A Letter to Congress from Concerned Mental Health Experts

December 11, 2017

Dear Congress Member:

Since the election of 2016, an increasing number of mental health professionals have come forth to warn against President Trump’s psychological instability and its implications for national and international security. Recently, the signs of his instability have grown markedly worse: a return to conspiracy theories, more frequent tweets, and an attraction to violent imagery. We would like to discuss these concerns further with you, at the contacts below.

Seven months ago, a group of us put our concerns into a book, The Dangerous Case of Donald Trump: 27 Psychiatrists and Mental Health Experts Assess a President. Since release, it has become an instant bestseller with the public. Macmillan, a top publisher, could not keep up with the demand for weeks.

Much of what we warned about in the book has come true. Our ultimate concern is happening now. The developments with the special counsel’s investigations are not just a matter of criminal indictment but of critical concern with respect to the president’s mental stability. He has shown marked signs of impairment and psychological disability under ordinary circumstances, unable to cope with the slightest criticism or unpleasant news. With additional stressors, his condition will assuredly grow worse. We fear that this difference will bring us over the brink into disaster, where even ultimate destruction will be possible.

As mental health professionals, some of us with an expertise on violence, we deal with the risk of harm as a routine part of our practice. When someone exhibits signs of danger to oneself, others, or the general public, it is considered an emergency. All 50 states confer to us the legal authority, sometimes obligation, to act. When someone poses a threat, our response is as follows: (a) containment; (b) removal from access to weapons; and (c) an urgent evaluation. As health professionals, we cannot choose not to treat in an emergency, regardless of whether the person is our patient or has offered consent.

Mr. Trump has far exceeded our usual threshold for an urgent evaluation for signs of danger. Just a few of these signs would be: verbal threats of violence, a history of sexual assault, incitement of violence, an attraction to violence and powerful weapons (the more powerful the weapons, the greater the temptation to use them), and the taunting of hostile nations with nuclear power. Traits that are highly associated with danger include: impulsivity, recklessness, paranoia, loss of touch with reality, a lack of empathy, rage reactions, and a constant need to demonstrate power. These traits make one incapable of thinking rationally, and the usual inhibitions, such as a nuclear holocaust or even the annihilation of humankind, will not likely deter someone who is preoccupied by internal needs.

We are concerned enough to be ready to present to your office, at the soonest occasion possible, to explain our observations in person. While mental health experts who contributed to the book number at 27, there are thousands of us with the same medical consensus—and we are ready to communicate our case to you, should you choose to hear us.

Our contacts are: (917) 328-2492; bandy.lee@yale.edu; and dangerouscase.org.

Sincerely,

Bandy X. Lee, M.D., M.Div.
Assistant Clinical Professor of Psychiatry, Yale School of Medicine, New Haven, CT
Judith L. Herman, M.D.
Professor of Psychiatry, Harvard Medical School, Boston, MA
Philip Zimbardo, Ph.D.
Professor Emeritus of Psychology, Stanford University, Palo Alto, CA
Craig Malkin, Ph.D.
Lecturer of Psychiatry, Harvard Medical School, Boston, MA
Lance Dodes, M.D.
Assistant Clinical Professor of Psychiatry (retired), Harvard Medical School, Boston, MA
Michael J. Tansey, Ph.D.
Assistant Professor (retired), Northwestern Medical School, Chicago, IL
Leonard L. Glass, M.D., M.P.H.
Associate Professor of Psychiatry, Harvard Medical School, Boston, MA
Henry J. Friedman, M.D.
Associate Professor of Psychiatry, Harvard Medical School, Boston, MA
James Gilligan, M.D.
Clinical Professor of Psychiatry, New York University School of Medicine, New York, NY
Diane Jhueck, M.A., L.M.H.C.
Designated Crisis Responder, Island County, WA
Howard H. Covitz, Ph.D., A.B.P.P.
(Former) Director, Institute for Psychoanalytic Psychotherapies, Philadelphia, PA
Betty P. Teng, L.M.S.W.
Psychotherapist, Institute for Contemporary Psychotherapy, New York, NY
Jennifer C. Panning, Psy.D.
Clinical Psychologist, Evanston, IL
Harper West, M.A., L.L.P.
Licensed Psychotherapist, Clarkston, MI
Luba Kessler, M.D.
(Former) Faculty, Institute for Psychoanalytic Education (New York University), New York, NY
Steve Wruble, M.D.
Private Practitioner of Psychiatry, New York, NY, and Ridgewood, NJ
Elizabeth Mika, M.A., L.C.P.C.
Psychotherapist, Chicago, IL
Edwin B. Fisher, Ph.D.
Professor of Health Behavior, Gillings School of Global Public Health,
University of North Carolina, Chapel Hill, NC
Nanette Gartrell, M.D.
(Former) Associate Professor of Psychiatry,
University of California School of Medicine, San Francisco, CA
Dee Mosbacher, M.D., Ph.D.
(Former) Assistant Clinical Professor of Psychiatry,
University of California School of Medicine, San Francisco, CA
Frederick M. Burkle Jr., M.D., M.P.H., D.T.M.
Psychiatrist, Pediatrician, and Professor of Emergency Medicine (retired),
Harvard Medical School, Boston, MA

