by Bandy X. Lee
The Social, the Personal, and the President
Our culture tends to put the social and the personal in opposition. Echoing the tradition of the “self-made man,” or Governor Romney’s campaigning about “job creators,” President Trump himself has bristled at suggestions that his business accomplishments are not wholly of his own doing. Consider, too, the scorn of many for Hillary Clinton’s book title It Takes a Village, and contrast that title with Nancy Reagan’s admonition to “Just say ‘no.’” But a major trend in social and behavioral science of the past decades is toward an integration of the development and behavior of the individual with the contexts of culture, community, family, neighborhood (e.g., Fisher 2008). Among numerous examples, living in a neighborhood with only fast-food outlets and no supermarkets raises one’s chances of being obese far more than living in a neighborhood with only supermarkets, even after controlling for important factors such as education, ethnicity, and income (Morland, Diez Roux, and Wing 2006). Similarly, after controlling for other characteristics, community violence is associated with numbers of individuals with asthma and with the frequency of their problems with the disease (Wright et al. 2004; Sternthal et al. 2010). Thus, our social and community contexts have real impacts on our behavior and health. Key, however, to this perspective is recognition of the reciprocal nature of influence; just as the community may influence the family, so the family may influence the community, and the individual may influence both.
The interaction of the personal and the contextual can be seen in President Trump’s often-alleged narcissism and heightened sensitivity to personal insult. A common effect of these is an erosion of social connections as slights lead to aggressive responses that drive others away. The contrast with President Kennedy’s assembly of advisers during the Cuban Missile Crisis is not between one who is socially well connected and one who is socially isolated. President Trump clearly has a number of friends and social contacts. How his personal characteristics may limit the nature and variety of the advice he receives, however, may be a major difference. According to Robert Kennedy’s memoir, if President Kennedy became aware that some with alternative views had been excluded from meetings, he would often “enlarge the meetings to include other options … President Kennedy wanted people who raised questions, who criticized, on whose judgment he could rely, who presented an intelligent point of view regardless of their rank or viewpoint.”
The apparent extent of President Trump’s narcissism has drawn increasing attention. In varied meetings and interviews, his preoccupation with and exaggeration of the size of his Electoral College victory, his claims that voter fraud accounted for Secretary Clinton’s popular vote margin of over 3 million, and his claims about the size of the crowd at his inauguration have been remarkable. Central to narcissism is the self-referential defense. In response to strong condemnation of his sharing highly classified intelligence information with Russian foreign minister Lavrov and Russian ambassador Kislyak, his first tweet read, “As President I wanted to share with Russia … which I have the absolute right to do, facts pertaining…” Noteworthy is the primacy in the tweet of his role “as President” and his “absolute right.” Closely related, too, is the attention to power. Commenting on the choices to disclose top-secret information to the Russians, to be the first to congratulate President Erdogan for a disputed election victory that shrank democratic processes in Turkey, and to praise and invite to the White House President Duterte, widely blamed for thousands of extrajudicial killings in the Philippines, political commentator and journalist Eugene Robinson (2017) summarized it well: “He conflates power with virtue.”
Reflecting the interplay of personal and social, narcissistic concerns for self and a preoccupation with power may initially shape and limit those invited to the narcissistic leader’s social network. Sensitivity to slights and angry reactions to them may further erode it. Those left tend to be indulgent of the individual and to persist for other gains. Either way, the advice and counsel they provide are liable to be guided by their motives for persisting. Also, those who remain are likely to be constrained lest ill-considered words create a rift that distances them and compromises the gains they anticipate. A disturbing feature of this kind of dynamic is that it tends to feed on itself. The more the individual selects those who flatter him and avoid confrontation, and the more those who have affronted and been castigated fall away, the narrower and more homogenous his network becomes, further flattering the individual but eventually becoming a thin precipice. President Nixon, drunk and reportedly conversing with the pictures on the walls, and praying with Henry Kissinger during his last nights in office, comes to mind.
