Armchair Amateur Diagnosing Can Be Hazardous to Another’s Health

I have been out of commission for several months now on medical/surgical leave from my work as a psychiatrist and about everything else, weathering reparative surgeries, elective very aggressive interim chemotherapy to more than ever insure continued remission. But finally I am bringing all this to a close, regaining energy, able to use my arms and forearms each week (that prevented almost all typing, computer work, even holding books etc.) and can start devoting myself to my publishing and commentary efforts, though mostly using dictation software to digitize my thoughts on the viewable gizmos of our age.

I have thought a great deal about the growing chorus in the citizen media concerning the temptation (a pointed characterization on my part of this phenomenon) to diagnose our new President, Donald Trump. The President has perhaps unwittingly on his part, for the most part, demonstrated public behavior that has drastically broken nearly every unwritten” rule” or traditional expectation of political behavior and leadership script of our American Presidents literally since the earliest independence days of this country. In brief, I will summarize some of the customary channels of behavior that we have come to expect of our Presidents. Granted my grasp of this is not nearly equal to that of a true historian of the American  Presidency. But I have read a number of presidential biographies and viewed many tv documentaries since my childhood of American Presidents. These two sources of information have given me at least more than a modicum of background data on the almost “institutional’ behaviors of Presidents. So I think that I do have at least a moderately well-grounded foundation for offering several “behavioral mores” that devolve upon American Presidents.

I feel that perhaps the strongest expectation facing and almost forcing itself upon any elected person who becomes President, is that a President becomes much less political in their public statement, and more careful and considered in pronouncements. One example is that when an American President has to comment on the American economy, the stock market, and markets in general, the President tempers their statements with a very careful eye toward the possible effect on the nation’s economy. During the still recent busts, downturns, financial crises of 1999, 2008-9, Presidents Clinton, Bush and Obama, had to hold back much terrifying truth regarding the depth and danger of those financial recessions that saw the near collapse of portions of the financial components of the nation’s functioning, big banks, the housing mortgage system, the early “dot com” industries, etc. Those Presidents almost were so low key and reassuring concerning those dangerous many months that their press conferences and staged performances of explanation and lobbying for life-saving legislation and national economic repair was actually BORING to a fault.

Second, Presidential behavior in the public eye has had to be careful, diplomatic, and nonconfrontational. In short, the President has been “supposed to” be NON-political. Any political fireball throwing or negative comments are to suddenly disappear once one is the actual President. In short, American Presidents are supposed to be mostly above the political fray, a phrase long used in the reporting media as gospel. So it is a big deal when a President “goes up to the Hill,” to Congress to lobby for legislation.

Third, a somewhat lesser and less familiar expectation has been that Presidents is supposed to speak to all, to represent all the entire nation and its citizens. The President often can and should function as the center of the country. This position and expectation have a large influence on the behavior and role of leadership of the American President. Consequently, American Presidents abandon the political rhetoric that got them elected, at times to the points that their political statements and behavior once elected are so dramatic that to some it appears that the newly elected President has abandoned political promises.

I would summarize all this by saying that the American President, no matter who they are as a person, what their temperament is, their personality and interpersonal style is, have in the past comported and presented themselves as the all-wise, unflappable, reassuring father/leader for all citizens of not only this nation to whom the President owes everything in a way, but also to leaders of other countries important to the USA whether for reasons of cooperation or competition.

The new President Trump has virtually sacked and destroyed all these traditional rules of behavior of American Presidents. I use the term “behavior” since I am a  psychiatrist and view people’s actions as phenomena that originate, come from, are products of many factors such as personality style, past emotional and relationship development and experiences from their families, friends, peers, mentors, educations, etc., as well as biological factors, innate intelligence, occupational influences or training (such as that of a military person), brain conditions and modes and levels of functioning. This poly-component, multidetermined view of one’s actions opens the approach that can analyze origins of person’s actions, statements, reactions, relational abilities and approaches to the staggering amount of importance of problems the President must and is expected by the nation’s citizens who, like children of a huge family, must depend upon the President.

