And no, it’s not about the man who’s about to occupy the White House.
In 1919, President Woodrow Wilson suffered a devastating stroke that left him partially paralyzed, semi-blind and so fragile that his wife and doctor hid him from the public. In 1923, Wilson’s successor, Warren G. Harding, died suddenly in office from what was later determined to be congestive heart failure. The fragile mortality of the presidency was on display as at no other time in American history, and in 1928, Congress codified a new White House position: the personal physician to the president. Now, a doctor would always be on hand if the president were physically ill.
Left untouched in 1928, however, was the president’s mental health. After all, mental illness in the 1920s was most commonly associated with asylums, not the White House. But nearly a century later—and after a revolution in the science of psychiatry—we now know that anyone, even presidents, can suffer from a mental illness. The newly sworn in Congress now has a chance to strengthen the health of all future presidents by appointing a psychiatrist from the military to work alongside the presidential physician.One of the most stressful and consequential offices in human history ought to have easy access to the best medical care available, including when it comes to mental health.
This is not about assuaging the fears or stoking the jeers of those who have called Donald Trump a psychopath or a narcissist. The assumption that presidents have robust mental health was wrong long before the 45th president came along. As I have written before, at least two presidents—John F. Kennedy and Richard M. Nixon—surreptitiously took daily psychiatric medications such as Valium and other anxiety treatments while occupying the Oval Office. Another—Lyndon B. Johnson—was so emotionally erratic that his top aides consulted psychiatrists and confronted the first lady about his behavior. And Abraham Lincoln experienced such deep bouts of depression during his life that he was confined to bed and contemplated suicide.
Despite the mercurial behavior and pill-popping, there is no one employed to keep tabs on the president’s mental health. Nor has any presidential physician ever been a trained psychiatrist. Today, the presidential physician periodically releases a summary of the president’s checkups, but these reports do not contain psychiatric information. Those presidents who are known to have received psychiatric medication had to arrange for it in secret, most often from doctors without backgrounds in mental health. (We do know, however, that Nixon, while serving as vice president, received prescriptions from a psychiatrist.)
Mental health problems have been destigmatized in American culture over the past few decades, yet mental health remains fair game in the political arena—as some presidential-level politicians have learned the hard way. In 1972, reports arose that Democratic nominee George McGovern’s running mate, Thomas Eagleton, had undergone shock therapy. Eagleton eventually withdrew from the ticket, and McGovern’s judgment was called into question. President Nixon, meanwhile, kept his psychiatric medication secret by getting a Valium prescription from his and Henry Kissinger’s osteopath, as reported by Evan Thomas in his book Being Nixon. And Michael Dukakis got tagged with the psychiatric stink without even seeing a psychiatrist. As George H.W. Bush’s campaign was trying to gin up rumors about Dukakis’ mental health, President Ronald Reagan answered a question on the topic by quipping, “Look, I’m not going to pick on an invalid.” The political media went wild, and Dukakis’ large lead in the polls began to shrink.
It’s true that some mental illnesses are so severe that they would make one unable to serve as president. But the greatest governing risks—not just to the president but to the world—come from not getting treatment. Just as physical illnesses include everything from the flu to terminal cancer, mental illnesses range in severity from treatable anxiety disorders to more serious diseases like schizophrenia. “A president can function very well if he has a mild anxiety disorder or obsessive compulsive [disorder],” George H.W. Bush’s presidential physician Burton Lee told me. Indeed, some already have.
The introduction of a presidential psychiatrist would surely carry political risks. Would the president’s judgment be trusted if people knew of psychiatric sessions? What would happen if the president’s medical files were leaked and the public found out the commander in chief was on anti-depressants?
In fact, the appointment of a presidential psychiatrist would actually be the most politically prudent way for a president to receive psychiatric care. As is the current practice with the presidential physician, the president could choose to keep any or all parts of his or her psychiatric medical files private. Even appointments need not be disclosed. The leak of any medical information about the president would breach both doctor-patient confidentiality and the military chain of command, providing an extra layer of privacy to the president.