Additional Signatures
Scott Banford, M.S.W., LCSW
Fort Lee, NJ
Susan G. Bednar, M.S.W.,LCSW
Monticello, IL
Brenda Berger, Ph.D.
New York, NY
Cherylynne Berger,
M.S.W., LCSW
Pasadena, CA

Susan Edelman Blank,
M.S., LPC, NCC
Atlanta, GA
Paula Bloom, Psy.D.
Atlanta, GA
Suzanne Burger, Psy.D.
Pound Ridge, NY

 

Kimberly Corbett, Psy.D.,
LMFT, SAP
San Diego, CA
Tammy Dale, M.A.
Lee’s Summit, MO
E.D., MSW, LCSW
Portland, OR
Jennifer Farris-Young,
LMHC
Largo, FL
Ellen V. Garbuny, LSW
Butler, PA
Patricia Geller, Ed.D.
Lexington, MA
Carolyn Jankowski, M.A.,
CDMS, LPC
Laurel, MD
Maureen S. Kapatkin, M.S.,
NP
FL and GA
Gabriella Janet King, M.S.
Laurel, MD
Emily Krestow, Ph.D.
LMHC
Hollywood, FL
Barbara Lavi, Psy.D.
Weston, CT and MA
Avigail Lev, Psy.D.
CA
Sarah Church Liebman,
M.S.
Oakland, CA
Lynn Groff Loomis, M.Ed.
Harrisburg, PA
Diane K. Mahoney, Ph.D.
Marstons Mills, MA
Robert McDonald, Ph.D.
Fairview, NC
Raechel McGee, MSW
Somerset, MA
Julia McLaughlin, M.A.,
LPC
Columbus, OH
Melissa Mendenhall,
M.S.W., LISW
Cedar Falls, IA
Cheri Parmely, Ed.D.
Newton, MA
Michelle Pawkett, M.A.,
LMHC
Buffalo, NY
Sandra Petrakis-Childs,
L.C.S.W., LMFT
Atlanta, GA
Emily Polak, Ph.D., LCSW
IL and Crown Point, IN
Randye Semple, Ph.D.
Los Angeles, CA, and New
York, NY
Gail Sheehy, Ph.D.
New York, NY
Claire Silverman, Ph.D.
New York, NY
Andrew Spitznas, M.D.
Johnson City, TN
Sunda Friedman
TeBockhorst, Ph.D.
Boulder, CO
Margaret Thompson,
M.S.W., LCSW
Salt Lake City, UT
Barbara M. Turk, Psy.D.,
LPC, NCC
Harrisburg, PA
Karin Wandrei, Ph.D.
LCSW
Rohnert Park, CA
Harper West, M.A., LLP
Rochester Hills, MI
Elizabeth Zoob, LICSW
Cambridge, MA
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An Authoritarian or a Madman?

By Elizabeth Mika and Frederick Burkle

Professor Ruth Ben-Ghiat’s WaPo opinion piece from Nov. 30,  No, Trump is not a madman — because he knows exactly what he’s doing, posits that Trump’s not a madman but an authoritarian. She says that the historical framework of authoritarianism, rather than psychology and psychopathology, is best used to explicate the Trump/ism phenomenon.