This brings us to the factor of trust in our leader the President. This is a circumstance that is shared by every country, its leader, and citizens. In a democratic society with free speech and publication of the commenting media, i.e., the free press, we are free to make known differences with our leader, our President. Criticism is not only tolerated but also expected in this nation’s political life. Given this institutional and historical permission to engage in such observational and even adversarial verbal commerce, criticism, questioning and disagreement with the behavior, style, and content of leadership by the American Present is routine. Inferences of reasons for Presidential behavior, guidance, and directives are also common and part of the national discourse. When Presidential is and for centuries, has been fairly predictable, the commentary concerning a President’s positions has been almost entirely restricted to POLITICAL origins and determinants. Aberrant behaviors on the part of the American President have been rare. One example would be the impairment of President Woodrow Wilson who suffered a stroke, was likely unable to function and his wife took over; this was a development with which America had no experience and many in the national government at that time permitted this ruse to continue with almost no public revelation or “outing.” Another example was that of President Nixon who apparently started to emotionally unravel in the last weeks of his Presidency when he began to face that he would be impeached and be labeled as a dishonest President. His staff apparently shepherded him around the last days of his Presidency and prevented anything untoward.

But above all, in this nation’s collective history, the issue of an individual as President who behaved day in and day out as our current President has. Rules of political and leadership decorum of being discrete, civil, careful and measured have disappeared. President Trump has been astonishingly transparent revealed through his invective-laden informal communications through Twitter, never before utilized by literally almost any national elected official.

Mr. Trump has openly revealed traits of his personal functioning that have alternately cheered his political followers who feel he is telling like it is as no other politician in American history has ever done. This reflects perhaps a view that politicians have not told the truth, the whole truth and nothing but the truth as the commonly used oath of testimony is wont to declare. His supporters feel that he has thankfully trounced and demolished the custom of using political correctness which his political popular movement has viewed as dishonest, devious and kowtowing to opposing interests who conceal things and do not say what they mean.

On the other hand, an equally staunch view opposing view has been that in so doing, being so open, perhaps denigrating, uncouth in a rarefied “fancy” view, and verbally combative, displaying alarming traits that come close to or might be “unbalanced,” possibly mentally ill etc. This bloc of political persons has more and more taken a mental health based view of President Trump as mentally unbalanced and even mentally ill. Many have even taken to off the cuff, though fervently expressed, diagnosing him as having one or another alarming sounding psychiatric/psychological diagnoses. This has arisen largely from non-professionals,  perhaps not trained in the diagnosis and treatment of the illnesses of brain functioning, personality disorders and such. There have been a few individual mental health practitioners and a number of mental health professionals in groups who have come forward and made public their views and diagnostic appellations of him as mentally ill or disordered. A few books have been published, none of which are very well known, not having gained much traction in sales or fame/notoriety.

One group in Asheville North Carolina, headed by Dr. Stephen Buser Ph.D. published a somewhat in February 2017, A Clear and Present Danger: Narcissism in the Era of President Trump with his co=editor Len Cruz. The book is multi-author compendium of essays more or less regarding the personality structure of Mr. Trmp from Jungian analytic view. It has a yowie-zowie cover and implies alarming reading but does not deliver such, and is rather a somewhat uneven academic discussion of personality disorder issues from a Jungian viewpoint. It does however make for interesting readying. There is less material overall about President Trump and more about Jungian theory for readers focused on the issues of understanding Mr. Trump’s behaviors as our current President. It is more sociological in focus and less focused on supposed clinical portrayals of the President. Jung had quite esoteric and mystical theories such as the archetype and collective unconscious that never caught on beyond a very small number of practitioners in the Western world and still is relegated to a tiny minority status in medicine and psychiatry worldwide. Any reader not familiar with Jungian theories will find this book boring, obtuse, confusing and difficult to apprehend in its attempt to diagnose President Trump in an understandable and meaningful way even if just for intellectual discussion. But it appears to have been one of the first volume published to take on Trump’s idiosyncrasies in an open way.

