Psychiatry

Interpersonal and Biological Processes

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The Dangerous Case of Donald Trump: 27

Psychiatrists and Mental Health Experts Assess a
President.

Reviewed by Jon Frederickson

To cite this article: Reviewed by Jon Frederickson (2018) The�Dangerous�Case�of�Donald�Trump:

27�Psychiatrists�and�Mental�Health�Experts�Assess�a�President., Psychiatry, 81:4, 408-414, DOI:
10.1080/00332747.2018.1529989

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Psychiatry, 81:408–414, 2018 408
Ó Washington School of Psychiatry
ISSN: 0033-2747 print / 1943-281X online
DOI: https://doi.org/10.1080/00332747.2018.1529989

Book Review

LEE, BANDY, ed. The Dangerous Case of nonprofessional opinion? (3) And what kind
Donald Trump: 27 Psychiatrists and Mental of forensic assessment process should exist
Health Experts Assess a President. New York: for high government officials when questions
St. Martin’s Press, 2017. 360 pages. ISBN-13: of capacity arise? Editor Bandy Lee’s 2017
978-1250179456. $27.99 hardcover. book, titled The Dangerous Case of Donald
Trump, attempted to address those ques-
Reviewed by JON FREDERICKSON tions. While excellent chapters were offered
on other topics by Reiss, Dodes, Kessler,
On November 8, 2016, Americans Teng, Mika, and Singer, this review focuses
voted for president a man who had boasted on those chapters addressing the central
about his ability to financially exploit vendors questions raised by Lee’s book.
and sexually assault women, courted the votes
of the Ku Klux Klan, and invited his followers
to shoot his opponent. In response to this grow- WHAT IS THE ROLE OF
ing list of disturbing actions, armchair psychia- PSYCHIATRY IN THE POLITICAL
trists at home, in bars, and in television studios LIFE OF A DEMOCRACY?
bandied about psychiatric terms like narcissis-
tic personality disorder and dementia, offering Section 7.3 of the American Psychiatric
uninformed opinions about the mental health Association (APA, 2013) ethics code specifies
of the president elect. While everyone else felt that “a psychiatrist may share with the public
free to speculate about Donald Trump’s diag- his or her expertise about psychiatric issues in
nosis and mental health, one group remained general. However, it is unethical for a psychia-
largely silent: psychiatrists, psychologists, and trist to offer a professional opinion unless he
social workers. As a result, we were drowning or she has conducted an examination and has
in a cacophony of the uninformed without a been granted proper authorization for such a
thoughtful, impartial, and professional opinion statement” (https://www.psychiatry.org/psy
to examine a serious question: When and how chiatrists/practice/ethics).
do we assess whether a leader in a democracy is This section, known as the Gold-
cognitively fit to serve? It was as if anyone water rule, was designed to keep psychia-
could make stuff up and consider it a psychia- trists from making unprofessional and
tric assessment. unwarranted opinions based on insufficient
And yet out of this witch’s brew of data. Instead, psychiatrists could admit
misinformation, disinformation, and specu- they had not examined the person and
lation three important questions arose: (1) then offer an opinion based on what they
What is the role of psychiatry in the political had read. But in March 2017, shortly after
life of a democracy? (2) What differentiates a Trump’s presidential inauguration, the
public opinion of psychiatric expertise from a APA broadened the rule to apply to “any

Jon Frederickson, MSW, is affiliated with the Washington School of Psychiatry in Washington, DC.
Address correspondence to Jon Frederickson, Washington School of Psychiatry, 3000, Connecticut Avenue NW
#400, Washington, DC 20008. E-mail: [email protected]
Book Review 409