We would like to add that this framework, although useful and necessary, is incomplete without understanding the psychology and psychopathology of the strongmen, their followers, and societies that enable their rise. Even though the question of strongmen/tyrants’ “madness” keeps coming up with cyclical regularity in discussions about tyrants past and present, it has never received a satisfactory response. It also has never been fully applied to an American leader until now (for good reasons).

One of us, Dr. Burkle, is a psychiatrist by training (among other specialties) and has a long and distinguished record of working the world over for humanitarian and peace causes, which involved diplomatic dealings with various strongmen in power, including Saddam Hussein. He has studied the psychology of strongmen and written a seminal paper about it, noting the increase in their numbers since the Cold War, which, not surprisingly, corresponds to the spread of fascistic ideologies all over the world today. The co-author, raised under an oppressive political system in Eastern Europe and trained as a clinical psychologist, has authored a chapter on Tyranny as a Triumph of Narcissism in the recently published NYT bestseller, “The Dangerous Case of Donald Trump.”

We maintain that the knowledge of psychology, and specifically psychopathology of the autocrats/tyrants and their followers, is crucial to grasping the rise, development, and inevitable fall of tyrants and the socio-political movements they inspire and lead. This knowledge is also necessary to create the shared understanding of conditions that give rise to fascism and other oppressive political movements, as they are all built on the same fundamental individual and collective psychopathology, fueled by specific socio-political factors. Such understanding, we hope, will help prevent development of these movements in our future and make the world a safer, better place.

Studying biographies of strongmen/tyrants shows that they all share the same essential character structure, or more accurately a character defect (disorder): a severely impaired conscience — which makes them unable to experience pro-social emotions like empathy, guilt and shame, and understand higher human values — combined with an insatiable drive for power and adulation. A clinical name for this specific character structure, which is not mental illness, is narcissistic psychopathy, also known in its extreme form as malignant narcissism (which is comprised of paranoia, sadism and Machiavellianism, in addition to narcissism and psychopathy). Neither term is included as a diagnostic category in DSM, and there are some mental health experts who don’t believe that narcissistic psychopathy or malignant narcissism constitute pathological conditions. Some see them as just garden-variety “badness.”

Nevertheless, it is a specific character disorder with well described symptomatology and prognosis, which allow us to recognize it and predict its progression inevitably leading to dire outcomes for the afflicted individual’s behaviors, those around him and the society at large. In fact, understanding the psychology or rather psychopathology of the strongman/tyrant-wannabe and that of his supporters has allowed us to correctly predict Trump’s presidential win, along with the subsequent general political developments, in early 2016.

Strongmen differ in their individual personality characteristics, but they share essential easily recognizable core features, specifically the aforementioned deficits of conscience and an abiding and insatiable desire for power and adulation.

Not all strongmen turn tyrants; those who do exhibit unusually high levels of narcissism of the malignant type characterized by sadism and paranoia. Once the strongman/tyrant-wannabe achieves the ultimate position of power, these malignant characteristics intensify, leading to what we call psychological decompensation. His grandiose expectations balloon, along with his sense of aggrieved entitlement and rage when they are frustrated, which happens sooner or later. The rage fuels his paranoid distrust of others and the compulsive (sadistic) need to hurt them.  With time and progressing decompensation, no one is immune to the tyrant’s escalating rage. This is when his pathology becomes most apparent, although his sycophants and enablers are the last ones to notice it (or at least to admit it), invested as they are in placating him and protecting their privileged positions or even lives.

Bereft of a conscience and driven by the insatiable need to dominate others and avenge their non-ending humiliations, real and imagined, strongmen/tyrants are compulsively and sadistically vindictive. This assures that whenever they achieve ultimate power, a destruction of democratic institutions will follow, leading to chaos, disorder, oppression and eventually bloody conflicts.  It’s not a matter of if it happens, but how soon.

We have delineated the specifics of the narcissistic psychopath’s psychological functioning elsewhere. Dr. Burkle’s seminal 2016 paper on Antisocial Personality Disorder and Pathological Narcissism in Prolonged Conflicts and Wars of the 21st Century talks about political leaders with this character pathology and notes the increase in their numbers since the Cold War. Not coincidentally, this increase corresponds to the current rise in fascistic movements world over.