The second volume entitled, The Dangerous Case of Donald Trump: 27 Psychiatrists and Mental Health Experts Assess a President by Bandy X. Lee and Robert Jay Lifton, was published more recently, late in 2017. Dr. Lee is a female psychiatrist at Yale University School of Medicine. She has taken an openly strong and polemical stance toward Mr. Trump endeavoring to use the book as a very strong vehicle for condemning as a very disturbed personality disorder. The volume introduces an almost anecdotally based concept of special personality type and frames it to fit Mr. Trump and him to fit it in a circular way. I do not offer this characterization to condemn her work but state that this is largely the literary vehicular manner in which her argument is offered. Her descriptions and connections her book and articles by several authors are far closer to Mr. Trump’s well-known behaviors than are those offered in Dr. Buie’s book which is very loosely constructed and weak as an argument and case for its assertions regarding the mental health valence of Mr. Trump’s behaviors. 

Dr. Bandy has come under quite severe public criticism and scrutiny within the formally organized professions of psychiatry. A number of citizens from ordinary walks of life, as well as well placed mental health and professional authorities, have openly called for her censure, disciplinary action and even ‘disbarment’ or expulsion from psychiatry and loss of her license. However, sine is a not a member of the professional “guild” of psychiatry, she cannot be nationally disciplined. Yale University, being such an institution committed to academic freedom has not and most likely will not take any censorious action as she has not harmed anyone, committed a crime and Mr. Trump is a public figure if ever there was one, and her work is not viewed as libelous under the law.

The basis for consideration of the professional psychiatric error in diagnosing public figures comes from the “Goldwater Rule defintiion from Wikipedia” an almost forgotten obscure rule of psychiatric professional ethics. This concept and rule of ethics is officially embodied in the written code of ethics for psychiatrists. It has a very interesting history which bears retelling for the benefit of any reader who has no familiarity with it.

In 1964 President Lyndon Johnson ran for his re-election as President after ascending to the President on the sad occasion of JFK’s assassination in November 1963. HIs Republican opponent was Senator Barry Goldwater from Arizona. The campaign was a bitter one pitting a staunch well disciplined and knowledgeable conservative in the person of Sen. Goldwater against President Johnson, who was turning toward centrist but more government intervention governance and legislative initiatives that came to be the Great Society with the introduction of the Civil Rights Act, Medicare and Medicaid, all opposed by the Republicans as too much government, helping people too much, undermining the free enterprise system, reinforcing eh evils of personal initiative and dependence upon welfare and the government. LBJ ran a controversial political ad, which really was in retrospect, one of the earlies attach ads and it was a “beaut.” Sen. Goldwater was well known for an explosive temper and salty language. HIs image as a temperate statesmanlike figure was viewed by many at the time, as unsteady, unstable and alarming. The ad aired by the Democratic Party showed an atomic bomb explosion with the frightening mushroom cloud while intoning in the background implied questions about Sen. Goldwater’s supposed personal stability. LBJ won by a landslide in one of the most one-sided Presidential victories ever in American political history. As a side note, that ad and the shellacking suffered by Republicans , were viewed as sealing an enormously bitter and angry anger of the Republicans toward Democrats that has lasted to this date, and motivated decades of revenge and stimulus for egregious political illegalities including the Watergate debacle of the Nixon years, political dirty tricks etc. But this is a controversial view but in a way germane to the present focus and origin upon Mr. Trump and his potential for dangerous political moves that alarms those who do not admire and accept his style as the new normal. I. E., Trump is the New Goldwater and such unspoken conflations.

