BANDY X. LEE, M.D., M.DIV.
Possibly the oddest experience in my career as a psychiatrist has been to find that the only people not allowed to speak about an issue are those who know the most about it. Hence, truth is suppressed. Yet, what if that truth, furthermore, harbored dangers of such magnitude that it could be the key to future human survival? How can I, as a medical and mental health professional, remain a bystander in the face of one of the greatest emergencies of our time, when I have been called to step in everywhere else? How can we, as trained professionals in this very area, be content to keep silent, against every other principle we practice by, because of a decree handed down from above?
I am not speaking of the long-standing “Goldwater rule,” which is discussed in many places throughout this book and is a norm of ordinary practice I happen to agree with. I am rather speaking of its radical expansion, beyond the status we confer to any other rule, barely two months into the very presidency that has made it controversial. This occurred on March 16, 2017, when our professional organization essentially placed a gag order on all psychiatrists (American Psychiatric Association 2017), and by extension all mental health professionals. I am also speaking of its defect, whereby it does not have a countervailing rule, as does the rest of professional ethics, that directs what to do when the risk of harm from remaining silent outweighs the damage that could result from speaking about a public figure—which, in this case, could even be the greatest possible harm. Authors in this volume have been asked to respect the Goldwater rule and not to breach it unnecessarily, but I in turn respect their choices wherever their conscience has prompted them to take the professionally and socially radical step to help protect the public. Therefore, it would be accurate to state that, while we respect the rule, we deem it subordinate to the single most important principle that guides our professional conduct: that we hold our responsibility to human life and well-being as paramount.
My reasons for compiling this compendium are the same as my reasons for organizing the Yale conference by the title, “Does Professional Responsibility Include a Duty to Warn?”: the issue merits discussion, not silence, and the public deserves education, not further darkness. Over the course of preparing the conference, the number of prominent voices in the field coming forth to speak out on the topic astonished me. Soon after the 2016 presidential election, Dr. Herman (coauthor of the Prologue), an old colleague and friend, had written a letter urging President Obama to require that Mr. Trump undergo a neuropsychiatric evaluation before assuming the office of the presidency. Her cosignatories, Drs. Gartrell and Mosbacher (authors of the essay “He’s Got the World in His Hands and His Finger on the Trigger”), helped the letter’s publication in The Huffington Post (Greene, 2016). I also reached out to Dr. Lifton (author of the Foreword), whose “Mass Violence” meetings at Harvard first acquainted me with Dr. Herman years ago; together, they had sent a letter to the New York Times (Herman and Lifton 2017). His ready consent to speak at my conference sparked all that was to follow.
I encountered others along the way: Dr. Dodes (author of “Sociopathy”), who published a letter in the New York Times with thirty-five signatures (Dodes and Schachter 2017); Ms. Jhueck (author of “A Clinical Case for the Dangerousness of Donald J. Trump”), who cowrote and posted a letter to the head of New York City’s Department of Health and Mental Hygiene with seventy signatures; Dr. Fisher (author of “The Loneliness of Fateful Decisions”), who also expressed concerns in a letter to the New York Times (Fisher 2017); and Dr. Gartner (author of “Donald Trump Is: [A] Bad, [B] Mad, [C] All of the Above”), the initiator of an online petition, now with fifty-five thousand signatures, who cofounded the national coalition, “Duty to Warn,” of (as of this writing) seventeen hundred mental health professionals.
The Yale Conference
On April 20, 2017, Dr. Charles Dike of my division at Yale started the town hall–style meeting by reaffirming the relevance and reasons for the Goldwater rule. As assistant professor in law and psychiatry, former chair of the Ethics Committee of the American Academy of Psychiatry and the Law, chair of the Connecticut Psychiatric Society Ethics Committee, member of the Ethics Committee of the American Psychiatric Association, and Distinguished Fellow of the American Psychiatric Association, he was more than qualified to do so. It was important that we start with a firm ethical foundation: whatever our conclusion, it could not hold if we were not scrupulous about our ethical grounding. I invited as additional panelists Drs. Lifton, Herman, and Gilligan (the last the author of “The Issue Is Dangerousness, Not Mental Illness”), with the purpose of bringing together the finest minds of psychiatry I could to address the quandary. They are all colleagues I have known for at least fifteen years and highly esteem not only for their eminence in the field but also for their ethics. They were beacons during other dark times. They abided by the Goldwater rule in that they kept the discussion at the level of dangerousness, without attempting to diagnose.1 The transcript of the meeting can be found in an online appendix, the link to which is at the end of this book.
