Our Witness to Malignant Normality
ROBERT JAY LIFTON, M.D.
Concerning malignant normality, we start with an assumption that all societies, at various levels of consciousness, put forward ways of viewing, thinking, and behaving that are considered desirable or “normal.”
Yet, these criteria for normality can be much affected by the political and military currents of a particular era. Such requirements may be fairly benign, but they can also be destructive to the point of evil.
I came to the idea of malignant normality in my study of Nazi doctors. Those assigned to Auschwitz, when taking charge of the selections and the overall killing process, were simply doing what was expected of them. True, some were upset, even horrified, at being given this task. 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 was a process of adaptation to evil that is all too possible to initiate in such a situation. Above all, there was a normalization of evil that enhanced this adaptation and served to present participating doctors with the Auschwitz institution as the existing world to which one must make one’s adjustments.
There is another form of malignant normality, closer to home and more recent. I have in mind the participation in torture by physicians (including psychiatrists), and by psychologists, and other medical and psychological personnel. This reached its most extreme manifestation when two psychologists were revealed to be among architects of the CIA’s torture protocol. More than that, this malignant normality was essentially supported by the American Psychological Association in its defense of the participation of psychologists in the so-called “enhanced interrogation” techniques that spilled over into torture.
I am not equating this American behavior with the Nazi example 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.
There is still another kind of malignant normality, one brought about by President Trump and his administration. Judith Herman and I, in a letter to the New York Times in March 2017, stressed Trump’s dangerous individual psychological patterns: his creation of his own reality and his inability to manage the inevitable crises that face an American president.
He has also, in various ways, violated our American institutional requirements and threatened the viability of American democracy. Yet, because he is president and operates within the broad contours and interactions of the presidency, there is a tendency to view what he does as simply part of our democratic process—that is, as politically and even ethically normal.
In this way, a dangerous president becomes normalized, and malignant normality comes to dominate our governing (or, one could say, our antigoverning) dynamic.
But that does not mean we are helpless. We remain a society with considerable openness, with institutions that can still be life-enhancing and serve truth. Unlike Nazi doctors, articulate psychological professionals could and did expose the behavior of corrupt colleagues and even a corrupt professional society. Investigative journalists and human rights groups also greatly contributed to that exposure.
As psychological professionals, we are capable of parallel action in confronting the malignant normality of Trump and his administration. To do so we need to combine our sense of outrage with a disciplined use of our professional knowledge and experience.
This brings me to my second theme: that of witnessing professionals, particularly activist witnessing professionals. Most professionals, most of the time, operate within the norms (that is, the criteria for normality) of their particular society. Indeed, professionals often go further, and in their practices may deepen the commitment of people they work with to that normality. This can give solace, but it has its perils.
It is not generally known that during the early Cold War period, a special governmental commission, chaired by a psychiatrist and containing physicians and social scientists, was set up to help the American people achieve the desired psychological capacity to support U.S. stockpiling of nuclear weapons, cope with an anticipated nuclear attack, and overcome the fear of nuclear annihilation. The commission had the task, in short, of helping Americans accept malignant nuclear normality.
There have also been parallel examples in recent history of professionals who have promoted equally dangerous forms of normality in rejecting climate change. But professionals don’t have to serve these forms of malignant normality. We are capable of using our knowledge and technical skills to expose such normality, to bear witness to its malignance—to become witnessing professionals.
When I did my study of Hiroshima survivors back in 1962, I sought to uncover, in the most accurate and scientific way I could, the psychological and bodily experience of people exposed to the atomic bomb. Yet, I was not just a neutral observer. Over time, I came to understand myself as a witnessing professional, committed to making known what an atomic bomb could do to a city, to tell the world something of what had happened in Hiroshima and to its inhabitants. The Hiroshima story could be condensed to “one plane, one bomb, one city.” I came to view this commitment to telling Hiroshima’s story as a form of advocacy research. That meant combining a disciplined professional approach with the ethical requirements of committed witness, combining scholarship with activism.
I believe that some such approach is what we require now, in the Trump era. We need to avoid uncritical acceptance of this new version of malignant normality and, instead, bring our knowledge and experience to exposing it for what it is. This requires us to be disciplined about what we believe we know, while refraining from holding forth on what we do not know. It also requires us to recognize the urgency of the situation in which the most powerful man in the world is also the bearer of profound instability and untruth.