In the months leading up to the November 1964 election date, a political rag of the time FACT then ran a survey of over 2000 American psychiatrists about the political figures of the day. Exactly 1, 187 psychiatrists responded negatively about Sen. Goldwater, offering diagnoses, free-form analyses of him etc. Approximately 700 refused to respond and some wrote publicly and to the American Psychiatric Association of their severe misgivings regarding the survey. In its construction of questions, it evolved toward the conclusion by the end of the survey, asking whether the responding psychiatrist considered Sen. Goldwater emotionally fit to hold the Presidency. It asked for open comments about that psychiatrist’s view of Sen Goldwater. Many opened opined off the cuff analyses of Sen. Goldwater’s personality and psychiatric functioning and diagnoses. This data was published in this magazine FACT and stirred up enormous publicity that played no small part in costing Sen. Goldwater the election it was felt in many quarters. Groups supporting Goldwater saw it as part of a movement or even a conspiracy to unfairly taint Sen Goldwater etc. The “liberal” media was pilloried and blamed for playing all this specious data up for negative effect upon Sen. Goldwater. And to a great extent, though rather off in their analysis of some grand collusion (such a loaded term these days and I apologize but it is an appropriate term in this context) on the part of the Democrats, the leading media vehicles of the day. If one reads the excerpts from the survey, the terms and characterizations come across as really outmoded, naive, stupid and downright lame. But in that day, they carried undeserved weight. The profession in the body of the American Psychiatric Association and mature heads recognized this whole survey business as dangerous, unethical and ill-advised. The APA undertook a profession-wide review and policy analysis of the whole affair. The resulting “Goldwater Rule in APA Ethics” was installed in the formal book of rules of ethics for all members of the APA’s Guide to Ethics.

[As an aside, this rag went out of business after only four years’ publication. Sen. Goldwater was reportedly quite bitter about the hatchet job done on him through the ad and the skilled but still dirty for that day and time, negative political advertising thrown his way personified by the atomic bomb ad which went down in advertising history as one of the great ads along with the Apple 1984 MacIntosh computer ad. Years later in his last several years of retirement, Sen. Goldwater began to publicly argue against the Reagan Revolution, the growing right-wing extreme positions of his Party. He took increasingly unpopular positions differing with the new ideologies of the Party especially the NeoCon ideology surprising the New Conservative wing. He demonstrated again in his last years that he was still his own man.]

What resulted was the Goldwater Rule, codified and enacted in 1973. It was roundly emphasized within the profession and overwhelmingly accepted as “gospel,” a term that I choose purposefully to convey how serious this rule was taken.

The Goldwater Rule, in short, states in the firmest terms, that a psychiatrist can only diagnose an individual if one interviews the person face to face, establishes a responsible treatment relationship and conducts this process responsibly up to practice and ethical standards. IN other words, NO armchair, off the cuff, barroom psychiatric pontificating at all. A practitioner may have a personal opinion as to the functioning of a public figure but one may not at all state unsupported diagnostic formulas about an individual. And it follows that if a psychiatrist evaluates a person in the context of treatment or a forensic examination, that diagnosis is protected from public disclosure by the rule of physician-patient confidentiality and can only be disclosed upon court order such as in a competency or forensic legal proceeding etc.

So, psychiatric public diagnosing of President Trump is forbidden to psychiatrists. Period. It is unfair to Mr. Trump no matter how one feels toward him politically or personally.  Some figures have argued that the 25th Amendment to the Constitution about the impeachment of the President, or the necessary relief of the President’s duties if the Presiden becomes so impaired they he/she cannot perform their duties, permits discussion in the public realm for the benefit of the nation’s public good and thereby permits the discussion of whether a President can be diagnosed as mentally unfit to permit an orderly process of relief of their duties on psychiatric-mental health grounds for protection of the nation and its citizens. Almost always, such a line of logic refers to the finger on the nuclear trigger in the now modern atomic era as justification for fudging the Goldwater Rule and getting around it, again an ironic new parallel perhaps to the anti-Goldwater rule with its mushroom nuclear cloud image. And personally, I think that ad was an atrocity itself. But then again so was the survey itself, an unscientific loaded, biased survey if there ever was one and anyone who reads would agree I think no matter their political position in today’s spectrum.