The shrinking of the network to those most loyal in spite of affronts and exploitative treatment applies to the relationships of the office of the president with national and international allies. A number of commentators have suggested that Republicans in the House of Representatives who voted for a new health care bill in early May 2017 would have given President Trump an opportunity to claim an accomplishment around the end of his first one hundred days in office, while giving themselves major problems in their reelection campaigns in 2018. So, too, much has been written about the international importance of trust in the president’s words. Especially as his own and his advisers’ descriptions of the firing of FBI director Comey have collided, and after his sharing of highly classified intelligence information with the Russian foreign minister and ambassador to the United States, writers have questioned the ability of President Trump to draw allies together in a major crisis if they are untrusting of his assurances or his characterizations of events. Writing in 1967, Robert Kennedy anticipated much of this concern:
[H]ow important it was to be respected around the world, how vital it was to have allies and friends. Now, five years later, I discern a feeling of isolationism in Congress and through the country, a feeling that we are too involved with other nations, a resentment of the fact that we do not have greater support in Vietnam, an impression that our AID program is useless and our alliances dangerous. I think it would be well to think back to those days in October, 1962.
Kennedy goes on to recount the importance of the support from the Organization of American States, the NATO allies, and critical countries in Africa (Guinea and Senegal), from which Russian planes might have delivered arms to Cuba, circumventing the quarantine. The trust and affirmation of all of these “changed our position from that of an outlaw acting in violation of international law into a country acting in accordance with … allies.”
The narcissism that is central to the shrinking networks of those who seek blind loyalty and flattery in their relationships leads also to a preoccupation with the credit and praise received. President Trump’s preoccupation with his election or the size of his inaugural crowd contrasts sharply with President Kennedy’s stance at the end of the thirteen days:
After it was finished, he made no statement attempting to take credit for himself or for the Administration for what had occurred. He instructed all members of the Ex Comm and government that no interview should be given, no statement made, which would claim any kind of victory. He respected Khrushchev for properly determining what was in his own country’s interest and what was in the interest of mankind. If it was a triumph, it was a triumph for the next generation and not for any particular government or people.
A fitting end to this chapter draws on the concluding words of Robert Kennedy’s Thirteen Days: “At the outbreak of the First World War the ex-Chancellor of Germany, Prince von Bülow, said to his successor, ‘How did it all happen?’ ‘Ah, if only we knew,’ was the reply.” Delicate are the dynamics and nuanced are the judgments that may keep the world safe or plunge it into the abyss. We are currently led by a man broadly flawed in his own person and supported by a truncated set of advisers. As the breadth and “vigor”—to use a word JFK favored—of advice sought by Kennedy in 1962 contrasts with that reported to surround President Trump, so the personal characteristics of
President Trump leave us alarmed over the prospect of his narrowing further his network of advisers, leaving him few on whom to rely. The impulsive, ill-considered, narcissistic, reckless, and apparently intentional lies, threats, and bravado not only damage the country but may leave the president even more isolated. That President Trump might ever occupy the loneliness of deciding about a potentially catastrophic course of action is rightly our most urgent and greatest fear.
Coda
Apart from the contrasts drawn here, several similarities in their backgrounds and personal characteristics almost make Presidents Kennedy and Trump something of a natural experiment. Both of their fathers were highly successful in business, men who sometimes worked on both sides of the border of legality. Both were born to privilege. Both went to “the best schools.” Both, apparently, were “womanizers,” but also apparently cared much for their families. These similarities, along with the many contrasts in their behavior, point to the uncertainty in our understanding of all these matters. That uncertainty, however, leads us back to the wisdom of focusing on the actual behavior in question. Wisdom from the fields of psychology and medicine can illuminate our understanding of these problems, their social and personal sources, and the likelihood that they may change or be tempered by events, but judgment of them rests with us all.
Edwin B. Fisher, Ph.D., is a clinical psychologist and a professor in the Department of Health Behavior in the Gillings School of Global Public Health at the University of North Carolina at Chapel Hill. He is a past president of the Society of Behavioral Medicine and editor of Principles and Concepts of Behavioral Medicine: A Global Handbook (Springer, 2017). In addition to community and peer support in health and health care, asthma, cancer, diabetes, smoking cessation, and weight management, he has written on concepts of psychopathology, including depression and schizophrenia, and on the relationships between mental illness and physical disease.
Acknowledgments
Thanks to Rebecka Rutledge Fisher, Ruth Salvaggio, Kathryn Skol, Barbara and Richard Vanecko, and to the editor, Bandy Lee, for their helpful comments on a preliminary draft.
