Putting Trump on the Couch
A new novel from the psychiatrist famous for Listening to Prozac imagines a Trumplike president’s sessions with a shrink.
This article was featured in One Story to Read Today, a newsletter in which our editors recommend a single must-read from The Atlantic, Monday through Friday. Sign up for it here.
In 1973, the American Psychiatric Association established the so-called Goldwater Rule as a response to the many mental-health professionals who had ventured glib and florid diagnoses of Senator Barry Goldwater during his 1964 presidential campaign. “I believe Goldwater has the same pathological makeup as Hitler, Castro, Stalin, and other known schizophrenic leaders” was a representative comment; many other psychiatrists and psychologists deemed him schizophrenic, a “megalomaniac,” and “chronically psychotic.” In the four decades between its enshrining and the 2016 election, the Goldwater Rule—which prohibits psychiatrists from issuing diagnoses of public figures they haven’t seen as patients—was mostly honored.
But from the earliest moments of Donald Trump’s campaign, his behavior, falling far outside the boundaries of conventional candidate comportment, raised the question of whether he could be adequately assessed in purely political terms. Where did politics end and psychology—or psychopathology—begin? Thus the Trump years have inevitably given rise to the routine flouting of the Goldwater Rule, most notably in a collection of writings assembled by the former Yale psychiatrist Bandy Lee, The Dangerous Case of Donald Trump: 37 Psychiatrists and Mental Health Experts Assess a President. (Lee subsequently got fired from Yale for publicly arguing that Alan Dershowitz was suffering from a “shared psychosis” with Trump.)
Now, with Trump the Republican 2024 front-runner—his accumulating indictments notwithstanding—the psychiatrist Peter D. Kramer seems to have successfully engineered an end run around the Goldwater Rule: In his interesting and challenging new novel, Death of the Great Man, Kramer takes on some of the relevant psychological issues of the Trump era via fiction.
Kramer, the longtime Brown University medical-school professor who became internationally famous 30 years ago for writing the best-selling Listening to Prozac, helped transform how we think about psychopharmacology and the self. In this novel, he confronts his protagonist, an idealistic psychiatrist named Henry Farber who shares much of Kramer’s biography, with the question of how and whether to provide psychotherapy to an American president who shares much of Trump’s biography.
Kramer is at pains to emphasize that he doesn’t intend a one-to-one correlation between his fictional president, who is referred to only as the “Great Man,” and the real-life Trump. Yet in his general behavior (he’s an erratic and autocratic populist who has shredded democratic norms) and many details (he has an attractive, younger European wife, and has refused to accept defeat in his reelection campaign, which took place amid the depredations of a global pandemic), the Great Man is unmistakably Trumpian.
The Great Man is also—we learn in the novel’s third sentence—dead, almost certainly murdered; his body was discovered on the couch in Farber’s consulting room in Providence, Rhode Island. The novel flashes back (how did the president come to be in Farber’s office?) and forward (who killed the Great Man? Will Farber get fingered for it?), but it is not a classic whodunit, because Kramer heavily seasons the mystery with stylistic elements drawn from literary fiction and political satire, which allows for both comedy and commentary. For instance, Kramer depicts the Great Man’s wife, Náomi, who on the surface seems much like Melania Trump, as a literary intellectual and former dramaturge with liberal leanings and an interest in existential philosophy. So nauseated is Náomi by the moral (and literal) stench of her husband that she routinely retches when he’s nearby. She also turns out to have been the secret instigator of the effort to recruit a therapist for the Great Man. She may also be his murderer.
I interviewed Kramer on Zoom earlier this summer. Our conversation has been edited for length and clarity.
Scott Stossel: What inspired this novel?
Peter D. Kramer: This was an epiphany. It was December of 2016, and Trump had just been elected. I was in New York, consulting on clinical cases at Cornell medical school. One of my editors had a short amount of time for me at the end of the day, and so I went to Union Square, near my publisher’s offices, a little early. It was rainy, so I went into the Barnes & Noble to look for books for my grandsons. I was on the escalator and the book just came to me: I thought I should write a novel that relates to Trump. The framework came to me almost whole. I went into a little corner in the children’s books section and started writing notes on my phone.
And then I went in and presented my idea to the editor, and he said: “Absolutely not.” And I thought, well, this is what I have to write, and I sat down to write it anyway.
Stossel: What was the editor’s objection? Fear of political blowback or just “this isn’t gonna sell”?
Kramer: I knew from the start that this book was going to begin with a toxic populist U.S. president dead on a psychiatrist’s couch—and of course if Trump had died at some point in between the writing of the book and its publication, that wouldn’t have been amusing.
This editor had another reasonable objection, which is that assassination for regime change is an illiberal expedient. It’s not amusing. You can’t kill off presidents—it’s just morally not the right thing. But in the novel, this isn’t murder for regime change; every character around him has a reason to want the Great Man dead. And these reasons are really only incidentally political. He’s just so horrible to everyone, and so many people have their own motives for killing him.
