Emily Yoffe is a contributing editor at the Atlantic.

It would be crazy to diagnose the president as mentally ill without a formal, in-person consultation. It would be just as crazy to ignore the troubling signs that something’s not quite right in Donald Trump’s head.

Mental health professionals have long been reluctant to diagnose politicians because of the so-called Goldwater Rule, which holds that psychiatrists should not pass judgment on public figures without having examined them and received permission to speak. Named after Republican nominee Barry Goldwater, who was declared by hundreds of psychiatrists in 1964 to be “psychologically unfit” to be president, the rule was written into the American Psychiatric Association’s code of ethics in 1973 after a fierce backlash. Ever since, calling presidents crazy has been considered a disreputable thing to do.


Recently, however, a small but growing number of mental health professionals have been willing to stick their necks out to shrink the head of the 45th president; just last week, representatives from a coalition of 800 mental health professionals met at Yale Medical School to discuss what they call their “duty to warn” the public about Trump’s behavior. For the sake of the country, these and other professionals believe it’s time for a psychological diagnosis of Trump, to provide an explanation for, among other things, the bizarre Twitter rants, peddling of easily provable lies, head-spinning policy reversals, incoherent interview answers and unhinged attacks on his perceived enemies.

Let us stipulate that it is not known for a fact that Trump has any kind of psychiatric diagnosis. Let us also stipulate that, to many observers, the most powerful man in the world displays many of the definitional traits of one disorder in particular: Narcissistic Personality Disorder, characterized by behavior that is impulsive, dramatic and erratic. According to the Mayo Clinic, people with NPD “come across as conceited, boastful or pretentious,” require “constant admiration” and belittle people they “perceive as inferior.” This grandiose, bullying shell hides profound insecurity, so “anything that may be perceived as criticism” can provoke “rage or contempt.”

I’m not a mental health professional, so I’m not bound by the APA code of ethics. But forget about a formal diagnosis: It’s pretty clear that Trump is a narcissist at least in the colloquial sense of the word. And at a minimum, he shares a lot of traits of someone who has been formally diagnosed with NPD. So what should we do about it? More specifically, how should those who interact with him frequently on the job—White House staff, members of Congress and foreign leaders—best handle him? As a public service, I have spoken to experts on narcissism and other psychological disorders to pass along their advice for constraining, rather than enabling, Trump’s worst impulses where possible. After all, there is much at stake in the state of Trump’s psyche—the fate of the free world, for instance. Their collective wisdom amounts to a veritable handbook for managing our narcissistic president.

Given the Goldwater Rule, some professionals I contacted were willing to talk only in general terms about working for a person with NPD, but others were not so circumspect. John Gartner, a psychologist practicing in Maryland and New York who previously taught at Johns Hopkins University Medical School, is among the latter. He started a petition right after the inauguration calling for mental health professionals to declare that Trump should be removed from office under the 25th Amendment on the grounds of mental illness. Gartner believes Trump suffers from a form of narcissism so extreme that it is “malignant narcissism,” a venerable but unofficial diagnosis that adds the callous, conscienceless traits of the psychopath to the mix. Trump’s apparent disorder can’t be cured, or even really contained, Gartner says. “He has one mode: attack.”

Some degree of narcissism is necessary to be an effective person. It provides the conviction that we matter and the drive for accomplishment and recognition. But for people with NPD, the need for praise and acknowledgment to prove they are uniquely superior is consuming. Gartner suggests that staffers can channel their boss’ narcissistic predilections toward more productive ends by framing policy as a way of “winning”—a Trump obsession. Given the administration’s fumbling of the Obamacare repeal and the travel ban, Gartner says, “Trump has started to realize when he listens to more reasonable people, he’s more likely to win.” Wendy Behary, a New Jersey therapist and author of Disarming the Narcissist, didn’t want to diagnose Trump, but she says that when working for a leader with Trump-like traits, advisers might sometimes need to indulge their boss for the greater good. For example, those adviserswould do well to make such a boss think their own ideas were his. “You have to feed the narcissism,” she says, acknowledging, “It’s a little nauseating.”

