Diagnosis at a Distance


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At the turn of the twentieth century, Sigmund Freud and his otolaryngologist friend Wilhelm Fleiss parted ways in bitter disagreement. The men’s vexation arose before a lethiferous background of cocaine use and abuse, and was ultimately ended by that same route, with the pair discovering they had developed a difference of opinion about cocaine’s medical usefulness. But before they disbanded, Freud often expressed his deep admiration for Fleiss (and not only because he had originally agreed with his colleague that cocaine was a wonderful medicine, particularly for nose and throat complaints). “My respect for your diagnostic acumen has only increased further,” wrote Freud in a letter to Fleiss on June 28, 1892, after Fleiss had accurately diagnosed an illness in one of Freud’s relatives. But what was so impressive to Freud was that Fleiss had reached his diagnosis from afar, without even having met the patient. It was an exemplary case of what has come to be known as “diagnosis at a distance” or “long-distance diagnosis,” and a skill that Freud greatly admired in his friend, a kind of parascient force of perception that Freud himself wished to attain.1

By the mid-1890s, however, Freud had begun to sense that he had developed not just an admiring attachment to his colleague, but a professional dependency. It was a reliance that went further than the regular solicitation of cocaine prescriptions from his friend, who was authorised to prescribe the drug. With some insight, Freud identified that he had come to rely on his colleague’s ability to accurately diagnose his and his family members’ illnesses. His adulation would not last. In his “technique papers,” beginning in about 1912 with “Dynamics of Transference,” Freud began to eschew the notion, at least implicitly, that a medical professional could adequately establish a “clinical picture” of their patient’s illness without significant analysis. As Freud would note, the patient should be seen in situ, and often for a minimum of some weeks, before any assessment could be made of their illness. And sometimes even more preparation would be needed. Difficult cases required a “trial analysis to determine the patient’s analyzability,” a preliminary meeting in which the patient’s potential for successful analysis could be adjudged.2 Perhaps one of the reasons that Freud would come to regard the consultation as so important was that he felt it could allow the clinician to discriminate between what Freud recognised as the two fundamental kinds of neurosis. On the one hand, there were what Freud called the “actual neuroses.” These were those disorders that had a physiological aetiology. On the other hand, there were the “psychogenic neuroses,” those disorders that had derived from early childhood trauma, such as the hysterical, obsessional, or anxiety-centered disorders.3

As Steven J. Ellman has argued, Freud’s distinction between actual and psychogenic neuroses probably stemmed from his inability to observe “transference” reactions in those whose neuroses were “actual” or biological. These latter neuroses did not require psychoanalysis at all—which is to say, they did not require the retrieval of pathogenic memories—but instead needed physical treatment. The patient might need to exercise more, for instance; or, as was Freud’s more characteristic prescription, they might need to engage in more sexual activity, to release or discharge their libidinal energy or cathexes more often. The “actual” neuroses, after all, were not generally responsive to the psychoanalytic method, located, as they were, in the body. By contrast, the psychogenic neuroses were distinguished—and indeed could be diagnosed—by the appearance of transferences in the patient. These transference reactions are, in Freud’s formulation, the acted-out simulacra of the same original impulses that gave rise to the neurosis ab initio. But these impulses would now find a new object, a new target, in the figure of the psychoanalyst. Instead of the figure who originally engendered them through trauma, it was the analyst who would now be treated as though they had authored the originary trauma. As such, these transferences could quite sharply bring into view the shape and severity of the pathogenic memory.