opinion on the affect, behavior, speech, or person. They fail to differentiate a clear
other presentation of an individual that and specific threat by a patient from a pos-
draws on the skills, training, expertise, sible threat by a president. By trying to
and/or knowledge inherent in the practice expand this law to cover what it was never
of psychiatry” (American Psychiatric Asso- intended to cover, they engage in a dismissal
ciation, 2017). Whereas the Goldwater rule of precedents, which they deplore. Then
provided ethical guidelines for free speech, there is the problem of their “analysis.”
the APA’s new rule deprived psychiatrists Gilligan claims that “one does not need
of the right to free speech. to have had 50 years of professional experience
The contributors to this book rightly in assessing the dangerousness of violent crim-
question the legitimacy of the APA’s gag inals to recognize the dangerousness of a pre-
order. According to Glass, the Goldwater sident who …” and then lists a number of
rule conflates a professional opinion about a Trump’s statements (p. 173). Yet nearly half
patient under one’s care with a professional of American voters chose a president whom
opinion offered in a nonclinical role. For they did not feel was dangerous. Precisely
instance, on Sunday evening television, we because it was not obvious to nearly half of
might hear the clinical implications of a foot- voters, psychiatrists must think about why it
ball player’s torn hamstring described by an was not obvious, what their audience sees and
orthopedist who is not treating the patient. A does not see, before trying to educate anyone.
clinical opinion about a patient in treatment Gilligan’s arrogant tone only contributes to
differs from a nonclinical opinion about polarization. Condescension is not comprehen-
observed behaviors in public. In the second sion.
case, there is no issue of confidentiality In our tendentious political climate,
because there is no patient. every president has been viewed as dangerous
by the opposing political party in recent years.
Glass argues that mental health pro-
When mental health professionals have no
fessionals have a “duty to warn [as] an
clear criteria for assessing dangerousness in
expression of our concerns as citizens pos-
political officials, it becomes impossible to
sessed of a particular expertise; not as clin-
differentiate a professional finding from a
icians who are responsible for preventing
political lynching. Of course mental health
predictable violence from someone under
professionals have the right to free speech.
our care” (p. 153; emphasis added). This
But what does a professional opinion look
claim raises two questions, however: (1)
like? How does the mental health profes-
What is the basis for a “duty to warn”? (2)
sional’s unique expertise differ from a layper-
And what is this particular expertise mental
son’s opinion in public discourse?
health professionals can offer?
The contributors to this book believe
that they have a duty to warn when a public
WHAT DIFFERENTIATES
official’s mental health issues make him or
PSYCHIATRIC EXPERTISE FROM A
her unfit for duty. They try to expand the
LAYPERSON’S OPINION?
Tarasoff decision, which held therapists
accountable for informing others if a patient
represented a concrete threat to the life of Zimbardo and Sword describe Trump
another person. However, Trump is not as an “extreme present hedonist” who will do
their patient. They do not have the Tarasoff anything to “pump up his ego” without
obligation to break confidentiality to inform regard to past reality or future consequences.
a third party of a specific threat. There is no They believe that he has a narcissistic person-
evidence that the president represents a con- ality, making him mentally unfit to be presi-
crete physical threat to harm another dent: “[I]t is the responsibility of mental
410 Book Review

