First released in 2017, the book “The Dangerous Case of Donald Trump” (Thomas Dunne Books, 2019) has recently been re-issued with nearly 100 additional pages of essays. The book, which was a New York Times best seller, features 37 mental health experts offering their professional opinions on the state of national politics and the current administration.
New England Psychologist’s Catherine Robertson Souter spoke with Craig Malkin, Ph.D, a Cambridge-based clinician and a lecturer in psychology at Harvard Medical School. They discussed his contribution to the book, his work with narcissism and his thoughts on why a revision is needed of the Goldwater Rule, which prohibits mental health professionals from offering diagnoses of public figures they have not personally examined.
You wrote a book called, “Rethinking Narcissism” (Harper Wave, 2015), in which you talk about a healthy form of narcissism. Can you explain?
There are studies, including our own, that find that people who don’t see themselves as average, but see themselves as exceptional and unique and through what I think of as slightly rose-colored glasses, tend to thrive. They are more likely to be driven by big dreams. They strive for more, persist in the face of failure, and they may even live longer.
Narcissism is a sense of feeling special in some way. Healthy narcissism is feeling a little special in the way that we just described, self-enhancing somewhat. On the other hand, people who addictively self-enhance, who need to feel exceptional and unique to stand out from the other seven billion people on the planet no matter the cost, start demonstrating unhealthy or pathological narcissism and that is where we start to see problems.
So, there is a spectrum?
If you view narcissism along a spectrum in that way, zero causes problems, moderate is healthy, and extreme causes problems.
When we used our narcissism spectrum scale, we found that when people scored on the high end, they demonstrated the hallmark of what I call triple E, which is “exploitation,” doing whatever it takes to feel special, “entitlement,” acting as if the world owes you and should bend to your will, and “empathy impairment,” needing to stand out and feel special to a point where you lose sight of other people’s needs and feelings.
That pretty much explains and predicts every awful behavior that you see in Narcissistic Personality Disorder including threats, extreme vindictiveness and envy, violence, lashing out, and even workplace sabotage.
So, “narcissism” is a pervasive universal human trait, that exists to some extent in all of us, the drive to feel special. A “narcissist” is anyone who scores above average on trait narcissism. They may or may not be disordered. Then think of Narcissistic Personality Disorder as someone who is addicted to feeling special and demonstrates the hallmarks of unhealthy narcissism, or triple E.
So, how does this relate to politics?
We already know, from large scale studies of historical and biographical data, that if you score them using the narcissistic personality disorder inventory, most presidents scored high enough to be called narcissists.
The most recent study looking at presidents and narcissism showed that the more their narcissistic traits increased, so did the likelihood of facing impeachment proceedings, abusing positions of power, tolerating unethical behavior in subordinates, stealing, bending or breaking rules, cheating on taxes, and having extramarital affairs.
So, if we already know that most presidents are narcissists, that is something that we should be considering to make sure that a person drawn to that position isn’t just tipping from these high narcissistic traits into other problems that can actually be destructive and dangerous.
To put it briefly, people who are drawn to be president are going to feel special enough to think they can be president of the United States. We just want to make sure they are healthy people who are seeking office.
How did you get involved in the book, “The Dangerous Case of Donald Trump?”
I had already written a couple of articles, where I adhere strictly to the Goldwater Rule, to simply educate people about narcissism and how presidents tend to be high in it, and the distinction between that and pathological narcissism, and what to look for and what problems can result.
That is why Bandy X. Lee, M.D., (Yale University professor) wanted my voice in the book. She appreciated the way that I talk about pathological narcissism without really diagnosing Trump or anyone in particular.
Others in the book are being more specific about raising red flags…
They are exploring somewhat of a differential diagnosis but I don’t even do that. I am probably more conservative than most people in the book.
Why is that?
One reason is that I don’t want to put the emphasis on the diagnosis itself because that reinforces the idea that dangerousness and mental health diagnoses are one and the same. I want to make it really clear what I am talking about when we are discussing dangerousness.
Which is behavior. That is why I wanted to be really careful about conflating the two. There are plenty of people with Narcissistic Personality Disorder who are not dangerous at all.
Why is it important to do something like this?
To fill the void. There are plenty of pundits, bloggers, and other people with no expertise and no training trying to speak to the mental status of Donald Trump or other politicians. They go way further than any of us in the mental health field. The Goldwater Rule runs the risk of silencing people who do have some informed contribution to make.
How do you hope this book will change the dialogue around the Goldwater Rule?
The original justification for the Goldwater Rule was that people came to think of the psychiatric diagnostic interview as the gold standard. But there are decades now of psychological research that completely contradicts that. The interview is terrible at diagnosing especially when you are looking at something like narcissism because people with Narcissistic Personality Disorder are often experts at impression management.
It turns out that NPD is pretty easy for people to see. There is a bit of a “walks like a duck and quacks like a duck” effect going on there.
Back when the Goldwater Rule was introduced, we didn’t have thousands of hours of video tape, tweets, statements, and written expressions of a candidate anywhere; now there is a gold mine. We have plenty of information to determine what is going on with someone now. And observational data are actually more accurate than the in-person interview.
So, the information out there about Donald Trump…?
The strongest predictor of future behavior is prior behavior and there are plenty of instances of him making erratic decisions. You see things like he was a bully in school, he punched a teacher in the face. The people who worked on his show, The Apprentice, said that he would lose his temper and fire someone for no good reason and they had to reverse engineer a reason. They would go through the video tape and put together a story line as to why he made the decision.
We are in this remarkable position today, all of us, of witnessing daily threats and name calling, the kind of behavior we see from impulsive bullies, from the President of the United States who has all kinds of power and access to the military and to important information.
If we, as mental health professionals, had someone who showed up in the emergency room who had a history of threatening behavior and a present example of it and had access to weapons or the ability to make good on their threats, we would contain and assess them. I find this truly remarkable.
So, for that reason alone, independent of mental health diagnoses, the fact that past dangerousness is predictive of future dangerousness and aggression, we need to be having this conversation.
What would you say to our audience of psychologists?
I would say it is incumbent upon us to educate the public. That is where experts come in, to educate people about things like triple E, the presence of exploitation, entitlement, and empathy impairment. There is a valid reason for giving people more information so that, in the absence of a revision of the Goldwater Rule, they can decide for themselves about a candidate’s mental fitness.