About me, credentials, background, etc.
Yesterday when I posted Distinguished shrinks weigh in on the anonymous N.Y. Times OpEd, and so do I a commenter ask the following:
What sort of information about (or from) Donald Trump might a more conservative mental health professional feel would be necessary for making an informed diagnosis under the Goldwater Rule, that we don’t already have in thousands of hours of video and in person coverage of Donald Trump’s behavior and expressed thoughts? Is there a set of specific questions that would have to be answered by Trump personally?
I tried to answer.
Before you read this, here’s my disclaimer. I am not an expert in forensic diagnosis, or fitness for duty assessments like psychiatrist David Reiss, who does “fitness for duty” evaluations for police departments and is a contributor to "The Dangerous Case of Donald Trump." He said that the president “likely would not qualify to be an Air Force officer entrusted with a nuclear weapon.”
I have diagnosed uncountable clients in my 40-year career prior to retirement but only a few represented a major challenge. (Before the Internet I missed the diagnosis of a client with this problem)
With someone who is not trying to deceive the therapist diagnosis is fairly easy. I never did fitness for duty or forensic evaluations. Therapists experienced in these kinds of assessments have vast experience working with less than candid clients and outright liars.
No client ever came close to approaching the difficulty even an experienced therapist would have in assessing Trump’s fitness to be president to the level that would be necessary to present in a hearing called in the Senate to determine whether the 25th Amendment temporary removal is justified. It would be more difficult to remove Trump from office than to deny an unstable police officer the right to carry a gun and badge, let alone stop someone from working in a nuclear missile command center, yet Trump has the ability to start a nuclear war,
Trump would have every reason to attempt look good in a mental health assessment with his presidency at stake. In the examiners benefit, he has no idea how to fake a psychiatric assessment. He simply doesn’t know what “normal” (non-pathological) behavior is.
Here’s what I came up yesterday with a few embellishments added today.
If anyone felt constrained by the Goldwater rule they would refrain from making any diagnosis whatsoever unless they interviewed him and of course gave permission to release their assessment and recommendations to the public. Freed from the constraints of the Goldwater Rule here’s what I’d want done.
I would want Trump to authorize the clinician to contact all his prior medical professionals, anyone who taught him in school, and just about anyone else who had interactions with him, and instruct them to fully release any written information they had on him and, crucially, to discuss with me their impressions of him.
I would want the examiner to be able to talk to just about anyone they deemed to have relevant information including family members. I would also want the examiner or a designated top expert or experts to conduct a complete battery of psychological tests possible to included neuropsychological tests many of which the layman is not familiar with. These tests would include those which assess his problem-solving ability in addition to those generally used to tease of indications of psychopathology.
Depending on recommendations from other evaluators I might also want a referral to a behavioral neurologist to look for signs of cognitive impairment such as early-onset dementia. I’d want to use any other expert who would help.
Then the primary clinician would meet with a group of top experts in psychological, psychiatric, and neurological assessment for consultation to make a plan as to how to proceed with the in-person examination.
I would want the option of having a co-therapist conducting the interview or more likely several interviews. The possibility of having marital and family assessments must be left open.
I don’t see the in-person assessments as being antagonistic, in fact, every effort would be made not to deliberately provoke Trump. However, he would have to be presented with numerous examples of his potentially diagnostically relevant behavior and asked to explain what he was feeling and thinking at the time.
Self-awareness and insight into his own motivations would all be evaluated.
He would be asked to explain the reasoning behind his grandiose statements. He would be asked what he was feeling and thinking when he made them.
He would be asked to explain what he feels when people insult or attack him.
He would be asked what he felt when incited people to act out their own aggressive feelings.
His contradictory statements, and of course his outright lies would have to be brought up without deliberately provoking him. His explanations would be duly noted. The clinician should attempt to follow Trump’s internal logic.
All of the behaviors indicative of
would be fully explored.
All efforts would have to be made not to get him defensive or anger him so if he did respond this way it would not be because of the clinician setting him up.
If Trump managed to be on his best behavior and not erupt into episodes of rage only then would I want the clinician to push him gradually by confronting him with his most blatant contradictions and lies to see whether or not he had an impulse control disorder.
Additions:
From a psychotherapist friend:
To engage the cognitive is often to reduce the amygdala’s emotional activity. Asking him to co-create a four-generation family diagram with the clinician can be inherently calming in its focus on collecting facts of multigenerational family functioning. Repetitive intergenerational patterns, including patterns of strength (he will respond to that), sibling birth order, how, as a child, he observed adults responding to one another when anxious, traumas in past and current generations, etc. should be part of the assessment. Context is key to any thorough assessment. One must see the self in the family system and the family system in the self!
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Here’s a list of possible indications of cognitive impairment and decline which would have to be assessed. It is from Trump's troubling behavior raises questions his medical exam didn't answer, by John Gartner, David Reiss and Steven Buser published Jan. 22, 2018 in USA Today:
►Declining complexity of thought, rambling speech, difficulty completing a thought
►Markedly declining vocabulary over recent years, with over-reliance on superlatives
►Episodes of slurred speech
►Failure to recognize old friends (link corrected)
►Perseveration of thought (perpetual repetition of the same concepts)
►Decreased fine motor coordination
►Difficulties reading, listening and comprehending
►Suspect judgment, planning, problem-solving, and impulse control
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Afterthought: Can you see President Trump taking Adrian Monk’s (a famously difficult client) place in Dr. Kruger’s office, or Tony Soprano’s place in Dr. Melfi’s office?