The conference was initially meant to be a collaboration between Yale School of Medicine, Yale School of Public Health, and Yale School of Nursing, but when the other schools fell away as the date approached, I released the School of Medicine for what I correctly perceived would be “inevitable politicization.” In case something went wrong, I did not wish to imperil my alma mater and home institution.
Our nation is now living, in extremes, a paradigm that splits along partisan lines, and the quick conclusion will be that the speakers or contributors of this volume “must be Democrats” if they are casting a negative light on a Republican president.
However, there are other paradigms. For the mental health professional, the paradigm we practice by is one of health versus disease. We appeal to science, research, observed phenomena, and clinical skill developed over years of practice in order to promote life and to prevent death. These goals cannot be contained within the purposes of a political party or the campaigns of a candidate. Rather, we are constantly trained to bring medical neutrality—or, if we cannot, to recuse ourselves of the therapeutic situation. It is a glimpse of this perspective that we hope to bring to the reader.
Our meeting gained national and international attention (Milligan 2017; Bulman 2017). While only two dozen physically attended the conference in an atmosphere of fear, about a hundred tuned in online, and hundreds more got in touch with me for recordings or in a show of support. It felt as if we had tapped into a groundswell of a movement among mental health professionals, and also an army of people who wanted to speak about the issue (DeVega 2017). What was intended as a publication of the proceedings led to this volume (initially so large that we had to reduce it by a third), and five top-tier publishers in the country vied for it.
Authors had to submit their manuscripts within three weeks of the meeting. It was a harrowing time, as the nation’s mood changed from relief as Mr. Trump seemed to settle into his office after the first one hundred days, to a new onslaught of scandals, starting with his firing of FBI director James Comey on May 9, 2017.
Many of the contributors here do not need an introduction, and I am humbled to have the opportunity to present such an assembly of brilliant and principled professionals.
A Compendium of Expertise
This volume consists of three parts, the first being devoted to describing Mr. Trump, with an understanding that no definitive diagnoses will be possible. In “Unbridled and Extreme Present Hedonism,” Zimbardo and Sword discuss how the Leader of the Free World has proven himself unfit for duty by his extreme ties to the present moment, without much thought for the consequences of his actions or for the future. In “Pathological Narcissism and Politics,” Malkin explains that narcissism happens on a scale, and that pathological levels in a leader can spiral into psychosis and imperil the safety of his country through paranoia, impaired judgment, volatile decision making, and behavior called gaslighting. In “I Wrote The Art of the Deal with Trump,” Schwartz reveals how what he observed during the year he spent with Trump to write that book could have predicted his presidency of “black hole-level” low self-worth, fact-free self-justification, and a compulsion to go to war with the world.
In “Trump’s Trust Deficit Is the Core Problem,” Sheehy highlights the notion that beneath the grandiose behavior of every narcissist lies the pit of fragile self-esteem; more than anything, Trump lacks trust in himself, which may lead him to take drastic actions to prove himself to himself and to the world. In “Sociopathy,” Dodes shows that someone who cons others, lies, cheats, and manipulates to get what he wants, and who doesn’t care whom he hurts, may be not just repetitively immoral but also severely impaired, as sociopaths lack a central human characteristic, empathy. In “Donald Trump Is: (A) Bad, (B), Mad, (C) All of the Above,” Gartner emphasizes the complexity of Trump’s presentation, in that he shows signs of being “bad” as well as “mad,” but also with a hypomanic temperament that generates whirlwinds of activity and a constant need for stimulation.
In “Why ‘Crazy Like a Fox’ versus ‘Crazy Like a Crazy’ Really Matters,” Tansey shows that Trump’s nearly outrageous lies may be explained by delusional disorder, about which Tansey invites the reader to make the call; even more frightening are Trump’s attraction to brutal tyrants and also the prospect of nuclear war. In “Cognitive Impairment, Dementia, and POTUS,” Reiss writes that a current vulnerability in our political system is that it sets no intellectual or cognitive standards for being president, despite the job’s inherently requiring cognitive clarity; this lack of clarity can be even more serious if combined with other psychiatric disorders. In “Donald J. Trump, Alleged Incapacitated Person,” Herb explains how, as a guardianship attorney (in contrast to a mental health professional), he is required to come to a preliminary conclusion about mental incapacity before filing a petition, which he does in his essay, while reflecting on the Electoral College and the Twenty-Fifth Amendment to the U.S. Constitution.