As psychological professionals, we act with ethical passion in our efforts to reveal what is most dangerous and what, in contrast, might be life-affirming in the face of the malignant normality that surrounds us.
Finally, there is the issue of our ethical behavior. We talk a lot about our professional ethics having to do with our responsibility to patients and to the overall standards of our discipline. This concern with professional ethics matters a great deal. But I am suggesting something more, a larger concept of professional ethics that we don’t often discuss: including who we work for and with, and how our work either affirms or questions the directions of the larger society. And, in our present situation, how we deal with the malignant normality that faces us.
This larger ethical model applies to members of other professions who may have their own “duty to warn.” I in no way minimize the significance of professional knowledge and technical skill. But our professions can become overly technicized, and we can be too much like hired guns bringing our firepower to any sponsor of the most egregious view of normality.
We can do better than that. We can take the larger ethical view of the activist witnessing professional. Bandy Lee took that perspective when organizing the Yale conference on professional responsibility, and the participants affirmed it. This does not make us saviors of our threatened society, but it does help us bring our experience and knowledge to bear on what threatens us and what might renew us.
A line from the American poet Theodore Roethke brings eloquence to what I have been trying to say: “In a dark time, the eye begins to see.”
Professions and Politics
JUDITH LEWIS HERMAN, M.D., and
BANDY X. LEE, M.D., M.DIV.
Soon after the presidential election of 2016, alarmed by the apparent mental instability of the president-elect, we both separately circulated letters among some of our professional colleagues, expressing our concern. Most of them declined to sign. A number of people admitted they were afraid of some undefined form of governmental retaliation, so quickly had a climate of fear taken hold.
They asked us if we were not wary of being “targeted,” and advised us to seek legal counsel. This was a lesson to us in how a climate of fear can induce people to censor themselves.
Others who declined to sign our letters of concern cited matters of principle. Psychiatry, we were warned, should stay out of politics; otherwise, the profession could end up being ethically compromised. The example most frequently cited was that of psychiatrists in the Soviet Union who collaborated with the secret police to diagnose dissidents as mentally ill and confine them to prisons that fronted as hospitals (Medvedev and Medvedev 1971).
This was a serious consideration. Indeed, we need not look beyond our own borders for examples of ethics violations committed by professionals who became entangled in politics. We have recently witnessed the disgrace of an entire professional organization, the American Psychological Association, some of whose leadership, in cooperation with officials from the U.S. military, the CIA, and the Bush White House, rewrote its ethical guidelines to give legal cover to a secret government program of coercive interrogation and to excuse military psychologists who designed and implemented methods of torture (Hoffman et al. 2015; Risen 2014).
Among the many lessons that might be learned from this notorious example, one in particular stayed with us. It seemed clear that the government officials responsible for abusive treatment of prisoners went to some lengths to find medical and mental health professionals who would publicly condone their practices. We reasoned that if professional endorsement serves as important cover for human rights abuses, then professional condemnation must also carry weight.
In 2005 the Pentagon organized a trip to the Guantánamo Bay detention camp for a group of prominent ethicists, psychiatrists, and psychologists. Participants toured the facility and met with high-ranking military officers, including the commanding general. They were not allowed to meet or speak with any of the detainees. Dr. Steven Sharfstein, then the president of the American Psychiatric Association, was one of the invited guests on this trip.
Apparently, what he saw and heard failed to convince him that the treatment of detainees fell within the bounds of ethical conduct. “Our position is very direct,” he stated on return. “Psychiatrists should not participate on these [interrogation] teams because it is inappropriate” (Lewis 2005). Under Dr. Sharfstein’s leadership, the American Psychiatric Association took a strong stand against any form of participation in torture and in the “interrogation of persons held in custody by military or civilian investigative or law enforcement authorities, whether in the United States or elsewhere” (American Psychiatric Association 2006).
Contrast this principled stand with the sorry tale of the American Psychological Association. Its involvement in the torture scandal illustrates how important it is for leaders in the professions to stand firm against ethical violations, and to resist succumbing to the argument that exceptional political circumstances, such as “the war on terror,” demand exceptions to basic ethical codes. When there is pressure from power is exactly when one must abide by the norms and rules of our ethics.