Stossel: How close did you mean to make the Great Man to Trump? Did you start with the public Trump we all see on TV and try to imagine his inner life?
Kramer: The thinking began with Trump, but of course characters take on their own lives for the writer. I am not an expert on politics or history, so I focused on what Trump would look like to a psychotherapist. That meant I had to create what I didn’t know about, which is this intimate person: How does he treat his wife? How does he treat people around him? How would he do in therapy? And I was running into this other constraint, which is that psychiatrists are not supposed to diagnose public figures from a distance. I didn’t want to violate the Goldwater Rule by saying, “Oh, this is fiction” and then depicting Trump exactly. I wanted, instead, to play with the question of what psychiatrists would do if they could really get close to a Trump figure.
Stossel: The reader’s mind inevitably goes to Trump because the Great Man behaves in very Trumplike ways and has a very Trumplike biography.
Kramer: My model was the dictator fiction that’s common in Latin America. In The Autumn of the Patriarch, Gabriel García Márquez takes a particular dictator, Gustavo Pinilla of Colombia, and adds elements of General Franco of Spain and Juan Vicente Gómez of Venezuela, and creates this outrageous version of a dictator. Márquez has him basically governing the country from the grave. So that gave me, I thought, license to create a comic character who was outrageous in certain ways. Whether he’s more outrageous than Trump, I can’t say. But he’s outrageous in his own way, and specifically Trumplike in five or six other ways.
Stossel: Let’s talk about the Goldwater Rule. Don’t mental-health professionals have a “duty to warn” when somebody poses a danger to themselves or others? And what if that danger posed is not to an individual but to the entire American population, which is clearly how some of the experts in the Lee book see Trump?
Kramer: The real function of the Goldwater Rule is to protect psychiatry from itself—from all these doctors expressing their political views through making diagnoses without a careful respect for the clinical facts. I remember an era when—this is way back—people would say, “Well, if your patient has not expressed anxiety about the atom bomb, the patient is in denial.” And I thought, My patients will express whatever they express, and the introduction of uniform political views into psychiatry is a disaster. I’ve had patients who were very much on the front lines of the anti-abortion movement, and I am very much on the other side. But you are out to treat the patient who’s in front of you—you’re not out to impose your views or ask them to see things differently than they do.
You just need to deal with patients as you find them—even with patients who are racist and prejudiced and anti-Semitic or whatever. To create some kind of internal rule in psychotherapy that integrates political views is a disaster.
Stossel: Let’s say you have a patient referred to you with depression, and he quickly evinces extreme racist and misogynistic views, and election denialism. What would that encounter in the consulting room look like?
Kramer: This is very much one of the topics of the book. One of the worries regarding Henry Farber is that he will go and treat the Great Man, and that will just give the Great Man some ease, and make him better able to do the terrible things he does. Farber has great faith in his therapeutic method, so the setup is this: He’s known—as I am—for writing a book early in his career that was a best seller, and he’s also known as a sleep doctor. Later in life he’s specialized in the treatment of paranoid men. And he’s brought in to treat the Great Man’s insomnia, but secretly there’s some hope on the part of the people who bring him in that he will treat the personality problems as well. And I think Farber is comfortable with what seems like a corrupt assignment, because he just believes in his therapeutic method, which is that if he sits empathetically beside his patient—metaphorically speaking—and looks out at the world as his patient does, and gets the patient to feel what he feels and be aware of his feelings, good things will happen, that there will be some general liberation, and that will be useful both for his sleep problems and his disordered personality. But he’s not trying to nudge the person in any direction; he’s trying to get the person to free himself of whatever it is that constrains his feeling and thinking.
Farber’s extreme commitment to this approach is comic. When the Great Man throws him into a jail cell at one point, Farber thinks, How can I utilize this thing that my patient has done? The patient will indirectly notice how I behave in the jail cell, and maybe I can do that in a way that’s therapeutic; I’ll prepare for our next encounter by reviewing similar cases. I don’t know that I am self-abnegating in that way. But I do retain an idealistic faith in the therapeutic method that if you put people in touch with themselves—that’s your job, and your job isn’t to guide the direction of progress.
Stossel: Let’s say, as implausible as this is, Ivanka calls you up and says, “My father is suffering from grave depression after his brush with COVID mortality”—would you do as Farber does and take Trump on as a patient?
