The Red Herring of the Candidates’ (Physical) Health

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The recent Pneumonia-gate peeled off yet another layer of dangerous absurdity in this presidential election. After Hillary’s fainting episode on 9/11, the media pounced on her health problems, legitimizing the voices of Trump surrogates, trolls and other misguided souls who have already diagnosed Clinton with everything from aphasia to autism, with no evidence to support their conclusions.

The WaPo and NYT convened their editorial boards to issue official statements of concern over the candidates’ [plural] health, demanding that they make their health history public. There was not one demand, however, that the disclosed records include results of psychological and psychiatric evaluations — either because mental health is implicitly assumed to be part of a general health exam and/or because it is a taboo subject for several reasons, one of which is the very apparent but unmentionable character defect of the GOP candidate.

And it does appear to be the latter, given the insistence with which the media pursue Hillary’s real and imagined ailments, while essentially giving a pass to her opponent who openly derides the process by, among so many other things, offering a letter about his astonishingly excellent health that seems to be created, like much of his campaign and life, as a prank. (Sadly, it/they are not.)

This is just another example of how bizarre this presidential election is, and how its bizarreness is augmented and supported by the complicit mainstream media that chase the latest outrage and focus on issues of little significance, while remaining mum about the huuuge elephant in the room, that of Trump’s profoundly deficient character. This defect has been amply evidenced in his behavior, and documented, for decades, probably more thoroughly than that of any other American citizen.

Whatever physical ailments Hillary or any presidential candidate may have, they are either curable or manageable. Should the worst happen, we have a vice president and others down the chain of command ready to take on the executive role. Physical ailments certainly do not disqualify presidents from office, nor pose a risk for the country and the world. America has had several competent enough commanders-in-chief with serious physical ailments before. But we have never had a president with such seriously disordered character as Trump — yet we are not talking about it. Because ethics.

Specifically, because of the well-meaning prohibition, applied to mental health professionals, against diagnosing strange people from a distance, also known in the U.S. as the Goldwater Rule.

Well, yes, we can talk Trump’s mental unhealth if we are lay people and/or use common vernacular that does not reference his defect directly but describes it in oblique and non-biding ways, through various pejorative terms if needed (like deplorable, or a chronic liar or thin-skinned bully, for example). Lay people can also use “expertly” language, calling the candidate a psychopath, for instance; but this will be accompanied by an understanding that lay people do not possess requisite knowledge and expertise to make such assessments matter. (To their credit, lay people often nail it.)

Meanwhile, those who do possess such knowledge and expertise are prohibited, or, more accurately, strongly discouraged from making such assessments, as the American Psychiatric Association recently reminded everyone.

This is madness. (Pun intended. I think.)

It has resulted in a most peculiar version of reality where those in-the-know cannot comment on what’s apparent and the subject of their expertise; and those who see the apparent, but don’t necessarily understand it, search confusedly for explanations which are not coming, as the experts are directed to remain mum. Thank heavens for the Internets, however, and common sense, which fill the knowledge gap somewhat.

There are obvious ethical and humane reasons for not diagnosing strange people from a distance, not the least of which is sparing the pain and stigma for subjects of such diagnoses, as well as avoiding diagnostic mistakes, which are far more common than most lay (and not) people realize. Psychiatric and psychological diagnosis is not an exact science.

Nevertheless, we do know, diagnostically speaking, some things about human beings and their psychological maladies, and this knowledge can be useful in helping us understand, and sometimes even predict to some degree, people’s general behavior.

The language of psychopathology, just like the language of physical health problems, can and should be disseminated and used freely in the public discourse when it’s warranted — i.e., when we are dealing with manifestations of mental unhealth and disorders. This language and the knowledge it conveys are not proprietary and an exclusive domain of the mental health professions. Our society can and should talk openly about depression, for example, or character disorders, learning (one hopes) more about them in the process. It is as much a matter of public health and safety as it is the case when dealing with physical body disorders.

When we encounter, for example, a person with symptoms of a dangerous physical disease, it would be helpful for people to know how the disease manifests and what its risks are, how to generally treat the affected person, and what to do to protect ourselves.

Similarly, we need to stress public health education with respect to character disorders, some of which — specifically those that, like psychopathy and narcissism, severely impair a conscience — pose a clear danger to society.

Individuals who do not possess a functioning conscience (the main feature of psychopathy) and cover up this lack with a grandiose sense of their own importance and specialness, accompanied by entitlement, often aggrieved, and contempt for others (the main features of narcissism) tend to be inherently destructive.

Their incurable character defect, known as narcissistic psychopathy (also, closely enough, malignant narcissism), is the most dangerous form of psychopathology known to humankind and the source of much, if not all, of human-made evil in the world.

