The Dangerous Case of Donald Trump: 27 Psychiatrists and Mental Health Experts Assess a President, edited by Bandy Lee, St. Martin's Press, 360 pages, $27.99
Thomas S. Szasz: The Man and His Ideas, edited by Jeffrey A. Schaler, Henry Zvi Lothane, and Richard E. Vatz, Routledge, 215 pages, $52
Is the president of the United States mentally ill, or is he just an asshole? That is the puzzle posed by The Dangerous Case of Donald Trump: 27 Psychiatrists and Mental Health Experts Assess a President. The question would have amused Thomas Szasz, the late psychiatric iconoclast whose legacy is considered in a new essay collection edited by Jeffrey Schaler, Henry Zvi Lothane, and Richard Vatz.
Szasz, who died in 2012 at the age of 92, spent his career calling attention to the ways in which "the myth of mental illness" (the title of his best-known book) muddles our thinking about troublesome people and problematic conduct. The sweeping, creeping medicalization of thought and behavior that Szasz decried is epitomized by the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM), which is where "mental health experts" look when trying to diagnose Trump (or anyone else).
The most promising label mentioned by the contributors to The Dangerous Case of Donald Trump, edited by Yale psychiatrist Bandy Lee, is "narcissistic personality disorder." According to the DSM-5, the latest edition of that psychiatric bible, the symptoms of this condition include grandiosity, attention seeking, self-centeredness, "exaggerated self-appraisal," condescension, feelings of entitlement, lack of empathy, and relationships that are "largely superficial and exist to serve self-esteem regulation."
That seems like a pretty accurate summary of the president's personality. But what is gained by calling this collection of traits a "mental disorder" (and implicitly a disease, since psychiatrists are medical doctors)? Diagnosing Trump is a rhetorical trick that allows his opponents to medicalize questions about his competence, temperament, and policies, giving experts like Lee special authority to render political judgments that are supposedly beyond the ken of laymen.
"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," Lee writes in the introduction. "How can I, as a medical and mental health researcher, 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?"
Lee is alluding to the "Goldwater rule," which bars members of the American Psychiatric Association (APA) from diagnosing at a distance public figures whom they have not personally examined. It is so named because it was created in response to psychiatric critiques of 1964 Republican presidential nominee Barry Goldwater—in particular, a Fact article in which APA members described the candidate as "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."
Lee says she objects not to the Goldwater rule itself but to an excessively broad interpretation of it that prohibits psychiatrists from bringing their expertise to bear on an orange-haired menace who poses an existential threat to humanity. The truth that she and her colleagues are capable of revealing, she says, "could be the key to future human survival."
And time is running out. "As more time passes," Lee told Newsweek in January, "we come closer to the greatest risk of danger, one that could even mean the extinction of the human species. This is not hyperbole. This is the reality." Furthermore, she told The New York Times, people are clamoring to hear what she and her colleagues have to say. "The level of concern by the public is now enormous," she said. "They're telling us to speak more loudly and clearly and not to stop until something is done, because they are terrified."
Other contributors to Lee's book are equally breathless. They say Trump is "the most dangerous man in the world," an extreme sociopath whose presidency will "most likely be catastrophic," "a profoundly evil man exhibiting malignant narcissism," and "an American Hitler" with "the power to reduce the unprecedentedly destructive world wars and genocides of the twentieth century to minor footnotes in the history of human violence."
If you are not a fan of Trump but doubt that he is on the verge of killing us all, or if you view his antics as more funny than terrifying, Lee and her allies have a ready response: Where is your medical degree? Where did you acquire the mental health expertise that is necessary to read the president's mind and see the deadly danger lurking there?
Szasz's response to this sort of wild speculation and grandiose pretension was notably different from the APA's. That organization saw its members slapping psychiatric labels on a politician they'd never met and said, essentially, "Cut it out. You are making us look bad." According to the Goldwater rule, "it is unethical for a psychiatrist to offer a professional opinion unless he or she has conducted an examination and has been granted proper authorization for such a statement."
Szasz showed that the unethical conduct the APA condemned, which gave value judgments a pseudoscientific veneer, was fundamentally similar to the professional practices the APA endorsed. Psychiatric diagnoses, which equate things people say and do with diseases, are inherently subjective, cannot be verified by biological tests, and tell us nothing about etiology. Even if a psychiatrist talked to Trump at length and had him complete a battery of questionnaires before concluding that he suffers from narcissistic personality disorder, the diagnosis would not tell us anything important that we don't already know.
Richard Vatz, co-editor of Thomas S. Szasz: The Man and His Ideas, sees little evidence that Americans have taken to heart the renegade psychiatrist's point that mental illness is a metaphor and should not be taken literally. He notes that politicians and pundits still routinely cite mental illness as an explanation for outrageous acts of violence, even though it explains nothing, and describe drug addiction as a disease, which they take to be the enlightened and scientific view.
"The rhetorical refuge of attributing unusually horrible acts or simply unusual actions to mental illness has not noticeably abated since Szasz first questioned the existence of 'mental illness' over a half century ago," writes Vatz, a professor of political rhetoric and communication at Towson University. "The responsibility-denying rhetoric of mental illness, steeped in mystification and self-serving explanations of the difficult-to-explain, will perhaps forever successfully endure."
Such rhetoric is appealing because it is useful, even when it makes little sense. Consider civil commitment of sex offenders, which is authorized by about 20 states and the federal government. Under these laws, sex offenders who have completed their prison sentences can be confined indefinitely in "treatment centers." The Supreme Court approved that policy based on the premise that certain sex offenders suffer from "a volitional impairment rendering them dangerous beyond their control."