Appointing a presidential psychiatrist would also be a fitting addition to an unprecedented decade of bipartisan mental health policy reform in Congress. In 2008, Congress passed Democratic Representative Patrick Kennedy’s mental health parity law, which required health insurance companies to cover mental and physical illness equally. And just last month, Congress incorporated Republican Representative Tim Murphy’s Helping Families in Mental Health Crisis Act, which overhauled the federal bureaucracy that deals with mental health, into the 21st Century Cures Act. Back in 1928, some lawmakers didn’t like that the presidential physician would automatically be given the rank, pay and allowance of a colonel; others felt that the president should pay for his own doctor rather than charge the taxpayers. But a majority ultimately decided that the position should no longer be optional. Today, the presidential physician’s salary is less than $200,000 annually, out of the federal government’s $3.9 trillion budget—a reasonable sum for maintaining the health of the leader of the free world.
Of course, whether or not a presidential psychiatrist is good policy is very different from whether it’s good politics. Republicans don’t want to be perceived as saying their party’s president needs professional help, while Democrats have already shown a willingness to wield Trump’s psyche as a political weapon. Appearing at the Democratic National Convention in July to support Hillary Clinton, former New York City Mayor Michael Bloomberg said America should reject Trump and vote for the “sane, competent person.” David Plouffe, President Barack Obama’s former campaign manager and an adviser to Clinton’s campaign, said in August, “We basically have a psychopath running for president. I mean, [Trump] meets the clinical definition.” Plouffe went on to diagnose Trump as having a “grandiose notion of self-worth, pathological lying, lack of empathy and self-worth,” before acknowledging “I don’t have a degree in psychology.”
The media has enabled this kind of armchair psychology of the president-elect. Reporters interviewed psychiatrists throughout the campaign asking them to assess Trump’s mental health despite never having met him. The Atlantic dedicated a cover story to “the mind of Donald Trump.” The Washington Post’s Bob Woodward has told multipleaudiences that a notable psychiatrist says Trump appears to be “the most classic example of narcissistic personality disorder I’ve ever seen.”
Enough psychiatrists were quoted in various publications that the American Psychiatric Association issued a statement calling such psychoanalysis of candidates “unethical” and irresponsible.” The group cited what’s known as “The Goldwater Rule,” which “prohibits psychiatrists from offering opinions on someone they have not personally evaluated. The rule is a legacy of the 1964 campaign, when 1,189 psychiatrists controversially declared Republican nominee Barry Goldwater mentally unfit to be president. Trump could very well suffer from some form of mental illness (about 18 percent of the adult U.S. population does), but the point is that none of the people saying so actually knows.
The fraught politics of mental health have clearly not gone away. But Congress could try to avoid them in the short term by quickly codifying the presidential psychiatrist position before Trump is sworn in on January 20. And in the long term, such a move could actually help to destigmatize mental health problems among politicians.
Mental illnesses are caused by both environment and genetics, and history makes clear that the Oval Office can be a psychologically unhealthy place. Far from alleviating any nagging psychoses, being elected to one of the most powerful and demanding positions in the world often brings out old gremlins to gnaw on a presidential psyche. Talking to a psychiatrist every once in a while is like preventative medicine to keep such subconscious demons at bay.
“The pressures [of the presidency] are beyond anything that human beings are designed to handle,” David Axelrod, former senior adviser to President Barack Obama, told me last year, adding that in an ideal world the president should be able to see a psychiatrist any time. Even if Trump or any of his successors doesn’t wants to meet the psychiatrist, the president should have easy access in case the pressures of the job change his or her mind.
The world order we know is already over, and Russia is moving fast to grab the advantage. Can Trump figure out the new war in time to win it?
A little over a year ago, on a pleasant late fall evening, I was sitting on my front porch with a friend best described as a Ukrainian freedom fighter. He was smoking a cigarette while we watched Southeast DC hipsters bustle by and talked about ‘the war’ — the big war, being waged by Russia against all of us, which from this porch felt very far away. I can’t remember what prompted it — some discussion of whether the government in Kyiv was doing something that would piss off the EU — but he took a long drag off his cigarette and said, offhand: “Russia. The EU. It's all just more Molotov-Ribbentrop shit.”
