Recently some have made comments criticizing the fact that I am a contributor to the book The Dangerous Case of Donald Trump: 27 Psychiatrists and Mental Health Experts Assess a President.

I wanted to respond and clarify my stance on whether mental health professionals should speak up about Trump’s emotional and behavioral issues.

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Some believe that mental health professionals should not speak up about political figures or issues, because it establishes a political “bias” that may affect our relationship with patients. Some have even stated we should not speak up for fear of offending Trump supporters.

Some believe we should follow the advisement of the American Psychiatric Association’s “Goldwater Rule” that psychiatrists not comment on the “mental illness” of public figures, due to an incident related to presidential candidate Barry Goldwater in 1964. That incident involved opinions that surmised about Goldwater’s mental state based only on assumptions.

Clearly, it is unethical to make public statements involving a specific diagnosis about a private person based on one or two observations. But Trump is certainly not a private person. He has spent his life clamoring for publicity and 18 months running for president. He has very little expectation of privacy.

Given today’s media environment and his very public persona for many decades, we have a wealth of information on which to make judgments about Trump’s behavior.

In addition, his mental health is of the utmost importance, especially given the nature of his behavior — volatile, impulsive, erratic, irrational, unrepentantly deceptive, angry, hateful, unethical, and unpredictable.

Many believe Trump has one or more personality disorders. The current diagnostic criteria in the Diagnostic and Statistical Manual (DSM) for personality disorders are all about observable behaviors: “grandiose sense of self-importance,” “preoccupied with fantasies of unlimited success, power, brilliance, beauty or ideal love,” “requires excessive admiration,” and “lacks empathy,” among others. The Goldwater Rule states that psychiatrists cannot diagnose without a one-on-one interview to assess for these characteristics. Yet these traits are readily observable in Trump and, in fact, observing the patient in real life or interviewing others is usually the best way to ascertain the traits of someone with a personality disorder, as they usually misrepresent themselves in therapy (and elsewhere).

Many believe that we do not even need to “diagnose” Trump. Common sense tells us he is dangerous. As psychologists, we are trained in assessment to understand that, “If it happens in the therapy room, it happens outside the therapy room,” meaning that if we experience a person as submissive, moody, argumentative, defensive, narcissistic, threatening, etc., then that is also likely the experience of others when dealing with that person. We can make a fair assumption that this is a character or personality trait.

I also do not believe in diagnosing but it is because I am among those who are campaigning against the disease model of “mental disorders” advocated by the DSM, as an unscientific, arbitrary categorization system that over-complicates and falsely medicalizes emotional and behavioral problems.

I believe as a psychologist I have a duty to warn about Trump’s behavior.

The idea of “duty to warn” comes from a court case Tarasoff v Regents of the University of California that established that if a patient threatens to harm another person, the mental health professional had a duty to warn and protect that person, even if it means violating privacy and confidentiality laws and ethical rules.

The book I’m involved in came out of a group called Duty to Warn that is actively speaking out about Trump given his very obvious lack of mental and emotional fitness for office.

Not coincidentally, this is the same stance I take as a therapist who works with those harmed by abusive predators — whether they be parents, siblings, or intimate partners. My chapter in the book is entitled “In Relationship with an Abusive President,” as I see parallels between Trump and abusive personalities.

When I talk to victims of abuse, the descriptions of their partners are always the same: argumentative, jealous, controlling, unable to admit fault, vindictive, rageful, lacking in insight and accountability, dishonest, impulsive, entitled, paranoid, lacking in remorse or empathy, and other traits. Trump has very clearly has signs of these behaviors as well.

The cause of these behaviors is low self-worth, which leads this type of person to have poor shame tolerance. They learned in childhood to manage feelings of inadequacy by adopting unhealthy coping mechanisms to forestall or avoid shaming experiences. Generally, they try to off-load their shame onto others, so I call this type of person an “Other-Blamer.”

Trump is an extreme example of this poor shame tolerance, but less-extreme versions of Other-Blamer behavior exist in millions of people, including domestic abusers.

The core behavior to watch for in Other-Blamers is a lack accountability. They have great difficulty backing down in arguments, stubbornly argue for hours, and refuse to apologize.

