Inauguration Day USA.
The time has come for the 45th president, Donald Trump, to take the oath of office. The property developer and reality TV host is one of the richest people in the world and, at 70, the oldest president to be elected.

​But what do we really know about the man beyond the biographical facts and his rather cartoonish public image?
Underneath all the bluster, self-promotion and insatiable hunger for power, wealth and women, is there a sensitive, damaged soul? A conscience? An inner life? Or just the sound of a chill wind whistling through empty, dark chambers of the Trump machine, bereft of emotion, spirit, light or love?
Who is Donald Trump?
What is his psychology?
 
Narcissistic personality
Three prominent American psychiatrists wrote to president Obama in late November stating that Trump suffered from Narcissistic Personality Disorder and was thus unfit for office.
“Professional standards do not permit us to venture a diagnosis for a public figure whom we have not evaluated personally,” stated the letter, which was made public. “Nevertheless, his widely reported symptoms of mental instability — including grandiosity, impulsivity, hypersensitivity to slights or criticism, and an apparent inability to distinguish between fantasy and reality — lead us to question his fitness for the immense responsibilities of the office.”

The diagnosis of NPD—also the conclusion of five therapists in a story in Vanity Fair—is summarised by the industry standard reference book, The Diagnostic and Statistical Manual of Mental Disorders (DSM), as: “A pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:
1. Has a grandiose sense of self-importance (e.g., exaggerates achievements and talents, expects to be recognized as superior without commensurate achievements)
2. Is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love.
3. Believe that he or she is “special” and unique and can only be understood by, or should associate with other special or high-status people (or institutions)
4. Requires excessive admiration
5. Has a sense of entitlement
6. Is interpersonally exploitative
7. Lacks empathy: is unwilling to recognize or identify with the feelings and needs of others
8. Is often envious of others or believes that others are envious of him or her.
9. Shows arrogant, haughty behaviors or attitudes.”
 
Worse than Hitler
Others have meanwhile diagnosed Trump as a psychopath. One Oxford professor used a psychometric scale to conclude that Trump is more of a psychopath than Hitler.
Psychopaths, which I have written about previously, are usually not chainsaw-wielding serial killers but are instead the kind of driven, high-functioning, succeed-at-any-cost characters who can be found in all walks of life. In his 1993 book Without Conscience: The Disturbing World of the Psychopaths Among Us, Robert Hare estimated there were at least 2 million psychopaths in North America, and by that measure there are likely 400,000 in the UK.
Hare identified 20 characteristics of psychopaths that are used in his diagnostic test, the Psychopathy Checklist-Revised (PCL-R), such as: Glibness/superficial charm; Grandiose sense of self-worth; Pathological lying; Cunning/manipulative; Lack of remorse or guilt; Shallow emotions; Callousness/lack of empathy; Failure to accept responsibility for own actions; Need for stimulation/proneness to boredom; Impulsivity; Early behaviour problems; Promiscuous sexual behaviour. (Take this quiz if you want to find out your level of psychopathy.)
Psychopathy isn’t a recognised disorder in the DSM—it only gets a brief mention in the description of Antisocial Personality Disorder.” ASP is defined as “a pervasive pattern of disregard for and violation of the rights of others” and includes ego-centrism; self-esteem derived from personal gain, power, or pleasure; goal-setting based on personal gratification; lack of empathy, incapacty for intimacy; manipulativeness; deceit; callousness; hostility;  disinhibition. Criminal activity is also among its diagnostic indicators (eg. “Failure to conform to social norms with respect to lawful behaviors”).
 
I have met Trump on more than one occasion and in 2014 interviewed him for an hour and a half in his Fifth Avenue Trump Tower office for the American magazine Golf Digest (you can read it here). So as a qualified psychotherapist, what’s my professional opinion: NPD? Or ASP?
Neither.
Why?

