A First Rate Madness is a book written for the layman, but contains an impressive bibliography and research notes. The author clearly intends to maintain his scholarly creds, while appealing to a broader audience. In this, he succeeds. In his thesis, not so much.

A First Rate Madness by Nassir Ghaemi is an interesting book with an interesting premise.

“In times of crisis, we are better off being led by mentally ill leaders than by mentally normal ones.”

The book is written for the layman, but contains an impressive bibliography and research notes. The author clearly intends to maintain his scholarly creds, while appealing to a broader audience. In this, he succeeds. In his thesis, not so much.

However, that is not to say that his examples lack an element of truth. And his book was especially enlightening from a historical perspective. Ghaemi is on a mission with two objectives. The first is to open up the realm of psychological history and the second is to remove the stigma associated with mental illness. In the first, his arguments are well-reasoned and plausible. In this reader’s estimation he goes too far in the second by extolling the benefits of having an insane leader. A professional in the treatment of mental illness, he stretches too far in his general thesis.

All of the examples used in the book were interesting. With some, Ghaemi has probably done as good a job as a historian as he has as a psychiatrist. With others, his coverage is more superficial.

In order to understand the book, it is necessary to understand the terms, definitions, and assumptions employed in formulating the author’s thesis. Fortunately, he does an excellent job laying these out at the onset. By the end of the book, the reader is quite comfortable with an understanding of such terms as dysthymia (exhibiting low energy, slightly depressed), hyperthymia (exhibiting high energy, extremely upbeat), and cyclothymia (cycling between highs and lows).

The author contends that:

Mental health is the absence of mental disease, plus being the statistical average of personality traits.

However, he qualifies this a bit in his concluding remarks by pointing out that “the border between health, and mental illness is porous.” There really is no such thing as a “normal” state of mental health. Everyone has a different mix of traits and more or less neuroses. Basically, we’re all a little mentally aberrant in one mayor another. It’s just a matter of degree.

According to Ghaemi, those who are less stable mentally have made some of the best leaders throughout recent history. He attempts to prove his point through the use of historical examples. In order to do so, he first has to prove that these leaders might reasonably be diagnosed as mentally ill. Ghaemi indicates that this is not as difficult as it might seem and utilizes 4 criteria to determine his diagnosis. These are: symptoms, genetics, course of illness, and treatment.

In Ghaemi’s view, the fact that historical figures are dead does not pose a great difficult in diagnosing them. Ghaemi suggests that most patients lie or distort the truth about their conditions, either by guile or because they simply lack perspective. Therefore, the symptoms reliably observed in their actions and the testimony of others, may have more weight in a diagnosis. In the case of a historical figure, this is only marginally more difficult than it would be for a living person. As for genetics, familial history is fairly simple to ascertain in most cases, and may in fact be easier to delve into family histories when the people in question are long dead. The course of the illness, is akin to the symptoms in that there is a historical record which may actually provide an advantage over diagnosing a patient for whom no such history exists. “Treatment” may not necessarily indicate professional treatment, but may be inferred from how the subject self-medicated, using alcohol or drugs to cope with his malady, and this too can be derived from the historical record.

And so, Ghaemi methodically “diagnoses” each of the example leaders selected to prove his point. Because he is such a perfect example, by the author’s reckoning, the first subject discussed is General Sherman. Given the evidence presented and judging by the criteria above, the author makes a reasonable case that Sherman was a pretty sick guy. The link between Sherman’s mental illness and his brilliance in the use of total war tactics, is more tenuous. Ghaemi argues that it was Sherman’s ability to think outside the normal confines of Napoleonic tactics that separated him from McClellan. This might be true, but it isn’t clear that his mental illness had anything to do with it. He might have been just a smart guy, able to think outside the box, who happened to be mentally ill.

However, it is the cumulative set of examples that Ghaemi uses to prove causality. He claims that there is enough evidence, in the form of postmortem psychiatric diagnoses, to assert that:

All the major leaders of World War II can be shown, with reasonable evidence, to have been mentally ill or abnormal: …

In a cogent and succinct explanation of how the various illnesses manifested themselves, he also theorizes what the upside to these illnesses might be. And so, his plan for proving his thesis, is based on acceptance of these theories as well as his contention that the major world leaders were all nuts.

