He who knows syphilis knows medicine.
~Sir William Osler
Sir William Osler is a hero to a great many in the medical field. Regarded as the father of modern medicine, Osler practiced in the late nineteenth and early twentieth centuries, before penicillin reduced many a deadly pestilence to a treatable, curable illness. Before antibiotics, one of the most unwanted afflictions was syphilis—feared by the patient because it was incurable, and dreaded by the physician because it was so hard to diagnose. So wide was the range of other ailments that syphilis could cause or imitate—including arthritis, pneumonia, madness, and more—that Osler famously made the point that the physician who studies all of its possible side effects and misdiagnoses will ultimately learn about virtually every disease known to medicine at the time.
I’ve often thought of Osler as this study of President Trump’s mental state has deepened and expanded to include so many psychic afflictions. As we’ve seen, Trump’s unconscious has proved to be endlessly resourceful in its development of defenses and coping mechanisms to compensate for what in retrospect was a perfect psychic storm of childhood wounds, conditions, and circumstances. Our attempt to understand his sometimes-confounding state of mind has at times resembled a psychiatry textbook in its seemingly unending array of conditions and disorders. To paraphrase Dr. Osler, he who knows Trump knows psychiatry.
A working knowledge of psychiatric disorders is essential to understanding Trump. The language of psychoanalysis has become a remarkably central element in the national conversation about Trump that continues to dominate the media. While much of the biographical focus on Donald Trump’s early life has centered on his relationship to his tyrannical father, I am convinced that Donald experienced unusual and determinative challenges and losses in relationship to his mother, even before he was old enough to walk and talk. The man we now see before us is an adult with an infantilized worldview: a frightened child who is hungry—for power, for fast food, for admiration, for money, for loyalty. He surveys the world around him with uncanny radar for any aspersion, seeing everything but understanding nothing. I think Trump never got over his hurt and rage at not having had a deep preverbal bond with his mother, and the confidence-building joys that warmth, tenderness, touch, scent, or smiles might bring. He has been angry and determined to get his due ever since, spending his life trying to reach his idealized mother.
When concluding my previous presidential studies, I have posed the hypothetical question of what I would do if I treated the book’s subject as my patient. I imagined numerous questions I might ask Trump, but in the spring of 2018, events put a different, new spin on all those hypothetical questions. First, Trump’s White House physician Ronny Jackson suffered a devastating public humiliation after a surprise and unlikely nomination to become secretary of veterans affairs. Shortly thereafter, Trump’s previous private doctor Harold Bornstein revealed details of a harrowing and perhaps illegal records-seizing raid on his office—along with a confession that the letter in which he purportedly gave Trump a clean bill of health two years prior had in fact been dictated by Trump himself. Suddenly it was clear that treating Donald Trump was a risky proposition.
Jackson’s nomination for a job for which he demonstrated minimal credentials was widely perceived as a result of his enthusiastic, credibility-challenging assessment of Trump’s health a few months prior, in which evidence suggested that Jackson had misstated Trump’s height and weight to avoid his being labeled obese. The raid on Bornstein’s office closely followed his reporting that he had treated Trump with Propecia, a popular medicine prescribed to prevent male-pattern baldness. Jackson was ostensibly being rewarded, but he was cast into a Senate confirmation process that appeared from the outset to be doomed to failure (and which Trump immediately said that he wouldn’t subject himself to if he were Jackson). Bornstein compared the raid on his office, conducted by a team including Trump’s longtime bodyguard and one of his attorneys, to a rape, and risked professional ruin by revealing the origin of the letter he made public. Both doctors had tried to help Trump and ended up worse off; both colluded with Trump in misrepresenting the way he measured and presented his health and appearance, and learned the hard way that individuals who collude with Trump end up paying a price.
Does Trump treat his medical team through a system of punishment and reward tied to something as superficial as his own illusions about his appearance? The highly developed narcissistic impulses that we have observed in Trump would indicate that such a thing is certainly possible. But we’ve also seen enough about how Trump operates unconsciously to realize that his doctors found themselves at risk of repercussion because of something bigger: they knew the truth about the lies Trump tells himself about himself. To entrust a doctor with one’s medical (or psychiatric) treatment is to give the doctor access to intimate, private truths. Trump is so invested in keeping those truths from himself, let alone from others, that it should come as no surprise that the individuals who gain that knowledge are ultimately experienced as a threat to his illusion—and delusion—and end up suffering as a result of it.
This is of interest to me not simply because, for discussion’s sake, I might imagine a scenario in which I am the doctor and Trump is the patient; this is of interest because Trump has created a dynamic in which we all serve as his therapists. Similar to how Trump has put the nation in the position of having to parent an under-evolved child of a president, he has turned us into a nation of analysts, constantly on the lookout for signs of further psychic disintegration. If the fates of Trump’s own doctors—and lawyers, and advisers, and spokespeople, and even supporters—are any indication, it is a position that comes with considerable risks. The ideas in Trump on the Couch are intended to equip the reader with the analytic tools that can help make sense of Trump moving forward. And it’s a responsibility that requires each of us to face his own “inner” Trumps—the parts of each of us we’d rather not think about. It’s a responsibility we as Americans can’t afford to evade, even if it leads us to truths and insights that Trump finds threatening.
