By calling himself "a very stable genius" on Saturday, Donald Trump invited his psychiatrically inclined opponents to reiterate their claim that he is mentally unfit for office. "The level of concern by the public is now enormous," Yale forensic psychiatrist Bandy Lee told The New York Times. "They're telling us to speak more loudly and clearly and not to stop until something is done, because they are terrified."
Lee, who edited The Dangerous Case of Donald Trump: 27 Psychiatrists and Mental Health Experts Assess a President, thinks the public is clamoring to hear the opinions of brave experts like her. Trump thinks the public is sick of bogus issues like "Russian collusion" and "mental stability" propagated by "the Democrats and their lapdogs, the Fake News Mainstream Media." I think Lee and Trump both are drawing hasty conclusions based on biased samples, and Lee's belief that she has any special authority to judge the president's competence is at least as delusional as Trump's belief that his success as a developer, a reality TV star, and a politician puts his I.Q. score above 140.
Lee is rebelling against the American Psychiatric Association's rule barring members from diagnosing at a distance public figures whom they have not personally examined. The injunction, which can be found in Section 7 of the APA's Principles of Medical Ethics, is known as the Goldwater rule because it was largely a response to psychiatric critiques of the 1964 Republican presidential nominee—in particular, an article in Fact magazine that quoted APA members who described Goldwater as, among other things, "a dangerous lunatic," a repressed homosexual, a self-hating half-Jew, a paranoid schizophrenic, and "a mass-murderer at heart," just like "Hitler, Castro, Stalin and other known schizophrenic leaders."
The APA rejected such wild speculation as unprofessional and unethical, a pseudoscientific cover for political disagreements. Yet psychiatry itself is based on equating things people say and do with diseases, providing a medical veneer to value judgments. The profession's diagnoses are inherently subjective, say nothing about etiology, and cannot be verified by biological tests. If one of the psychiatrists quoted by Fact had talked to Goldwater before declaring him a paranoid schizophrenic, would that have made the label any more valid or informative?
Lee and her allies argue that the Goldwater rule, as applied to Donald Trump, conflicts with their "duty to warn" the public about the grave danger posed by a flagrantly unstable president. Allen Frances, who edited the fourth edition of the APA's Diagnostic and Statistical Manual of Mental Disorders (DSM), agrees that Trump is temperamentally unsuited for his job but questions attempts to cast that assessment as a psychiatric diagnosis. "He is definitely unstable," Frances told the Times. "He is definitely impulsive. He is world-class narcissistic not just for our day but for the ages. You can't say enough about how incompetent and unqualified he is to be leader of the free world. But that does not make him mentally ill."
The distinction drawn by Frances is rather mystifying in light of the DSM, including the version that Frances edited. DSM-IV, which was published in 1994 and revised in 2000, defines "narcissistic personality disorder," for instance, as "a pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy, beginning by early adulthood and present in a variety of contexts." The diagnosis requires at least five of these symptoms:
- Has a grandiose sense of self-importance (e.g., exaggerates achievements and talents, expects to be recognized as superior without commensurate achievements).
- Is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love.
- Believes that he or she is "special" and unique and can only be understood by, or should associate with, other special or high-status people (or institutions).
- Requires excessive admiration.
- Has a sense of entitlement, i.e., unreasonable expectations of especially favorable treatment or automatic compliance with his or her expectations.
- Is interpersonally exploitative, i.e., takes advantage of others to achieve his or her own ends.
- Lacks empathy: is unwilling to recognize or identify with the feelings and needs of others.
- Is often envious of others or believes that others are envious of him or her.
- Shows arrogant, haughty behaviors or attitudes.
As more than a few "mental health experts" (including contributors to Lee's book) have noted, the fit between these criteria and Trump's personality traits is striking, and the same is true of the somewhat modified criteria in DSM-5, which was published in 2013. According to the psychiatric bible that Frances edited, the pattern of behavior exhibited by the president is consistent with a "mental disorder," and I suspect that impression would hold up even after a proper, professional psychiatric examination. Why, then, is Frances so dismissive of the idea that Trump is "mentally ill"?
In recent years, Frances has expressed qualms about the APA's quest to classify every unlovely feature of human nature as a mental illness. "Psychiatric diagnosis still relies exclusively on fallible subjective judgments rather than objective biological tests," he noted in a 2013 Annals of Internal Medicine article. "Psychiatric diagnosis is facing a renewed crisis of confidence caused by diagnostic inflation. The boundaries of psychiatry are easily expanded because no bright line separates patients who are simply worried from those with mild mental disorders." Or as Frances put it more pithily in a 2011 interview with Gary Greenberg, "There is no definition of a mental disorder. It's bullshit. I mean, you just can't define it." In a 2012 Cato Unbound debate (in which I also participated), Frances declared that "mental disorders most certainly are not diseases."
If so, you may wonder, why are they treated by medical doctors? And is Frances now saying that Trump does not qualify for a DSM label or that, even if he did, it would not mean anything, because it's all "bullshit" anyway? I suspect, based on what Frances said in the Cato Unbound debate, that he is drawing a distinction between a diagnosis like "narcissistic personality disorder," which is little more than a list of unappealing characteristics that often go together, and a "serious mental illness" like schizophrenia, which may actually be several different things and may or may not involve an identifiable neurological defect but, in Frances's view, entails a lack of self-control that can justify coercive intervention.
Trump may be crazy, in other words, but he's not that kind of crazy. The upshot is that, even if you think some parts of the DSM have scientific validity, the argument about Trump has nothing to do with mental illness and everything to do with his abilities and temperament (as well as his policies, an unspoken motivation for many, if not most, of the critics who worry about his mental health). Voters knew what they were getting with Trump, and almost half of them decided to give him a shot anyway. Trump provides daily ammunition to anyone who wants to argue that was a mistake. My own view is that his antics are more hilarious than terrifying and have the salutary effect of undermining respect for the presidency, which may lead to long-overdue limits on its powers. I am open to being persuaded otherwise by anyone whose arguments do not depend on psychiatric pseudoscience.