health professionals to warn the citizens of there was no precedent for such a decision.
the United States and the people of the world Alas, this chapter was a parody of what
of the potentially devastating effects of such psychiatric thought and assessment should
an extreme present-hedonistic, world lea- be. Amateurs’ night.
der”(p. 46). Gail Sheehy states, “We don’t need psy-
“Extreme present hedonist” is simply chiatrists to see that this president is not con-
another label for an impulsive person: putting sidered in his thinking or reliably attached to
old wine in new bottles. That “insight” does reality… . It is therefore up to us, the American
not require a psychiatrist. We have had impul- public, to call him on it” (p. 79). Notice the
sive presidents before, and the Twenty-Fifth rhetorical stance: “We don’t need psychiatrists
Amendment cannot be activated merely due to to see that this president is not … attached to
impulsivity, bullying, and racism. While these reality.” Likewise, Gartner claims that Trump
traits are horrible, we cannot impeach some- is “so visibly psychologically impaired that it is
one for being a lout. We can impeach only obvious even to a layman that ‘something is
when an individual cannot complete his or wrong with him’” (p. 93). Yet 85% of those
her duties, for instance, due to psychosis or who voted for Trump in 2016 said they would
dementia. Without such limiting criteria, an do so again in. They think Trump is connected
ever-expanding range of character traits to reality. When we deny that fact, we fail to
could be misused for political purposes as a recognize differences of opinion and the need
pretext for impeachment. Further, the absence for dialogue with people outside of our bubble.
of clear criteria for the terms unfit and danger- This is not psychiatric thinking but a failure to
ousness creates a faulty basis for their argu- think about those voters, what they see, what
ment, rendering it useless. they do not see, and why they do not see it. One
In Lee’s book, a ghostwriter with a would hope that mental health professionals
degree in American studies was invited to could mentalize about those with whom they
offer a diagnosis. Yet the book’s subtitle is disagree. Humility rather than arrogance
27 Psychiatrists and Mental Health Experts should characterize our particular expertise.
Assess the President. By including a ghostwri- Gartner argues, “Trump can be both evil
ter, the editor makes no distinction between a and crazy, and that unless we see how these
mental health professional’s opinion based on two components work together, we will never
unique expertise and a layperson’s opinion truly understand him. Nor will we recognize
based on personal experience. how much danger we are in” (p. 94). However,
Another “expert” is a guardianship demonization is not evaluation. We must not
attorney who believes Trump has a histrio- conflate a moral judgment (evil) with a psycho-
nic personality disorder. He filed suit in logical assessment (narcissistic).
court to have Trump declared incapacitated Gartner also wonders whether Trump
to seek or retain employment. The case was is “crazy.” Is this the language of profes-
thrown out on the grounds that a state court sional assessment? When considering the
could not restrict Trump from seeking the possibility of whether Trump has delusions,
presidency because he met the requirements. he says that “insight into this question
A nonpsychiatrist offered a psychiatric diag- comes from … Joe Scarborough,” a well-
nosis without interviewing the person, he known television host, who said that “the
filed suit in a court that could not overturn president is not crazy like a fox. Just crazy.”
the vote of the public, and he declared a A layperson’s opinion about a person is not
person incapacitated who was managing data about that person. Otherwise, anyone
a billion-dollar business. One man believed can throw in any opinion from anybody, call
that his own “assessment” should override it an insight, weave it into a fantasy, and call
the votes of millions of people, even though it “assessment.” Why does a mental health
Book Review 411