Firstly, there’s the American Psychiatric Association’s “Goldwater Rule” which stipulates that its members should not make a diagnosis of someone who they have not examined face-to-face; nor should they publicly discuss the mental health of anyone without their consent.
The rule takes its name from the 1964 election, when Fact magazine reported psychiatrists’ opinions—not “facts”—about the mental health of the Republican nominee Barry Goldwater, describing him as “warped,” “narcissistic,” “impulsive,” a “paranoid schizophrenic,” with much condemnatory armchair speculation as to his psychobiography, motivation and overall mental health. Goldwater lost the presidency but won a lawsuit against Fact for libel.

Many practitioners have broken the Goldwater Rule—desperate times apparently call for desperate measures. And there is no explicit equivalent of the rule to be found among the ethical guidelines of British psychotherapy professional bodies like the UKCP and BACP. But mental health professionals’ urge to diagnose public figures from afar is to be resisted. Anyone is free to have an opinion about a public official and express it, within the bounds of libel law--calling someone for instance a lying, power and money-hungry sexist racist bigot. But using your professional position to label any human being—yes, Trump is human—with a specific clinical diagnosis without their input and consent is an an act of violence to that person and to the absolutely vital notion of confidentiality which underlies the profession.

For me, however, a bigger concern with branding Trump as an NPD or an ASP is with the validity of such diagnostic labels.
There is an obsession in western psychiatry with attempting to apply a medical model to mental health, as if all psychological distress can be divided up into a textbook of discrete, objectively-measurable, uniform conditions, as if terms like “depressed” or “schizophrenic” or “narcissist” were something more than broad adjectives that mask vast individual differences, experiences and meanings.
This return to a reductive conception of mental illness has been driven by political and economic forces. There is much commerce in pathologising aspects of the human experience that are deemed problematic, itemising them according to their supposedly reliable patterns of symptoms, ascribing biological causes to those symptoms, then prescribing drugs which promise to reduce or eradicate them.
The DSM is a kind of license to medicate. By 2005 for instance, facilitated by enormous amounts of sponsored “research” and marketing, one in 10 Americans had a prescription for an antidepressant. “Shyness” is now considered an unacceptable sickness. The diagnosis of “bipolar” has risen by 4,000 percent since the mid-1990s.
This is not to say that mental illness is a myth, a mere social construction, a form of political control, as the “antipsychiatrists” like Laing and Szasz claimed.
Nor is it to say that there is no place for medications and biological considerations of the psychological, or that the DSM has no value—it does provide a framework and a language; a shorthand that facilitates communication among colleagues, and clues about treatment direction.

But to pretend that there is such a uniform, distinct condition like NPD or ASP that descends on the unwitting, passive recipient as might measles or tuberculosis, is ridiculous. Our psychology affects how we live our lives, and how we live our lives affects our psychology, leading to an infinite branching of the tree of function and dysfunction. The complexity of humans and the diversity of their distresses defy neat pigeonholing.

So what can we say about Trump?
The most accurate “diagnosis” of the new president is that he has a very extreme case of being Donald Trump. Society has richly rewarded him for that. He represents a kind of extrapolation of the laws of the jungle, a quintessence of capitalism, where there is no place for doubt or indecision or self-reflection; no let up. Like a hungry shark, Trump is always swimming, alone, and everything else in the ocean is viewed solely in terms of opportunity and threat. In his get-rich, self-help, self-homage book Think Big, he writes: “The world is a vicious and brutal place. We think we’re civilised. In truth, it’s a cruel world and people are ruthless. They act nice to your face, but underneath they’re out to kill you.” 

A psychologist in the magazine The Atlantic last year concluded: “It is always Donald Trump playing Donald Trump, fighting to win, but never knowing why.”

New Yorker writer Mark Singer memorably described Trump’s life as “an existence unmolested by the rumbling of a soul.”

In my interview with him, I concluded by asking Trump if there was ever a pause in the relentless self-promotion and salesmanship:
Q: Does it ever stop? Do you ever switch off?
A: Um, probably, but... not too often.
Trump looks puzzled, as if this notion had never occurred to him. He laughs.
Q: Yeah.
A: I don't know.
Q: What would happen if you did?
A: I don't know. It might be a disaster. I think it could be a disaster.