Norms and Rules in the Political Sphere
Norms and rules guide professional conduct, set standards, and point to the essential principles of practice. For these reasons, physicians have the Declaration of Geneva (World Medical Association 2006) and the American Medical Association Principles of Medical Ethics (2001), which guide the American Psychiatric Association’s code for psychiatry (American Psychiatric Association 2013).
The former confirms the physician’s dedication to the humanitarian goals of medicine, while the latter defines honorable behavior for the physician. Paramount in both is the health, safety, and survival of the patient. Psychiatrists’ codes of ethics derive directly from these principles. In ordinary practice, the patient’s right to confidentiality is the bedrock of mental health care dating back to the ethical standards of the Hippocratic Oath.
However, even this sacrosanct rule is not absolute. No doubt, the physician’s responsibility is first and foremost to the patient, but it extends “as well as to society” (American Psychiatric Association 2013, p. 2). It is part of professional expectation that the psychiatrist assess the possibility that the patient may harm himself or others. When the patient poses a danger, psychiatrists are not merely allowed but mandated to report, to incapacitate, and to take steps to protect.
If we are mindful of the dangers of politicizing the professions, then certainly we must heed the so-called “Goldwater rule,” or Section 7.3 of the APA code of ethics (American Psychiatric Association 2013, p. 6), which states: “it is unethical for a psychiatrist to offer a professional opinion [on a public figure] unless he or she has conducted an examination and has been granted proper authorization for such a statement.”
This is not divergent from ordinary norms of practice: the clinical approaches that we use to evaluate patients require a full examination. Formulating a credible diagnosis will always be limited when applied to public figures observed outside this intimate frame; in fact, we would go so far as to assert that it is impossible.
The Goldwater rule highlights the boundaries of practice, helps to preserve professional integrity, and protects public figures from defamation. It safeguards the public’s perception of the field of psychiatry as credible and trustworthy. It is reasonable to follow it. But even this respectable rule must be balanced against the other rules and principles of professional practice.
A careful ethical evaluation might ask: Do our ordinary norms of practice stop at the office of the president? If so, why? If the ethics of our practice stipulate that the health of our patient and the safety of the public be paramount, then we should not leave our norms at the door when entering the political sphere. Otherwise, a rule originally conceived to protect our profession from scandal might itself become a source of scandal.
For this very reason, the “reaffirmation” of the Goldwater rule in a separate statement by the American Psychiatric Association (2017) barely two months into the new administration seems questionable to us. The American Psychiatric Association is not immune to the kind of politically pressured acquiescence we have seen with its psychological counterpart. A psychiatrist who disregards the basic procedures of diagnosis and treatment and acts without discretion deserves reprimand. However, the public trust is also violated if the profession fails in its duty to alert the public when a person who holds the power of life and death over us all shows signs of clear, dangerous mental impairment.
We should pause if professionals are asked to remain silent when they have seen enough evidence to sound an alarm in every other situation. When it comes to dangerousness, should not the president of a democracy, as First Citizen, be subject to the same standards of practice as the rest of the citizenry?
Assessing dangerousness is different from making a diagnosis: it is dependent on the situation, not the person. Signs of likely dangerousness due to mental disorder can become apparent without a full diagnostic interview and can be detected from a distance, and one is expected to err, if at all, on the side of safety when the risk of inaction is too great.
States vary in their instructions. New York, for example, requires that two qualifying professionals agree in order to detain a person who may be in danger of hurting himself or others. Florida and the District of Columbia require only one professional’s opinion. Also, only one person need be in danger of harm by the individual, and the threshold is even lower if the individual has access to weapons (not to5 mention nuclear weapons).
The physician, to whom life-and-death situations are entrusted, is expected to know when it is appropriate to act, and to act responsibly when warranted. It is because of the weight of this responsibility that, rightfully, the physician should refrain from commenting on a public figure except in the rarest instance. Only in an emergency should a physician breach the trust of confidentiality and intervene without consent, and only in an emergency should a physician breach the Goldwater rule.
We believe that such an emergency now exists.
Test for Proper Responsibility
When we circulated our letters of concern, we asked our fellow mental health professionals to get involved in politics not only as citizens (a right most of us still enjoy) but also, specifically, as professionals and as guardians of the special knowledge with which they have been entrusted.