professional offer a layperson’s opinion as a (p. 115). This is neither a professional tone
substitute for clinical facts and the analysis to take nor a professional opinion to offer.
of them? Making stuff up requires no unique expertise.
Then Gartner proposes that “Trump Tansey’s comment destroys any pretense of
could be the poster child for the dictum that educating. The issue of Trump’s mental
when it comes to hypomania, nothing fails like health is too important an issue to conclude
success” (p. 105). To support this diagnosis, he with a crude quip. We would expect to hear
quotes an article by David Brooks (2016) that this type of opinion in a bar after a few
refers to Trump’s “mania,” “flight of ideas,” drinks, not in a book purportedly offering a
and “formal thought disorder.” While Brooks professional opinion.
is a columnist, Gartner is a psychiatrist. Why Later, Tansey writes that the election
does Gartner regard a layperson’s opinion as a was not about traditional views of opposing
substitute for a clinical assessment? Is his a parties: “Quite literally, it was about apoc-
professional tone when he refers to Trump as alypse, not politics” (p. 121). The tone of
a “poster child” for hypomania or calls him a histrionic hyperbole removes it from any
“profoundly evil man exhibiting malignant consideration as a professional opinion.
narcissism”? We cannot educate the larger Hysteria and devaluation are hardly the
public if we are speaking to the converted basis for debating a serious issue.
within our bubble. As mental health profes- Then Tansey concludes that Trump
sionals, we should analyze polarization rather would have “unequivocably” passed a lie
than contribute to it. Gartner conflates moral detector test if questioned about his lies
judgments with clinical assessment; he equates because he believes them. We cannot know
lay opinions with clinical insights; and he sub- that. The question of whether Trump actu-
stitutes stereotypes for a careful clinical analysis ally believes his counterfactual statements
of data. But then it gets worse. cannot be assessed without a clinical inter-
Referring to the election of Trump, view. An empirical question needs to be
Gartner says, “It’s a catastrophe that might tested, not given a pseudoanswer in the
have been avoided if we in the mental health form of an assumption treated as a fact.
community had told the public the truth” When Tansey offers assumptions as if they
(p. 107). Does Gartner really think that if are facts, his “psychiatric opinion” is no
mental health professionals had called different from any fantasy a layperson
Trump mentally ill, the American public, in could offer.
particular the Republican Party, would have Jhueck claims that Trump meets the
voted against Trump? This seems a grand- criteria for dangerousness. Yet the criteria
iose overestimation of the power of psychia- for ruling in and ruling out are never shared.
tric opinion. Without exclusion criteria and research to
Tansey, a psychoanalyst, speculates back it up, it is Jhueck’s belief versus the
about why Trump admires dictators. Laypeo- reader’s belief. Then, the chapter descends
ple can speculate. If a clinician speculates, we into self-parody. Jhueck informs us that
call it projection: a failure to think. Instead of patients are suffering from “election
speculating in the absence of data from trauma,” and Panning refers to “Trump
Trump, we are supposed to systematically anxiety disorder,” a condition supposedly
analyze data and offer insights that would caused by Trump’s election. Elevating a dif-
not occur to the average layperson. After ference of opinion (“People should have
pointing out that Trump has admired a num- voted for my candidate”) to “trauma” repre-
ber of dictators, Tansey writes, “There is sents a category error: “Because trauma
considerable evidence to suggest that abso- occurs in reality, reality is traumatizing;
lute tyranny is [Trump’s] wet dream” therefore, I can say that any reality I do
412 Book Review

not like traumatizes me.” When we pay our current diagnostic system is neither sta-
attention to media outlets, which feed our tistically reliable nor valid. If the authors
fantasies daily, we can be shocked when had known that basic fact about our field,
reality bumps into those fantasies. The only they would not have embarrassed them-
way we can be traumatized by an election, selves by serving up this smorgasbord of
however, is to deny reality, imagine that our unscientific offerings. Their evaluations are
candidate cannot lose, and assume that our all over the map, linked to no consistent
point of view is “obvious.” We live in an age method of analysis and no formal testing—
of competing forms of narcissism. in short, to no professionalism. Another rea-
West’s chapter, “In Relationship With son for the Goldwater rule.
an Abusive President,” collects anecdotes to Alas, most of the chapters in the first
support a pop psychology metaphor. We can third of book do not express any thinking
cherry-pick data to support any metaphor, different from that of the ordinary layper-
but that is not clinical thought. When West son. The frequent use of projection as a
calls Trump the “Other-blamer in chief” substitute for clinical thought, the treatment
(p. 258), his name-calling engages in the of opinions as facts, and the use of inflam-
devaluing discourse he deplores. matory language fall short of what an opi-
In “Trump’s Daddy Issues,” Wruble nion by a mental health professional should
writes, “I imagine that there is a good be in the public sphere. The arrogance, dis-
chance he identifies with his father’s missiveness, and contempt for those who
aggressive business style and parenting, disagree are unprofessional and perpetuate
and is now employing that orientation to the divisive discourse that ideally they
his role as president” (p. 273). Later, he should analyze.
notes that “Trump was unconsciously Comments by mental health profes-
sabotaging his chances of winning the elec- sionals should provide unique insights
tion because a part of him recognized he based on their expertise, a professional
wasn’t worthy and/or capable of being suc- tone, thoughts based on observable data,
cessful in that position” (p. 275). Freud systems of analysis that account for contra-
(1911) referred to this as “wild analysis.” dictory facts and arguments, and a rhetorical
Anyone can make stuff up. Speculation style that encourages dialogue through
masquerading as clinical thought gives respect for one’s interlocutor. Most of the
our profession a bad name. contributors fail to meet these criteria.
And then there is the issue of diag- The contributors’ frequent lack of a
nosis. Diagnosing people without conduct- professional tone mirrors the political dis-
ing an evaluation is irresponsible. Without course that they abhor. While it is easy to
that process of scientific assessment, we are see aspects of narcissism in Trump, it is less
engaged in name-calling for political pur- easy to see how we can cocoon ourselves in
poses rather than assessment for psycholo- our own bubbles, where our opinions are
gical purposes. It not only discredits our “obvious,” our projections are the same as
field but also enacts the corrosive political the truth, we do not have to think about
discourse that we should be analyzing and other minds, and we imagine we are enga-
transcending. ging in political discourse when we are
In this book, authors variously diag- preaching to the choir of the convinced.
nosed Trump as having a narcissistic person- These failures erase any distinctions between
ality disorder, having a histrionic personality a layperson’s reaction and a professional’s
disorder, having a delusional disorder, and assessment.
being a sociopath. That makes sense. Psy- As mental health professionals, we
chotherapy researchers have shown that understand countertransference and role
Book Review 413