And here, we have to digress. Dr. Ghaemi would no doubt cringe at the choice of words in the last sentence. He is fairly categorical in his assertions that mental illness carries as stigma and should not do so. This is indeed the case, and insensitive words notwithstanding, (used for literary effect), mental illness is real and should no more be stigmatized than any other disease. However, Ghaemi goes too far in his laudable desire to lessen the plight of the mentally ill. He argues that it is advisable to put such people at the reins of power. An analogy comes to mind, while we sympathize with the visually impaired, we wouldn’t put them at the wheel of a school bus.

Nowhere is this argument more ludicrous than in his depiction of John F. Kennedy’s miserable (literally full of misery) life. But, we’ll set that aside for a moment and return to Ghaemi’s methodology in A First Rate Madness.

For each of the leaders in question, Ghaemi first attempts to prove they were mentally ill, using the four criteria, symptoms, genetics, course of illness, and treatment. Some of his diagnoses are more believable than others. However, for the sake of argument, and the fact that he is an expert in the field of psychiatry, we’ll submit that the WWII leaders in question, all exhibited some degree of mental illness. This is easier to swallow in conjunction with the author’s assessment of the overall nature of the human mental condition, and that “normality” is pretty hard to define. In other words, everybody exhibits some degree of mental illness. Having laid out his arguments for mental illness in his subject, Dr. Ghaemi moves back into the realm of historian, and attempts to link action with causality.

For this reviewer, the booked hummed along without too much to cause skepticism, until Ghaemi gets to FDR. It is not a difficult leap to believe that FDR’s world view was probably affected by being struck down with Polio. In other words, Polio changed who FDR was. We’ll even buy that FDR suffered from mental illness. However, while Ghaemi necessarily glosses over a lot of history, he presents a somewhat skewed picture of FDR’s personality. In fact, he gives FDR far too much credit. He ignores FDR’s categorical failure at Yalta, his attempts to subvert the Constitution by changing the structure of, and packing the court, and his hubris. (FDR, like Kennedy was not only, mentally unhealthy, but also physically ill with even more serious problems than the polio-caused paralysis. Indeed a recent book by Steven Lomazow and Eric Fettmann reveals that he suffered from melanoma which was studiously kept from the American people. He was in no way fit to run for a 4th term, and yet did so — hubris. (Interestingly enough, hubris is the fatal flaw that Ghaemi attributes more to “normal” crisis leaders than to those of his mentally ill ideal.) Instead, Ghaemi paints FDR as a loquacious charismatic guy with great strength of character and few, if any faults. He finds no difficulty in FDR’s promiscuous behavior (just an aspect of his mental illness), and extolls his virtues. If seeking to prove the beneficial side effects of mental illness by using FDR as an example, Ghaemi doesn’t succeed, as this leader was not a good president. FDR’s economic policies were abject failures, and it was only World War II that saved the economy. His leadership was not particularly inspired or unique. There were a lot of people responsible for winning the war. Admittedly this reviewer has a bias against FDR, but it is certainly more than counterbalanced by Ghaemi’s superficial hagiography.

For practical reasons of space and time, we’ll skip Gandhi, Hitler, Churchill, and Martin Luther King. However, the arguments to support King’s mental illness are some of the weakest in the book.

Skipping forward, we arrive at John F. Kennedy. This was one of the most fascinating sections of the book from a historical perspective. Ghaemi is much more thorough and meticulous in this section than in any other. Well-documented research brings to light some things that other historians have missed or glossed over. JFK suffered from Addison’s disease and was, according to Ghaemi, also mentally ill. Kennedy suffered terribly, even after finally being diagnosed. Like FDR, he was extremely promiscuous both before and after marriage. Because of a weakened immune system engendered by the Addison’s disease, there were serious complications from Kennedy’s sexual escapades. He continually suffered urinary tract infections and nearly died shortly after being elected. Kennedy was under the care of quack doctors who frequently injected him with a veritable pharmacological cocktail. He was amped on amphetamines and steroids much of the time. Ghaemi blames the Bay of Pigs fiasco and Kennedy’s lack of success in meeting with Kruschev, on his toxicological state. He then posits a turning point in the Kennedy administration that occurs when some of Kennedy’s staff are successful in ousting the quack doctor. At this point, the medical team was supposedly able to get Kennedy’s medications in better balance. In fact, Ghaemi is almost ebullient in his assessment of this period of Kennedy’s life. There is a whole chapter entitled: A Spectacular Psycochemical Success, quoting another doctor’s assessment of the miracle of living through chemistry.