Why do we think this was permissible? It is all too easy to claim, as we did, that an emergency situation requires a departure from our usual practices in the private sphere. How can one judge whether political involvement is in fact justified? We would argue that the key question is whether mental health professionals are engaging in political collusion with state abuses of power or acting in resistance to them.
If we are asked to cooperate with state programs that violate human rights, then any involvement, regardless of the purported justification, can only corrupt, and the only appropriate ethical stance is to refuse participation of any sort.
If, on the other hand, we perceive that state power is being abused by an executive who seems to be mentally unstable, then we may certainly speak out, not only as citizens but also, we would argue, as professionals who are privy to special information and have a responsibility to educate the public. For whatever our wisdom and expertise may be worth, surely we are obligated to share it.
It doesn’t take a psychiatrist to notice that our president is mentally compromised. Members of the press have come up with their own diagnostic nomenclature, calling the president a “mad king” (Dowd 2017), a “nut job” (Collins 2017), and “emotionally unhinged” (Rubin 2017). Conservative columnist George Will (2017) writes that the president has a “disorderly mind.”
By speaking out as mental health professionals, we lend support and dignity to our fellow citizens who are justifiably alarmed by the president’s furious tirades, conspiracy fantasies, aversion to facts, and attraction to violence. We can offer a hand in helping the public understand behaviors that are unusual and alarming but that can all too easily be rationalized and normalized.
An important and relevant question that the public has been asking is this: Is the man simply crazy, or is he crazy like a fox? Is he mentally compromised or simply vile? When he lies, does he know he is lying, or does he believe his own lies? When he makes wild accusations, is he truly paranoid, or is he consciously and cunningly trying to deflect attention from his misdeeds?
We believe that we can help answer these questions by emphasizing that the two propositions are not mutually exclusive. A man can be both evil and mentally compromised—which is a more frightening proposition.
Power not only corrupts but also magnifies existing psychopathologies, even as it creates new ones. Fostered by the flattery of underlings and the chants of crowds, a political leader’s grandiosity may morph into grotesque delusions of grandeur. Sociopathic traits may be amplified as the leader discovers that he can violate the norms of civil society and even commit crimes with impunity. And the leader who rules through fear, lies, and betrayal may become increasingly isolated and paranoid, as the loyalty of even his closest confidants must forever be suspect.
Some would argue that by paying attention to the president’s mental state, we are colluding with him in deflecting attention from that by which he should ultimately be judged: his actions (Frances 2017). Certainly, mental disturbance is not an excuse for tyrannical behavior; nevertheless, it cannot be ignored. In a court of law, even the strongest insanity defense case cannot show that a person is insane all the time.
We submit that by paying attention to the president’s mental state as well as his actions, we are better informed to assess his dangerousness. Delusional levels of grandiosity, impulsivity, and the compulsions of mental impairment, when combined with an authoritarian cult of personality and contempt for the rule of law, are a toxic mix.
There are those who still hold out hope that this president can be prevailed upon to listen to reason and curb his erratic behavior. Our professional experience would suggest otherwise; witness the numerous submissions we have received for this volume while organizing a Yale conference in April 2017 entitled “Does Professional Responsibility Include a Duty to Warn?”
Collectively with our coauthors, we warn that anyone as mentally unstable as Mr. Trump simply should not be entrusted with the life-and-death powers of the presidency.
Our Duty to Warn
BANDY X. LEE, M.D., M.DIV.
Possibly the oddest experience in my career as a psychiatrist has been to find that the only people not allowed to speak about an issue are those who know the most about it. Hence, truth is suppressed. Yet, what if that truth, furthermore, harbored dangers of such magnitude that it could be the key to future human survival? How can I, as a medical and mental health professional, remain a bystander in the face of one of the greatest emergencies of our time, when I have been called to step in everywhere else?
How can we, as trained professionals in this very area, be content to keep silent, against every other principle we practice by, because of a decree handed down from above? I am not speaking of the long-standing “Goldwater rule,” which is discussed in many places throughout this book and is a norm of ordinary practice I happen to agree with. I am rather speaking of its radical expansion, beyond the status we confer to any other rule, barely two months into the very presidency that has made it controversial.
This occurred on March 16, 2017, when our professional organization essentially placed a gag order on all psychiatrists (American Psychiatric Association 2017), and by extension all mental health professionals. I am also speaking of its defect, whereby it does not have a countervailing rule, as does the rest of professional ethics, that directs what to do when the risk of harm from remaining silent outweighs the damage that could result from speaking about a public figure—which, in this case, could even be the greatest possible harm.
