To those who say mental health professionals have no business “diagnosing” President Donald Trump “from afar” — I have bad news. I diagnose narcissists from afar every day. In fact, I believe it would be unprofessional and unethical if I did NOT do so.
Now, technically, I do not diagnose from afar. A diagnosis is actually a medical decision that is formally entered into a patient’s medical chart to be used to guide treatment or intervention and to aid in insurance billing.
However, I do “diagnose” in that I believe I owe it to my patients to educate them about the toxic people in their life who might have personality and character flaws that cause damage in relationships. In the same way, I believe as a profession we have a duty to warn and protect the country and world from the dangers of Trump’s emotional issues. Many people do not understand the harm these self-absorbed and abusive Other-blamers (as I call them) can cause.
In fact, narcissistic Other-blamers can turn into authoritarians and autocrats when given power in a country or organization.
“Fire and Fury” Fuels Debate about Trump’s Mental Health
The controversy over Trump’s mental health has crescendoed in the last week after he tweeted about the size of “his nuclear button” and after the release of Michael Wolff’s “Fire and Fury” book.
The good news is that it has reignited interest in the book I contributed to, “The Dangerous Case of Donald Trump: 27 Psychiatrists and Mental Health Experts Assess a President.”
Our book addresses the ethical concerns of whether mental health professionals should “diagnose from afar” without first personally assessing a patient. The American Psychiatric Association’s members are advised to follow the so-called “Goldwater Rule” that states they should not offer an opinion on public figures they have not examined. The American Psychological Association suggests its members follow the same guideline. I am a member of neither organization, so am not required to follow the Goldwater Rule.
In addition, my co-authors and thousands of other mental health professionals believe the Goldwater Rule is superseded by a professional “duty to warn and protect.” If we have information that makes us believe that someone is in danger, in many states we are mandated to take steps to intervene to alleviate that danger, even if that may break confidentiality and privacy.
Why I Diagnose Narcissists from Afar
Every time this debate comes up between the Goldwater Rule and the Duty to Warn, I say to myself: In nearly every session I “diagnose from afar.” In fact, I could not do my job ethically as a psychotherapist if I did not take educated guesses about the emotional and behavioral patterns of people I have never met.
I believe I must do so to help patients recover from what I call Other-blamer Abuse Syndrome.
There are millions of people like Trump in the world, who create havoc in their personal relationships because of their inability to tolerate shame. Their feelings of low self-worth make it difficult for them to be accountable for their behaviors, so they blame-shift in ways that cause escalating arguments, dysfunctional relationships, and even emotional or physical abuse. For extreme cases, the traditional psychiatric diagnosis might be narcissistic personality disorder or sociopathic personality disorder. Unfortunately, the Diagnostic and Statistical Manual does not have a category to diagnose those who have less-severe presentations of these blame-shifting behaviors.
Most people come into therapy to figure out why they are anxious or depressed or struggling in their marriage or to make sense of their childhood relationship with their parents. In actuality, many of these people are experiencing the results of the abuse they have suffered at the hands of a sociopath or narcissist, aka Other-blamer.
Just a few examples include:
- A child is sexually molested by her uncle, who is described as charming and pleasant on the surface and has fooled many people, but cruelly violates the rights of children through his criminal actions. This sexual predator has molested dozens of family members and no one has spoken up about it for fear of his angry and vindictive reactions. He refuses to be accountable for anything in his life, whether it is his abuse or his financial affairs.
- A wife comes in describing her husband as someone who is lazy in performing chores, self-absorbed in their sex life, and cold and uninvolved in caring for their children. He is unable to hold a job because he get in arguments with his bosses who are consistently described as dumb. These bosses are mysteriously described as dumb after he has been disciplined for coming in late to work or otherwise failing to do his job. He also constantly accuses his wife of faults any time she expresses a concern about his behavior. After years of this she is confused, anxiously walks on eggshells, and is full of self-doubt.
- A man comes in struggling with his relationship with his mother who is described as over-bearing, intrusive, and a “know-it-all.” If he expresses an opinion, she steamrolls over him and dominates his life. He submits, but struggles with depression and is unable to make decisions and function as an adult.