His casual reference to the Hitler-Stalin pact dividing Eastern Europe before WWII was meant as a reminder that Ukraine must decide its future for itself, rather than let it be negotiated between great powers. But it haunted me, this idea that modern revolutionaries no longer felt some special affinity with the West. Was it the belief in collective defense that was weakening, or the underlying certitude that Western values would prevail?
Months later, on a different porch thousands of miles away, an Estonian filmmaker casually explained to me that he was buying a boat to get his family out when the Russians came, so he could focus on the resistance. In between were a hundred other exchanges — with Balts and Ukrainians, Georgians and Moldovans — that answered my question and exposed the new reality on the Russian frontier: the belief that, ultimately, everyone would be left to fend for themselves. Increasingly, people in Russia’s sphere of influence were deciding that the values that were supposed to bind the West together could no longer hold. That the world order Americans depend on had already come apart.
From Moscow, Vladimir Putin has seized the momentum of this unraveling, exacting critical damage to the underpinnings of the liberal world order in a shockingly short time. As he builds a new system to replace the one we know, attempts by America and its allies to repair the damage have been limited and slow. Even this week, as Barack Obama tries to confront Russia’s open and unprecedented interference in our political process, the outgoing White House is so far responding to 21st century hybrid information warfare with last century’s diplomatic toolkit: the expulsion of spies, targeted sanctions, potential asset seizure. The incoming administration, while promising a new approach, has betrayed a similar lack of vision. Their promised attempt at another “reset” with Russia is a rehash of a policy that has utterly failed the past two American administrations.
What both administrations fail to realize is that the West is already at war, whether it wants to be or not. It may not be a war we recognize, but it is a war. This war seeks, at home and abroad, to erode our values, our democracy, and our institutional strength; to dilute our ability to sort fact from fiction, or moral right from wrong; and to convince us to make decisions against our own best interests.
Those on the Russian frontier, like my friends from Ukraine and Estonia, have already seen the Kremlin’s new toolkit at work. The most visible example may be “green men,” the unlabeled Russian-backed forces that suddenly popped up to seize the Crimean peninsula and occupy eastern Ukraine. But the wider battle is more subtle, a war of subversion rather than domination. The recent interference in the American elections means that these shadow tactics have now been deployed – with surprising effectiveness – not just against American allies, but against America itself. And the only way forward for America and the West is to embrace the spirit of the age that Putin has created, plow through the chaos, and focus on building what comes next.
President-elect Trump has characteristics that can aid him in defining what comes next. He is, first and foremost, a rule-breaker, not quantifiable by metrics we know. In a time of inconceivable change, that can be an incredible asset. He comes across as a straight talker, and he can be blunt with the American people about the threats we face. He is a man of many narratives, and can find a way to sell these decisions to the American people. He believes in strength, and knows hard power is necessary.
So far, Trump seems far more likely than any of his predecessors to accelerate, rather than resist, the unwinding of the postwar order. And that could be a very bad — or an unexpectedly good — thing. So far, he has chosen to act as if the West no longer matters, seemingly blind to the danger that Putin’s Russia presents to American security and American society. The question ahead of us is whether Trump will aid the Kremlin’s goals with his anti-globalist, anti-NATO rhetoric– or whether he’ll clearly see the end of the old order, grasp the nature of the war we are in, and have the vision and the confrontational spirit to win it.
***
To understand the shift underway in the world, and to stop being outmaneuvered, we first need to see the Russian state for what it really is. Twenty-five years ago, the Soviet Union collapsed. This freed the Russian security state from its last constraints. In 1991, there were around 800,000 official KGB agents in Russia. They spent a decade reorganizing themselves into the newly-minted FSB, expanding and absorbing other instruments of power, including criminal networks, other security services, economic interests, and parts of the political elite. They rejected the liberal, democratic Russia that President Boris Yeltsin was trying to build.
Following the 1999 Moscow apartment bombings that the FSB almost certainly planned, former FSB director Vladimir Putin was installed as President. We should not ignore the significance of these events. An internal operation planned by the security services killed hundreds of Russian citizens. It was used as the pretext to re-launch a bloody, devastating internal war led by emergent strongman Putin. Tens of thousands of Chechen civilians and fighters and Russian conscripts died. The narrative was controlled to make the enemy clear and Putin victorious. This information environment forced a specific political objective: Yeltsin resigned and handed power to Putin on New Year’s Eve 1999.