Freud’s description of the transferences as early as 1905 augurs the significant role they will later play in his psychoanalytic framework. “What are the transferences?,” he asks in “Fragment of an Analysis of a Case of Hysteria.” His answer is instructive:

They are new editions or facsimiles of the impulses and phantasies which are aroused and made conscious during the progress of the analysis; but they have this peculiarity, which is characteristic for their species, that they replace some earlier person by the person of the physician. To put it another way: a whole series of psychological experiences are revived, not as belonging to the past, but as applying to the person of the physician at the present moment. Some of these transferences have a content which differs from that of their model in no respect whatever except for the substitution. These then—to keep to the same metaphor—are merely new impressions or reprints.4

Different to resistances, transference reactions are reactive behaviours in the patient that, though revealing the shape of the pathology, may yet mark an obstacle to be overcome. While the transferences point to the terrain of the pathogenic material, they may still be conceived of as impediments in analysis, blocks that stand in the way of recovering the true nature of the pathogenic memory. For this reason, Freud came to regard transference as a kind of resistance in “The Dynamics of Transference.” But by their nature, they were more than simple resistances, more then defenses to the treatment itself, and more than frustrations born of disinterest or boredom. For in the way that they revived the patient’s past psychological experiences, the transferences pointed rather ostensibly to the general source of the patient’s neurosis, and constituted a trace of the distressing psychogenic memory. It is because of their character, then, that the transferences can be seen (as Merton Gill has seen them) as “the only vehicle of the analytic situation.” For the point of psychoanalysis (depending on one’s theoretical orientation) is less to actually retrieve or recollect the patient’s childhood memories so much as to analyse the dynamics of this transference reaction itself, to master its mechanisms, and, in so doing, to control the power of those memories by proxy.5

Freud’s development of a theory of transference, as well as his earlier distinction between the actual and psychogenic neuroses, is likely to have been partly engendered by his feud with Fleiss. Indeed, even if the dynamics and ramifications of the Fleiss–Freud relationship are in many ways still uncharted, one of the things on which historians of psychoanalysis seem increasingly to agree is that Freud’s dissociation from Fleiss was a catalyst for the neurologist’s transition from biology-centered medicine to psychology-based psychoanalysis. When Freud and his colleague went their separate ways, it was a symbolic break: Freud’s rejection of his friend represented a rejection of his physicalist methods, just as his rejection of Breuer before him had been a rejection of Breuer’s methods (that is, of hypnotherapy and hypnosis). Perhaps more interestingly, though, it would be on the day after his own father’s funeral, on the 26th of October, 1896, that Freud would pronounce in a letter to Fleiss, in dramatic passive voice, that he had taken the decision to kick the cocaine habit. “Incidentally, the cocaine brush has been completely put aside,” he wrote to his colleague summarily. It was this break not just from the drug but from his colleague—from the man who had shown him how to diagnose from a distance—that allowed Freud to apprehend the imaginative vision of a “new science” of psychoanalysis, to “imagine,” as Justin Clemens has put it, “the possibility of the isolation of language itself as a force of transformation.” If, from this moment onward, Freud could evade “the problems of treating human psychology as if it were reducible to physiology,” it was because he had constituted the perfect litmus test for his intuition that the mind could overpower matter.6 His ability to abstain from cocaine would be a proof of his theory: that many of the neuroses were not biological but psychogenic.7

Now more than a century after the publication of Freud’s first psychoanalytic works—whether one marks his Studies on Hysteria (1895) or The Interpretation of Dreams (1901) as the inaugurating text—psychiatrists and psychoanalysts alike tend to caution against the notion of diagnosis at a distance. However, a number of psychiatrists remain tempted to throw these cautions to the wind—together with the professional statute, known as the “Goldwater rule,” which aims to guard against what the APA president Herbert Sacks called “psychobabble”: that idle speculation about a public figure’s mental illness that, when “reported by the media, undermines psychiatry as science.”8 Known more formally as section 7, rule 3 of the American Psychiatric Association’s professional ethical code, the Goldwater rule was drafted after the 1964 Presidential election in which Republican Senator and Presidential nominee Barry Goldwater was defeated by incumbent President Lyndon Baines Johnson. Goldwater had sued the now-defunct Fact magazine after it conducted a survey of members of the American psychiatric profession, calling on more than 12,000 psychiatrists to provide their professional assessment of the Republican candidate. Highly unscientific, the survey yielded almost 1,200 responses, a huge cachet of long-distance diagnoses, all of which had been scathing in their assessment of the Arizona Senator. The result was published in Fact’s next issue, its cover declaring starkly that “1,189 Psychiatrists say Goldwater is Psychologically Unfit to be President!” As Sacks, the later president of the APA, commented in his presidential column in 1999, “The bulk of the political responses, couched in psychiatric terminology, were so unfair and so outrageous to Goldwater that he sued and won a substantial settlement.”9

