Much has been written by U.S. commentators, pundits, and even mental health professionals about Donald Trump’s mind and psyche during the 2016 campaign for the presidency and his first 20 months in office. Little of it was grounded in applied psychoanalysis, the practice of using psychoanalytical principles to understand the actions, motivations, and limitations of historical figures.

To fill that gap, I wrote “Trump on the Couch,” a task made easier by the revealing historical record on his family and early years and his own published record, from the books he has authored over the years to his more recent, incomparable Twitter output. These sources provide an unprecedented look at how the unconscious patterns Trump developed in childhood influence his words and deeds in adulthood.

A single appearance on “Fox & Friends,” a morning talk show on the Trump-friendly Fox News network, reveals the depth and breadth of the character evaluations and mental illness diagnoses that I made from my analyses.

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It was April 26, 2018, the day that White House physician Dr. Ronny Jackson withdrew as Trump’s surprise nominee for Secretary of Veterans Affairs following allegations of improper professional conduct. From the privacy of his White House retreat, Trump called into the show, and for nearly 30 minutes delivered a rambling monologue, weighing in on topics from Jackson’s announcement to Michael Cohen and Stormy Daniels, James Comey, and Kanye West.

This half-hour revealed how destabilized the president can become and showed many of the disturbing patterns seen elsewhere in Trump’s actions and writing. Three of the most striking were his deep-seated feelings of victimhood, repeating himself, and difficulty answering questions or staying on point. He remarked, for example, that he had made NBC “a fortune.” He then went on to say, “You would think these guys would treat me great” before repeating “I made them a fortune.” And then he said, “They treat me falsely.” His disbelief was palpable.

In most situations, Trump’s impulse is to blame others for the problems he encounters. On “Fox & Friends,” he blamed the Democrats. His tendency to view the “other” as bad, dirty, or destructive was illustrated here by his rants against James Comey, CNN, and Robert Mueller.

A worrisome escalation of Trump’s cognitive limitations was heard in his inability to follow the thread of a conversation, as when he jumped from getting a card for Melania’s birthday to talking about Macron’s wife to talking about Iran — all in a span of three sentences. He said things that just don’t make sense, like there is “a horrible group of deep-seated people” out to get him.

The paranoid portrayal of himself as victim continued in a similar manner. “It’s a witch hunt,” Trump said, “and they know that. … I would give myself an A-plus. Nobody has done what I’ve been able to do and I did it despite the fact that I have a phony cloud over my head that doesn’t exist.”

Also on display was the now-familiar disconnect between Trump’s language, meaning, and the truth, most conspicuously when he contradicted himself while railing against his perceived enemies on “fake news” networks: “I don’t watch them at all. I watched last night.”

What troubled me even more was the acceleration of Trump’s anger, which threatened at times to escape his control and explode into full-throated rage. The same destructive impulses to which he gives free expression from the rally podium sounded out of control when coming from an isolated, disembodied voice over the phone.

Trump on the Couch Cover
Avery/Penguin Random House

The show’s three hosts, Ainsley Earhardt, Brian Kilmeade, and Steve Doocy, kept trying to change the topic in an apparent attempt to distract the president from erupting into full-blown chaos. Without their knowing it, they were unconsciously attempting to serve as the human equivalent of The Wall, the psychic skin that Trump’s disordered personality relies upon to keep him from falling apart entirely. But the “Fox & Friends” hosts’ calm had the opposite effect. After their attempts to contain him continued to fail, they ended the conversation just as he was revving up for another round of invective against Comey, the FBI, and the Clinton Foundation.

Moments before ending the “conversation,” Kilmeade interrupted Trump’s tirade against the “council of seven people” on CNN of which “every one is against me.” Kilmeade suggested, “I’m not your doctor, Mr. President, but I would, I would recommend you watch less of them.”

It’s clear from the transcript of the episode that Trump was incapable that morning of simultaneously appearing on the show and listening closely to what was being said. If Kilmeade had said something comparable to another guest while Trump was watching, it’s easy to imagine what Trump’s take on it would have been: He would have seen the fact that the host was so exasperated by the guest’s volatile mental state that he introduced the notion of how a doctor might address it as a confirmation of the guest’s instability. The tweet would have been “Loser.” Instead, the president didn’t acknowledge the suggestion that he could use a doctor to help him maintain his mental stability.

Questions about Trump’s mental health and the possible need for treatment have been topics for public discussion that predate his presidency, and they will continue after it is over. Much of the initial discussion came from the political left, then expanded into what remains of the center. But if that discussion is now reverberating in the pro-Trump, conservative media echo chamber exemplified by “Fox & Friends,” it has reached an entirely new level. If Fox News is suggesting that the president’s moods could benefit from medical attention, there’s no telling who is next.

The president’s performance on Fox & Friends struck me and many viewers as one of a frighteningly unhinged individual. It supported my conclusions from hundreds of hours of analysis that Trump is mentally unfit in ways that make him psychologically unsuited for the presidency. I would have written the book in all caps if I thought that would have better conveyed the sense of urgency with which it should be read.

