Psychiatry’s Recusal from the Mad World (Part II)

Last time I looked at psychiatry’s recusal from jumping into the speculating about the sanity of the forty fifth president of the United States. The critical question being, how unstable is the man, and is there any safeguards in all of society to even stop him on these grounds even if he was.  The curious answer is … um, no … on account of an ethical guideline called the Goldwater Rule that prohibits psychiatry from engaging in what could be political punditry.  But further than that, there is no established way to legally or ethically pronounce a president incompetent.  There is no lifeguard at the political pool.  It turns out that psychiatrist are a bit like cops and quarters: you never have one when you need one.


Some people are hoping to change all this, however. There has been legislation introduced in the House to establish a method to even examine this possibility.  And there have been some mental health professionals of different ilk who have come forward to warn the world that Trump is unstable as all get out.  The wrinkle in all this, however, is that the mental health opinion relies very much on the kind of diagnosis that’s been most bandied about: malignant narcissism.


Here I will devote the bulk of this essay unpacking what this term, malignant narcissism, means; because it not only describes a pathological pattern in the president, not only a narrow pathological psychologizing, but itself implies what is to be done about it, and what it means for the rest of society.  More important than the mere act of pathologizing Trump is to understand the social psychology that prepares a culture for Trumpism.  This move not only sidesteps the Goldwater Rule, but points us toward a more interesting project of a systematic critical social and psychological introspection in a world of increasing shallowness and hateful reactivity.  Wherever there is a post-truth president, there shall we find the post-truth world.


What is Malignant Narcissism?

Malignant narcissism refers to a particular constellation of personality disorders often discovered in dictators and strongman totalitarians – narcissistic, paranoid, antisocial and sadistic – coined by social psychologist Erich Fromm in the paranoid year of, (you guessed it), 1964. Fromm called the condition the “quintessence of evil.”  He had good authority to write about this and was a giant at the time, writing about violence, alienation, and human bondage in a number of books with titles like Escape from Freedom, The Sane Society and The Anatomy of Human Destructiveness, the latter in which he detailed some compelling psychological profiles of prominent Nazis with a blend of existentialism and post-Freudian psychoanalysis.  Prior to the Goldwater fiasco, psychoanalysts and philosophers of the mid-century era were compelled to use the tools of psychology socially.  Not all of it was as specious as the Fact piece.  Fromm demonstrated how psychology can help explain malicious human behavior, joining other post war figures like Sartre, Arendt, Adorno, Fanon, Horkheimer, among others, who were researching the psychological roots of totalitarianism and demagoguery.

erich fromm
Erich Fromm



When Hillary Clinton rhetorically asked at a rally, “I’ll leave it to the psychiatrists to determine why Trump has an affinity for dictators,” she perhaps unknowingly was referring to an answer that has already been given.


It is a bit ironic that psychology has these profiles they’ve produced about other people’s dictators. It’s become something like anthropology is a study of other people’s cultures, or myth is other people’s religion.  Psychologists are in fact employed to analyze America’s enemies, whether rival states or insurgent communities.  A recent article in the journal Scientific American highlighted this problem by publishing noted personality disorders in a number of foreign dictators of Iraq and North Korea.  It brings up the ironic paradox to permit the tools of psychology for the benefit, but not critique, of American power.


I should note that not every psychiatrist agrees that Trump is a narcissistic personality disorder.  Of notable dissent is Dr. Allan Frances, co-author of the DSM-4, who wrote in the Times:


Most amateur diagnosticians have mislabeled President Trump with narcissistic personality disorder.   I wrote the criteria that define this disorder, and Mr. Trump doesn’t meet them.  He may be a world-class narcissist, but this doesn’t make him mentally ill, because he does not suffer from the distress and impairment required to diagnose mental disorder.


