Opinion

Opinion | Leonard L. Glass and Bandy X. Lee

We aren’t diagnosing Trump. We’re sounding an alarm

Mandatory Credit: Photo by Ron Sachs/POOL/EPA-EFE/REX/Shutterstock (9314104a) Donald J. Trump and Jim Mattis Trump Cabinet Meeting, Washington, USA - 10 Jan 2018 US President Donald J. Trump makes opening remarks as he holds a Cabinet meeting in the Cabinet Room of the White House in Washington, DC, USA, 10 January 2018. Looking on from right is US Secretary of Defense Jim Mattis.
Ron Sachs/POOL/EPA-EFE/REX/Shutterstock
President Trump and Secretary of Defense Jim Mattis at a Cabinet meeting in the White House on Jan. 10.

While questions about Donald Trump’s mental fitness for the presidency have swirled since he announced his candidacy, they were augmented by his tweets and comments since taking office as well as by two new books. Our book, “The Dangerous Case of Donald Trump,” expressed the concerns of 27 mental health professionals who felt a “duty to warn” the public about the president’s mental instability. This past week, the publication of Michael Wolff’s “Fire and Fury” ostensibly offered a view inside the White House in which the staff’s doubts about the president reinforced these same concerns.

As contributors to “The Dangerous Case of Donald Trump,” we have been gratified by the book’s enthusiastic reception, bearing in mind that all profits from it are used to fund public service projects. But we have been mystified by the lack of recognition that we have not and do not diagnose Trump. Major Garrett on the CBS Evening News said the book’s contributors admit we “are diagnosing from a distance.” WGBH news show host Jim Braude wondered if diagnosing and commenting may be “a distinction without a difference.”

Our focus has been squarely on Trump’s dangerousness. Yet sophisticated reporters from television, print, and radio as well as from the psychiatric community itselfcan’t seem to grasp that we are fulfilling our humanitarian duty to warn about the danger that arises from Trump’s power and proximity to powerful weapons, not diagnosing. Dangerousness has nothing to do with diagnosable illness, as most people who are dangerous are not mentally ill, and mentally ill people are no more dangerous than the general population.

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Why is this an important distinction? Psychiatrists have specialized training, experience, and knowledge akin to that in other branches of medicine. Other clinicians have helped the public understand what course of treatment John McCain’s brain tumor might require or what a quarterback’s shoulder separation could imply. But psychiatrists and other mental health professionals have been forbidden to offer perspectives about public figures by their national organizations, which have been fearful of a loss of credibility from conflicting or ill-considered opinions that might arise. That prohibition was disrupted with the publication of our book.

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We anticipated criticism from political sources and have gotten that, from damning letters to the editor to death threats. What we didn’t expect was that many would not discern the difference between making a formal psychiatric diagnosis, which is crucial in the medical care of a patient and upon which an individualized treatment plan is developed, and providing expert commentary as part of an open discussion that enlightens and informs the public and is done for the purpose of enhancing the public’s understanding, awareness, health, and safety.

One disturbing example of the recurring inability to recognize the difference between mental health professionals participating in the public debate as opposed to our tainting the profession is the accusation from a colleague, Dr. Jeffrey Lieberman, a former American Psychiatric Association president who has denounced our book for diagnosing, despite the fact he himself did that in print while we have steadfastly refrained from doing so. This obfuscation is confusing and misleads reporters and the public about our work in important ways.

Conflating diagnosing and commenting plays into the stifling and impoverishing of public discourse. The silence of professionals facilitated the rise of the Nazis and, in the aftermath, led to the World Medical Association’s Geneva Declaration, which universally obligated physicians to their broader humanitarian role. Indeed, history has shown silence to be as harmful as active collusion with a dangerous regime.

Trump’s diagnosis, if he has one, is his business and that of his family and physicians. It is Trump in the office of the presidency that is of interest to us; if he were running a real estate empire, we would not be concerned about him, as he would not be a danger. Dangerousness can be reliably established from public records; it does not require a face-to-face interview, however much added value that might contribute. Once a dangerous situation has been assessed, whether where domestic violence may occur or, on a larger scale, where ethnic cleansing or the threat of war can be anticipated, steps to contain the danger could be mobilized.

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So why can’t so many smart reporters and professional colleagues get it straight: that commenting about a public figure who isn’t your patient is different from diagnosing someone who is a patient in your office?

For one thing, when doctors offer an opinion, many people assume they are speaking within the traditional clinical role. It’s why advertisers often have white-coated spokesmen who, as the cliché goes, are not doctors but “play one on TV.” Also, for many in the media, it’s simpler to gloss over seeming subtleties. Further, when the issue has been framed by authoritative national organizations, it’s easier to carry forward the “diagnosis from afar” paradigm unexamined than to question its fundamental legitimacy. Finally, psychiatric terms have migrated into common parlance and are even used as epithets. When we have characterized the president’s worrisome behavior as impulsive, grandiose, or narcissistic, to some that readily sounds like a formal diagnosis, not a straightforward description. But our book steadfastly refrains from diagnosing Trump.

Unwarranted, intimidated silence on the part of professionals has contributed greatly to secrecy and stigma. It is about time that we not leave the search for frank discourse to Seth Meyers or the Twittersphere, especially where the public’s safety is concerned.

Dr. Leonard L. Glass is associate professor of psychiatry at Harvard Medical School and a senior attending psychiatrist at McLean Hospital. Dr. Bandy X. Lee is assistant clinical professor in law and psychiatry at Yale School of Medicine.