Authors in this volume have been asked to respect the Goldwater rule and not to breach it unnecessarily, but I in turn respect their choices wherever their conscience has prompted them to take the professionally and socially radical step to help protect the public. Therefore, it would be accurate to state that, while we respect the rule, we deem it subordinate to the single most important principle that guides our professional conduct: that we hold our responsibility to human life and well-being as paramount.
My reasons for compiling this compendium are the same as my reasons for organizing the Yale conference by the title, “Does Professional Responsibility Include a Duty to Warn?”: the issue merits discussion, not silence, and the public deserves education, not further darkness.
Over the course of preparing the conference, the number of prominent voices in the field coming forth to speak out on the topic astonished me. Soon after the 2016 presidential election, Dr. Herman (coauthor of the Prologue), an old colleague and friend, had written a letter urging President Obama to require that Mr. Trump undergo a neuropsychiatric evaluation before assuming the office of the presidency. Her cosignatories, Drs. Gartrell and Mosbacher (authors of the essay “He’s Got the World in His Hands and His Finger on the Trigger”), helped the letter’s publication in The Huffington Post (Greene, 2016).
I also reached out to Dr. Lifton (author of the Foreword), whose “Mass Violence” meetings at Harvard first acquainted me with Dr. Herman years ago; together, they had sent a letter to the New York Times (Herman and Lifton 2017). His ready consent to speak at my conference sparked all that was to follow.
I encountered others along the way: Dr. Dodes (author of “Sociopathy”), who published a letter in the New York Times with thirty-five signatures (Dodes and Schachter 2017); Ms. Jhueck (author of “A Clinical Case for the Dangerousness of Donald J. Trump”), who cowrote and posted a letter to the head of New York City’s Department of Health and Mental Hygiene with seventy signatures; Dr. Fisher (author of “The Loneliness of Fateful Decisions”), who also expressed concerns in a letter to the New York Times (Fisher 2017); and Dr. Gartner (author of “Donald Trump Is: [A] Bad, [B] Mad, [C] All of the Above”), the initiator of an online petition, now with fifty-five thousand signatures, who cofounded the national coalition, “Duty to Warn,” of (as of this writing) seventeen hundred mental health professionals.
The Yale Conference
On April 20, 2017, Dr. Charles Dike of my division at Yale started the town hall–style meeting by reaffirming the relevance and reasons for the Goldwater rule. As assistant professor in law and psychiatry, former chair of the Ethics Committee of the American Academy of Psychiatry and the Law, chair of the Connecticut Psychiatric Society Ethics Committee, member of the Ethics Committee of the American Psychiatric Association, and Distinguished Fellow of the American Psychiatric Association, he was more than qualified to do so.
It was important that we start with a firm ethical foundation: whatever our conclusion, it could not hold if we were not scrupulous about our ethical grounding. I invited as additional panelists Drs. Lifton, Herman, and Gilligan (the last the author of “The Issue Is Dangerousness, Not Mental Illness”), with the purpose of bringing together the finest minds of psychiatry I could to address the quandary. They are all colleagues I have known for at least fifteen years and highly esteem not only for their eminence in the field but also for their ethics. They were beacons during other dark times.
They abided by the Goldwater rule in that they kept the discussion at the level of dangerousness, without attempting to diagnose. The transcript of the meeting can be found in an online appendix, the link to which is at the end of this book.
The conference was initially meant to be a collaboration between Yale School of Medicine, Yale School of Public Health, and Yale School of Nursing, but when the other schools fell away as the date approached, I released the School of Medicine for what I correctly perceived would be “inevitable politicization.” In case something went wrong, I did not wish to imperil my alma mater and home institution.
Our nation is now living, in extremes, a paradigm that splits along partisan lines, and the quick conclusion will be that the speakers or contributors of this volume “must be Democrats” if they are casting a negative light on a Republican president.
However, there are other paradigms. For the mental health professional, the paradigm we practice by is one of health versus disease. We appeal to science, research, observed phenomena, and clinical skill developed over years of practice in order to promote life and to prevent death. These goals cannot be contained within the purposes of a political party or the campaigns of a candidate. Rather, we are constantly trained to bring medical neutrality—or, if we cannot, to recuse ourselves of the therapeutic situation. It is a glimpse of this perspective that we hope to bring to the reader.