Frances’s problem with the diagnosis highlights a problem with psychiatric diagnoses in general in that the categories they invented focus on the pathology of the individual rather than the individual in their social or environmental context. Neither does the diagnosis consider causes for these conditions much less cures.  By Frances’s definition, Trump is basically not ill because he’s not seeking help for his mental suffering and so has not consulted a psychiatrist.  It’s a rather convenient definition for him but is obviously bogus because there are many suffering people who do not have the insight to perceive their own suffering or the suffering they inflict on others.  This is precisely the meaning of narcissism.  It could also be argued that Trump does in fact suffer – staying up all night watching television, his anxious hurried tweets, his lashing out, his reputed germophobia, and sorted social difficulties.  And yes, he also has been rewarded for this pathology while at the same time manifesting in the suffering of others – those he’s insulted, belittled, assaulted, robbed, stiffed and conned.


While I, as a psychotherapist myself, don’t agree with Frances’s (lack of) diagnosis, I do find use in his prescription for the Trump problem.  Frances says finally, that “the antidote to the dystopic Trumpean dark age is political, not psychological.”  I find this a very useful statement.  The way this can be read is that psychiatry has a limited role and it should not be looked to for political authority.  But this is complicated further by the fact that psychology is in fact historically appealed to for political and social authority, not in politics, but elsewhere in commerce, public relations, spycraft, law enforcement, education, and childrearing.


Medicalizing Moral Problems

If we consider the implications of a term like malignant narcissism, what we really mean is that a pernicious character form has become manifest. The term malignant itself suggests what is really a moral issue, and using the insights of psychology, a method of studying the mind, helps explain the character of human evil.  Where a concept of evil may have been a subject for religion or moral philosophy has now drifted into the lane of science.  This is a continual problem for psychiatry since its inception, since the days when phrenologists were studying the bumps and contours of prisoners’ heads for evidence of defect.  So it was that evil characters became “megalomaniacs” and “psychopaths” which then became “antisocial personality disorder.”  The names of the disorders become a little more of a mouthful as time goes on, but the moralizing root is still active.  “Antisocial personality disorder” is basically a twelve syllable term for an asshole.  Or, perhaps a type of asshole … a … dick.  You get the drift.


What does it mean to use these personality disorder diagnoses you may ask.  The diagnosis of malignant narcissism itself does not propose a cure.  One cannot alleviate this condition with the techniques of talk therapy.  One cannot simply put Trump on the symbolic couch to have him “cry it out.”  Nor can you give him a foam bat to beat an empty chair representing his father.  Nor can psychiatrists cannot cure this condition with a prescription pad.  Zoloft, Zyprexa, Haldol, Latuda and Ambien may help calm him – they’ll calm anything – but chemical restraints will not improve his judgment, insight, or emotional intelligence.  There is no pill for personality disorders in which the would-be client has a fundamental deformation of their ability to form basic trust, empathy or follow the norms of society.


Further, having this kind of condition does excuse one’s self from their actions.  It isn’t a pass from culpability, nor is it sympathetic or pitiable, as some conditions may engender from others.  A personality disorder in itself is not disqualifying a person from executing their duties.  I’m sure there have been plenty of politicians with these disorders.  In fact, if you excluded these folks, there may not be many politicians left.  Narcissism is as common in showbiz as it is in politics, which Roger Stone cheekily said “is showbiz for ugly people.”


But what if Trump wasn’t a pinned for a personality disorder, but instead of suffered something else – like Alzheimer’s disease. This would be disabling, and you may in that case have the medical field responding differently – because Alzheimer’s disease is not specific to psychiatry but crosses over into the specialty of neuropsychology.  It is unclear what would be done in that case.  (Some claim Ronald Reagan had this in the White House in the 1980s, but others covered for him.  Or, as George Carlin japed, “When Reagan was diagnosed with Alzheimer’s, how did they know?”)  In any event, there still is no legal body to even examine, much less make this an authoritative claim.


Much has been said about stigmatizing the mentally ill, which is true, as people make judgments about mental issues that society is beginning to better understand.  But perhaps more distressing is the inverse, not moralizing medical issues, but the compulsion to medicalize moral issues.  This is a key argument with the critics of psychiatry like Thomas Szasz, David Cooper and R.D. Laing.  This lane-crossing is especially apparent, and often pernicious, in the uses of diagnostics for children.  There is scarcely a child’s diagnosis that does not have to do with the child’s inability to sit still, be compliant and obey their caregivers.   They come up with terms like oppositional defiant disorder, attention deficit disorder, and conduct disorder.   It can rightly be argued that these are moral and pedagogical positions that psychiatry is taking, especially when the DSM does not have diagnoses for families, communities or systems.  Diagnoses focus on disordered individuals.  Corrupt systems, environments, societies, according to psychiatry, are confined to silence.