The defect is found in genocidal tyrants, mass killers, gurus and toxic religious leaders, and many CEOs alike. Their lack of conscience and their grandiosity that drive them to realize their main life objective — obtaining as much power and adulation for themselves as possible, without any regard for interpersonal and social consequences — guarantee to cause destruction on a small or large scale, depending on the reach of their influence. That much we know. There is, or should already be, no doubt about it. This knowledge is one obviously helpful aspect of (correct) diagnosis.

We also know that this character defect — which is NOT mental illness — is incurable and renders one so afflicted, particularly if in an advanced age, with little to no capacity of learning and change. It is an extremely important piece of information when we consider such an individual for a leadership position, especially in the area in which he has no previous experience. Hoping that the candidate will acquire knowledge and behaviors necessary for his duties is both foolish and dangerous, given what’s at stake. Again, recognizing this is helpful in disabusing such lingering, misguided hopes.

If there is one subset of the human population that should be kept away from positions of power, it is people with this character defect. Unfortunately, their pathology propels them to seek just such positions. And they hide behind what Hervey Cleckley called the mask of sanity so effectively that they can fool even experts.

This makes it especially important that we, as a society, implement protective measures which would stop these characterologically impaired individuals from finalizing their power-driven pursuits, since we know, or should already, about the inevitable exploitation and destruction that will ensue if we don’t.

One way to do so would be by employing psychological assessments to weed such people out of, say, presidential races. We use various forms of psychological testing to determine job suitability for candidates in many different domains with lesser responsibilities — why not for the highest office where mental health and character are of utmost importance? It is reasonable to ask why is it necessary to need psychological assessments for job candidates in the restaurant business, for example, but not for the highest positions in the government?

Surely we can see that thoughtfulness, patience, and empathy, along with the capacity for guilt, critical self-reflection, and the ability to understand and strive to live according to the highest human values (a.k.a conscience) are more important in presidents than their cholesterol or blood sugar levels. Why then don’t we assess those former capacities as seriously as we do the latter? It is true that relevant psychological assessments would be more complicated than simple blood tests, but their results are far more important in this context.

Another aspect of the societal self-protective measures against destruction caused by conscience-impaired individuals is education. Polish psychiatrist Kazimierz Dabrowski warned that:

“[our] general inability to recognize the psychological type of [psychopaths] causes immense suffering, mass terror, violent oppression, genocide and the decay of civilization.” [source]

We have to do a better job educating the public about mental health and lack of it, paying special attention to character disorders which far too often not only go unrecognized as dangerous pathology, but are glamorized and championed as signs of successful adjustment to our society. This education cannot take place if psychiatrists and psychologists are discouraged from offering their opinions and their debates are confined to academic and professional journals. Mental health experts must be given opportunities to openly and widely share their expertise with the public, and this is where the cooperation with the willing media is necessary.

One of the goals of such sharing would be demystification of psychiatric and psychological diagnoses which are complex, but in the general sense (i.e., outside of the privileged and confidential encounter with a patient in the doctor’s office) are not always best left exclusively to professionals. We too often forget that professionals, experts as they are, do not have a monopoly on describing and alleviating various forms of human mental suffering; and one could argue that a wider and greater understanding of these and related mental health issues could possibly lead to better health outcomes, in individuals and groups.

Of course the ethical prohibitions encapsulated in the Goldwater Rule do not apply to general discussions about mental disorders, but to diagnosing real people from a distance.

But it is difficult to have such general discussions while strenuously avoiding specific teachable examples whose presence looms large in our daily reality and collective consciousness. It is one of many reasons why the Goldwater Rule has been a subject of ongoing debate, this year more so than ever. The debate’s main arguments have been best summarized in The Ethics of APA’s Goldwater Rule by Jerome Kroll and Claire Pouncey.

The authors challenge the rule by, among other things, pointing out its unenforceability and showing its aspects that are inconsistent with reality-based practice. They also weigh the ethical prohibitions against ad hoc remote diagnoses issued (usually) for media consumption and often without a good reason, against the professionals’ ethical duty to warn the public about individuals who pose danger to society, noting that:

For the individual moral agent choosing a course of action, the Goldwater Rule provides no direction, except to require that he prioritize the reputation of the profession.

Along the way, they bring up examples of professionals grappling with the rule, one of which is a 2011 NYT editorial by psychiatrist Richard A. Friedman.

The subject of the editorial was the aftermath of Dominique Strauss-Kahn sexual assault scandal, during which, as Friedman writes, “a parade of psychiatrists stepped forward to offer their expert opinion in the news media.” Even though Kroll and Pouncey do not directly comment on this, the editorial is notable for its darkly ironic, in 2016, twist.