The work of assessing the president’s mental health certainly won’t end here. The goal of my analysis was never to diagnose Trump, but to observe, comprehend, and provide some context to help educated readers understand some characteristics of the president’s behavior.

But beware: Simply becoming an educated reader can be seen as an act of defiance against a president who audaciously proclaimed on the campaign trail, “I love the poorly educated.” Education can put one at odds with Trump’s supporters as well: Poorly educated voters returned Trump’s love, awarding him victories in 43 of the nation’s 50 least-educated counties in 2016 (and only 10 of the 50 most educated). Trump’s pathology flourishes when unchallenged by awareness or insight. Information is power, but it is also a responsibility.

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Nothing about studying Trump’s psyche has reduced my concern about his fitness for office. The more I learned and the deeper I looked, my conviction that he is a menace to himself and the American people grew ever stronger. This knowledge has only raised my anxiety, an effect I suspect it will also have on many readers. But anxiety, though unpleasant, is not something we have to run away from. Anxiety is a source of information, and in that respect is a responsibility as well.

The book is not a personal attack on Trump, nor is it a rebuttal to some of his messages, because that would overlook the genuine grievances Trump supporters have with Washington elites in general and the Obama administration in particular. These are real and passionate feelings of dislocation and impotence, to which Trump has given voice.

Instead, the book is a call to action for all Americans, because Trump reminds us of what happens when anxiety is denied or ignored. He is consumed and misled by a lifetime of unprocessed, unacknowledged anxiety, which has no doubt been exacerbated by the power and responsibility of his office. Trump challenges us to avoid making the same mistakes. It’s time we heed that call.

Justin A. Frank, M.D., is a clinical professor of psychiatry at George Washington University Medical Center and author of “Trump on the Couch: Inside the Mind of the President” (Avery/Penguin Random House, September 2018), as well as related books on George W. Bush and Barack Obama.

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  • @ Ann. You are quite confused here. The DSM is a manual which lists criteria for diagnoses but there are variances. No, you cannot take a blood test and find out, for instance, that you have bipolar disorder, it is ifa person meets certain criteria that they will receive this diagnosis. The tricky part is that different people present differently and we can also only diagnosed based on the symptoms reported to us. Further, there is sometimes consistency from one professional to another and sometimes different therapists will interpret information differently as well. I see diagnosis as a general guideline that some people got exactly and others only somewhat.

    Further, there is plenty of scientific evidence thru brain imaging that certain mental illnesses like schizophrenia are detected on these scans…there is also quite a bit of evidence to support chemical imbalances in the brain causing changes in mood. There have been studies of identical twins raised in different homes with no contact with each other who all have the same mental health diagnoses, supporting that there is likely some genetic component to all this as well.

    Lastly, group therapy (of which there actually is many different types) is only one among several approaches used in an inpatient treatment setting. Patients will also be treated with medications and individual therapy. For the record, you are very incorrect in your contention that all treatments are the same. In my practice alone I use cognitive behavioral therapy, dialectical behavioral therapy, family systems therapy, solution focused therapy and many others. Treatment is tailored towards the individuals history, symptoms and goals.

    • @Joy

      In experiment after experiment, the “patient” gets a different diagnosis every time — even from the SAME quack — Oops! I mean (ahem) “doctor.”
      When the same college kid is sent back by the experimenters to the SAME “DOCTOR” a few months later, instructed to pretend to have the same symptoms, there duplication of the diagnosis is not greater than random.

      It’s interesting to read your self-described variations of “treatment.”

      1) On what criteria do you decide that one person needs cognitive behavioral therapy, for example, while another needs dialectical behavioral therapy?

      2) During these “therapy” sessions, how would an outside observer discern which therapy you are using? I had the idea that in all cases, the patients talked and you said something back.

      3) What is your evidence that what you do actually works? How are your patients’ outcomes better than those of patients who got solutions-focused therapy, for example? How do you conduct your “Outcomes” research?
      Or do you just charge ahead and do some “therapy” (indistinguishable from some other theory of “therapy” and just assume that your decision is more effective than some other therapy — or really, better than no therapy at all?

      4) Are any of your patients’ outcomes “the same” or even “worse” after “treatment” with a carefully selected therapy (talking to each other) based on a non-reproducible diagnosis?

      5) If so, how do you explain this negative outcome? Do you give the patient a refund? Are you pro-social enough to refund the insurance company?

  • I’m a therapist. I also have a degree in history as well. When we look at many of the world’s dangerous leaders in history: Hitler, Mao, Stalin etc. we almost always see grandiosity and paranoia has main features of these people’s personalities. That is what I see in Trump. His sense of entitlement, delusions of grandeur, inability to accept criticism (which one would think anyone would know is part of being President), vindictiveness, lack of empathy etc. all lead one down the path to a likely diagnosis which all my colleagues have privately also agreed upon. It is obvious.
    What I find even more disturbing is the almost cult like following he has. Some of his supporters are willing to completely break with obvious reality and defend even his worst behavior or obvious lies. It’s as if reality no longer applies and no rules apply, because what trump says is always ok. You can see from the previous comment you received even how those who support him are willing to defy all logic and like trump blame, accuse and criticize anyone but him. This, to me, is the most dangerous and frightening aspect of all.