The diagnostic system also faults on being rather culturally specific.  In another culture, say for instance in Nigeria, or Guatemala, or Thailand, these apparent disorders as they are written have little meaning.  In the drive towards “multi-cultural competence” mental health is forced to, when having a client from a foreign country, hesitate to diagnose as freely as they would an American.  They don’t for instance, diagnose Hmong families with terms like “co-dependency” or “enmeshment” because they are so tight-knit and culturally don’t emphasize individualism.  Other cultures, it should be noted, have conditions specific to them.  The Japanese have kitsune, a type of psychosis specific to their culture in which individuals believe they are foxes.  In Haiti, there is a condition of zombieism that is not understood outside of their culture.


What psychiatry does do, however, is promote itself as an authority on human behavior in so-called “Western” culture (which itself is a prickly definition).  It has drawn the territories of what is considered aberrant without describing what is considered normal.  So when courts ask for an evaluation of clients, they turn to the diagnostic skills of forensic psychology because it carries the authoritative air by standing under the banner of objectivity, empirical evidence, and big science.  The appeal to the full psychiatric profile promises to get to bottom of things with its objective tools, its diagnostics in this tradition of “Western” empiricism.



Despite this ostensible authority over the knowledge of human development and sanity, there is an enormous amount of psychology and difference that psychiatry has no comment about.  It takes a position in the family, in school, on the individual, but not on society.  The DSM will not tell us anything about our addiction to mass media or social media.  It will not tell us how disembodied our culture is.  It has no category for our ecocidal behavior.  It says nothing about our relationship with our planet.  The DSM says nothing about the depletion of fisheries, damming of rivers, clearcuts, air pollution, coral reef bleaching or global warming.  It says nothing about greed, or our fascination with money, celebrities, or exploitation.  It says nothing about racism, classism or sexism.  Is says nothing about why we tolerate homelessness despite there being five empty houses for every homeless person in this country.   It is only a list of disorders in a culture that is constructed out of thousands of maladaptive behaviors.  Beyond these limits, the study of the mind and culture empties into is sociology, ecology, anthropology and more broadly, philosophy.



The further problem is that the diagnoses themselves show a great deal of variance. Have three psychiatrists evaluate the same patient, and they may all have different impressions and different prescriptions.  This variance and relativity at the same time make psychiatry both interesting and risky.  The key to understand here is the role of the psychiatrist in their best educated guess, their personal impression.  To put it cogently, they may be shrinks, but they aren’t robots (though some may act like it).  Shrinks are human too.  They have personal feelings attached, and as such, are not just doctors, but citizens with their own cultural, ethnic, and linguistic heritage.  And like all citizens, they can be ideological as well.  There are liberal doctors and there are libertarian ones.  I’ve worked with both.


The most compelling reason why psychiatry alone recuses itself from these kinds of cases is that it exposes the limits of their objectivity.  Liberal psychiatrists will see grievous problems with conservatives, as hopelessly nostalgic, paranoid and lizard brained.  Conservative psychiatrists may see liberals as undisciplined, uncultured violent maniacs.  It would be a far leap to a dystopia where psychology is used as a tool of state ideological conditioning where deviants of the state are pathologized.  (This too, is one of the embarrassments of the psychiatry past, which resulted in the pathologizing of depressed housewives of the 1950s, who were given barbiturates like Miltown as “mommy’s little helpers.”)