Friedman, who is supportive of the Goldwater Rule, says the following:

Of course, there are exceptions to all rules. Patient confidentiality is not absolute, for example: If a patient of mine told me he was thinking of killing someone, I would have an ethical and legal duty to violate confidentiality and warn both the person at risk and the police.
And one could reasonably argue that an exception should be made for psychiatric profiles of foreign political leaders, which United States intelligence services (and those of other countries) have been doing at least since World War II. An evaluation of Col. Muammar el-Qaddafi of Libya, for example, might well be in the national interest because it could help guide how we deal with this difficult figure.
Colonel Qaddafi’s ruthlessness, near-delusional grandiosity and love of absolute power all suggest a severe personality disorder called malignant narcissism. Because people with the disorder have a defect in moral conscience, they lack empathy, so there is no room to appeal to them on human terms. Instead, they are more likely to respond to the right mix of flattery, power and a credible threat of force.
Whether the foregoing diagnosis is correct or useful, I have no idea, but it is ethically defensible.
Despite what some of us might believe, though, none of our celebrities or politicians is likely to rise to the level of a national threat that justifies violation of the Goldwater rule.
It’s not sexy and probably won’t make headlines, but experts should just stick to the facts and educate the public, and leave the pleasure of diagnostic speculation to the amateurs.

It just so happens that this year one of our celebrities-turned-politicians, “blessed” with essentially the same character defect that afflicted Colonel Qaddafi (and not surprisingly a fan of the late dictator himself), has risen, aided and abetted by the complicit media and the general silence of experts, to the level of a potential national threat if elected to presidency. He too evidences the “ruthlessness, near-delusional grandiosity and love of absolute power [which] suggest a severe personality disorder called malignant narcissism,” and he too is “more likely to respond to the right mix of flattery, power and a credible threat of force.”

Those are the facts. No, they are not sexy — on the contrary; but they should make headlines precisely because of that.

So can we talk about them now? And if not now, when?

The media, preoccupied with Hillary’s coughs but taking seriously the Trump’s health records charade and treating him like a normal candidate despite overwhelming evidence to the contrary, seem to believe that never is an appropriate answer. The APA obviously agrees.

But not all experts and concerned citizens do.

In his seminal paper on Antisocial Personality Disorder and Pathological Narcissism in Prolonged Conflicts and Wars of the 21st Century, Frederick Burkle, discussing foreign leaders with character disorders, says:

It is both concerning and curious that these “bad leaders” are not properly referred to or named as having ASPD when the diagnosis is clear. For the most part these individuals have discernible character disorders not mental illness per se including psychoses. (…)
Inability to properly deal with intractable ASPD behaviors in a timely manner provides the chronic offenders an enduring protective blanket or status deserved only for national and international public figures with long, respected, and properly earned careers in the service of the people. (…)
Resistance to labeling international offenders as having a character disorder such as ASPD is confusing and unacceptable with ramifications that can be lethal.

He cautions that:

Failure to acknowledge the dangers of denying the importance of ASPD in key areas of the world and not incorporating this diagnosis and information in both short- and long-term strategies is risky.

Of course the same concerns apply, or should, to our own leaders as well.

Late Polish-British psychoanalyst Hanna Segal who spoke eloquently about the destructive forces within human nature, their influences on politics, and the responsibility of mental health experts to protect and promote peace, wrote that silence is the real crime. She urged mental health professionals to take a more active and direct role in disseminating their knowledge about individual and collective psychopathology and its threat to our peace and survival. As a psychoanalyst, she did not burden herself with psychiatric diagnoses, but she still spoke openly and critically of the specific pathologies characterizing our political leaders and groups.

If / when Trump is elected and proceeds to dismantle our democracy (yes, we know this is a very real possibility, thanks to correct diagnosis, as chaos and destruction are assured by his character defect; but he also said so, should there be any doubts), will we perhaps revisit and rethink the Goldwater Rule? If we have that chance, of course, and courage and a desire to do so.

Neither are guaranteed, mind you. As Daniel Fisk tells in his book The Pursuit of the Nazi Mind: Hitler, Hess, and the Analysts, after Hitler came to power in 1933, the German Society for Psychology announced him “a great psychologist” and “a bold and emotionally deep leader who set an example to others.” The country’s mental health practices were quickly and appropriately adjusted to reflect his psychological “greatness;” and any opposition to those developments was squelched and eliminated, as it is always the case. (We understand this, or should, thanks to, among other things, our diagnostic knowledge of human psychopathology. The word diagnosis comes from Greek diagignōskein, which means to ‘distinguish, discern,’ from dia ‘apart’ + gignōskein ‘recognize, know’.)

This is one of many history lessons that we should not ignore. Yes, it can always happen here. And Trump is already fashioning himself a tremendous psychologist, while his surrogate and ardent supporter, Omarosa Manigault, promises that:

Every critic, every detractor, will have to bow down to President Trump. It’s everyone who’s ever doubted Donald, who ever disagreed, who ever challenged him. It is the ultimate revenge to become the most powerful man in the universe.


Originally published at on September 23, 2016.