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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.

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.

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.

  • It’s very concerning that the republican members of the senate continue to enable an individual who sits in the Oval Office and is so obviously mentally ill- I do not understand why getting him the help he needs is something no one is willing to do -why?

  • Oh, those ungrateful “celebrity athletes” exercising their right to bring attention to critical issues facing our nation. But then, maybe you don’t believe there is an issue.

    Notwithstanding, perhaps the laughter is for another reason.

  • I have listened to press releases. I’ve also listened to Trump trying to talk and express his opinions. It seems he is concentrating on why Americans are flushing the toilet 10 – 15 times. At a round table duscussion of all places. Are people telling Trump this or is he calling them and asking them about their flushing habits? You have to remember, when Trump says people, he is talking about himself. Obviously, he has some issues going on. Delusional…

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