Following this incident, the APA issued a number of press releases that denounced such instances of long-distance diagnosis. But no less than nine years would pass before that the APA would formally enshrine the Goldwater rule in its ethical code, a short rule book titled Principles of Medical Ethics with Annotations Especially Applicable to Psychiatry published in 1973.10 Last updated in 2013, this current version of the code renders the Goldwater rule as follows:

On occasion psychiatrists are asked for an opinion about an individual who is in the light of public attention or who has disclosed information about himself/herself through public media. In such circumstances, a psychiatrist may share with the public his or her expertise about psychiatric issues in general. However, it is unethical for a psychiatrist to offer a professional opinion unless he or she has conducted an examination and has been granted proper authorization for such a statement.11

Practitioners and scholars have recently discussed reasons or justifications for dismissing the Goldwater rule in certain circumstances, such as when the diagnosis of a particular individual might be necessary for “national security” purposes, such as to avoid a situation in which the would-be patient might “rise to the level of a national threat” in the absence of such a diagnosis.12 If such arguments are to be accepted among the psychiatric fraternity, then it is indeed possible that the diagnosis of powerful figures or even state leaders, such as Donald J. Trump or Vladimir Putin—each of whom has recently been subject to diagnosis at a distance, variously by lay people and specialist practitioners—may be, in some circumstances, justifiable, which is to say not a breach of the ethical principles that underpin the Goldwater rule. What those circumstances may involve, however, remains unclear.

In any case, it is notable that a range of commentators have recently offered their diagnostic evaluation of Trump, variously diagnosing him with narcissistic personality disorder, “psychopathic narcissism,” and ADHD.13 But among the many who have offered their diagnostic hypothesis, one of the most prominent diagnosticians, John D. Gartner, a practicing psychotherapist who has previously trained psychiatric residents at Johns Hopkins University Medical School, has informally diagnosed Trump with “malignant narcissism.”14 Also the author of a book on former president Bill Clinton titled In Search of Bill Clinton: A Psychological Biography, Gartner might be said to work, perhaps unwittingly, not as a psychiatrist as such, but in an interdisciplinary field that is increasingly notable in literary and psychology studies, a field in which the ethical codes of the APA need not apply: that is, in the field of psychobiography.

But what is psychobiography? William Todd Schultz, professor of psychology at Pacific University, editor of the Oxford University Press’s (OUP) psychobiographical series “Inner Lives,” and author of the OUP’s Handbook of Psychobiography (2005), describes the subdiscipline as “the analysis of historically significant lives through the use of psychological theory and research.” The “aim” of psychobiography, he continues, is “to understand persons, and to uncover the private motives behind public acts, whether those acts involve the making of art or the creation of scientific theories, or the adoption of political decisions.”15 What psychiobiography is not, Schultz emphasises, is “pathography.” As Schultz notes,

People are not diagnoses. A diagnosis is a name—a label—not a true explanation. What we want to know is how someone became who she is, not what her DSM-derived “disease” might be.16

Schultz’s remarks recall the “label theorists” who participated in the anti- or critical-psychiatry debates—those such as Frank Tannenbaum or Erving Goffman. However, Schultz’s definition of psychobiography also suggests the importance of developing a detailed, complex, and essentially non-diagnostic description of the person under study. Outside of the psychiatric profession’s ethics code, then, the Goldwater rule might be seen as little more than a disciplinary persuasion. Whereas the scholar who produced a full and rich account of a historical person’s personality might be said to produce a psychobiography, those whose focus remains on diagnosis might be said to engage in pathography.