Kramer: I would take the case in a minute. I think Farber cross-examines this stuff: Is he taking the case because this will demonstrate that he’s a virtuoso of empathy, or out of his own self-aggrandizement because this is such a challenging case? I do think I would be tempted by the level of effort that would be required. I like taking on cases that I thought were difficult for me because they were unlikable patients. (Anyone who’s my patient: That wasn’t you!) I do think the book is my attempt to imagine what the level of effort would be like. Farber keeps looking for the element of full humanity in his patient. When he perceives this little spark of it, he’s so encouraged by it; he thinks there’s something here he can work with. I think that would be a challenge with someone like Trump: sort of waiting him out until you see that little hint of something that’s not propaganda and self-praise but something that has a little texture and dimensionality to it. I mean, I was really trying to imagine what that would look like for Trump.
Stossel: And what would that look like?
Kramer: I think it could be exposure of vulnerability. Could just be genuine emotion. There are easy emotions like anger, which is sort of the lowest-level emotion; patients who can’t access much else can often access rage. But there are other moments where I imagine under all the grievance there could be some genuine pain or sadness, and you’re curious about that.
Stossel: Imagine Trump meeting with a child psychiatrist when he was a younger person. Do you think this would help him process whatever the trauma of growing up with his father was?
Kramer: I think it’s at least possible to think that this grudge against the world, the constant sense of having been wronged, could have been diminished. That’s what psychiatry that examines early-childhood injuries is out to do—free people from being in the thrall of their resentment for the rest of their lives.
Stossel: Allen Frances, the psychiatrist who presided over the composition of the DSM-4, has written that Trump’s presidency and aberrant behavior are more symptoms of culture that’s gone mad than of any psychiatric illness. And Jeffrey Lieberman, a psychiatrist at Columbia, has written that Trump doesn’t have any DSM illness—he’s just “a jerk.” Do you think there are links between various personality types and certain political ideologies or behaviors?
Kramer: I know Jeff and Allen a little bit, and I don’t agree with the argument “Well, this is just evil, and diagnosis has nothing to do with it.” Diagnosis aside, I think what we saw was four years of a certain kind of personality on display. And it was almost impossible to be a political analyst without wondering about certain of his actions; there wasn’t enough logic in the behavior to explain it only in political terms. In the book, I write about “arbitocracy.” This isn’t really authoritarianism, because it’s not consistent enough, or organized well enough—not that authoritarian regimes generally are either—but this seemed to be even more arbitrary and herky-jerky. So, yes, I think personality is relevant in talking about the politics of Trump.
Stossel: I know you don’t want to diagnose Trump. But having sat, as Henry Farber, in therapy sessions with the imaginary Great Man, what would you diagnose Great Man with? If he’s gonna file an insurance claim, that requires your giving him a DSM diagnosis, right?
Kramer: Right. I’m with Farber, who says that the men in his paranoid-men’s group do not meet a strict by-the-book definition of paranoia; they’re people who have this same kind of hypervigilant posture in the world. And he says of the Great Man, “Yes, he would qualify as one of my patients.” So it’s sort of a loose paranoia for the Great Man.
Stossel: Is paranoia a DSM disorder?
Kramer: It’s a delusional disorder, which is in the DSM. And of course I diagnosed patients in my practice for the purpose of deciding which medicine to use, and for insurance claims. I think diagnosis is very helpful. But personality disorders—that is, borderline personality, sociopathy, or paranoia, the kinds of diagnoses that were debated with regard to Trump—were never something where I’ve found the particulars that useful. Patients don’t necessarily stick with one personality-disorder diagnosis—they can have one and a year later have another, or the diagnosis can even disappear, and they end up with just depression or drug abuse or something, and don’t have the personality disorder. It’s not a very stable diagnosis.
Stossel: Are personality disorders susceptible to treatment by medication? If you were treating Trump—or, if you prefer, if Farber is treating the Great Man—is there a drug regimen that could ease their distress or make them less inclined to wreak pain and havoc on everyone around them?
Kramer: Well, the experience of treating personality disorder with medication has not been terrific. There certainly was a lot of use of SSRIs in treating borderline personality disorder, with some success and a lot of failure. I think the results were similar for lithium. In Listening to Prozac, I talk a lot about rejection sensitivity, a category that isn’t written about a lot anymore. And people had this diagnosis of rejection sensitive dysphoria, which sometimes did well on antidepressants. It turned out that really what was going on was that their vulnerability to social insult was so great that they looked very erratic, and on medication they could be less erratic and less in pain.
But as a therapist looking at the relationship between Henry Farber and the Great Man, I wasn’t tempted for Farber to reach for the prescription pad. I did not want to introduce medication to the book.
Stossel: You can’t medicate a politician into making better policy.
Kramer: Yeah. I mean, I think if you got up close to one of these political figures and saw that he had ADHD, maybe a stimulant would be calming in a paradoxical way. Or if the person really is manic, maybe lithium would be helpful. You can imagine some diagnosis that can’t be made from a distance but here up close you might see something that was not as evident in these speeches and debates. Medication could possibly help with those.
When you buy a book using a link on this page, we receive a commission. Thank you for supporting The Atlantic.