that Trump has behaved in this way. They should be prepared to witness many more situations in which Trump feels betrayed and turns on those who have previously served him. Paranoids are always finding betrayal in those surrounding them, and react with retaliatory anger—Hitler and Stalin, by murdering their newly minted enemies; and Trump, by firing them. Psychiatric knowledge and terminology will save reporters and the public from remaining confused and attempting to find explanations of behavior that could easily be understood if Trump’s paranoid character were always kept in mind. This is the only way to ensure the preservation and viability of our democracy and our national security.
Henry J. Friedman, M.D., is an associate professor of psychiatry, Harvard Medical School (part time), on the editorial boards of Psychoanalytic Quarterly, the American Journal of Psychoanalysis, and the Journal of the American Psychoanalytic Association, with main interests in the therapeutic action of psychoanalysis and analytic psychotherapy. Friedman is also chair of the “Meet the Author” at the biannual meetings of the American Psychoanalytic Association.