By now the reader may have already crafted the insights in these pages into a set of lenses through which to view the president’s behavior in an instructive, psychoanalytic light. His April 2018 phone call to Fox & Friends, for example, offered vivid illustrations of several concepts the reader might recognize. In his first television appearance in several months, calling into the show the same morning that Admiral Jackson withdrew from consideration for the VA post, Trump struck many viewers as simply and frighteningly unhinged. But revisiting that disturbing appearance from the perspectives developed in these pages, we recognize patterns with which we are now familiar, including: an impulse to blame others for any problems he encounters (in this case the Democrats); a concerning escalation of cognitive limitations (his inability to follow the thread of a conversation); a reminder that in Trump’s perspective the “other” is always viewed as bad, dirty, or destructive (in this case James Comey, CNN, and Robert Mueller); and the continued paranoid portrayal of himself as victim. Also on prominent display was the now-familiar disconnect between Trump’s language, meaning, and the truth, most conspicuously when he contradicted himself mid-rant while railing against his perceived enemies on “fake news” networks: “I don’t watch them at all. I watched last night.”
Perhaps most troubling was the relentlessness with which Trump’s tone grew ever angrier, threatening at times to escape his control and explode into full-throated rage. Phoning into the relative calm of morning talk television, Trump sounded out of place in the elevated dudgeon that plays so well at his rallies. Presumably calling from the privacy of his White House retreat, the off-camera Trump attacked his familiar targets with mounting agitation, as his remote audience of the three Fox & Friends hosts tried to maintain calm on-screen. The same destructive impulses to which he gives such free expression from the rally podium sounded more out of control when coming from an isolated, disembodied voice—as if Trump’s familiar destructive impulses somehow posed a greater risk to Trump himself without the presence of a live, adoring audience to reflect and join him in his rage.
The looks on the hosts’ faces suggested they knew they were failing to contain Trump’s rage. Their discomfort also betrayed their growing realization of just how badly the president needed to be contained. The less they were able to contain him, the more agitated Trump became. They 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 Trump needs the collusion of a copacetic crowd to keep his rage from overtaking him. The Fox & Friends hosts’ calm had the opposite effect. Instead of acting as a wall, their efforts simply highlighted how desperately Trump needs to be walled in. After their attempts to contain him continued to fail, they ended the conversation before he got even worse on their watch.
The confrontation would have proved challenging for any trained mental health professional. Presumably following control-room instructions, the hosts eventually cut Trump off, just as he was revving up for another round of invective against Comey, the FBI, and the Clinton Foundation. The timing of the shutdown was not apparent, as it had been clear since early in the interview that Fox News’s favorite president was not showing himself to his best advantage that morning and was clearly out of control. (Later on MSNBC, Lawrence O’Donnell speculated that the unilateral decision to end the interview required the intervention of network News Corp Executive Chairman Rupert Murdoch himself.) But moments before he abruptly ended the interview, Fox & Friends cohost Brian Kilmeade had exposed a central element to the dynamic that had previously remained hidden. Interrupting Trump’s tirade against the “council of seven people” on CNN, of which Trump said, “every one is against me,” host Kilmeade offered, “I’m not your doctor, Mr. President, but I would—I would recommend you watch less of them.”
With the possible exception of Sean Hannity’s Fox News broadcast, there is no television media environment more solicitous and sympathetic to Trump and his presidency than Fox & Friends. Multiple studies have tracked the correlation between Fox & Friends slants on the news and Trump’s tweets, which regularly and at times immediately echo their stories. It’s clear from the transcript that Trump was incapable that morning of simultaneously appearing on the show and listening closely to what was being said. But 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: the fact that the host was so exasperated by the mental state of his guest that he introduced the notion of how a doctor might address the guest’s volatile mind-set would have been heard by Trump as confirmation of that guest’s instability. Instead, the suggestion that Trump could use—and perhaps even has—a doctor to help him maintain mental stability was unacknowledged. Instead, Trump retorted with the earlier-mentioned defensive contradiction—“I don’t watch them at all. I watched last night”—at which point cohost Steve Doocy attempted unsuccessfully to stifle a laugh.
The question about Trump’s mental health and the possible need for treatment has been a topic for public discussion that predates his presidency, and it will continue long past his presidency. Much of that 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, then it has reached a whole new level. If Fox News is suggesting that the president’s moods could benefit from medical attention, there’s no telling who is next.
As this manuscript was being delivered to its publisher, Trump was sounding more unstable than ever. At no point has there been any evidence that Trump’s mental health is going to improve. Rather, indications suggest that his psychic state is deteriorating and will likely continue to get worse and more widely discussed. Any survey of his mental health conducted at this point will thus inevitably feel incomplete; in that respect, the book I never expected to write has become the book I never expect to finish.
The work of assessing the president’s mental health will go on. The goal of this study has never been to diagnose but to observe, comprehend, and provide some context, to improve our understanding of the characteristics of Trump’s behavior. In other words, Trump on the Couch has endeavored to offer the beginning of an education in psychiatric principles that will help add depth and structure to concerns about the state of the president’s mental health. An educated reader, one hopes, is a reader who is empowered, motivated, and even inspired.
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: the poorly educated voters returned Trump’s love, awarding him victories in forty-three of the nation’s fifty least-educated counties in 2016 (and only ten of the fifty 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 his people grew ever stronger. This knowledge has only raised my anxiety, an effect I suspect it will have on many readers too. 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.
This 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. This 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. The work begun in these pages must continue.