In July 2018, after President Donald Trump met with Russian President Vladimir Putin in Helsinki, Trump suggested that the United States could hand over former U.S. ambassador to Russia Michael McFaul and British financier Bill Browder. Putin was displeased with both men because they had criticized his regime.

Trump and Putin had met for two hours with only their interpreters present. Afterward, Trump’s suggestion raised questions about whether he was disregarding the American tradition of defending free speech and opposing dictators, acting transactionally in pursuit of business interests, or being manipulated by the Russian government. McFaul and Browder, whom AlterNet interviewed at the time, were confident that U.S. law would protect them. Trump eventually moved on to other matters.

Psychiatrist Dr. David M. Reiss, a contributor to the book “The Dangerous Case of Donald Trump,” describes this type of behavior as “impressionistic thinking.” In an interview with AlterNet, lightly edited for clarity, context and length, Reiss discussed Trump’s conduct, the limits of psychiatric assessment without a clinical examination and the possibility that unpredictability can serve as a political distraction. The original interview was published by AlterNet. The interview therefore centers on the distinction between publicly observable behavior and conclusions that cannot responsibly be made without a clinical examination.

“President Trump is deteriorating”

Rozsa: You have said the president seems to be deteriorating. At times he appears more scattered or openly bizarre, such as when he praises a senator’s backside or rambles about architecture while the country is fighting a war. You have also said it is impossible to determine which factors are responsible, including age, stress, lack of sleep, neurological decline, another illness or medication. Why is it so difficult to separate those factors, and why do you think at least some of them are probably involved?

Reiss: We have no valid information about any of them. We do not have reliable medical information. As a physician, all I can say is that these are the possibilities. I have some ideas, but I cannot reliably say which is more or less likely, other than that it is probably some mixture of all of the above. All of them are possible, and without information proving they are not happening, they remain possible.

Rozsa: You describe the main issue as “impressionistic thinking,” in which his thoughts follow the emotion of the moment rather than logic or consistency. He has described this as “the weave,” a term popularized by the New York Times that he used to charm voters, including during his appearance on the Flagrant podcast during the 2024 election. What does this mean for his ability to implement policy, and for the way his worst qualities, such as corruption and narcissism, may become worse?

Reiss: We all do that to some extent because that is what we do as children, and we carry some of it with us. Impressionistic thinking itself is not a pathology. The pathology is failing to step back and say, “I have this thought. Let me examine and analyze it. Does it fit the facts? Is it realistic? What are the consequences?” That is different from saying, “This is what I feel, so that is it. I am doing it.”

The problem is not simply that he has impressionistic thoughts. It is that he does not appear to step back and compare them with facts, rationality, logic and consequences. Nor does anyone seem to be saying, “Have you thought of this? Have you thought of that?” or placing guardrails around the thoughts. When he feels something, he treats it as fact rather than as a thought that should be tested for logic. He treats feeling something as proof that it is true.

Rozsa: But you have not addressed both parts of the question: the policy consequences and his corruption and narcissism.

Reiss: The policy consequence is that he will do things that have not been thought through in terms of logic and consequences. They are simply what strikes him at the moment. That is not how policy is made. You want a wide range of ideas, but then you sort them out: What are the consequences? What is more likely? What is the expense? Reality has to modify which ideas are best. He is not doing that. He is pulling an idea out of a hat and acting on it. Policy becomes whatever is pulled out of the hat, driven by emotion rather than logic.

As for corruption, if something is self-serving, financially or in terms of power, then it is good because there is no consideration of the consequences, or of what is logical or reasonable. It feels good, so it is good. When he has a corrupt thought, he does not necessarily recognize it as corrupt. His reasoning is: “This is what I feel, so this is reality, so I am going to do it.”

Because he is so immature, what he feels is what a child might feel. If you pass a bank and think, “I want to go in and grab the money,” you then tell yourself that it is not a good idea. He does not reach that point. The narcissism is failing to reach the conclusion that something is a bad idea. It is, “I think that would feel good. Okay, done.”

“President Trump is the perfect puppet”

Rozsa: I want to discuss your interactions with other mental health professionals. The Goldwater rule says that psychiatrists should not diagnose a public figure whom they have not clinically assessed. Yet you and other professionals are also not supposed to publicly discuss the pathologies of people you have clinically assessed, at least without their permission. Is that correct?