Prof. Ben-Ghiat goes on to describe the main features of the authoritarian strongman’s pathology — his disruptiveness, shape-shifting, a proclivity toward violence, and disregard for norms and values– which in the right socio-political context, that of widespread inequality and growing social unrest, as well as shared narcissistic woundedness that stems from frustrated expectations of collective and individual greatness, become his assets.

The strongman/tyrant-wannabe’s withdrawal from our shared reality into his own version of it, suffused with a grandiose sense of entitlement and eternal victimhood, and seasoned with dreams of redemptive glory and punishment for his manufactured enemies, appeals to the segment of the population that feels similarly aggrieved and looking for scapegoats onto which they can unload their misery. The tyrant-in-the-making would not amount to much if it weren’t for his supporters who see in him the embodiment of their own hopes for the settling of scores, avenging their humiliations and restoring their personal power.

This is the case where narcissistic pathology of an individual colludes with the needs of his similarly afflicted supporters. This process of narcissistic collusion is what fuels the growth of anti-democratic parties as well as cults and other destructive social movements. Such movements eventually fall, as do their leaders, crippled by their own pathology, specifically by unchecked grandiosity and paranoia that drive them to commit acts of political suicide and /or destruction evoking pushback and rebellion.

Ben-Ghiat is right that the behavior of strongmen in general is methodical in that it is designed to achieve a specific goal: maximize power and adulation, and minimize resistance and personal humiliations. It is not quite rational, however, as the needs for power and adulation driving it are insatiable and because of that ultimately lead to destruction of others and usually himself as well. His behaviors, even though purposeful and effective in helping him achieve his goals, something that renders the label of “madness” questionable in many observers’ eyes, are not normal, and certainly not healthy. While such adjectives like mad and crazy, strictly indicating a psychotic break with reality driven by delusions and hallucinations, may not necessarily apply to the strongman’s functioning, certainly not at all times, his incurable character defect makes him not only mentally unhealthy but also dangerous.

Where “madness” is concerned, it is crucial to note that one can be abnormal without being mentally ill. Not having a conscience – a main feature of psychopathy — is not an illness but a defect, still an abnormality, just like not having a limb would be considered an abnormality but not an illness. Psychopaths are not “mad” in the colloquial (or even clinical) sense of the word — their reality testing is intact and they are capable of effective, goal-oriented functioning in the world. Being free of scruples and treating other people as objects to exploit turns out to be an asset in the world that champions greed and the pursuit of power. There is logic, consistency, and predictability in their actions, and they can be seen as reasonable from the point of view of realization of their personal objectives and an effective adjustment to — and/or exploitation of — a society where primitive goals rule.

It is important to remember, as difficult as it may be to accept, that the problematic behavior of a narcissistic psychopath in a position of ultimate power will not change for the better, but will most certainly grow worse with time. We know that he will be destructive. We know that he will sow chaos, legitimize and incite violence, and quite likely start wars. We know that with the help of his always eager sycophants and supporters, he will dismantle anything that stands in his way to power, and that includes institutions, norms and values that support human civilization. Eventually this destruction will also reach many, if not most of his supporters, especially if they fail to provide him with the adulation and obedience he craves.

The debate about mental un/health of the current occupant of the White House as well as strongmen/tyrants in general is a good opportunity for educating our society about still poorly recognized dangers of conscience-impairing character defects like narcissistic psychopathy and malignant narcissism. If there is one lesson that we should be able to learn already, based on our historical and psychological knowledge, it is that of the necessity of keeping individuals with these defective characters away from power. That is because once they achieve a position of ultimate power, there isn’t much that can be done to prevent the predictable destruction they unleash on society.

Elizabeth Mika is an educational consultant and therapist in private practice in the Chicago area. Frederick Burkle is a psychiatrist with the Harvard Humanitarian Initiative.

Pathological Narcissism and Sociopathy in Political Leaders Are More Pervasive Than You Think

The text below is a rejected op-ed submission to The Washington Post from October 17, 2016 — one of several on the subject which met the same fate that year. After Trump’s election, The WaPo put “Democracy dies in darkness” as its slogan in the masthead.

