On the morning of February 15, 2019, President Donald Trump declared a national emergency to redirect billions in federal funds toward building a wall along the United States-Mexico border. Despite the various ethical and constitutional concerns that arose from the president’s haphazard announcement, it was his manner of delivery that seemed to dominate subsequent media coverage. His 50-minute address — riddled with contradictions, false statements, grammatical errors, and references to “winning” — was dissected by various news outlets, many of which portrayed the speech as a sign of the president’s mental instability. Vanity Fair’s Tina Nguyen called the announcement a “rambling mess,” while HBO’s “Real Time” host Bill Maher deemed it a “‘call the nursing home’ rant” and CNN political commentator Van Jones proclaimed it “psychotically incoherent.” That Trump’s mental state was at the center of this political commentary should come as no surprise. The media’s reactions to this speech are only the most recent examples of the public skepticism around the president’s mental competency that has plagued Trump since his 2016 campaign.
Not all of the discussion around Trump’s mental health has come from political commentators and media figureheads, however. Despite the regulatory safeguards put in place by medical associations to prevent mental health diagnoses from being used for partisan purposes, many mental health professionals have broken from precedent by speaking out about Trump’s mental state and what they perceive to be the risks it poses to the nation. The Dangerous Case of Donald Trump, edited by Dr. Bandy X. Lee, and the Duty to Warn association, created by Dr. John Gartner, have redefined the point at which mental health professionals feel it necessary to bring presidential mental health into the public sphere — namely, when they believe public safety is at stake. Although these professionals have faced heavy criticism for contributing to the politically fraught conversation on Trump’s mental fitness, they maintain that their choice to do so is not ideological but rather grounded in genuine concern for the wellbeing of the American public.
Historical Scrutiny of Presidential Mental Fitness
Before the rise of President Trump, the American Psychiatric Association’s Goldwater Rule had prevented unofficial diagnoses of public figures from its members for decades. The rule takes its name from 1964 presidential candidate Barry Goldwater, whose psychological fitness for office was questioned in a public poll published in Fact Magazine. The resulting discourse accused Goldwater of suffering from a range of afflictions, from schizophrenia to psychosis, though most of these claims are now believed to have been a response to his conservative political views rather than to his actual mental health.
Goldwater’s victorious opponent, 36th U.S. President Lyndon B. Johnson, provides another example of unofficial diagnosing. His erratic behavior during the Vietnam War — particularly following his order to send more American troops to Vietnam in 1965 — sparked concerns of bipolar disorder, known then as manic depression. His press secretary, Bill Moyers, recalled Johnson exhibiting “paranoid” and “depressed” behavior that was almost debilitating. However, the president took intense precautions to hide any mental illnesses he may have had from the public.
In 1973, the APA addressed the disconcerting political effects of this kind of unofficial speculation around public figures’ mental health with an official policy stating that “it is unethical for a psychiatrist to offer a professional opinion [of public figures] unless he or she has conducted an examination [of them] and has been granted proper authorization for such a statement.” The policy did not, however, stop the kind of public conversation around presidential mental health faced by Goldwater and Johnson.
Similar questions emerged around 40th U.S. President Ronald Reagan, who was officially diagnosed with Alzheimer’s disease in 2004. Throughout his presidency, Reagan faced accusations of senility. Such concerns were mainly voiced by Democrats during his 1984 campaign for re-election, particularly after he appeared disoriented and confused during the first debate. Although media attention on the subject subsided after his electoral victory, many of his top White House advisers remained concerned. Some even discussed the possibility of invoking the 25th Amendment, which allows for a president to be involuntarily removed from office if the vice president and a majority of the Cabinet deem him “unable to discharge the powers and duties of his office” — though these conversations never led to any tangible results. Despite his alleged lapses in attention and judgment, most felt that the president’s mental health did not pose a great risk to the nation’s safety — a sharp contrast to the situation at present.
Modern politics seem characterized by the very practice that the Goldwater Rule aimed to prevent; mental health has become ingrained in political commentary. Even former President Barack Obama has talked about his own mental capacities, remarking that he persevered through the stress of the presidency and “earned [his] gray hair.” In this climate, it might seem easy to dismiss questions around Trump’s mental health as the same kind of undue speculation leveled at Goldwater. However, many medical professionals contend that the matter of this president’s mental health is a unique one.
A Very Stable Genius
Although Trump has expressed confidence in his mental fitness in his tweets and speeches, mental health professionals have categorized Trump’s behavior as indicative of mental disorders ranging from narcissistic personality disorder to sociopathy. Dr. Lance Dodes, a training and supervising analyst emeritus with the Boston Psychoanalytic Society and retired assistant clinical professor of psychiatry at Harvard Medical School, maintained in an interview with the HPR that Trump “meets the criteria for a diagnosis for antisocial personality disorder.” In the absence of a formal diagnosis, he continued, “it’s simpler to say that he’s a sociopath.”
Evidence for this personality disorder and its characteristic lack of empathy consistently come through in Trump’s communications with the public, such as when he mocked a disabled reporter. “It’s the sort of thing that if you saw it in a five- or 10-year-old,” Dodes said, “you’d take them aside and say, ‘that’s not right’ … But he doesn’t care, he doesn’t have any sense of the feelings of that person who is being mocked.” Although he is primarily concerned with this sociopathy, Dodes also agreed that Trump fits the pattern of behavior for narcissistic personality disorder.
While Dodes’ statements and the now-colloquial use of the word ‘sociopath’ may initially feel reminiscent of the Goldwater scandal, Dodes argued that a key difference between the two cases lies in the intent behind his diagnosis. He sincerely believes that Trump’s lack of empathy, intense need for a fan base, and villainization of dissenting views have severe implications for the safety of the American people. Already, Trump’s rhetoric has inspired white supremacists and may increase the risk for hate crimes and domestic terrorist attacks against minority groups.