Our meeting gained national and international attention (Milligan 2017; Bulman 2017). While only two dozen physically attended the conference in an atmosphere of fear, about a hundred tuned in online, and hundreds more got in touch with me for recordings or in a show of support. It felt as if we had tapped into a groundswell of a movement among mental health professionals, and also an army of people who wanted to speak about the issue (DeVega 2017).
What was intended as a publication of the proceedings led to this volume (initially so large that we had to reduce it by a third), and five top-tier publishers in the country vied for it.
Authors had to submit their manuscripts within three weeks of the meeting. It was a harrowing time, as the nation’s mood changed from relief as Mr. Trump seemed to settle into his office after the first one hundred days, to a new onslaught of scandals, starting with his firing of FBI director James Comey on May 9, 2017.
Many of the contributors here do not need an introduction, and I am humbled to have the opportunity to present such an assembly of brilliant and principled professionals. A Compendium of Expertise This volume consists of three parts, the first being devoted to describing Mr. Trump, with an understanding that no definitive diagnoses will be possible.
In “Unbridled and Extreme Present Hedonism,” Zimbardo and Sword discuss how the Leader of the Free World has proven himself unfit for duty by his extreme ties to the present moment, without much thought for the consequences of his actions or for the future.
In “Pathological Narcissism and Politics,” Malkin explains that narcissism happens on a scale, and that pathological levels in a leader can spiral into psychosis and imperil the safety of his country through paranoia, impaired judgment, volatile decision making, and behavior called gaslighting.
In “I Wrote The Art of the Deal with Trump,” Schwartz reveals how what he observed during the year he spent with Trump to write that book could have predicted his presidency of “black hole-level” low self-worth, fact-free self-justification, and a compulsion to go to war with the world.
In “Trump’s Trust Deficit Is the Core Problem,” Sheehy highlights the notion that beneath the grandiose behavior of every narcissist lies the pit of fragile self-esteem; more than anything, Trump lacks trust in himself, which may lead him to take drastic actions to prove himself to himself and to the world.
In “Sociopathy,” Dodes shows that someone who cons others, lies, cheats, and manipulates to get what he wants, and who doesn’t care whom he hurts, may be not just repetitively immoral but also severely impaired, as sociopaths lack a central human characteristic, empathy.
In “Donald Trump Is: (A) Bad, (B), Mad, (C) All of the Above,” Gartner emphasizes the complexity of Trump’s presentation, in that he shows signs of being “bad” as well as “mad,” but also with a hypomanic temperament that generates whirlwinds of activity and a constant need for stimulation.
In “Why ‘Crazy Like a Fox’ versus ‘Crazy Like a Crazy’ Really Matters,” Tansey shows that Trump’s nearly outrageous lies may be explained by delusional disorder, about which Tansey invites the reader to make the call; even more frightening are Trump’s attraction to brutal tyrants and also the prospect of nuclear war.
In “Cognitive Impairment, Dementia, and POTUS,” Reiss writes that a current vulnerability in our political system is that it sets no intellectual or cognitive standards for being president, despite the job’s inherently requiring cognitive clarity; this lack of clarity can be even more serious if combined with other psychiatric disorders.
In “Donald J. Trump, Alleged Incapacitated Person,” Herb explains how, as a guardianship attorney (in contrast to a mental health professional), he is required to come to a preliminary conclusion about mental incapacity before filing a petition, which he does in his essay, while reflecting on the Electoral College and the Twenty-Fifth Amendment to the U.S. Constitution.
The second part of the book addresses the dilemmas that mental health professionals face in observing what they do and speaking out when they feel they must.
In “Should Psychiatrists Refrain from Commenting on Trump’s Psychology?” Glass argues against a technicality that would yield a simple yes-or-no answer to the Goldwater rule; instead, he advocates for a conscientious voicing of hazardous patterns, noting that the presence of mental illness is not as relevant as that of reliable functionality.
In “On Seeing What You See and Saying What You Know,” Friedman notes that technological advances that allow assessment and treatment from a distance, especially in underserved areas, have changed the clinician’s comfort level with remote evaluations, even when detecting a totalitarian mind-set or a multidimensional threat to the world.
