Mental Health Professionals Must Continue To Speak Truth To Power

Our fraught times demand it. But to speak with authority, we need to respond to critics.

Shortly after Trump’s election in 2016, many mental health professionals spoke out about the new president’s unfitness for office. They linked Trump’s behaviors with distinct psychological patterns that result in harm to others. Two mental health advocacy groups sprung up to disseminate information on Trump’s dangerousness. The World Mental Health Coalition, under the supervision of Bandy Lee, M.D., and Duty To Warn published edited volumes of appraisals of Trump’s dangerous psychopathology. The public seemed to have an appetite for insight into Trump’s psyche, as evidenced by the rise of The Dangerous Case of Donald Trump, published by The World Mental Health Coalition, to the New York Times bestseller list.

Was this effort impactful? Most political analysts felt the election was primarily a referendum on Trump. Biden was not considered a particularly strong candidate, and the record-breaking turnout was primarily due to negative appraisals of Trump. Substantive portrayals of his psychopathologies undoubtedly contributed to the large voter turnout that helped defeat him. Many voters considered the election an existential moment for the country, and warnings from professionals validated that concern. It certainly seemed that the input from the mental health community was one of the factors contributing to Trump’s defeat.

And yet… for many of us in that community, it seemed like our findings should have had a greater impact. After all, many of us had spelled out psychological disturbances that demonstrated Trump was unfit for office, clinically dangerous, and really was an existential threat. Given those findings, how could the election have even been close? How could Trump have garnered more votes (other than Biden) than any presidential candidate in history?

Since election night in 2020, we have witnessed the attack on the Capitol, the shredding of democratic norms (most notably the peaceful transfer of power), and a deep polarization that has become a cold civil war. Several factors contribute to our current political crisis, but the impact of Trump’s psychiatric condition is a crucial ingredient. The existential threat himself has been voted out of office but still lurks. The former and potentially future emperor — exposed by mental health professionals to have no clothes — is still elegantly robed in the eyes of many. He remains the leading candidate for the Republican nomination. His destructive set of personality traits reverberates through our body politic.

A significant gap remains between the ongoing manifestation of Trump’s destructive personality traits and the public’s appreciation of their impact. We need to do everything we can to close that gap. To speak with more authority and provide more sunlight for our findings, it behooves us to address the criticisms against mental health professionals who have spoken out. Critics, some of whom are undoubtedly well-intentioned, zero in on three concerns:

* It is unethical to diagnose a public figure, even one who significantly impacts the country’s general welfare, without their permission.

* You are unable to conduct a trustworthy psychological evaluation on someone if they refuse to collaborate on a clinical interview.

* You have added nothing substantive to our understanding of the man. You are just affixing psychiatric labels to the behavior you find distasteful. We will address these criticisms in turn.

1

Critics argue that mental health professionals are constrained from diagnosing political figures “from a distance” because of the Goldwater Rule. The Goldwater Rule is found in section 7.3 of the American Psychiatric Association’s (APA) code of ethics and asserts that it is unethical to offer a professional opinion on a public figure that has not been personally examined and where consent has not been obtained.

These ethical guidelines are called the Goldwater Rule because, during the 1964 Presidential campaign, FACT magazine (now defunct) invited psychiatrists to participate in a survey of the psychological makeup of candidate Senator Barry Goldwater. Psychiatrists that responded branded Goldwater with various diagnoses and descriptors, such as “paranoid,” “schizophrenic,” “psychotic,” and “narcissistic.” Most responders claimed Goldwater was “dangerous” and unfit to be president. Goldwater later successfully sued the magazine for libel. The verdict in that case and the episode as a whole damaged the reputation of mental health professionals. And deservedly so, since most conclusions were not based on a rigorous or objective assessment or tied to scientifically-based knowledge. Indeed, one lesson of the Goldwater affair is to approach diagnoses of public figures with caution, humility, and rigor

Although mental health professionals behaved unprofessionally in the Goldwater incident, there remains a natural tension between the stipulation to secure someone’s authorization to share psychological findings and the concern over whether that someone might be a harm to others. If a mental health professional has reason to believe a public figure might be a threat to others based on a valid psychological assessment, they would have an ethical obligation to warn the community. This ‘duty to warn’ principle stemmed from a court decision in California in 1976 (the Tarasoff case). Also, explicit ethical guidelines encourage mental health professionals to engage with and educate the public, particularly about hazards to the general welfare.