    • It is a truth universally acknowledged that it is a breach of ethics to diagnose a person you have not spoken to for even one single second.

      Not that anything a Fake Professional would do would surprise me, no matter how unethical it is.

      Furthermore, your unethical behavior is compounded by how deeply your conclusions are directed by your political sentiments. That is how Communist countries put people in insane asylums for having wrong thoughts.

      I was also dismayed to see that you have diagnosed ONE HALF of your fellow Americans (the non-Commies, the deplorables, etc — but not the anarchists and Antifa) as dangerously mentally ill.

      That diagnosis isn’t adding anything to your credibility.

  • Reply to Roger W.

    I was hoping to read a response from someone who is not so defensive, or not anti-psychoanalysis; I wanted to be able to continue the dialogue with a more intelligent person who possesses the perspective of a profound group of individuals who spend their entire lives, learning about the human condition of others, whether personally known or not.

    I speak myself for my own profession and the never ending requirements to continue to learn about the human nature and its complexities that require that those of us who are truly responsible, ethical and especially possess the integrity that is always the most significant aspect of the psychoanalytical practitioner; I am especially grateful to read your response to this topic.

    The media who are responsible journalists, are truly experiencing the same sort of response from the readers who don’t have the ability to recognize another’s perspective, about most topics.

    Within the more knowledgeable population, the ability to realize this is a profound experience, especially when the topic of discussion is about an individual who is experiencing so many issues that reflect the individual’s own behaviors and the offering of some credible hypotheses, as to the actions of an individual who is supposed to be the leader of a nation.

    There are no surprises at all with this author’s observations. The fact that STAT is choosing to make this column available is because STAT is about so many different types of topics within the medical field, and includes the mental health practioners too, is why we are reading this column from STAT. They don’t discriminate, what constitutes the reason for their choice, that they publish. I would be rather suspect if they excluded the individuals from the mental health profession. But they have published many different types of mental health issues, including the topic of this column, a person who is experiencing obvious issues with his own psyche. How that is going to effect our own lives is of a great concern for anyone who knows what our country could actually expect from one who has a long history of some rather dubious behavior and more than questionable experiences with the truth, just to begin.

    The truth is about more than politics here, and especially in the current zeitgeist of our entire nation, we need to read more about this topic, like never before. I am grateful for STAT, to recognize the necessity for our recognizing what we must consider, when the topic is about the character of a person and the others who are amongst his “loyal legions,” and why everyone is so adamantly stuck in some sort of way, that they are unable to make the ethical choices for the good of the citizens of our nation.

    I could go on about this topic, but I know that I am not writing anything that has not been read elsewhere, by countless others who are from varying populations already. I wanted to let STAT know that I agree with the decision to have this topic stated in the way it requires, in order to be an authentic statement based upon facts.

    • @Catherine

      Hi, Catherine ~

      It’s not surprising that you wish to shield your fake profession from even more instances of quackery.

      The teenage son of one of my friends landed in a highly-esteemed mental hospital for fighting.
      When I went to visit him, I was astonished to find that all the careful, responsible, highly-educated diagnoses of all the patients needed the exact same treatment! (Group therapy)
      This was amazing. It is so useful that really, you’d almost think that the diagnosis was immaterial.
      It would be like carefully diagnosing pregnancy, polio, giardiasis, and a broken wrist … and then giving them all the same treatment!

      Furthermore, the patients needed the group “therapy” treatment all for the exact same length of time — fortunately, the time for their insurance to run out1
      it was pretty amazing … until I remembered something:

      This fake profession fails the test when challenged in a covert experiment to give a reproducible diagnosis EVEN WHEN THEY SEE THE PATIENT IN PERSON.
      In the experiment, a plant is coached to say he has certain symptoms for entrance to a mental hospital.
      At each hospital, he receives a different diagnosis!

      Wow! It almost seems that the diagnosing psychologist is just MAKING IT UP.
      https://en.wikipedia.org/wiki/Rosenhan_experiment

      The worst case I read about involved the same patient getting a different diagnosis from the SAME QUACK.
      Hahaha.
      Not that it made any difference.
      In your laughable profession, ALL diagnoses require the same treatment.
      http://www.continuingedcourses.net/active/courses/course101.php

      This is more like a religious miracle than it is like science.

      And to compound your fake profession’s inability to make a believable diagnosis even IN PERSON, this risible article purports to diagnose a person they have not ever spoken to — or even laid eyes on!
      That really IS a religious miracle.

      The fact is that your fake profession’s failure of reproducibility even of controlled laboratory experiments — never mind actual diagnosis of people you have never laid eyes on — this failure is a national disgrace.
      https://www.npr.org/sections/health-shots/2018/08/27/642218377/in-psychology-and-other-social-sciences-many-studies-fail-the-reproducibility-te

      You should all be arrested for consumer fraud, and I have no doubt that you WILL all be arrested for it eventually.

      You can’t fool all of the people all of the time.

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