Narcissistic bosses, especially those with Trump-like manic energy and distractability, often have at least one trusted adviser with an instinct for flattering and cajoling the boss into being more circumspect. Kellyanne Conway seems to have played that role during the campaign; an Atlantic profile called her the “Trump whisperer” for her ability to get Trump to use the teleprompter and reduce his tweeting, and she guided him to making a grudging apology after the “Access Hollywood” tape scandal (while vehemently defending him). But now that her own gaffes (“alternative facts,” “Bowling Green massacre,” etc.) have drawn mockery, Conway has largely disappeared from public view.

Enter Javanka. Some have cast Trump’s kleptocratic impulse to put his more moderate daughter Ivanka and son-in-law, Jared Kushner, in positions of power as beneficial to the country because the couple may act as a brake on his impulses. But their presence is not just about the family business; it is a psychological balm for Trump, Gartner argues, because narcissists see favored family members as extensions of themselves. Since Trump has said that he is his own best policy adviser (“I’m speaking with myself, No. 1, because I have a very good brain and I’ve said a lot of things”), Gartner says Trump can interpret the advice from Ivanka and Jared as a form of listening to himself. If Gartner is right, those who seek to influence Trump’s thinking would likewise do well to cultivate this pair.

A danger, however, for subordinates is that they can be inclined to distort reality to keep the boss happy, says Michael Maccoby, a psychoanalyst, business consultant and author of Narcissistic Leaders: Who Succeeds and Who Fails. Maccoby demurs at tagging Trump with a psychiatric diagnosis, but after dealing with dozens of narcissistic leaders in business and government, he says he sees one in Trump. Spinning or slanting the facts to please the boss (as Trump’s subordinates are known to do) isn’t just a bad idea because it distances the president from reality. It can also backfire, because when reality inevitably breaks through, the flatterer will be held responsible for mishandling events. Narcissistic leaders aren’t inclined to blame themselves for their own failures.

When a hastily approved special operations raid in Yemen went wrong, for instance, resulting in the death of Navy SEAL Ryan Owens, Trump blamed the military rather than accepting responsibility—an unheard-of move for an American president. “This was something they wanted to do,” he said. “They came to me, they explained what they wanted to do, the generals, who are very respected, the most respected that we’ve had in many decades, I believe. And they lost Ryan.”

The same dynamic can be seen in the saga of White House press secretary Sean Spicer. Not long ago on CNN, a group of reporters who had dealt with Spicer when he was communications director at the Republican National Committee said they no longer recognized the thin-skinned, hostile person at the White House podium who now traffics in provable falsehoods. In trying to please an audience of one, Spicer appears to be mirroring his boss’ own tendencies. But debasing oneself to satisfy a narcissist will likely end with the narcissist’s contempt. Indeed, the Washington Post reported Trump’s rage at Spicer’s awkward defense of the inaugural crowd lies (and at Spicer’s ill-fitting suit). Spicer’s employment has been considered so tenuous that the Post more recently reported that at a working lunch with the president, someone wondered aloud whether Spicer was a short-timer. Trump surprised them by saying Spicer’s job was safe, for now, because his press briefings get great ratings. So the cycle of flattery and reality distortion continues, as Spicer’s credibility suffers.

At the same time, Spicer must know that he can’t overstep his bounds. Maccoby warns that subordinates who become celebrities themselves will eventually grate on the narcissistic boss. Where is Conway again these days? Or just look at the decline of political strategist Steve Bannon, whose Time magazine cover and other assorted power moves have reportedly annoyed Trump. “The ones who are going to succeed,” Maccoby says, “will be the ones who maintain their expertise and stay out of the limelight.” He points to Secretary of State Rex Tillerson, who has avoided the press, deferred to the president and, in turn, seen his stock at the White House rise. “He’s very clever not to talk to reporters,” Maccoby says. “He doesn’t want anybody to give him credit.”

