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Paula Joan Caplan's Authors Guild Blog

The President’s Fitness: Can Professionals Help Decide?

First published May 8, 2020, at https://www.madinamerica.com/2020/05/presidents-fitness-can-professionals-help-decide/ [new material added here is in square brackets below]

 

Even before Donald Trump became President of the United States, speculations about whether he was fit to serve were rampant. Although it is beside the point, much time and heated debate consisted of questions such as, "Is he mentally ill?" and "Which kindof mental illness does he have?" In our psychiatrized nation, such discussions have widely been heard as meaning: "Trump is mentally ill, and that makes him unfit to serve as President."

 

Most readers of Mad in America know that both the overarching category of "mental illness" and the hundreds of alleged subcategories listed in psychiatric classification systems have no scientific basis and are not useful in helping people who are suffering or stopping those who make other people suffer. I addressed this in an article I wrote fairly early in the debate, called "The Truth about Trump and Psychiatric Diagnosis."

 

Most readers of Mad in America also have a healthy skepticism about what—or whether—professionals have anything to contribute to the benefitting of society. So the question is whether that skepticism applies to determining whether Trump or any President is fit to serve in that office. I think that, for once, it does not, but I have a very specific reason for saying this.

 

The 25th Amendment to the United States Constitution was supposed to provide for the removal of an unfit President. It was "proposed by Congress and ratified by the states in the aftermath of the assassination of President John F. Kennedy" and "provides the procedures for replacing the president or vice president in the event of death, removal, resignation, or incapacitation." However,  the devil is in the details, and the Amendment turns out to be woefully inadequate. Why? Because Section 4 provides that:

 

Whenever the Vice President and a majority of either the principal officers of the executive departments or of such other body as Congress may by law provide, transmit to the President pro tempore of the Senate and the Speaker of the House of Representatives their written declaration that the President is unable to discharge the powers and duties of his office, the Vice President shall immediately assume the powers and duties of the office as Acting President.

 

However, even if that happened in Trump's case, the Amendment provides that if the President just declares in writing that "no such inability exists," he continues in his office unless the Congress determines by two-thirds vote of both Houses that the President is unable to discharge the powers and duties of the office. It's not hard to imagine that with the current Senate, that would be unlikely to happen, given the Senate's utter failure to act after the House of Representatives impeached the President.


Congressman Jamin Raskin (D-MD), a brilliant Constitutional law scholar, has tried to draft legislation that would get around the highly political nature of the process as it is described in the Amendment. He aimed to create a mechanism for determining fitness to serve by creating a Commission for that purpose. In correspondence with me (Sept. 4, 2017), he explained the further wish to avoid making the process solely "psychiatric or medical," because then, "people will say the decision has been medicalized or psychologized when it is properly a public policy question."

 

His idea was to constitute a Commission with a mix of public policy, medical, and psychiatric professionals. Since fitness to serve can be affected by such physical impairments as those caused by strokes and comas, it makes sense to include medical personnel who are not psychiatrists. The legislation he proposed was HR 1987 from the 115th Congress, to which 70 members of the House of Representatives signed on, all Democrats.

 

I sent Congressman Raskin a proposal in which I strongly argued against including mental health professionals who would likely focus on psychiatric diagnosis. I pointed out not only that such diagnoses are unscientific but also that many people who have been given such labels have done great work and done no harm.  I then pointed out that some psychologists and educators can offer information and tools that are directly relevant to fitness to serve.

 

In fact, it strikes me as quite simple: Determination of fitness to serve should be based on whether the office-holder can carry out the crucial elements of the job. Professionals who are trained in developing and administering reliable, valid achievement tests and tests of memory and abstract thinking—primarily some psychologists and educators—could play crucial roles in such a Commission.

 

Here are excerpts from what I wrote to the Congressman on January 4, 2018, and which still applies. I have added slight clarifications in square brackets.

