Like many Americans, Christopher Kilmartin, a professor emeritus of psychological science at the University of Mary Washington, couldn’t bear to watch the last presidential debate.
"It’s too painful for me," Mr. Kilmartin said of the insult-filled encounter between Hillary Clinton and Donald J. Trump.
Unlike most Americans, however, Mr. Kilmartin is a mental-health professional who can apply scientific terms to what has been taking place and then offer voters educated conclusions about what it might mean.
In the behavior of Mr. Trump — who repeatedly blurted out denials as Mrs. Clinton criticized his treatment of women and the disabled, and his statements on nuclear weapons and the Iraq war — Mr. Kilmartin sees evidence of what psychologists call "narcissistic rage."
It doesn’t mean Mr. Trump is likely to go around hitting people, Mr. Kilmartin explained. "But I think a person who is prone to narcissistic rage is a dangerous person to have in the White House, because he can push the button down," he said, referring to starting a nuclear war.
Mr. Kilmartin is among those mental-health experts who believe such professional assessments should be shared publicly. "If we have reliable, evidence-based knowledge that is important for people to know, then I don’t think we should be withholding it," he said.
Others in his extended field, however, aren’t so sure. Some argue that professional diagnoses of a subject’s mental health should be made only by experts who have personally examined that individual. Discussing a psychological evaluation in public, they say, is never appropriate without the subject’s consent.
"I don’t think that, without an examination of an individual, one can make an assessment of the person’s psychological profile," said Maria A. Oquendo, a professor of psychiatry at Columbia University who is also president of the American Psychiatric Association.
An expert can observe the public behavior of a political candidate, Dr. Oquendo said. "But you really cannot know what is motivating the behavior or what the underlying thought process is," she said.
Revisiting the ‘Goldwater Rule’
Dr. Oquendo recently reminded members of the psychiatric association about a professional code, dating to the 1970s, that bars psychiatrists from offering professional opinions on public figures they have not examined in person.
Mr. Kilmartin, meanwhile, is a member of the much larger American Psychological Association, which does not have such restrictions.
The differing professional approaches have become a cause for soul searching among many mental-health experts, some of whom are left to wonder if a rigid interpretation of patients’ rights is really in the best interest of the people they have dedicated themselves to serving.
Dan P. McAdams, a professor of personality and developmental psychology at Northwestern University, is among those struggling to get the balance right. Mr. McAdams wrote an 8,700-word essay this past summer in The Atlantic speculating on how Mr. Trump’s behavioral characteristics — including "narcissism," "disagreeableness," and "grandiosity" — might shape his presidency.
Although not a member of the psychiatric association, Mr. McAdams said he respects its so-called Goldwater rule, which was enacted as a rebuke to a 1964 magazine poll in which nearly 2,000 psychiatrists offered their opinion on whether Sen. Barry Goldwater of Arizona, the Republican presidential nominee, was mentally fit to be president. (Most said he was not.)
Others in the psychological association are conflicted, Mr. McAdams said. He described colleagues as saying: "I can either violate the rule and be true to some kind of higher concern I may have regarding his dangerousness, or I could sit silent and then violate my own moral compunction."
The range in experts’ attitudes toward public pronouncements is partly a matter of professional boundaries. Psychiatrists are medical doctors who generally dispense drugs and, as part of that process, make formal determinations of a patient’s mental condition. As such, they put heavy emphasis on the significance of declaring specific personality disorders like paranoia, schizophrenia, or narcissism. Psychologists are more typically involved in patient counseling. But some borders are shifting, and some psychologists now prescribe medications.
Mr. McAdams said his Atlantic essay describes what he sees in Mr. Trump — his disposition, mental habits, motivations, and self-conception — but avoids anything that would amount to a formal medical diagnosis. "I was very careful not to even get close to those kinds of concepts," he said.
That said, there’s no doubt Mr. Trump has narcissistic goals, Mr. McAdams said. "You don’t have to have half a brain to know that," given how widely and prominently he places his name on his properties, he said.
"It’s very unusual," Mr. McAdams said. "It’s something you can’t help but remark on in a psychological commentary."
Talk of clinical disorders in Mr. Trump’s case also should be avoided, Mr. McAdams said, because disorders prevent people from getting along in society. For all of Mr. Trump’s behavioral characteristics, Mr. McAdams said, he is certainly functional, as evidenced by his ability to head both a family and many businesses.
Some mental-health professionals question whether the Goldwater rule helps guide them through the real-world choices they face. That’s because the rule doesn’t seem to be actually enforced, said Charles R. Figley, a professor in disaster mental health at Tulane University who directs the Tulane Traumatology Institute.
The American Psychological Association and its members learned the need for explicit rules and consequences, Mr. Figley said, from the revelations in recent years of their involvement in helping the Central Intelligence Agency interrogate and torture terrorism suspects.
The American Psychiatric Association had always banned psychiatrists from being involved in interrogations that could lead to torture, and the psychological association long believed its rules on the matter were "as strong if not stronger," Mr. Figley said. But when the psychological association ordered an investigation of its actions, it concluded that it had been on a "slippery slope," he said. "We spent a lot of time in navel-gazing and analysis of how we went wrong," Mr. Figley said.
Beyond offering public comments about presidential candidates, mental-health scientists sometimes directly advise political campaigns, usually without generating much complaint. Some campaigns use psychology experts to craft messages that appeal to specific groups of voters. Mrs. Clinton used them to help her prepare for her debates with Mr. Trump.
Exploring a candidate’s mental health doesn’t necessarily mean giving voters a negative assessment, Mr. Kilmartin said. Anyone running for president probably exhibits some characteristics of narcissism, and a healthy dose of that trait could indicate that someone is determined to do great things, he said.
"I don’t think you can divorce your profession from public life," he said. "There’s a lot to lose if the wrong candidate gets elected, and so you’re put in this ethical dilemma of, What if I don’t use my expertise and then something bad happens as a result of my not using it?"
Despite all the attention on the Goldwater rule, Mr. McAdams said, most voters aren’t even looking for experts to offer a formal diagnosis of Mr. Trump. "They just want to understand who the man is," he said.