Despite Schultz’s apparent misgivings, there is also arguably a place for pathography. Indeed, one of the most fascinating aspects of pathography is the potential for the diagnostic hypothesis it produces—its speculation about the subject’s mental disorder—to be revealed as true. In this way, the work of pathography might resemble the work speculative fiction: it always offers a glimpse at a possible future, providing its reader or consumer with what Philip K. Dick called a “shock of dysrecognition” or what Darko Suvin called a sense of “cognitive estrangement.” As both Dick and Suvin knew, the role of science and speculative fiction is not simply to adumbrate a vision of a possible future; rather, it also serves to unveil an alternate present—to expose an underlying layer of our present-day reality—and in so doing to unsettle the prevailing understanding of what is currently possible, and of what is currently real.17 Indeed, it is exactly the uncertainty of the pathographer’s proposed diagnosis—the impossibility of confirming or disproving their pathographic speculation—that is fascinating. The question is not the formal one that involves a purely scientific process: “Can this diagnosis be verified as legitimate?” It is an informal, preternatural one, a question of faith in what I have called the diagnostician’s “parascient force of perception”: “Has the long-distance diagnostician uncovered the reality of the subject’s mental state?” In most cases, the latter question is often necessarily the only one that may be posed: for instance, the diagnosis may be of a deceased person, or of a political actor, in which case it is impossible for a consultation, for a formal psychiatric interview, to be carried out.

But even in the absence of a scientific trial, and in the absence of any statistically significant evidence, it can be illuminating to work through the pathographic speculation. If we return to Gartner’s diagnosis of Trump, for example—to his pathographic speculation that Trump is a malignant narcissist—we immediately notice the specificity of the diagnosis itself: it is malignant narcissism, rather than the more formal, more stable category of narcissistic personality disorder or NPD. To understand Gartner’s thinking, we must next look for the texts from which this specific diagnosis has been drawn. Doing so, we note that the term “malignant narcissism” appears in the DSM-V only once, and, even then, it appears in scare quotations and in parentheses, as though the designation were not a criteria-based index so much as a shorthand for a yet-unknown quantity, a disorder that one “knows when they see it.” The specific text reads as follows:

Trait and personality functioning specifiers may be used to record additional personality features that may be present in narcissistic personality disorder but are not required for the diagnosis. For example, other traits of Antagonism (e.g., manipulativeness, deceitfulness, callousness) are not diagnostic criteria for narcissistic personality disorder (see Criterion B) but can be specified when more pervasive antagonistic features (e.g., “malignant narcissism”) are present.18

Malignance, then, is an “additional personality specifier” of those with NPD; it is not, at least according to the DSM-V, a discrete personality disorder in and of itself, one that is separate from NPD. Nevertheless, some scholars working in mental health have identified malignant narcissism as “a serious condition [that is] largely ignored in psychiatric literature and research,” and a disorder that is especially difficult to diagnose because there is “no structured interview or self-report measure that identifies Malignant Narcissism and proposes a foundation for treatment.”19 A long-distance diagnosis of Trump with malignant narcissism, then, may be no more unclear, no less verifiable, than a diagnosis born of a detailed clinical analysis, so ambiguous is the specifier.

Still, others have identified the particular relevancy of “malignant narcissism” to the figure of the tyrant. In an examination of the psychological literature of politics (a field sometimes called “psychopolitics”), Betty Glad implicitly adverts to the insufficiency of the DSM-IV (as was then the latest edition) and its definition of malignant narcissism, appealing not to the manual for clarification but to the descriptive elaborations of Otto Kernberg, Vamik Volkan, and Jerrold Post—all academic psychiatrists—to supplement and reconfigure the “related subtypes” of narcissistic personality disorder that have been thus far proposed.20 Glad even suggests the inadequacy of the DSM’s theoretical foundation when she notes that the manual has been developed out of normative consultative experience, and published in order to provide guidelines for those situations in which the patient or subject could be expected to conform to the dysfunctions pervasive in the general population. By contrast, the dysfunctions observable in some figures—and, in the case of her analysis, the figure of the tyrannical political leader—actually lie outside of the normative parameters of dysfunction that arise in the general treatment of the population; accordingly, the DSM cannot be relied on to account for the dysfunctions of these individuals. As she writes,