Finally, there is a different standard for communicating psychological findings to the public, coined by the term’ duty to inform’. The duty to inform principle is based on the idea that an informed citizenry is essential for a functioning democracy. Thus, candidates and officeholders are expected to disclose critical information about their health and competency in the contemporary era. If a candidate for high office was diagnosed with an incurable neurological disease that affected their judgment, we would feel entitled to that knowledge. If a candidate was diagnosed with a medical condition and was not expected to survive their term in office, we would feel privileged to know that. Thus, if a candidate or office holder had a psychiatric condition that guaranteed he would inflict harm on others, we likewise have a right to know. And mental health professionals have a duty to inform the public about just that predicament with Trump.

While the ‘duty to inform’ proposal opens the door more widely to the psychological assessment of public figures, it does come with a caveat: mental health professionals should refrain from judging the candidate or office-holders fitness for office. The valid diagnostic information that can contribute to a more informed citizenry is encouraged, but conclusions regarding fitness for office are better left to the political arena.

If we do choose to bring psychological findings and insights about a political figure into the public square without their permission, it is essential that we stand on solid, scientific ground. This brings us to…

2

Critics contend that you cannot conduct a thorough and trustworthy assessment without the benefit of a face-to-face interview. They have a point. A clinical interview of the patient is typically considered essential in providing a bona fide psychiatric diagnosis. During the interview, mental health professionals gather information about the patient’s history and symptoms, conduct a mental status examination, and perhaps administer psychological tests. They then use their knowledge of psychopathology to determine whether the patient meets the criteria for a particular disorder, as enumerated in the Diagnostic and Statistical Manual of Mental Disorders (DSM-V), or for assessment of a specific syndrome, such as violent behavior.

Generally, the Goldwater Rule provision of a personal interview is a sound principle. For most diagnoses, you need an in-depth interview and a mental status exam to secure all the necessary data. However, like with many rules, there are exceptions. For example, Bandy Lee, an expert on violence, notes that her evaluation of Trump as “dangerous” is based on observation of long-standing patterns of behavior and other publicly available evidence.

The key to making a valid diagnosis is access to the relevant data needed for the diagnosis. For mental health evaluations, there are three sources of such data: informants — family, friends, and business associates — who have relevant information about the client; archival sources, such as taped interviews, videotapes, tweets, and court records; and data from a personal interview. What matters is the relevance and quality of the data, not its source. For some diagnoses — personality disorders would be a good example — you do not need a mental status or personal interview. However, you do need access to voluminous data to assess lifelong emotional, interpersonal, and behavioral traits.

Of course, with Donald Trump, we are awash with information. He is arguably the most well-chronicled candidate in history. A partial list of informational sources would include 13 autobiographical efforts, 71 biographies, many of which are richly sourced, and hundreds of interviews from print, radio, and television. This abundance of data on Trump puts mental health professionals in a solid position to determine whether the ex-president and possible future candidate does or does not have certain psychiatric conditions.

One of those conditions is Psychopathic Personality Disorder (PPD). Even though the term psychopath is used rather frequently and casually (not only in the general culture but also in the mental health community), PPD is a relatively rare diagnosis. Less than 1% of the population meets its demanding diagnostic criteria.

PPD is an ominous diagnosis. Ominous because a clinical psychopath will inflict significant harm on all those in his orbit. Ominous because he is at the mercy of three hard-wired traits: an utter lack of conscience, an insatiable drive to dominate others, and extreme impulsivity. Ominous because these traits are immutable with no effective treatment possibilities. It is a terrible, loveless affliction, which you would probably take a bullet to prevent your child from having.

But PPD is also a robust diagnosis. Since the diagnosis of PPD is precisely defined and arrived at through an empirically-validated assessment procedure, it has generated much research (over 70,000 studies, according to Google Scholar). As a result, it is one of the best understood, most precisely delineated, and thoroughly validated conditions in the field of psychopathology.

The diagnostic process for PPD is rigorous and requires advanced training for the mental health professional. It is fair to say that the demands placed on the evaluator of PPD are greater than those involved in diagnosing most conditions in DSM-V. An interview is not required for this condition. Indeed, research indicates that the clinical interview detracts from the examiner’s evaluation because of the psychopath’s skill in lying and inability to see any of his behavior as problematic.

We are not saying diagnosing a public figure or anyone else at a distance is generally acceptable. On the contrary, a clinical interview conducted by a trained professional is instrumental in arriving at most diagnoses in DSM-V. But we are saying — without reservation — that an appropriately trained professional can evaluate anyone for PPD from a distance if the yield of information from archival and informant sources is sufficient.