I feel very strongly that my role as a psychotherapist is to educate these victims about the behavior patterns of Other-blamers. To do so I must make educated guesses about these narcissistic and sociopathic people based only on the descriptions of my patients.
Of course, I present my discussions about these Other-blamers with a disclaimer that I am making an educated assessment without the benefit of a personal interview and that perhaps I am wrong. When I describe blame-shifting behavior patterns I am universally met with head nods and statements of “that describes her exactly!”
Most clinicians know that with narcissists the very best description we get of their behavior is often from someone else.Other-blamers are notoriously lacking in self awareness (because it triggers shame) and are terrible at accurate self-reporting. This is because these Other-blamers have an deep fear of admitting their faults and being honest and vulnerable. They cannot tolerate shame in healthy ways, but must find a way to off-load it to someone else through excuses, rationalizations, and denials.
Many times I have experienced this sort of scenario: A man comes in to therapy at the insistence of his wife because their marriage is in trouble. I hear his side of the marriage, which often involves lots of complaints about his wife’s behavior and no accountability for his role in the marital conflict. Then they agree to joint therapy to address the marriage and the wife comes in. When they both describe what happened in a disagreement, it sounds as if these two people are living in different realities. I experience a strong sense of confusion (a tell-tale marker that you may be involved in a web of blame-shifting). Certainly, it can be difficult from outside a relationship to accurately assess who is being more accurate. But that is actually not important for me to do as a therapist. This confusion and the widely divergent narratives tells me all I need to know. Someone isn’t telling the truth. I just watch for who engages in more blame-shifting. Who is better able to own up and be accountable for his or her behaviors? That identifies the person who has fewer Other-blaming behaviors. If one person engages in lots of finger-pointing, I have a good sense of who is more likely to be the worst blame-shifter.
Educating About Narcissists Helps Heal
Educating about narcissists allows the victim to recover from this abuse more quickly and completely and be healthier emotionally.
It also directly helps Self-blamers, who tend to lack assertiveness and are under-attuned to their own emotional needs and boundaries. They often seem to lack the ability to judge others accurately and assess whether a person will be a danger. Part of my therapeutic interventions work to strengthen the self-worth of Self-blamers so that they stand up for themselves. I often tell them this: Through evolution we humans developed emotions and intuition and judgment to assess whether someone is “friend or foe.” We must use these skills when we meet new people and pick life partners so that we make good, healthy judgments about whether this person will be someone we can trust and depend on. If we turn off our judgments, we lose a very valuable source of information about another person’s character.
Other-blamers, as the name implies, prefer to set up relationship patterns with weaker, more easily controlled people. Often these are people who tend to Self-blame when facing shame or feelings of unworthiness — just the opposite of Other-blamers.
This leads to cycles of blame-shifting wherein the Other-blamer gets to off-load his uncomfortable feelings of shame onto his partner, who is primed to accept that blame because of her natural tendencies to be overly self-critical and self-doubting.
I think it is important to clearly inform people about Other-blamers because these dominating and manipulative people are often very successful at emotionally spellbinding family and friends into believing the Other-blamer is not at fault.
So, yes, I diagnose from afar. It is essential to do so for the health of my patients. In the same way I believe it is essential for mental health professionals to speak up directly and clearly about Trump’s emotional and behavioral concerns that I believe make him a danger to others.
In most of the relationships I deal with daily, the dangers are only of emotional abuse. But with Trump’s position of power and access to nuclear weapons, the danger is much more of a physical nature.
While I am not Trump’s treating clinician and have not entered an official diagnosis on his medical chart, I can observe years of very obvious behavioral patterns that tell me all I need to know: He is driven by fear and shame and, as a result, has a propensity to react with abusive behaviors toward others. By speaking up, I believe we may help stop Trump’s abusive and blame-shifting behaviors from resulting in a war or nuclear destruction.
And, if you think about it, diagnosing is at its core just using our good ole’ human intuition and judgment to determine if someone is “friend or foe.”
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