In “The Issue Is Dangerousness, Not Mental Illness,” Gilligan discusses the ethics of not diagnosing a public figure versus the duty to warn potential victims of danger; when invoking the latter, he emphasizes, what matters is not whether a person is mentally ill but whether he is dangerous, which is possible to assess from a distance.
In “A Clinical Case for the Dangerousness of Donald J. Trump,” Jhueck notes that the United States legally confers mental health professionals and physicians considerable power to detain people against their will if they pose a danger due to likely mental illness—and Trump more than meets the requisite criteria.
In “Health, Risk, and the Duty to Protect the Community,” Covitz offers an ancient reference and two fables to illustrate just how unusual the mental health profession’s response is to a dangerous president, as we do not to speak up in ways that would be unthinkable for our role with other members of society.
In “New Opportunities for Therapy in the Age of Trump,” Doherty claims that the Trump era has ruptured the boundary between the personal and the public, and while clients and therapists are equally distressed, integrating our roles as therapists and citizens might help us better help clients.
The book’s third part speaks to the societal effects Mr. Trump has had, represents, and could cause in the future.
In “Trauma, Time, Truth, and Trump,” Teng points out the irony of seeing, as a trauma therapist, all the signs of traumatization and retraumatization from a peaceful election; she traces the sources of the president’s sudden military actions, his generation of crises, his shaken notions of truth and facts, and his role in reminding patients of an aggressive abuser.
In “Trump Anxiety Disorder,” Panning describes a unique post-election anxiety syndrome that has emerged as a result of the Trump presidency and the task that many therapists face with helping clients manage the stress of trying to “normalize” behavior that they do not feel is normal for a president.
In her essay “In Relationship with an Abusive President,” West illustrates the dynamics of “other blaming” in individuals who have feelings of low self-worth and hence poor shame tolerance, which lead to vindictive anger, lack of accountability, dishonesty, lack of empathy, and attention-seeking, of which Trump is an extreme example.
In “Trump’s Daddy Issues,” Wruble draws on his own personal experiences, especially his relationship with his strong and successful father, to demonstrate what a therapist does routinely: uses self-knowledge as an instrument for evaluating and “knowing” the other, even in this case, where the other is the president and his followers.
In “Birtherism and the Deployment of the Trumpian Mind-Set,” Kessler portrays the broader background from which “birtherism” began and how, by entering into the political fray by championing this fringe sentiment, Trump amplifies and exacerbates a national “symptom” of bigotry and division in ways that are dangerous to the nation’s core principles.
In “Trump and the American Collective Psyche,” Singer draws a connection between Trump’s personal narcissism and the American group psyche, not through a political analysis but through group psychology—the joining of group self-identity with violent, hateful defenses is as much about us as about Trump.
In “Who Goes Trump?” Mika explains how tyrannies are “toxic triangles,” as political scientists call them, necessitating that the tyrant, his supporters, and the society at large bind around narcissism; while the three factors animate for a while, the characteristic oppression, dehumanization, and violence inevitably bring on downfall.
In “The Loneliness of Fateful Decisions,” Fisher recounts the Cuban Missile Crisis and notes how, even though President Kennedy surrounded himself with the “best and the brightest,” they disagreed greatly, leaving him alone to make the decisions—which illustrates how the future of our country and the world hang on a president’s mental clarity.
In “He’s Got the World in His Hands and His Finger on the Trigger,” Gartrell and Mosbacher note how, while military personnel must undergo rigorous evaluations to assess their mental and medical fitness for duty, there is no such requirement for their commander in chief; they propose a nonpartisan panel of neuropsychiatrists for annual screening.
In spite of its title, 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.
The ascendancy of an individual with such impairments speaks to our general state of health and well-being as a nation, and to how we can respond: we can either improve it or further impair it.
Mental disorder does not distinguish between political parties, and as professionals devoted to promoting mental health, including public mental health, our duty should be clear: to steer patients and the public on a path toward health so that genuine discussions of political choice, unimpeded by emotional compulsion or defense, can occur.
Embracing our “duty to warn,” as our professional training and ethics lead us to do at times of danger, therefore involves not only sounding an alarm but continually educating and engaging in dialogue our fellow human beings, as this compilation aspires to do.
The Dangerous Case of Donald Trump. 27 Psychiatrists and Mental Health Experts Assess a President
Bandy Lee, MD.D., M.DIV
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