Reiss: Correct. That is actually much harder. The Goldwater rule was created by the American Psychiatric Association. If you are a member, you are supposed to follow it, but it is not a legal rule. Patient confidentiality, by contrast, is a legal obligation.

Rozsa: Does the association take action against members who violate the rule?

Reiss: I am not sure. Maybe it does and maybe it does not, because I am no longer a member of the APA. I left a long time ago because of its relationship with Big Pharma. I have my own ethics and do not need the association to establish them for me. I was a member for years, but I am not one now.

That is also why I will not say that Trump has dementia. As a physician, I can say that dementia is a possibility to rule out because we are seeing behaviors that could be consistent with it. That is not a diagnosis. It is like saying, “This person is limping. There is probably something wrong with his leg.” It does not identify whether the problem is the ankle, knee or muscle. That would be a diagnosis.

I will not give an Axis I diagnosis such as anxiety, depression or dementia. Axis II concerns character. The behaviors we are seeing may be consistent with certain character types. Does that mean he behaves that way at home and that this is who he is? I do not know. The evidence suggests that he probably is that way, obviously, but describing the behaviors is not a diagnosis.

That is very different from saying, “I am diagnosing anxiety” or “I am diagnosing dementia.” I am observing bizarre statements. Bizarre statements could result from A, B, C or D. Without an examination and information about the medication he takes, it is a guessing game. I can say it is probably a combination of factors, but I have no data and offer no diagnosis. I am saying only that certain possibilities could be consistent with the behavior.

The more behaviors there are, the more likely a possibility may become, but that still does not constitute a diagnosis. Some of my colleagues avoid even naming the behavior. To me, if someone is corrupt, that person is acting sociopathically. That is a description, not a diagnosis. Others say that he has dementia or a problem with his frontal lobe. I am not going there. I have not seen his CAT scan. He might have such a condition, or he might not.

Rozsa: You have said that trying to figure Trump out is a “strategic zero.” You argue that the real planning is being done by people such as budget director Russell Vought, chief of staff Stephen Miller, Secretary of State Marco Rubio and Secretary of Defense Pete Hegseth, although the last two might be leaving soon. Why would Trump’s unpredictability be an asset rather than a liability for them?

Reiss: Because it is a distraction. Whenever we see a clip of him saying something and people are trying to determine whether he is being foolish, we are not looking at the consequences of his actual behavior and policies. I think it is a useful distraction.

Rozsa: Do you think Trump has the psychology of someone who is, in some ways, ideal to be a puppet, whether for his immediate advisers or for foreign despots with whom he seems smitten, such as Vladimir Putin?

Reiss: Let me put it this way: It is a little facetious, but it is not facetious. If he is not a puppet, he is putting on a good performance. Is that what it appears to be? Yes. Can I absolutely say that it is not all an act? If I were betting on Kalshi, which I would not do, I would give you 100-to-1 odds against that.

But can I absolutely say it is not an act and that he behaves differently in his personal life? No. I am not there when he is with his wife, his son or anyone else. From what we see, this is what we see.

Rozsa: Your answer recalls July 2018, when Michael McFaul, President Barack Obama’s ambassador to Russia, was offered up to Putin by Trump along with British billionaire Bill Browder, who had been a whistleblower. This appeared to be a possible offer of friendship during the Helsinki summit. When I interviewed McFaul at the time, he said:

“I was deeply disappointed. The generous interpretation is that Trump didn’t understand what he was talking about. But let’s be clear, what Trump was doing was assigning moral equivalency to a legitimate indictment with lots of evidence against several Russian military intelligence officers for violating American sovereignty in 2016 during the presidential elections with a completely fabricated cockamamie story invented by Putin. To even for a moment give any kind of dignity to what President Putin proposed was not in America’s national interest from my point of view.”

Eight years later, Russia has invaded Ukraine, and Trump, as president, has often appeared to side with Russia over Ukraine. Does this anecdote reflect the themes we discussed about Trump being easily manipulated and about impressionistic thinking making him dangerous when guiding U.S. policy?

Reiss: Yes. What we do not know, and what people suggest in various combinations, is whether he is being blackmailed, whether he actually agrees with Putin, whether Putin simply flatters him and makes him feel good, or whether he is being paid off. It could be any or all of those, and the balance could change over time.

The behavior, as McFaul said, is not well thought through. I do not know what proportion comes from being paid off, being blackmailed or simply feeling good, and on different days it may be different things. But the behavior shows no consideration of the consequences or significance. Probably all he knows is, “This is what feels right to me right now.”