Gee, that’s great. The doctors were able to manipulate the most powerful man in the world by finally arriving at the right mixture of medications. But Ghaemi rushes to assure the reader:

John Kennedy abused anabolic steroids. He didn’t just take cortisone as a replacement for his body’s normal physiological needs. He abused testosterone-based anabolic steroids — literally the same drugs today used by bodybuilders — for their psychiatric effects. In so doing, Kennedy was changing his moods, probably causing manic and depressive symptoms, in a way that, for a while, harmed his ability to lead. Later, when his physicians got control of the president’s misuse of anabolic steroids, his medications not only kept him alive — they enhanced his function and contributed to his successes. Emphasis WWTFT. … Kennedy used more drugs than he needed, abusing anabolic steroids for manic-like enhancement of his physical and sexual energy. Left to himself, he overused those agents to the point of becoming erratic and error prone in his judgement. When his regimen was finally better regulated by some of his doctors, the drugs instead magnified his personality strengths, pharmacologically enhancing his hyperthymic resilience.

One has to ask two questions, who is in charge in such a situation and should the country ever have been put at risk by electing him in the first place. If Kennedy’s state was as described during the first two years of his presidency, then he was absolutely unfit for such responsibility.

Moving on, Ghaemi introduces a new term in the course of his narrative, homoclyte. A homoclyte is someone who falls into the normal band of mental health. Apparently the majority of the population falls into this category. According to Ghaemi, George W. Bush falls into this category. In proving his thesis that mentally ill people make the best crisis leaders, Ghaemi also has to assert that the mentally healthy make the worst crisis leaders. This was the most disappointing section of the book for several reasons. Not only do Dr. Ghaemi’s political views shine through undisguised, but his thesis begins to show significant cracks. All though it evidently pains him, Ghaemi argues forcefully, and convincingly that Bush is not insane. He then jumps to conclusions about the efficacy of his presidency. He completely glosses over Bush’s handling of the crisis after 9/11, for which he deserves much credit. While Bush’s presidency may not have been outstanding, Ghaemi has clearly bought into the liberal view of it as disastrous.

In either case, this does not prove Ghaemi’s thesis, namely that a sane leader in time of crisis is worse than a mentally ill leader. There are many notable instances of very good mentally healthy leaders who succeeded in time of crisis. Ronald Reagan is arguably one of the best presidents of the 20th century. He took office during a very troubled time in the country’s history. There was double digit inflation, the economy was in the tank, the country’s morale was low, the hostage crisis had not been resolved, and the military was in a state of ill-repair. Reagan’s presidency ushered in a long era of prosperity and economic growth. Similar arguments could be made for the presidency of Calvin Coolidge, or perhaps Harry Truman. Yet neither Reagan, Truman, or Coolidge fits Ghaemi’s thesis.

Ghaemi lists Carter and Truman as possible exceptions which prove the rule. In his view, they were capable of holding “nuanced and humble views of life and the world,” in spite of being mentally healthy. But, he asserts,

My claim is that mental illnesses, like depression, do not detract from such abilities, but in fact can enhance them. … the greatest leaders are often abnormal, even flat out mentally ill. We should accept, even celebrate this possibility. Emphasis WWTFT

Hitler was one of the examples used by Ghaemi, who asserts that he also was mentally disturbed. We should also accept, but not celebrate, that kind of possibility as well. All in all, Ghaemi is not troubled with “puritanical” notions of morality in leadership.

In Ghaemi’s world view, character doesn’t count, but in dismissing it he sweeps away the very foundation of self government.

Personal vices are, after all, much less of a problem than political shortcomings. I am aware this viewpoint goes against conventional morality and the opinion of at least one founding father, John Adams, who famously said, “Public virtue cannot exist in a Nation without private Virtue.”

To this we can add:

[O]nly a virtuous people are capable of freedom. As nations become corrupt and vicious, they have more need of masters. Benjamin Franklin

In summary, A First Rate Madness is an engaging and interesting book. Author Dr. Nassir Ghaemi makes a good effort to support his thesis, but ultimately was unsuccessful in convincing this reviewer. His generalizations are too sweeping. In as much as everyone is affected by what transpires in their lives, whether it be physical or mental struggles, it’s not a stretch to suggest that some mentally ill people have had their character or intellect shaped in ways which have proven advantageous to them in handling crises. However, Ghaemi attempts to link this to a general causality: the mentally disturbed make the best crisis leaders. (Or on the other hand, maybe he’s just trying to sell books.)