responsiveness, the processes by which we on a political cabinet to make a clinical

may unwittingly enact a problem our decision.
patients have. When mental health profes- Covitz believes it is his “ethical
sionals fail to examine their tone, their responsibility to work within the confines
thinking, their arguments, and their audi- of the law to have Mr. Trump psychologi-
ence, their discourse mirrors and perpetuates cally and psychiatrically examined—or, in
the problem they hoped to solve. This does the absence of his willingness to do so, to
not mean we should abide by a gag rule as have him removed from office” (p. 207).
proposed by the APA. But we do need to be However, mental health expertise has no
clear about what genuine clinical thought is, place in the Twenty-Fifth Amendment as it
so that our public writings reveal it. is currently written. Second, Covitz
As mental health professionals, we assumes that his expertise will influence
can express our concerns and even specu- members of the Cabinet, dominated by
late about the causes of a political figure’s political concerns, to take a step that
behaviors. But those are only personal opi- potentially damages their party. We have
nions we should make public. Our specu- two conflicting issues: (1) political con-
lations cannot be evidence for an cerns currently override a clinical assess-
assessment, much less grounds for ment and (2) assessment raises the specter
impeaching a president. Any determination of a clinical decision overriding the politi-
of fitness requires a systematic examina- cal will of the people.
tion done in a nonpartisan manner. Real This is the danger posed by Malkin’s
contributions could be made to public dis- suggestion that government specialists in the
course by discussing problems with the Central Intelligence Agency (CIA), Federal
Twenty-Fifth Amendment, such as criteria Bureau of Investigation (FBI), and National
for a lack of fitness, boundaries for those Security Agency (NSA) could provide foren-
criteria, and recommendations for a pro- sic assessments under the Twenty-Fifth
cess of assessment. Amendment. But who would make such an
assessment? How would it be initiated and
on what criteria would it be based?
WHAT FORENSIC ASSESSMENT Gartrell and Mosbacher suggest that
PROCESS SHOULD EXIST FOR because military personnel “who are responsi-
HIGH GOVERNMENT OFFICIALS ble for relaying nuclear orders must undergo
WHEN QUESTIONS OF CAPACITY rigorous mental health and medical evalua-
ARISE? tions” to assess fitness for duty (Osnos, 2017;
Colon-Francia & Fortner, 2014), presidents
Trump’s behaviors have raised the should too. They propose that Congress pass
question of his fitness for office and legislation requiring presidential and vice pre-
whether he could be impeached under the sidential candidates be assessed before an elec-
Twenty-Fifth Amendment. Under this tion and annually after an election by an
amendment, either the president declares independent, impartial panel of investigators.
his disability or the vice president and a Is it reasonable to suggest that forensic psychol-
majority of the Cabinet notify the speaker ogists and psychiatrists will be the ones to
of the House and president pro tempore of decide in advance who the American voters
the Senate that the president is unfit to will vote for?
discharge his duties. However, the Twenty- Unfortunately, because so few of the
Fifth Amendment provides no criteria for contributors are forensic psychologists,
either initiating or conducting such an basic errors in assessment were made. Some
assessment. Without such criteria, we rely authors conflate temperament or character
414 Book Review