Classification systems developed via clinical experience with persons who have been diagnosed as dysfunctional may need further elaboration for major political leaders. To understand the tyrant, we need to investigate the careers of individuals who have been successful in gaining absolute power in a broader political environment. Building on the work of Robins and Post (1997), we provide a basis for delineating, in a systematic manner, the advantages a malignant narcissist has in securing power in a chaotic or otherwise difficult situation. As discussed below, the attainment of nearly absolute power in the real world serves him while at the same time contributing to the psychological deterioration and behavioral overshooting that may lead to his eventual political undoing.21

Here, then, we see another way in which breaching the Goldwater rule may be justified—and not simply because one’s theoretical or disciplinary orientation, as I have outlined above, might enable one to claim they are simply speculating about the disorder as a pathographer, only musing as a curious dilettante, rather than offering an official diagnosis as a practising psychiatrist. Rather, the psychiatrist must deal with an inadequate manual, inadequate firstly because it is does not define the diagnosis narrowly enough, and because, secondly, its parameters, which are drawn from a normativised history of “clinical experience,” do not account for the particular dysfunction of the unusual patient. Faced with this impasse, the psychiatrist may decide to conduct a long-distance diagnosis, if only to simulate the consultation with, to gain some hypothetical access to, the unusual case study, who—often largely because of their unusualness, their anormativity—cannot be brought under the observation of the psychiatrist in any event. Thus, the psychiatrist must at once imagine the consultative experience, as well as newly define the disorder that the patient possesses—a disorder that is outside of the parameters of the instructive text. In this way, the long-distance psychoanalyst conducts a kind of clinical research both into the new diagnostic category, the new nosology, and the degree to which it might be accessed in the general population.

But for all this, others still have warned against long-distance diagnosis, and for reasons quite apart from the Goldwater rule, which seemed largely a fearful and defensive reaction to the likelihood of psychiatrists’ liability rather than a pure expression of ethical principle. For example, in what might be seen as an ironic countertransference, many psychiatric scholars have mused on the mental health of the psychiatrist Emil Kraeplin, although just as many have warned against the practice. Kraeplin, of course, remains “one of the most prominent and potentially controversial in contemporary psychiatry,” partly because he exhibited so many objectionable intellectual interests, including a belief in the potential for “negative eugenics” to “prevent the occurrence of ‘degenerative phenomena.’”22 As in the case of the tyrant, however, it is here that we see the borderlines that usually separate the discourses of epistemology, politics, and psychiatry transform into a blurry, complex, furrow. As the authors of one study have cautioned, the psychiatrist who is tempted to diagnose Kraeplin from a place and time far removed from the late-nineteenth-century, from Kraeplin’s world, will surely compromise their own professional and intellectual credibility.

But to engage in such retrospective, long-distance diagnosis and to subsume Kraepelin’s personality under the diagnostic categories of contemporary psychiatric systems is dubious in the extreme and may well reveal more about the convictions and interests of today’s psychiatrists than about the historical “patient” Emil Kraepelin. Moreover, attempts at such retrospective diagnoses put psychiatrists on the horns of professional dilemma. If they are to bring their professional expertise to bear on Kraepelin, then they must simultaneously compromise the very methods and standards on which their own expertise rests. They must forego that most important source of diagnostic information: the patient examination.23

After all, one need not diagnose an intellectual figure, need not appeal to psychiatry, to characterise a person’s ideas as wrongheaded. A racist or xenophobic argument or theory should be equally as wrong when expressed by a person free of any mental illness as when expressed by someone who has received a positive psychiatric diagnosis.