If you have [psychiatrists] on the Commission, whatever they say will not be scientific, not empirically demonstrable, and thus open to accusations that the process is improperly political. Where there is no science (there is none in psychiatric diagnosis), there is only opinion, and opinion is always highly susceptible to bias of many kinds.
The Commission ought to include a neuropsychologist, since they are trained to give standardized memory tests, and memory is of course an essential component of fitness to serve.  The Commission should arrange to have [chosen or] constructed the relevant tests of fitness, which are in many ways achievement tests — tests of knowledge about the Constitution ([a] book being published tomorrow includes…that someone tried to discuss the Constitution with Trump and got as far as the 4th Amendment before he changed the subject, so this is a timely way to point out the usefulness of the approach I suggest), how a bill becomes a law, geography, political systems globally, and tests of memory and of the understanding of abstract concepts including but not limited to cause-effect relationships.
The tests described in (2) have a parallel in the achievement tests a person applying for U.S. citizenship needs to take. As you said, the Constitution does not include requirements as in (2), but those become relevant once the question of fitness to serve is raised.
Various people throw around the term "mental" as in "mental impairment." It is essential to distinguish between two kinds of "mental impairment": There is emotional impairment [or difference] (e.g., absence of empathy and compassion, believing oneself to be Jesus Christ [if one is not]), and there is cognitive impairment (e.g., dementia, reading disability, math disability, inability to form or comprehend abstract concepts). Just a note: Trump may be suffering from both lifelong cognitive impairment (one of his professors from Wharton called him the dumbest student he ever had) and perhaps now, some dementia. [T]he way he slurred "United States" recently is not explained by dry mouth as was suggested. He could be having small strokes. That's why a neurologist as well as a neuropsychologist would be good to have on the Commission.
If you left out Trump's name and just told anyone some things he has said and done, they would assign labels such as "bully," "whopping sense of entitlement," "power-hungry," "stunning lack of empathy and compassion" [and "thug," "criminal," or "evildoer]. These are more than adequate to explain a huge amount of what we see in him. Ask people what they think calling him "mentally ill" would add. What does it explain that is relevant to fitness to serve as President? Saying he is unfit to serve because of being mentally ill is causing huge offense to people who have psychiatric labels, and that may well come close to 1/3 of the U.S. population. Abraham Lincoln would have been diagnosed as mentally ill. A psychiatric label is orthogonal to the matter of fitness to serve.
The kinds of tests described in (2) are exquisitely specific, jargon-free, and inarguably relevant to fitness to serve.


Congressman Raskin, in a May 6, 2020 email to me, said that if he were to rewrite the legislation today, he would include Governors and a neurologist. He noted: "All of the events we are living through reconfirm for me that the critical concept under Section 4 of the 25th Amendment is 'dangerous unfitness' to discharge the powers and duties of office."

 

Despite all of the above, many psychiatrists and psychologists have claimed that they have "special expertise" and extensive training that qualify them to judge Trump to be mentally unfit and dangerous to this nation's "public health." Their position is that they have a "duty to warn" that justifies their ignoring of the Goldwater Rule, https://www.madinamerica.com/2020/04/muzzled-psychiatry-time-crisis/ which prohibits the giving of professional opinions of anyone the therapist has not evaluated in person.

 

Of course, given that psychiatric diagnoses are not valid, the Goldwater Rule by all rights should specify that no one should ever give anyone a psychiatric diagnosis. But the rule refers to more than just diagnosis, so the professionals who claim special expertise—who tend to vary among themselves, and some of whom vacillate between saying he is mentally ill and saying diagnosis is beside the point [their leader, Yale psychiatrist Bandy Lee, has been quoted in a recent article in a publication that is opposed to psychiatric diagnosis https://www.madinamerica.com/2020/04/muzzled-psychiatry-time-crisis/ as saying that diagnosis is beside the point, when in fact she sometimes says that but has vigorously promoted a book she edited and a film about the book in which her chosen authors say that he is mentally ill, and some even claim to know he should be diagnosed with specific, but various, labels] —should stop claiming that they must speak out because of that alleged expertise.

 

For psychiatrists, psychologists, social workers, and other therapists to claim that they are essential for warning people that Trump is dangerous is to claim special expertise and insight to which they are not entitled, and it simultaneously demeans the judgment of nonprofessionals and helps strengthen the power of their guilds.

 

The fact is that, as longtime expert on dangerousness Dr. James Gilligan has said, the only good predictor of dangerous behavior is past commission of dangerous acts, and as Dr. Gilligan pointed out in a press conference at the National Press Club in February, 2018, Trump himself has acknowledged his own dangerous behavior, including but by no means limited to his sexual assaults.

My middle-school grandchildren observed this with no help from any professional or anyone older than they. There is, then, a role for some professionals in trying to remove unfit officials from office, but it is not the one that some would like us to believe.

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The Truth About Trump and Psychiatric Diagnosis — The Lightbulb Has to Want to Change

Originally published 02/20/2017 10:34 pm ET @ http://www.huffingtonpost.com/entry/58abb3b0e4b0417c4066c22b

Once you know a crucial fact about what gets called mental illness, the debate about whether or not President Donald J. Trump is mentally ill disappears, and what is left is what really matters. What really matters is that President Trump apparently has no desire to change behavior that has been described as totally self-absorbed, self-referential, misogynist, racist, xenophobic, and otherwise abusive.