Dodes maintained that his remarks about Trump’s mental health are not political, but are more like those of a cardiologist warning the public of a president’s imminent heart attack. “People in the mental health field need to, as a public service — as their duty, really — speak out if they perceive a risk” in a government leader’s mental fitness, he stated.
Other medical professionals have echoed these sentiments while also acknowledging the inevitable political ramifications of their comments. Dr. Gregg Henriques, director of the Combined-Integrated Doctor Program at James Madison University, was an early contributor to the psychological discourse over Trump’s mental fitness with his article in Psychology Today. While he acknowledged the dangers associated with public misconceptions about mental health disorders and the misuse of medical terminology, Henriques has identified concerning behavioral traits in Trump that he believes merit public attention.
Like Dodes, Henriques sees the structural characteristics of narcissistic personality disorder in Trump’s behavioral patterns. In an interview with the HPR, he cited Trump’s “repeated attention to [his] own grandiosity,” “very competitive, edgy attitude,” and “shallow understanding of self” as the main markers. Henriques believes that these patterns can have a damaging influence on citizens. “We psychologists know that lots of narcissistic personality is associated with all sorts of distress, either inside the individual, or around them. So we really don’t want to create a culture of narcissists,” he told the HPR.
The Ethics of Diagnosing
Henriques and Dodes are not alone in their claims. In early 2017, psychiatrist and Duty to Warn President John Gartner collected 41,000 signatures from mental health professionals: “We believe in our professional judgment that Donald Trump manifests a serious mental illness that renders him psychologically incapable of competently discharging the duties of President of the United States,” the petition read.
With so many mental health professionals questioning Trump’s mental fitness, the APA reaffirmed its support for the Goldwater Rule in March 2017 and warned its 37,000 members against breaking its ethical guidelines. Its ethics committee also released a statement in which APA President Dr. Maria A. Oquendo maintained that “offering a professional opinion or a diagnosis of someone they have not thoroughly examined compromises the integrity of the doctor and the profession and it has the potential to stigmatize those with mental illness.” Oquendo also claimed that issuing a professional opinion about a public figure one has not met violates the requirement of obtaining informed consent or authorization from the subject of psychiatric evaluations.
Lee, an assistant clinical professor of psychiatry at Yale University and an international expert on violence, has been widely accused of breaking the Goldwater Rule by speaking on the state of Trump’s mental health. As the editor of The Dangerous Case of Donald Trump, and the host of a December 2017 meeting with 12 members of Congress on the subject, Lee has maintained that the president’s mental health poses a public health and security risk to the American people, citing in particular worries around his access to the nuclear codes.
In an interview with the HPR, Lee asserted that despite her 20 years of experience as a forensic psychiatrist — a profession exempt from the Goldwater Rule in court-ordered evaluations of public figures — she holds the original APA guidelines in high regard and has never officially diagnosed an individual without an examination. However, she said, she disagrees with the wording of the APA’s 2017 affirmation of support for the rule’s enforcement, which she perceives as wrongly discouraging professional attention to presidential mental health. Lee resigned from the APA shortly after it released this statement.
She has since emphasized that the expanded Goldwater definition is damaging to public safety; it is, in effect, creating an ethical dilemma instead of settling one by seeking to prevent mental health professionals from fulfilling their duty to warn the public about their concerns. For her, worries over the politicization of presidential mental health are secondary to Americans’ wellbeing. “When there is potential danger or harm to public health involved,” Lee stated, “it is necessary for me to speak the truth, and to communicate that truth with the intent of educating the public.”
Changing The Public’s Perception
Henriques argued that the use of mental health criticism as a partisan political tactic stems largely from public confusion over the nature of mental health disorders. The APA’s reasons for reaffirming the Goldwater Rule are indicative of the different ways in which psychologists and psychiatrists view the role of mental health diagnoses.
“As a branch of medicine, psychiatry is oriented to view mental disorders as a kind of disease, or as illnesses that result from ‘broken biology,’” explained Henriques. Psychiatrists, unlike psychologists, are medical doctors, with the ability to prescribe medication. From this standpoint, the APA’s Goldwater Rule pertains to a biomedical approach to diagnosis associated with diseases like schizophrenia. In contrast, the evaluative approach of psychologists focuses on the behavioral and emotional patterns resulting from mental health disorders, which can manifest publicly in personality disorders like narcissism. Unlike the American Psychiatric Association, the American Psychological Association does not enforce a Goldwater Rule for its members.
According to Henriques, changing the public’s perception of mental health disorders by clarifying the distinctions between biomedical mental diseases and behavioral disorders could help reduce ethical concerns around diagnosing public figures. Ideally, an evaluation of a president’s psychological state would only reflect broader political intentions if the related behavioral patterns were recognized by experts as endangering national security. Providing this information would help eliminate unsubstantiated regulation rather than stigmatize mental illness, as the APA suggested in its ethical guidelines.
Henriques recognized that widespread misperceptions of mental health disorders and the colloquial use of mental health terminology, such as the press calling Trump’s speech “psychotically incoherent,” risk creating an association between the opinions of professionals and political conflicts. Even so, Henriques, along with Lee and Dodes, remains committed to an informed discourse around the president’s mental health. It seems clear for these experts that the dangerous case of the Donald Trump presidency has changed the conversation around ethics and unofficial diagnosing, testing the line that mental health professionals have historically used to hold themselves accountable while remaining conscious of public interest.
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