with cognitive fitness. While we may wish kind of civic discourse needed in a democ-
that certain types of character and tempera- racy. Outrage merely perpetuates the polar-
ment were required for higher office, that has ization that a psychiatric analysis would
never been the case. Thus, the real questions hopefully transcend and deactivate.
remain: How do we assess cognitive fitness in Further, when mental health profes-
leaders? What criteria would disqualify a lea- sionals offer opinions about political leaders
der and trigger the Twenty-Fifth Amend- in public discourse, they must move beyond
ment: neurological disorders affecting the intrapsychic focus (Trump’s diagnoses)
cognition such as dementia and Alzheimer’s, and describe the economic forces and group
psychotic disorders involving temporary dynamics that create the political despair
losses of reality testing, drug addiction? that leads voters to seek leaders who offer
The criteria for fitness or dangerousness magical answers. Mika’s chapter was brilli-
in leaders have never been established, nor has ant in this regard. Should it be a surprise
the process for such an assessment been devel- that Americans chose a leader who offered
oped. We have no clear constitutional standard to “make America great again” when 90%
for what defines a lack of fitness for office when of our population holds only 25% of the
the vice president must take over. Nor do we wealth? There is a clear role for mental
have any procedure for an impaired president health expertise in political discourse. The
who refuses such an assessment. As a result, we questions of fitness, assessment, and the
have an amendment without, for practical pur- Twenty-Fifth Amendment are serious and
poses, any real content. Assessing the fitness of deserve careful discussion. Unfortunately,
an impaired president is a forensic and political most of the chapters in this book failed to
issue that our Constitution should deal with. demonstrate the qualities or unique exper-
Because the Twenty-Fifth Amendment lacks tise that mental health professionals could
the criteria for fitness and a process for its offer. If anything, they point to the need to
assessment, these issues deserve further study be clearer about our particular expertise,
and discussion. what clinical thinking really is, how to
Instead, we find outrage. Outrage can write about it, and how to contribute to
be gratifying as any purge can be, but it is civil discourse within a democracy.
not careful analysis, nor is it a model for the

REFERENCES

American Psychiatric Association. (2013). The prin- 473435/af-improves-its-personnel-reliability-pro

ciples of medical ethics with annotations especially gram/
applicable to psychiatry. Arlington, VA: APA Press.
Freud, S. (1911). Wild Psychoanalysis. S.E. 11: 221-
American Psychiatric Association. (2017). APA 227. Trans. J. Strachey. London, England: Hogarth.
remains committed to supporting Goldwater
Kahn, C. (2017). Trump’s low approval rating
Rule. Retrieved from http://www.psychiatry.org/
masks his support among likely voters. Reuters,
news-room/apa-blog/2017/03/APA-remains-com
November 8. Retrieved from https://www.reu
mitted-to-supporting-Goldwater-Rul
ters.com/article/us-usa-trump-poll/trumps-low-
Brooks, D. (2016). Trump's enablers will finally approval-rating-masks-his-support-among-likely-
have to take a stand. New York Times, August 5. voters-reuters-ipsos-poll-idUSKBN1D8380

Colon-Francia, A., & Fortner, J. (2014). Air force Osnos, Evan. (2017). How Trump Could Get
improves its personnel reliability program. U.S. Fired. The New Yorker, May 8. Retrieved from
Air Force News, February 27. Retrieved from http://www.newyorker.com/magazine/2017/05/
http://www.af.mil/News/Article-Display/Article/ 08/how-trump-could-get-fired