And yes, Donald Trump meets the demanding criteria for PPD (the detailed findings are here). Therefore…

3

There is a lot we can say about Donald Trump, and we can say it with authority and precision. We can go far beyond just labeling him as “evil” or “narcissistic” as his detractors often have, or just “politically incorrect” or “bold” as his supporters have. Through the lens of his diagnosis, we can make sense of all his flamboyant and norm-shattering behavior. We have already and will continue to predict his behavior. But, most critically, we can address the nature and degree of his dangerousness. There are two essential qualities to emphasize in understanding the clinical psychopath. First, thanks to extensive and sophisticated research efforts, we know the essence of this condition is a set of three personality traits that inevitably result in harm inflicted on others:

• An arrogant interpersonal style, characterized by a relentless drive to dominate and the use of deceit to get their way.
• A deficiency in experiencing humanizing emotions — specifically the inability to bond with or have empathy for others, which leads to callousness; and the inability to experience shame, guilt or anxiety, which leads to remorselessness.
• Impulsivity, characterized by an inability to grapple with any issue that doesn’t serve their immediate, egocentric interests.

The psychopath is at the mercy of these hard-wired traits. In whatever situation he manufactures or faces, this trifecta of immutable traits dictates the limit of his capacities and anticipates the transgressions and ruin he will likely display. For example, after the election in 2016, no one could have predicted the emergence of a global, deadly pandemic. But, with a clinical psychopath in the White House, we could have predicted he would be unable to bring any focus, planning or discipline to the crisis (the impulsivity trait); that he would be unable to collaborate or defer with public health professionals, and would subvert policy to divisive culture wars waged with deceit (the drive to dominate trait); and that he would be unmoved by the scope of the threat and the suffering that flowed from it, and bear no guilt or responsibility for the damage (conservative estimate is 400,000 needless deaths) brought on by his dereliction (the remorselessness trait).

Our second essential message revolves around just how dangerous a clinical psychopath (Trump) is to those in his orbit. It turns out this is a complex message to deliver, which is the caveat of all the leading experts in the field who have spent their lives interviewing and studying psychopaths.

We all know what the word remorseless means, and we may even have vivid associations with it. But we can’t quite grasp what it is like to have no conscience at all, to feel utterly undaunted by the fear of punishment, to have no limiting concern for the damage inflicted on others.

It is also hard to fully grasp the trait of arrogant bullying. All of us know people with this tendency. But it is difficult to inhabit the consciousness of one who is loveless and can only operate in a predatory manner. It is hard to fathom the preternatural and exclusive ‘what’s-in-it-for-me’ and ‘win-at-all-costs’ focus of the psychopath. It is hard always to anticipate that at every choice point, in their work and relationships with others, power and dominance will prevail over the welfare of others.

And it is hard to fully appreciate the chaos, recklessness, and dereliction that flow from the psychopath’s impulsivity trait, which is not just ADD on steroids. The psychopath is helpless to curb their pervasive ‘what’s in it for me?’ impulse; powerless to give any issue a second thought, much less careful deliberation.

Why do we keep being taken in and conned by the psychopath? Why do we keep underestimating how dangerous they are? Part of the explanation is that most psychopaths are charming extroverts skilled at impression management. If caught in immoral or exploitative behavior, they are adept at avoiding responsibility for it or flipping the script and spinning themselves as deserving of pity.

However, it also seems we have a particular blind spot when detecting the utter remorselessness and lack of empathy of the psychopath. We have evolved as prosocial animals to live in groups, and our brains tend to default to believing others are decent and trustworthy. We are bewildered, at least initially, by someone who operates outside the human contract.

The danger that emanates from the psychopath’s traits is typically not apprehended until the damage has been done. The day after the 2016 election, there was shock, dismay, and dread in half the country. Many of us expected the worst. Still, did we really anticipate that POTUS would sow as many needless deaths as in World War II, the Korean War, and the Vietnam War combined? Did we really expect that our norms of civility and trust would be battered to the point that our liberal democracy is on the ropes?

Because of our knowledge of Psychopathic Personality Disorder and because he qualifies for the diagnosis, we have a duty to inform you that Trump is more dangerous than even his strongest critics exclaim. He possesses no embers of shame, guilt, or anxiety that might slow him down. Instead, he is like a man behind the wheel of a car with no brakes or steering and takes satisfaction in mowing down whoever crosses his path next.

We must continue to speak out. An informed citizenry with more profound insight into the nature of this clear and present danger is needed to protect our now fragile democracy.