Mental Health and the Presidency

Jeffrey A Lieberman, MD


August 24, 2016


The job of President of the United States and the campaign that one has to wage to hold that office have become so demanding and stressful that it begs the question, does a person have to be crazy to seek that office. Not crazy in a literal sense, as in psychotic or insane, but in terms of what motivates a person to want to be the most powerful person on the planet.

As a psychiatrist who studies the brain and behavior and who has treated thousands of people with mental disorders, it is not appropriate to speculate on the mental conditions, much less suggest diagnoses, of public figures with whom I have no direct experience. But I can speak about the qualities that might impel a person toward the presidency, the effects the rigors of the campaign and office might have, and the way mental health care could prevent or ameliorate adverse consequences.

Psychologically speaking, the major qualities I believe that would lead someone to seek the presidency are narcissism, grandiosity, and messianism. Narcissism refers to self-interest and valuation. The adaptive aspect of narcissism translates into self-confidence and entitlement; entitlement refers to the belief that one can and should hold such an exalted position. Grandiosity refers to the scale of things, in this case political office. Someone who is grandiose aspires to large and elaborate goals and, obviously, you can't find a position much bigger than the presidency. Messianism refers to helping or saving. In this case, it refers to a person's belief that he or she can help protect and improve the country.

The enormous physical and psychological demands of the grinding campaign and the pressures of the presidency require endurance and resilience. Presidential politics is not for the faint of heart. That is not to say that someone must be a triathlete, but stamina helps. And if a person lacks stamina, resilience is all the more essential. Bill Clinton is an example of both. He is well known for his endless endurance when campaigning, and he was dubbed the "comeback kid" for his ability to bounce back from defeat.

Candidates would also benefit from the cognitive qualities of control, compartmentalization, and reframing. Cognitive control is to the ability to manage emotions and not allow them to overwhelm or overly influence the decision-making process. An example of this is the Cuban Missile Crisis, in which President Kennedy avoided what could have been nuclear war through a combination of military action and diplomacy.

Compartmentalization refers to the ability to separate and contain issues and incidents and not let them preoccupy you when you need to focus on other parts of your job or life. For example, President Johnson's (understandably) overwhelming concern about the Vietnam War, and his inability to compartmentalize, ultimately led to him not seeking re-election, and President Clinton's ability to compartmentalize allowed him to effectively deliver his State of the Union address days after the Monica Lewinsky scandal broke.

Reframing refers to the capacity to see issues and events, particularly adverse ones, from a different perspective and in a new way. Ronald Reagan reframed the popular pessimism and dissatisfaction of the American people with an optimistic narrative in his "Morning in America" campaign.

The enormous toll that the campaign and the presidency take on a person makes me wonder whether more should be done to assess and provide care for the psychological well-being of our candidates and office holders. There are numerous instances in which this could have been an issue. Throughout his adult life, President Kennedy suffered from a number of physical ailments, including Addison disease and back pain, for which he was treated by the notorious Dr Feelgood, Max Jacobsen, with intravenous amphetamine, among other shocking things.

New documents released by the Nixon Presidential Library revealed that President Nixon took three psychotropic drugs: Dexedrine (stimulant), meprobamate (anxiolytic), and Doriden (sedative). He also took Dilantin, an anticonvulsant medication used to treat seizures, which was promoted by a dubious doctor as a miracle drug for mood instability. Ronald Reagan clearly was not the same after the assassination attempt. Between the effects of that and his subsequent development of Alzheimer disease, it is hard to know what the limitations in his mental function were.

Finally, after President George H.W. Bush fainted during a state dinner when he was visiting Japan in 1991, it was revealed that he had been taking the sedative Halcion to help him sleep and combat jet lag. Most physicians would have known that Halcion commonly causes adverse effects, including anterograde amnesia, prompting me to wonder who was providing his medical care.

In the same way that steps are taken to ensure the physical health of the president (and those who aspire to be), shouldn't we do the same for their mental health?

After all, despite their importance and high office, they are only human.


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