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HE’S GOT THE WORLD IN HIS HANDS AND HIS FINGER ON THE TRIGGER
The Twenty-Fifth Amendment Solution
NANETTE GARTRELL, M.D., AND DEE MOSBACHER, M.D., PH.D.
In 1994, President Jimmy Carter lamented the fact that we have no way of ensuring that the person entrusted with the nuclear arsenal is mentally and physically capable of fulfilling that responsibility (Carter 1994). Throughout U.S. history, presidents have suffered from serious psychiatric or medical conditions, most of which were unknown to the public. A review of U.S. presidential office holders from 1776 to 1974 revealed that 49 percent of the thirty-seven presidents met criteria that suggested psychiatric disorders (Davidson, Connor, and Swartz 2006). For example, Presidents Pierce and Lincoln had symptoms of depression (Davidson, Connor, and Swartz 2006); Nixon and Johnson, paranoia (Glaister 2008; Goodwin 1988), and Reagan, dementia (Berisha et al. 2015). President Wilson experienced a massive stroke that resulted in severely impaired cognitive functioning (Weinstein 1981). Although military personnel who are responsible for relaying nuclear orders must undergo rigorous mental health and medical evaluations that assess psychological, financial, and medical fitness for duty (Osnos 2017; Colón-Francia and Fortner 2014), there is no such requirement for their commander in chief.
Over the course of the U.S. 2016 presidential campaign, it became increasingly apparent that Donald Trump’s inability or unwillingness to distinguish fact from fiction (Barbaro 2016), wanton disregard for the rule of law (Kendall 2016), intolerance of perspectives different from his own (DelReal and Gearan 2016), rageful responses to criticism (Sebastian 2016), lack of impulse control (“Transcript” 2016), and sweeping condemnations of entire populations (Reilly 2016) rendered him temperamentally unsuitable to be in command of the nuclear arsenal. When Mr. Trump became the president-elect, we, as psychiatrists, had grave concerns about his mental stability and fitness for office. Despite the claim by gastroenterologist Dr. Harold Bornstein that Mr. Trump “will be the healthiest individual ever elected to the presidency” (Schecter, Francescani, and Connor 2016), there
is no evidence that Mr. Trump has ever received psychological testing or a neuropsychiatric examination. In fact, there is no evidence that any prior president completed such an evaluation before assuming the duties of office.
On November 10, 2016, we received a call from our psychiatrist friend and colleague Judith Herman, M.D., who shared our concerns about Mr. Trump’s grandiose, belligerent, and unpredictable behavior. She proposed that we send a private letter to President Obama outlining our observations, and recommending an impartial psychiatric evaluation of the president-elect. We agreed that such an assessment was warranted as a matter of national security. Dr. Herman offered to draft the letter. Each of us took responsibility for contacting colleagues who might be interested in cosigning.
The three of us have been allies since the early 1980s. As members of the Harvard Medical School faculty, Dr. Herman collaborated with Dr. Gartrell on national studies of sexually abusive physicians, and on mental health projects for the American Psychiatric Association. We knew that we could count on one another to be efficient and ethical.
At the end of November, the letter was sent to President Obama, stating that Mr. Trump’s “widely reported symptoms of mental instability—including grandiosity, impulsivity, hypersensitivity to slights or criticism, and an apparent inability to distinguish fantasy from reality—lead us to question his fitness for the immense responsibilities of the office” (Greene 2016). We also strongly recommended that the president-elect receive a “full medical and neuropsychiatric evaluation by an impartial team of investigators.”
We heard nothing from the White House. On December 16, Drs. Gartrell and Mosbacher were contacted by a journalist asking if we knew of any mental health professionals who would be willing to comment on Mr. Trump’s psychiatric conditions. The three of us decided that we were willing to take the step of sharing our letter, in the interest of placing our recommendation in the public discourse. The journalist asked our permission to circulate the letter, and the next thing we knew, it was published in the Huffington Post (Greene 2016). It went viral (Pasha-Robinson 2016). The coverage seemed to reflect a sense of foreboding that Mr. Trump’s erratic behavior represented a danger to the world order (Pasha-Robinson 2016; “Grave Concerns” 2016). We declined all requests for further comment, since most journalists wanted us to specify psychiatric diagnoses for the president-elect, even though we had not personally evaluated him.