The second part of the book addresses the dilemmas that mental health professionals face in observing what they do and speaking out when they feel they must. In “Should Psychiatrists Refrain from Commenting on Trump’s Psychology?” Glass argues against a technicality that would yield a simple yes-or-no answer to the Goldwater rule; instead, he advocates for a conscientious voicing of hazardous patterns, noting that the presence of mental illness is not as relevant as that of reliable functionality. In “On Seeing What You See and Saying What You Know,” Friedman notes that technological advances that allow assessment and treatment from a distance, especially in underserved areas, have changed the clinician’s comfort level with remote evaluations, even when detecting a totalitarian mind-set or a multidimensional threat to the world. In “The Issue Is Dangerousness, Not Mental Illness,” Gilligan discusses the ethics of not diagnosing a public figure versus the duty to warn potential victims of danger; when invoking the latter, he emphasizes, what matters is not whether a person is mentally ill but whether he is dangerous, which is possible to assess from a distance.
In “A Clinical Case for the Dangerousness of Donald J. Trump,” Jhueck notes that the United States legally confers mental health professionals and physicians considerable power to detain people against their will if they pose a danger due to likely mental illness—and Trump more than meets the requisite criteria. In “Health, Risk, and the Duty to Protect the Community,” Covitz offers an ancient reference and two fables to illustrate just how unusual the mental health profession’s response is to a dangerous president, as we do not to speak up in ways that would be unthinkable for our role with other members of society. In “New Opportunities for Therapy in the Age of Trump,” Doherty claims that the Trump era has ruptured the boundary between the personal and the public, and while clients and therapists are equally distressed, integrating our roles as therapists and citizens might help us better help clients.
The book’s third part speaks to the societal effects Mr. Trump has had, represents, and could cause in the future. In “Trauma, Time, Truth, and Trump,” Teng points out the irony of seeing, as a trauma therapist, all the signs of traumatization and retraumatization from a peaceful election; she traces the sources of the president’s sudden military actions, his generation of crises, his shaken notions of truth and facts, and his role in reminding patients of an aggressive abuser. In “Trump Anxiety Disorder,” Panning describes a unique post-election anxiety syndrome that has emerged as a result of the Trump presidency and the task that many therapists face with helping clients manage the stress of trying to “normalize” behavior that they do not feel is normal for a president. In her essay “In Relationship with an Abusive President,” West illustrates the dynamics of “other blaming” in individuals who have feelings of low self-worth and hence poor shame tolerance, which lead to vindictive anger, lack of accountability, dishonesty, lack of empathy, and attention-seeking, of which Trump is an extreme example.
In “Trump’s Daddy Issues,” Wruble draws on his own personal experiences, especially his relationship with his strong and successful father, to demonstrate what a therapist does routinely: uses self-knowledge as an instrument for evaluating and “knowing” the other, even in this case, where the other is the president and his followers. In “Birtherism and the Deployment of the Trumpian Mind-Set,” Kessler portrays the broader background from which “birtherism” began and how, by entering into the political fray by championing this fringe sentiment, Trump amplifies and exacerbates a national “symptom” of bigotry and division in ways that are dangerous to the nation’s core principles. In “Trump and the American Collective Psyche,” Singer draws a connection between Trump’s personal narcissism and the American group psyche, not through a political analysis but through group psychology—the joining of group self-identity with violent, hateful defenses is as much about us as about Trump.
In “Who Goes Trump?” Mika explains how tyrannies are “toxic triangles,” as political scientists call them, necessitating that the tyrant, his supporters, and the society at large bind around narcissism; while the three factors animate for a while, the characteristic oppression, dehumanization, and violence inevitably bring on downfall. In “The Loneliness of Fateful Decisions,” Fisher recounts the Cuban Missile Crisis and notes how, even though President Kennedy surrounded himself with the “best and the brightest,” they disagreed greatly, leaving him alone to make the decisions—which illustrates how the future of our country and the world hang on a president’s mental clarity. In “He’s Got the World in His Hands and His Finger on the Trigger,” Gartrell and Mosbacher note how, while military personnel must undergo rigorous evaluations to assess their mental and medical fitness for duty, there is no such requirement for their commander in chief; they propose a nonpartisan panel of neuropsychiatrists for annual screening.
A Disclaimer
In spite of its title, I would like to emphasize that the main point of this book is not about Mr. Trump. It is about the larger context that has given rise to his presidency, and the greater population that he affects by virtue of his position. The ascendancy of an individual with such impairments speaks to our general state of health and well-being as a nation, and to how we can respond: we can either improve it or further impair it. Mental disorder does not distinguish between political parties, and as professionals devoted to promoting mental health, including public mental health, our duty should be clear: to steer patients and the public on a path toward health so that genuine discussions of political choice, unimpeded by emotional compulsion or defense, can occur. Embracing our “duty to warn,” as our professional training and ethics lead us to do at times of danger, therefore involves not only sounding an alarm but continually educating and engaging in dialogue our fellow human beings, as this compilation aspires to do.