Because if Kraepelin is a controversial figure, it is at least partly due to his endorsement of the Lamarckian psychiatric concept of “pathogenic inheritance,” a concept perhaps first introduced in modern psychiatry by Bénédict Augustin Morel. Morel had also coined the neologism démence précoce in 1852 to identify a new nosological category, one that is today better known as schizophrenia. Against the backdrop of the political developments of the early twentieth century, Kraepelin’s support for research into racial hygiene, and his sympathies for the political goals of that work, has been the source of great controversy. And it is this, perhaps, that has led some to attempt to diagnose Kraeplin with a mental illness.

In 2013, Polity press published a translation of a similar work, first published in 2009, by two German scholars, the one, Hans-Joachim Neumann, a professor of medicine, and the other, Henrik Eberle, an historian. The scholars had attempted to diagnose Adolf Hitler once and for all, to settle the matter in what they called a “final diagnosis.”24 Titled Was Hitler Ill? A Final Diagnosis, the book is far from the first attempt to diagnose Hitler, and, as a comprehensive Wikipedia entry titled “Psychopathography of Adolf Hitler” makes clear, no less than 28 formal attempts have been made to systematically diagnose the Nazi leader, who has been said to have had all manner of mental disorders, from hysteria to schizophrenia, psychopathy to posttraumatic stress disorder, and asperger’s syndrome to abnormal brain lateralisation. Among the most famous diagnoses of Hitler was that produced by Walter Charles Langer, who was commissioned by the OSS (the precursor to the CIA) to develop psychological reports on Hitler before the end of the Second World War.25 Based on the testimony of psychiatrist Karl Kroner, Langer and his team proposed that Hitler had been treated in 1918 for hysteria, although the psychiatrist who treated him in a military hospital, Edmund Forster, had suicided in 1933, fearful of being interrogated.26

One of the most fascinating aspects of Langer’s hypothesis is that, because Hitler, in Mein Kampf, actually dates his decision to become a politician “to his hospitalization in the Pomeranian military hospital of Pasewalk in November 1918, where he experienced the end of the World War 1,” Hitler probably underwent some form of failed hypnosis there, or had suffered some form of hysteria in that hospital, which then triggered his will to rise to power and led to the efflorescence of his hysteria as a dictator.27 Interestingly, however, this period of time remains to this day, as Norman Ächtler notes, one of the “last opaque spots in Hitler’s biography.”28 So while the notion that Hitler underwent something of a conversion in the hospital—perhaps because he was being treated for mustard gas—is indeed a tantalising idea, the details are simply too scant to conclude with any certainty that any such conversion, any such “break with reality,” took place. It is a period that eludes even Neumann and Eberle, who rightly note that, while Hitler’s placement in the “neurology and psychiatry ward at Pasewalk field hospital would . . . appear to indicate a psychogenic condition,” Hitler’s subsequent actions are unlikely to have been a “product of an unsuccessful hypnosis” in Pasewalk, but instead would have “evolved slowly over a long period.”29 Indeed, as Neumann and Eberle finally note at the end of their volume, “the leader of the NSDAP, chancellor of the German Reich and commander-in-chief of the German Wehrmacht was healthy and accountable.”30

Perhaps one of the most responsible, albeit frightful, speculations we could make, then, is that a similar pathography as Hitler’s might now apply to those currently in similar positions of power, and to those who harbour impulses that are similarly tyrannical. To be sure, if made subject to psychiatric evaluation, dictators and tyrants may well be revealed to be malignant narcissists. However, it is also important to come to grips with the possibility that a seeming dictator may also be just as likely to exhibit no relevant symptoms, to act out no telling transferences, and so to be given a “clean bill of mental health” by the diagnostician. Alas, even if we accept that the ethical parameters outlined by the Goldwater rule are on occasion transgressible—after all, they are parameters designed to constrain professional psychiatrists in their media and public relations—what Freud implicitly understood as the defect of long-distance diagnosis remains insuperable. Having no ability to perceive a subject’s reactions, and having no capacity to observe the dynamics of their personal, extemporaneous “account” of what their actions mean, what their decision-making processes involve, one can but speculate as to what, exactly, those reactions, those transferences, might be.

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