Despite Trump’s bluster about his superiority in all matters military (“There’s nobody bigger or better at the military than I am,” “I know more about ISIS than the generals do,” etc.), New Jersey therapist Steve Becker, author of The Inner World of the Psychopath, says the clear power and influence wielded by the generals around Trump—Homeland Security Secretary John Kelly, Defense Secretary James Mattis, National Security Adviser H.R. McMaster—points to an effective strategy for dealing with Trump. Becker says these tough, accomplished men, who understand hierarchy, radiate that they will not be pushed around. Becker says confident subordinates can reframe truth-telling as loyalty. He assumes these military men have told the president that their responsibility is to be honest with him and, by fulfilling that responsibility, they will best serve Trump’s agenda and the interests of the nation.

All the mental health professionals I spoke with warned that it is essential for people working for someone with a severe personality disorder to keep one’s own psychological distance and moral compass—and always have an exit strategy. In trying to please such a boss, it is easy to get swept up into his distorted worldview, with potentially disastrous professional and personal consequences. Michigan psychotherapist Eleanor Payson says that for a narcissist boss, “The world of illusion is the only one that matters.” (Payson, who has written two books about NPD, also didn’t want to diagnose Trump, but she spoke in general terms about working for someone with the disorder.) Payson’s books describe how people with NPD are in a constant struggle to shore up their Potemkin-village sense of self, and how they project their internal struggle on the world around them. She writes that, as bosses, they live in a world of “winner vs. loser polarization,” and impose an “us vs. them” dynamic on the workplace—or, in Trump’s case, the world. Payson says it’s dangerous for those who work for such a boss to think they can manipulate this psychology. “You’re not going to outsmart the person at his own game,” she says. So she instead counsels that those who work for someone with NPD should strengthen their own honesty and integrity, and be prepared to quit or be fired in response.

Becker—who agrees with Gartner that Trump is a “malignant narcissist” and thinks he displays many psychopathic traits—says the essential mentality of the psychopath is to transgress, which one sees in Trump’s “contempt for limits, boundaries. His mentality is to get over on people and systems.” Crucially, such people do not experience shame, that unpleasant emotion that keeps us from doing terrible things. Of Trump, Becker says, “This enables him to execute any agenda of the moment, to lie and slander blatantly with no conscience.” He warns staffers that this means you can be in Trump’s favor one minute, and unknown to him the next. Think of Spicer portraying former campaign manager Paul Manafort and former national security adviser Michael Flynn, each being investigated for Russia ties, as marginal figures. Becker says anyone working for Trump (except perhaps his relatives) must accept that his or her position is not secure.

As for those outside the White House who deal with the president, the mental health professionals I spoke with had slightly different advice. Becker says malignant narcissists “salivate for battle,” so other world leaders should try to temper this tendency in Trump. “The way to be strong is to convey your dignity, to challenge the bluster,” he says. Quietly displaying strength and setting boundaries will work best. For example, the British firmly disputed the Trump administration’s suggestion that their intelligence service helped wiretap candidate Trump—and, ultimately, they got an apology from the White House. The Mexican president has made it clear that his country will not pay for a border wall. In an apparent concession, Trump this week tweeted that to get that project going, the American public will first foot the bill, to be reimbursed later by Mexico. In other words, Mexico isn’t paying for the wall. And at a recent visit to Mar-a-Lago, Chinese President Xi Jinping gave Trump a short history lesson that caused Trump to back off his demand that China immediately bring North Korea to heel. “After listening for 10 minutes, I realized it’s not so easy,” Trump said.

Republican members of Congress seem to have absorbed the lesson of not being cowed, too. In a recent tweet, Trump blamed the House Freedom Caucus for the failure of his health care bill, and then threatened to oppose their reelection campaigns. In response, Republican Justin Amash of Michigan told the Dallas Morning News, “Most people don’t take well to being bullied. It’s constructive in fifth grade—it may allow a child to get his way—but that’s not how our government works.” In a first confrontation with their new president, it was members of House who were confident enough to stand firm and call his bluff.

In reality, it’s not just Congress or world leaders or White House staffers who are in Trump’s orbit and at the whim of his personality traits. We all are. Wendy Behary says that when dealing with such a person, the best defense is to read deeply about psychopathology. Ultimately, she says, understanding the dynamics of personality disorders will help make what seems unpredictable predictable. The more people know, the less they will wonder, “How could he do that?” and come to understand, “How could he not?”