It’s ironic that the arguments on both sides of the debate about whether or not Trump is mentally ill are based on the one “alternative fact”: that deciding who is mentally ill is a science. That could not be farther from the truth.

Those who are arguably the world’s most powerful psychiatrists — those who periodically create and publish a new edition of the psychiatric handbook called the Diagnostic and Statistical Manual of Mental Disorders (DSM) — typically acknowledge that the foundational premise of the entire book, that it is possible to define “mental illness” in an adequate, appropriate, and useful way, is wrong. In each edition of the DSM, the new set of arbiters tries to create a definition of “mental illness,” since the book consists of hundreds of alleged categories and subcategories of mental illness and thus depends on their getting that primary definition right. Each time, they have acknowledged their failure to do so. Even Allen Frances, who oversaw creation of the DSM edition that held sway from 1994 to 2013, famously called psychiatric diagnosis “bullshit” (cited in Gary Greenberg’s excellent Book of Woe from his article in Wired based on his interview with the psychiatrist).

As far as I can tell, no one else weighing in on the debate about the President has served on a DSM Task Force...and then felt they had to withdraw because of what they had learned. I spent two years as an insider on Allen Frances’s Task Force, where I learned that — despite what is widely assumed to be true — psychiatric diagnostic categories are not scientifically derived but are constructed, made up by the handful of people with the most power in the DSM hierarchy. When Frances in various media currently gives the impression that he is uniquely qualified to judge President Trump because he wrote the criteria for Narcissistic Personality Disorder (NPD), the label that many therapists have recently applied to him, Frances neglected to note that the criteria for NPD change with every edition. Frances changed them somewhat from the DSM edition that came before his, and the NPD criteria in the edition subsequent to his — the currently in use DSM-5 — differ from his. These changes reflect the moving-target nature of this label.

The changes over time in how NPD is defined are important, because to debate about whether or not the President has NPD is to reify misguidedly and harmfully the notion that there is a scientific way to find out. I resigned from the DSM-IV Task Force because I could not participate in the creation of a book that would be marketed as scientific when I knew that it was not — and that would garner more than $100 million for its publisher, the American Psychiatric Association, and help Big Pharma earn billions of dollars for psychiatric drugs marketed as curing the ever-growing number of manufactured categories.

Some people try to prove that Trump does not have NPD on the grounds that his self-centeredness and so on do not cause him to suffer; but even that argument is irrelevant, because no version of NPD has specified that in order to “qualify” for this label, one has to be suffering because of its features.

Do people suffer and deserve help to alleviate that suffering? Of course, they do, and that is the subject of many books and other articles. But the research about how that is best done — what behavior, feelings, and/or thoughts can be changed — and what cannot is a side issue for our purposes here, because there is not a shred of evidence that President Trump wants to change. Remember that old joke: “How many therapists does it take to change a light bulb?” “One. But the lightbulb really has to want to change.”

There is great debate among therapists about whether or not any personality disorders belong in the manual of mental illnesses, since it is an arbitrary decision left to each individual therapist whether or not a particular patient’s personality is extreme enough to qualify as a disorder. To engage in the attempt to decide whether or not President Trump has NPD is to act as though that label is clearly a description of a mental illness, however one defines “mental illness.”

Some believe that if they were to prove that the President is mentally ill, it would be easier to turf him out of office. But it was morally wrong that Senator Thomas Eagleton was removed as George McGovern’s vice presidential running mate in 1972 when it became publicly known that he had suffered from bouts of depression and had been hospitalized for that reason, because what should have mattered for him and should matter for all elected officials is how well they can do their jobs. Eagleton had been a great Senator. Whether or not one believes that Trump is doing his current job well depends partly on whether or not you share his views of the world, partly on whether or not he is truthful with the people of this nation (many Presidents have not been), and partly on how he manages his various tasks.

At this crucial time in our nation’s history, the last thing we need is to let debates about whether or not the President is mentally ill divert us from deciding whether or not he is doing his job, whether or not we like what he is doing, and whether or not what he is doing is dangerous or evil.

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Author’s note: I am the author of They Say You’re Crazy: How the World’s Most Powerful Psychiatrists Decide Who’s Normal, which is my insider’s description of the process of creating the book that is called the psychiatrist’s “Bible” and is used to determine who is mentally ill. I am editor of Bias in Psychiatric Diagnosis and have written many articles and book chapters about psychiatric diagnosis, which I would be happy for people to read.
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