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PATHOLOGICAL NARCISSISM AND SOCIOPATHY IN POLITICAL LEADERS ARE MORE PERVASIVE THAN YOU THINK

by Frederick Burkle

Millions of Americans plan on voting a narcissist into the White House next month, and large numbers of narcissists of every ilk seek political power and cutthroat business dealings in the world and in our own society today. Historically, narcissists in power are always a grievous problem — so how did we get into this current dilemma? What made us more vulnerable today and what are the risks we face when one governs?

The end of the Cold War brought with it many protracted internal conflicts and wars that have lasted for decades and whose persistent volatility lies at the heart of both chronic nation-state and regional instability. Responsibility for these chronically failed states has been attributed to multiple unresolved political root causes within troubled countries. With previous governance and parties to power no longer trusted or acceptable, the vacuum of leadership in many cases has been filled with “bad leadership”. In a number of cases, opportunistic leaders, suffering from character (personality) disorders of severe narcissism and various degrees of antisocial behavior, have emerged first as saviors, then as despots; or as common criminals claiming to be patriots, sharing a psychological framework that differs little from those responsible for WWII and the Cold War that followed.

Character disorders are not mental illness nor are they treatable by traditional medical, psychiatric or psychological means. The identifying characteristics of this unique and poorly understood subset of the population (about 4%) are levels of narcissism that can reach pathological proportions, manifested in grandiosity, lies, fabrications, and unstoppable need for admiration that is characteristic of a petulant child, now grown up physically but not emotionally.

The narcissism varies over a wide spectrum of behaviors. While we may encounter people every day with lesser degrees of narcissism-driven behaviors that are nothing more than annoying, those who evidence more severe and pathological degrees of narcissistic attitudes and actions cause major problems for every society, especially if they are challenged or shamed. All have difficulties in personal relationships. While they are appreciated by many as being ‘smart’, they are not ‘bright’. Their concrete black or white view of the world and their place in it belies a lack of reflection, abstract reasoning, sound judgment, intuition, and sincerity in their thinking and decisions that may be tolerated in a spoiled child, but remains fixed no matter what age they are. Their constant and insatiable need for power, total lack of empathy, entitlement and inability to handle any criticism leave them easily shamed, which often leads rapidly to excessive rage and contempt. These individuals are driven by impulsive and callous aggression and boldness to seek the ultimate opportunity to control, dictate and live out their fantasies of power on the world scene.

Their presence in the world as heads of state has remained unabated in the 21st Century with many at the helm of current conflicts and dictatorships. Vladimir Putin’s history of contemptuous behavior toward both national political rivals and international leaders is one worrisome example. During the Cold War years, as head of the KGB in East Germany, he investigated Angela Merkel revealing her fear of dogs. In their first meeting years later, when he was Russia’s President and her Germany’s Chancellor, he purposely brought large dogs to the meeting to intimidate her. His pattern of assassinations of his political rivals is legendary, the last being completed symbolically on the steps of the Kremlin. Kim Jong-un is another disturbing example as he has in his possession nuclear weapons which he could easily deploy in a rage, feeling justified by the most insensible of provocations. These pathological leaders are never amenable to conventional diplomatic interventions, negotiations, mediations or international sanctions as evidenced by Serbia’s Milosevic’s invasion of Kosovo after being charmed by Western leaders for signing the Dayton Accords.

The list of narcissists in power, living and dead, is long; the destruction they cause fills countless history books.

We are at the cusp of our first chance at global governance wished for by the emerging millennial generation who see themselves more a global citizens and less as nationalists. By not strongly speaking out with every violation and taking every opportunity to educate through the world stage of communication available to us today, we seriously risk being seduced into losing much of our democracy, freedoms we cherish and an opportunity for global governance that makes sense and addresses humanity’s urgent needs.

Professor Burkle is a Senior Fellow & Scientist at the Harvard Humanitarian Initiative, Senior International Public Policy Scholar at the Woodrow Wilson International Center for Scholars in Washington, DC and author of “Antisocial Personality Disorder and Pathological Narcissism in Prolonged Conflicts and Wars of the 21st Century,” Disaster Medicine & Public Health Preparedness, 2016.