From beginning to end, the operation took three months. This is how the Russian security state shook off the controls of political councils or representative democracy. This is how it thinks and how it acts — then, and now. Blood or war might be required, but controlling information and the national response to that information is what matters. Many Russians, scarred by the unrelenting economic, social, and security hardship of the 1990s, welcomed the rise of the security state, and still widely support it, even as it has hollowed out the Russian economy and civic institutions. Today, as a result, Russia is little more than a ghastly hybrid of an overblown police state and a criminal network with an economy the size of Italy — and the world’s largest nuclear arsenal.
Even Russian policy hands, raised on the Western understanding of traditional power dynamics, find the implications of this hard to understand. This Russia does not aspire to be like us, or to make itself stronger than we are. Rather, its leaders want the West—and specifically NATO and America — to become weaker and more fractured until we are as broken as they perceive themselves to be. No reset can be successful, regardless the personality driving it, because Putin’s Russia requires the United States of America as its enemy.
We can only confront this by fully understanding how the Kremlin sees the world. Its worldview and objectives are made abundantly clear in speeches, op-eds, official policy and national strategy documents, journal articles, interviews, and, in some cases, fiction writing of Russian officials and ideologues. We should understand several things from this material.
First, it is a war. A thing to be won, decisively — not a thing to be negotiated or bargained. It’s all one war: Ukraine, Turkey, Syria, the Baltics, Georgia. It’s what Vladislav Surkov, Putin’s ‘grey cardinal’ and lead propagandist, dubbed ”non-linear war” in his science fiction story “Without Sky,” in 2014.
Second, it’s all one war machine. Military, technological, information, diplomatic, economic, cultural, criminal, and other tools are all controlled by the state and deployed toward one set of strategic objectives. This is the Gerasimov doctrine, penned by Valery Gerasimov, the Russian Chief of the General Staff, in 2013. Political warfare is meant to achieve specific political outcomes favorable to the Kremlin: it is preferred to physical conflict because it is cheap and easy. The Kremlin has many notches in its belt in this category, some of which have been attributed, many likely not. It’s a mistake to see this campaign in the traditional terms of political alliances: rarely has the goal been to install overtly pro-Russian governments. Far more often, the goal is simply to replace Western-style democratic regimes with illiberal, populist, or nationalist ones.
Third, information warfare is not about creating an alternate truth, but eroding our basic ability to distinguish truth at all. It is not “propaganda” as we’ve come to think of it, but the less obvious techniques known in Russia as “active measures” and “reflexive control”. Both are designed to make us, the targets, act against our own best interests.
Fourth, the diplomatic side of this non-linear war isn’t a foreign policy aimed at building a new pro-Russian bloc, Instead, it’s what the Kremlin calls a “multi-vector” foreign policy, undermining the strength of Western institutions by coalescing alternate — ideally temporary and limited — centers of power. Rather than a stable world order undergirded by the U.S. and its allies, the goal is an unstable new world order of “all against all.” The Kremlin has tried to accelerate this process by both inflaming crises that overwhelm the Western response (for example, the migration crisis in Europe, and the war in eastern Ukraine) and by showing superiority in ‘solving’ crises the West could not (for example, bombing Syria into submission, regardless of the cost, to show Russia can impose stability in the Middle East when the West cannot).
This leads to the final point: hard power matters. Russia maintains the second most powerful military in the world, and spends more than 5 percent of its weakened GDP on defense. Russia used military force to invade and occupy Georgian territory in 2008 to disrupt the expansion of NATO, and in 2013 in Ukraine to disrupt the expansion of the EU. They have invested heavily in military reform, new generations of hardware and weapons, and expansive special operations training, much of which debuted in the wars in Ukraine and Syria. There is no denying that Russia is willing to back up its rhetoric and policy with deployed force, and that the rest of the world notices.
The West must accept that Putin has transformed what we see as tremendous weakness into considerable strength. If Russia were a strong economy closely linked to the global system, it would have vulnerabilities to more traditional diplomacy. But in the emerging world order, it is a significant actor – and in the current Russian political landscape, no new sanctions can overcome the defensive, insular war-economy mentality that the Kremlin has built.