The theory is puzzling on its face, since these very same offenders were punished with prison terms based on the assumption that they could and should have controlled themselves. Stranger still, the mental illness that supposedly impairs their volition is defined by legislators rather than psychiatrists, and in some states it seems to be incurable, since the prisoners-cum-patients are almost never deemed well enough to be released. Supporters of civil commitment for sex offenders are untroubled by these contradictions, because the rhetoric of mental illness facilitates preventive detention of people they fear and detest.
The insanity defense, by contrast, offends most people because they don't like the results. Three-quarters of Americans thought justice was not served by the 1982 acquittal of would-be presidential assassin John Hinckley, according to an ABC News poll conducted at the time. The case, which Vatz mentions and Szasz frequently discussed, inspired legislation that made it substantially harder to successfully mount an insanity defense in federal court.
Hinckley, who received a primary diagnosis of schizotypal personality disorder in 1982, ended up spending more than three decades in a mental hospital. The judge who ordered his release in 2016 said his mental illnesses "have been in full and sustained remission for well over 20 years, perhaps more than 27 years," which suggests that punitive considerations (or fear of a public backlash) unofficially played a role in his continued confinement.
Vatz also points to criticism of the DSM's ever-expanding scope, which already encompasses something like half the population and may one day cover us all. He notes that "Szasz used to write particularly derisively of those who would argue only that mental illness was overdiagnosed: that mental illness was a major problem, just not as widespread as most people thought." Yet even that relatively mild critique of psychiatry has radical implications: If mental illness is not whatever psychiatrists say it is, what exactly is it?
Psychiatry's diagnostic difficulties are in fact fundamental, as recognized by no less an authority than Allen Frances, who chaired the committee that edited the fourth edition of the DSM. "Psychiatric diagnosis still relies exclusively on fallible subjective judgments rather than objective biological tests," Frances 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 the psychotherapist Gary Greenberg, "There is no definition of a mental disorder. It's bullshit. I mean, you just can't define it."
That is not a minor problem that can be tweaked by another revision of the DSM. "I agree completely with Schaler and Szasz that mental disorders are not diseases and that treating them as such can sometimes have noxious legal consequences," Frances wrote in a 2012 Cato Unbound debate that also featured Vatz's co-editor Jeffrey Schaler. "Mental disorders are constructs, nothing more but also nothing less." Frances thinks some of these constructs reflect impairments of rationality and self-control that may justify coercive intervention. "Schizophrenia is certainly not a disease," he wrote, "but equally it is not a myth."
The DSM-5 describes schizophrenia as "a severe and chronic mental disorder characterized by disturbances in thought, perception and behavior." The symptoms may include delusions, hallucinations, disorganized speech, flat affect, and "grossly disorganized or catatonic behavior." But what psychiatrists call schizophrenia, which is said to affect about 1 percent of the population, may "turn out to be many different things," as Trinity College Dublin psychologist Simon McCarthy-Jones recently observed in The Conversation, an online forum for academics and scientists.
Some of those things may involve measurable neurological defects. "It is important to remember," Vatz writes, "that a small percentage of people labeled (diagnosed) as schizophrenic…are brain diseased and cognitively incompetent. These people generally show signs of disease during an autopsy."
The possibility that some people who receive a diagnosis of schizophrenia have brain diseases—a point that Szasz conceded—does not mean that schizophrenia is a brain disease, let alone that all the other mental illnesses cataloged by the DSM are. To the contrary, a condition ceases to be a mental illness once an underlying biological cause for it can be identified. That is what happened with "general paresis of the insane," which moved from the province of psychiatrists to that of neurologists after it was understood to be a consequence of brain damage caused by syphilis. Neurological conditions such as multiple sclerosis, Alzheimer's disease, and Parkinson's disease likewise are not considered mental illnesses.
Still, if some people diagnosed with schizophrenia have brain diseases that make them "cognitively incompetent," that disability might justify a legal process that allows others to make decisions on their behalf, just as it might in the case of someone with Alzheimer's. A verifiable brain disease certainly seems like a firmer basis for limiting someone's freedom than speculation about a mental disorder that may or may not have a neurological component.
The libertarian writer David Ramsay Steele, who also contributed an essay to Thomas S. Szasz: The Man and His Ideas, agrees with Szasz that there is no such thing as mental illness if the phrase is taken literally. But he argues that "today the most popular unpacking of 'mental illness' by far is 'unidentified brain illness with mental symptoms,' and there is nothing incoherent about that." Steele challenges the close connection that Szasz drew between a belief in the reality of mental illness and the justification for psychiatric coercion. He notes that people with bona fide brain diseases are not typically treated against their will and that people with psychiatric diagnoses, including schizophrenia, are capable of making rational choices and do not necessarily pose a danger to others. To justify coercion, in other words, something more than a diagnosis is needed, whether the condition is a scientifically validated neurological disease or a mental disorder said to be caused by a "chemical imbalance" no one has managed to measure.
Likewise with judgments about Donald Trump's fitness for office. "The issue we are raising is not whether Trump is mentally ill," New York University psychiatrist James Gilligan writes in Lee's collection. "It is whether he is dangerous. Dangerousness is not a psychiatric diagnosis." The president could be mentally ill but not dangerous, Gilligan says, and he could be dangerous but not mentally ill.
Allen Frances draws a similar distinction. Trump "is definitely unstable," he told The New York Times in January, right after the president declared himself "a very stable genius" on Twitter. "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."
Gilligan and Frances may be right or they may be wrong, but the fact that they have medical degrees does not make them especially credible, because these are not medical conclusions. They are political conclusions.
Voters knew what they were getting with this president, and almost half of them decided to give him a shot anyway. Trump provides daily ammunition to those who think that was a mistake. But if they want to persuade others, they will have to put down the DSM and pick up a newspaper.
This article originally appeared in print under the headline "The Myth of Donald Trump's Mental Illness".