Point being, psychiatry far more relative to societal and ideological influences than anyone wants to admit.  To keep psychiatry going, everyone must agree to simultaneously overlook this profound fact.  This relativity was exposed by the Goldwater piece in Fact magazine.  Psychiatry has since tried to present itself as objective with its DSM, but remains bound to some cultural expectations and norms, not science.  Most of the diagnoses do not have objective tests compared to say the tests one might get when one has a broken arm, a growth, or a blood condition.  One cannot take a blood panel to discover attention deficit disorder.   Functional MRI scans can detect brain activity differences in very rare cases or research studies, but cannot explain etiology, much less remedy, nor can they make any claim to what is normative.  There are some tests and inventories psychologists are able to use, but more often than not, in most settings in the real world, psychiatrists use good old interviewing skills to form a diagnostic opinion.


This fact goes against those who would claim one cannot diagnose Trump because they are not able to get a true office interview.  First, Trump would not consent to such a thing because he has no idea anything is wrong.  And even if he did, he would likely lie as much as possible, attempt to overpower the psychiatrist, then attempt to diminish and discredit the clinician, calling him “very, very unfair,” and then talk ad nauseum about how he’s being victimized.  Second, psychiatrists don’t often spend that much time with clients unless there some serious forensic testing going on.  Some pro-Goldwater Rule psychiatrists say that one cannot accurately diagnose their client without months of observation and interviewing.  This is a bogus claim, although nice in an ideal world that has never existed.  Typical psychiatrists are comfortable diagnosing their clients someone after an initial session that lasts less than an hour.  Third, they say since none of these psychiatrists have met Trump personally, they cannot diagnose properly.  This is bogus as well.  In fact, Trump is probably the most psychologically exposed person currently on the planet.  True to his narcissistic self, Trump takes up the thoughts and energy and time of every living person far more than he deserves.


The Goldwater Rule, Reconstructed

To go back to Dr. Frances’ statement, “the antidote to the dystopic Trumpean dark age is political, not psychological,” I would modify this a little bit.  I think everything is psychological just as everything is also philosophical and political.  What we need is a political psychology.  That is to say, psychology has a lot to inform us about our society and political state, and ourselves as ideological and political people.  Part of this process includes using psychology not to diagnose individual figures, but to describe what this means as a society.  This gets squirrely, for sure, because a political psychology needs not achieve big science’s objectivity as an ostensible goal, but rather be socially salubrious and existentially beneficial.


For those mental health professionals feeling hamstrung by the rigid interpretation of the Goldwater Rule, this other way means surely engaging in social and political life fully equipped with their education, not as psychiatrists or psychologists in a relationship with political people, but as psychologically savvy citizens.  For to be psychiatric, is to be, as the Greek word origin indicates, “tending to the soul.”  Rather than total recusal or total engagement, consider this a third way.  I agree with Dr. Ronald Pies, who argued for something along these lines in Psychiatric Times:


“So restructured, the Goldwater Rule would in no sense limit psychiatrists or other health care professionals from expressing purely political views about, say, a presidential candidate. After all, psychiatrists, as citizens, are no less concerned about their country than are butchers, bakers, or candlestick makers. Psychiatrists have every right—indeed, an obligation—to make their political views known when the nation’s course and destiny are at stake.”    Deconstructing and Reconstructing the “Goldwater RulePsychiatric Times Ronald W. Pies, MD


We must also remember that there are other roles for psychiatrists, other than office visits and prescription pads; such as teachers, consultants, educators.  One doesn’t have to be a psychiatric sheriff, standing like a bouncer at the Oval Office, to be able to educate the public on what they know about narcissism, grandiosity, entitlement.  It’s critical, in fact.  People want and need to know what the hell is going on because reality has become so twisted that it seems the universe the is being swallowed up by the gravitational pull by Trump.


In this sense, we have to understand they psyche of Trump to understand ourselves.  It is useful to us to consider these psychological concepts, so that we may wrestle with these concepts within ourselves.  This is the strategy taken by the book Clear and Present Danger: Narcissism in the Era of President Trump.  It sidesteps the Goldwater Rule to get to a more important issue at hand – he’s a symptom of a narcissistic culture.



In the next entry of this series, called Post-Truth President / Post-Truth World, I will look at the psychodynamics of demagoguery, and how reactionary ideologies have revolted against reason retreated to a Trump universe of magical thinking.


Clay Bennett editorial cartoon
Clay Bennett, Chattanooga Times Free Press