***
How did we reach this point? After the collapse of the Soviet Union, Western security and political alliances expanded to fill the zone of instability left behind. The emerging Russian security state could only define this as the strategic advance of an enemy. The 9/11 attacks shattered Western concepts of security and conflict and expanded NATO’s new mission of projecting security. When Putin offered his assistance, we effectively responded “no thanks,” thinking in particular of his bloody, ongoing, scorched-earth war against the Chechens. We did it for the right reasons. Nonetheless, it infuriated Putin. This was the last moment when any real rapprochement with Putin’s Russia was possible.
Since that time, physical warfare has changed in ways that create a new kind of space for Putin to intervene globally. The Obama administration has a deep distaste for official overseas deployments of US troops and the associated political costs. ‘No new wars’ was the oft-repeated mantra — which altered America’s toolbox for, if not the frequency of, foreign interventions. Drone warfare was greatly expanded, as was the reliance on special forces— a politically easy choice due to their diverse capabilities and voluntary career commitment to service. But the actual number of special forces operators is exceedingly small and increasingly exhausted; soldiers deployed in shadow wars and shadow missions have far less protection than troops in traditional ground combat.
As the definitions of war and peace have blurred, creating impossibly vast front lines and impossibly vague boundaries of conflict, Putin has launched a kind of global imperialist insurgency. The Kremlin aggressively promotes an alternate ideological base to expand an illiberal world order in which the rights and freedoms that most Americans feel are essential to democracy don’t necessarily exist. It backs this up with military, economic, cultural and diplomatic resources. Through a combination of leveraging hard power and embracing the role of permanent disruptor — hacker, mercenary, rule-breaker, liar, thief — Putin works to ensure that Russia cannot be excluded from global power.
Putin tries to define recent history as an anomaly — where the world built with American sweat and ingenuity and blood and sacrifice, by the society founded on American exceptionalism, is a thing to be erased and corrected. The Russian version of exceptionalism is not a reflection of aspirational character, but a requirement that Russia remain distinct and apart from the world. Until we understand this, and that America is defined as the glavny protivnik (the ‘main enemy’) of Russia, we will never speak to Putin’s Russia in a language it can understand.
There is less and less to stand against Putin’s campaign of destabilization. It’s been 99 years since America began investing in European security with blood, and sweat, and gold. Two world wars and a long, cold conflict later, we felt secure with the institutional framework of NATO and the EU — secure in the idea that these institutions projected our security and our interests far beyond our shores. The post-WWII liberal world order and its accompanying security architecture ushered in an unparalleled period of growth and peace and prosperity for the US and other transatlantic countries.
I spend most of my time near the Russian frontier, and today that architecture seems like a Kodachrome snapshot from yesteryear. We joke that we yearn for a fight we can win with a gun, because the idea of a physical invasion is actually preferable to the constant uncertainty of economic, information, and political shadow warfare from the Kremlin.
Combatants in these shadow wars bear no designations, and protections against these methods are few. From the front lines, in the absence of the fabric of reassurance woven from our values and principles and shared sacrifice — and in the absence of the moral clarity of purpose derived from “us and them” — civil society is left naked, unarmored. Putin has dictated the mood of the unfolding era — an era of upheaval. This past year marks the arrival of this mood in American politics, whether Americans deny it or not. The example of Eastern Europe suggests that without renewed vision and purpose, and without strong alliances to amplify our defense and preserve our legacy, America too will find itself unanchored, adrift in currents stirred and guided by the Kremlin.
President-elect Trump harnessed this energy of upheaval to win the American presidency — a victory that itself was a symptom of the breakdown of the post-WWII order, in which institutional trust has eroded and unexpected outcomes have become the order of the day. Now it is his responsibility to define what comes next — or else explain to Americans, who want to be great again, why everything they’ve invested in and sacrificed for over the past century was ultimately for nothing.
As Obama did, Trump has already made the first mistake in negotiating with the Russians: telling them that there is anything to negotiate. Trump likes to discuss Putin’s strengths. He should also understand that much of it is smoke and mirrors. A renewed approach to dealing with Putin’s Russia should begin by addressing the tactics of Russia’s new warfare from the perspective of strength.