A small number of psychiatrists (I think that the number is small but this is a guess) have utilized what they see as Mr. Trump’s egregious and outrageous, or very very different behaviors compared to the past Miss Manner’s rules of etiquette for Presidents, as justification for calling out his supposed possible diagnoses publically. I would submit from a centrist, right in the uncomfortable middle and crossfire target/position in this controversy, that the diagnoses are always negative if not downright condemnatory. As such, they cast a negative mental diseased highly prejudicial imputation to Mr. Trump and violate the profession’s commitment toward fighting the negative stigma long attached to the state of having a mental disorder. A terrible contradiction that demands a higher level of discourse and approach to the question of Mr. Trump’s functioning in office. This question is a political one, a social one, an ethical one and not a psychiatric one. I could see this becoming a psychiatric one only if a President were to start becoming as delusional as Josef Stalin or his paranoid head the early Soviet KGB, Beria. Both these men were truly psychotic in their paranoia and murdered millions in their day. Another such figure was likely Pol Pot of Cambodia who murdered 2 million by estimates. Seriously disturbed psychotic leaders have existed to be sure and one can only look to Adolf Hitler as perhaps our best example, no matter what the Extremist Skinhead Neo-Nazis say.

And I will conclude this dreadfully long post by referring to the ONLY psychiatric armchair treatise and effort that can claim any ethical legitimacy in our modern psychiatry history. That is the work on Adolf Hitler commissioned by the then forerunner of the American CIA, the OSS, in World War II. It is entitled, A Psychological Analysis of Adolf Hitlerby Walter Langer MD. This volume was commissioned so the allies hopefully would have insights into the cognitive style of Hitler, his views and motivations that might give the allies ability to anticipate Hitler’s wartime decisions and strategies and outfox him and know his weaknesses. The book makes for almost astounding reading. It was presciently accurate which was all the more impressive since the author had little data and the methods of psychological analysis, family systems therapy, personality development, by modern standards were at best rudimentary. The current modern remake of this book in its current reprint has even more data and documentation/explanation of its methods and historical context. The original hardback volume I had years ago, recommended to me in 1974 by a German psychiatrist in my residency years, was thin and restricted to the original text. But it was fascinating reading then and still is one of the definitive explanatory works on Adolf Hitler. But it was a historical aberration and occurred in the setting of a national war for survival. It is like as an armchair psychiatric long distance guess at psychiatric diagnostic off-the-cuffing it will never be seen again. And it can not be utilized as a justification for the armchairing it of Mr. Trump or anyone else for the reasons and contexts given above. The book is an historical near treasure. It is surprisingly and uncannily accurate and almost stunning in the insights it afforded the American and British intelligence forces. These were used in pointed psychological warfare and disinformation campaigns not only on a public level to broadcast and propagate derogatory but accurate damaging information about Hitler himself but also to higher figures in the military ranks of the German forces. This information reportedly helped numbers of German High Command to distance themselves from  Hitler and plan their own defections. The accuracy of the book and its derivative information used by the intelligence figures in the American OSS and the British intelligence service, later to be the MI6, proved invaluable to this late “campaign” in the Allies’ war effort. Its effect was telling to the point that members of the High Command reportedly fed information to the Allies to secure a safe status for themselves after the surrender, safe passage etc. It was felt to have stimulated growing numbers of military officers’ defections and also feeding the Allies more and more telling information about Hitler’s own psychological dissolution. In short, this is perhaps the only American effort at long distance psychiatric analysis and diagnosis that was ethical and successful. But as they say, “That was then, and this is now.”

 

 

 

 

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