* * *
I am grateful to all the authors who have generously contributed their insights without an expectation of personal reward. I especially thank Drs. Judith Herman and Grace Lee for their very helpful advice in editing this manuscript and for their help in organizing the Yale conference; Drs. Nanette Gartrell and Dee Mosbacher for their additional assistance; and Drs. Lance Dodes and John Gartner for their help in conceiving this publication in the first place. I would also like to express my appreciation for Dr. Robert Rohrbaugh, who as deputy chair for education made the conference possible; Dr. Howard Zonana, who as director of the Law and Psychiatry Division, and as a role model, supported me with legal advice along with Dr. Madelon Baranoski; and Dr. John Krystal, who, as department chair, bore the brunt of the controversies surrounding the conference. I thank Mr. Scott Mendel, the most intellectually astute literary agent one could ask for; and Mr. Stephen Power, the most enthusiastic editor one could have. I am grateful to Atty. Glen Feinberg, specialist of psychiatric law, and Atty. Max Stern, civil rights counsel, who have graciously donated hours of their time to what they deemed “a worthy cause”; as well as Atty. Ronald London, First-Amendment lawyer, and Atty. Henry Kaufman, the publisher’s counsel. Finally, I would like to share my gratitude for my grandfather and physician, Dr. Geun-Young Lee, who is the inspiration for all my work in the world.
Bandy X. Lee, M.D., M.Div., is Assistant Clinical Professor in Law and Psychiatry at Yale School of Medicine. She earned her degrees at Yale, interned at Bellevue, was Chief Resident at Mass General, and was a Research Fellow at Harvard Medical School. She was also a Fellow of the National Institute of Mental Health. She worked in several maximum-security prisons, cofounded Yale’s Violence and Health Study Group, and leads a violence prevention collaborators group for the World Health Organization. She’s written more than one hundred peer-reviewed articles and chapters, edited eleven academic books, and is author of the textbook Violence.
References
American Psychiatric Association. 2017. “APA Remains Committed to Supporting Goldwater Rule.” www.psychiatry.org/news-room/apa-blogs/apa-blog/2017/03/apa-remains-committed-to-supporting-goldwater-rule.
Bulman, May. 2017. “Donald Trump Has ‘Dangerous Mental Illness,’ Say Psychiatry Experts at Yale Conference.” Independent, April 21. www.independent.co.uk/news/world/americas/donald-trump-dangerous-mental-illness-yale-psychiatrist-conference-us-president-unfit-james-gartner-a7694316.html.
DeVega, Chauncey. 2017. “Psychiatrist Bandy Lee: ‘We Have an Obligation to Speak About Donald Trump’s Mental Health Issues … Our Survival as a Species May Be at Stake.’” Salon, May 25. www.salon.com/2017/05/25/psychiatrist-bandy-lee-we-have-an-obligation-to-speak-about-donald-trumps-mental-health-issues-our-survival-as-a-species-may-be-at-stake/.
Dodes, Lance, and Joseph Schachter. 2017. “Mental Health Professionals Warn About Trump.” New York Times, February 13. www.nytimes.com/2017/02/13/opinion/mental-health-professionals-warn-about-trump.html?mcubz=1.
Fisher, Edwin B. 2017. “Trump’s Tweets Attacking Obama.” New York Times, March 6. www.nytimes.com/2017/03/06/opinion/trumps-tweets-attacking-obama.html?mcubz=1.
Greene, Richard. 2016. “Is Donald Trump Mentally Ill? 3 Professors of Psychiatry Ask President Obama to Conduct ‘A Full Medical and Neuropsychiatric Evaluation.’” Huffington Post, December 17. www.huffingtonpost.com/richard-greene/is-donald-trump-mentally_b_13693174.html.
Herman, Judith L., and Robert Jay Lifton. 2017. “‘Protect Us from This Dangerous President,’ 2 Psychiatrists Say.” New York Times, March 8. www.nytimes.com/2017/03/08/opinion/protect-us-from-this-dangerous-president-2-psychiatrists-say.html?mcubz=1&_r=0.
Milligan, Susan. 2017. “An Ethical Dilemma: Donald Trump’s Presidency Has Some in the Mental Health Community Re-Evaluating Their Role.” U.S. News and World Report, April 21. www.usnews.com/news/the-report/articles/2017-04-21/mental-health-professionals-debate-ethics-in-the-age-of-trump.