We have to accept we’re in a war and that we have a lot to lose. We need to look at this war differently, both geographically and strategically. For example, it’s hard to understand Ukraine and Syria as two fronts in the same conflict when we never evaluate them together with Moscow in the center of the map, as Russia does. We also need a new national security concept that adds a new strategic framework, connects all our resources, and allows us to better evaluate and respond to Gerasimov-style warfare: we have to learn to fight their one war machine with a unified machine of our own. This will also strengthen and quicken decisionmaking on critical issues in the US — something we will also need to replicate within NATO.
Exposing how the Kremlin’s political and information warfare works is a critical component of this strategy, as is acting to constrain it. We must (re)accept the notion that hard power is the guarantor of any international system: security is a precondition for anything (everything) else. That the projection of our values has tracked with and been amplified by force projection is no accident. Human freedom requires security. NATO has been the force projection of our values. It hasn’t just moved the theoretical line of conflict further forward: the force multiplication and value transference has enhanced our security. This is far cheaper, and far stronger, than trying to do this ourselves.
It’s also important to acknowledge that a more isolated, more nationalist America helps Putin in his objectives even while it compromises our own. We need to accept that America was part of, and needs to be part of, a global system — and that this system is better, cheaper, and more powerful than any imagined alternatives. For many years, the United States has been the steel in the framework that holds everything together; this is what we mean by ‘world order’ and ‘security architecture,’ two concepts that few politicians try to discuss seriously with the electorate.
Taken together, these steps would be a critical realignment to our strategic thinking and internal operations, and would allow us to plow through this era of upheaval with greater certainty and for greater benefit to the American people.
***
In an era increasingly cynical about American ideals, and skeptical about intervention abroad, how can the US build support for a new, more muscular global resistance to what Russia is trying to do?
We already have one model: the Cold War. Putin and his minions have spent the past 15 years ranting about how the West (specifically NATO) wants a new Cold War. By doing so, they have been conditioning us to deny it, and made us do it so continually that we have convinced ourselves it is true. This is classic reflexive control.
The truth is that fighting a new Cold War would be in America’s interest. Russia teaches us a very important lesson: losing an ideological war without a fight will ruin you as a nation. The fight is the American way. When we stop fighting for our ideals abroad, we stop fighting for them at home. We won the last Cold War. We will win the next one too. When it’s us against them, they were, and are, never going to be the winner. But when it's “all against all” — a “multipolar” world with “multi-vector” policy, a state of shifting alliances and permanent instability — Russia, with a centrally controlled, tiny command structure unaccountable for its actions in any way, still has a chance for a seat at the table. They pursue the multipolar world not because it is right or just, but because it is the only world in which they can continue to matter without pushing a nuclear launch sequence.
We must understand this, and focus now, as Putin does, on shaping the world that comes next and defining what our place is in it. Trump has shown willingness to reevaluate his positions and change course — except on issues relating to Russia, and strengthening alliances with the Kremlin’s global illiberal allies. By doing so, he is making himself a footnote to Putin’s chapter of history — little more than another of Putin’s hollow men.
Trump should understand, regardless of what the Russians did in our elections, he already won the prize. It won’t be taken away just because he admits the Russians intervened. Taking away the secrecy of Russian actions — exposing whatever it was they did, to everyone — is the only way to take away their power over the US political system and to free himself from their strings, as well. Whatever Putin’s gambit was, Trump is the one who can make sure that Putin doesn’t win.
Trump should set the unpredictable course and become the champion against the most toxic, ambitious regime of the modern world. Rebuilding American power — based on the values of liberal democracy — is the only escape from Putin’s corrosive vision of a world at permanent war. We need a new united front. But we must be the center of it. It matters deeply that the current generation of global revolutionaries and reformers, like my Ukrainian friend, no longer see themselves as fighting for us or our ideals.
In a strange way, Trump could be just crazy enough — enough of a outlier and a rogue — to expose what Putin’s Russia is and end the current cycle of upheaval and decline. This requires non-standard thinking and leadership — but also purpose, and commitment, and values. It requires faith — for and from the American people and American institutions. And it requires the existence of truth.
The alternative is accepting that our history and our nation were, in fact, not the beginning of a better — greater — world, but the long anomaly in a tyrannous and dark one.