The victims of this type of emotional abuse are generally very passive and unassertive. Many  have grown up in households with an authoritarian Other-Blamer as a parent, so they have a model of relationships as coercive and lacking in compromise or reciprocity. They believe others do not listen or respect their needs and that in this win/lose model, the Other-Blamer does all the winning and taking, and the victim does all the losing and giving.

With patients, I educate on the types of specific behavior that Other-Blamers employ in service of defending their feelings of inadequacy and shame. I work with victims to help them understand the effect of their fear of conflict on the relationship.

I teach that assertiveness does not have to be mean, and conflict does not have to be scary, even if that is the model with which they are familiar.

“Power without love is reckless and abusive, and love without power is sentimental and anemic. Power at its best is love implementing the demands of justice, and justice at its best is power correcting everything that stands against love.”

— Martin Luther King Jr.

As the MLK quote above notes: “Power at its best is love implementing the demands of justice,” which speaks to me of the need for the power of assertiveness in relationships. I believe that calm, thoughtful assertiveness is actually healthy and essential for establishing balanced, loving relationships.

In fact, if we do not speak up assertively, Other-Blamers will never be held accountable for their actions. Due to their defensive refusal to hear the truth about their behavior, Other-Blamers rarely change. But if no one speaks up, they certainly will never hear the error of their Other-Blaming ways and perhaps change.

In the same way, in a representative democracy, the people must have an ability to speak up and assert their needs and wishes to their representatives. Without this, democracy becomes autocracy.
Of course, Other-Blamers don’t want us to be assertive and speak up. They usually throw a tantrum when their flaws and lies are pointed out, because this shame feels so unbearable to them.

We now have an extreme Other-Blamer in the White House, surrounded by enablers and sycophants who all do not want to hear the truth, because then they would have to admit they made mistakes. There is evidence of this daily with Trump who lashes out with Tweets at those who hold him accountable, calling them “leakers” or “fake news.”

Mental health professionals, as experts in the nature of human behavior, must model the healthy, assertive, fearless boundary-setting behavior we teach our patients.

How can I, as a psychologist, advocate for patients speaking truth to power when I do not speak up against the biggest authoritarian abuser we have seen in decades? How can I push patients to be assertive and overcome their fear of conflict in the therapy room, if I do not do so myself in the public arena? How can I tell patients to be on the lookout for dominating and abusive behaviors in partners, then abdicate my responsibility to identify a dangerous abuser in the most powerful office in the land?

One of the things I tell someone who lacks assertiveness, is that by speaking up she may experience a wonderful, freeing, and emotionally healing sense of empowerment. Perhaps she has never felt this before, given that she may have grown up fearful and terrorized by abuse, harshness or rejection by parents or partners.

Empowerment is healing for someone raised in abuse, disempowered all her life. Through empowerment, she can gain an awareness of her emotions, values, and beliefs. She will gain a true sense of self and intrinsic self-worth. She will learn she has an ability to fight for justice, fairness, and reciprocity in her interpersonal relationships.Those with children often become assertive when they realize they have a duty to speak up to model for their children healthy, assertive behaviors.

In the same way, we as therapists and as a country have a duty to model healthy interpersonal behaviors and stand up to Other-Blamers like Trump. If we don’t, it only enables his behavior to continue, just as lack of assertiveness enables an abuser. Assertiveness is essential in healthy relationships — whether personal or presidential — if we have any hope of altering the dynamics of a toxic or abusive relationship.

One thing is clear about Other-Blamers:&nbsp: It takes a village to change their behaviors. If one or two people speak up, it is not enough. We must all speak up  consistently and persistently to hold them accountable. Otherwise, they will continue to find ways to make excuses and blame others for their faults. This is how Other-Blamers become Other-Blamers:  No one held them accountable early on in life.

Mental health professionals are the leaders in the “village” who are expert in relationships, as all of psychology is relational. We must be the ones to take the lead unmasking those who create unhealthy relationships, through their dangerous behavior and emotional instability. If we stand silently by, what example  are we creating for others of how to fight for fairness and assertively establish boundaries in relationships?

Just as I believe I have a duty to speak up forcefully and promptly to keep an abuse victim safe, I have an absolute duty to warn others of the dangers of an extreme abusive personality in the White House.

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