President Donald Trump’s behavior since he took office has been unsettling, to say the least. But is there more to it than just him behaving badly? Could Trump be exhibiting signs of mental instability?
Some have been brazen enough to suggest that Trump’s personality traits, including his attacks on the press and political opponents and his propensity to use violent rhetoric, may be signs of deeper mental problems. And that has a lot of people, including some in the field of psychiatry, very concerned.
Dr. Bandy X. Lee is a forensic psychiatrist and professor based out of Yale University. Her background in the study of psychiatric violence have been recognized with accolades from around the world. But when Trump began his campaign for president, and after he won the election in 2016, she began to have doubts about his ability to run the country — and fears about what his presidency could lead to if left unchecked.
I spoke to Dr. Lee earlier this week about Trump, as well as about broader topics regarding when it’s appropriate for psychiatrists or other mental health professionals to speak up when they see a political leader exhibiting dangerous traits that deserve further examining. Our discussion led me to believe that real changes and reforms need to come about, not just for Trump, but for future presidents and candidates for that office as well.
Chris Walker: What initially drew you to this topic and made you come to the conclusion that we need to take the issue of the president’s mental health more seriously?
Bandy X. Lee: I think it’s just from the fact that I am a psychiatrist and have concentrated on the issue of violence and violence prevention through about 20 years of my career. I haven’t been interested in domestic partisan politics or the political sphere. The manifestations of this president since he was a candidate alarmed me, especially his interactions with his followers.
But it was really the day after the election, after I was inundated by phone calls, by emails from various organizations I’d worked with on prison reform, civil society organizations, patient advocacy groups, lawyers, students, filmmakers, even state government workers — who said they were afraid of the violence that was to come. It was from answering all those phone calls and then examining the situation that I felt it was dire enough for me to speak up. Ordinarily I’m more of a clinician and an academic, doing global health work.
— willem middelkoop (@wmiddelkoop) January 6, 2019
CW: As you mentioned before, your background is more into the study of violence. President Donald Trump frequently uses violent rhetoric in his speeches and social media postings. Is that a sign of a larger problem?
BL: Definitely. When someone is exhibiting verbal aggression, it usually means that physical aggression is not far behind, and since aggressiveness or violence is actually a deep-seated pattern of behavior, seeing glimpses of it should raise alarms of a much more enduring, serious pattern.
CW: In 2017 you put together a book, along with 27 other psychiatrists, called “The Dangerous Case of Donald Trump.” Can you touch upon what that book’s purpose was, and why you felt it was important to put together?
BL: It wasn’t just myself who was alarmed by this presidency. In fact, whenever I spoke with people around me it seemed like there was a medical consensus that this was a serious problem, and that this degree of mental instability in the presidency would pose a danger. A former colleague of mine at Harvard, Dr. Judith Herman, had written a letter to President Obama at the time saying that the president-elect needed a neuro-psychiatric examination.
I agreed with that, and so I started composing my own letters. Most alarmingly, however, the American Psychiatric Association, rather than taking a leadership position in this crisis, actually took active steps to silence the profession by changing its ethical guidelines, especially its interpretation of an ethical rule in a way it was never meant to be.
CW: And that’s the Goldwater Rule that you’re alluding to, correct?
BL: That’s right.
CW: Can you expand upon why you were concerned about the change to that rule?
BL: So the Goldwater rule was a political compromise after the campaign of Barry Goldwater. He sued a magazine that over-inflated and misrepresented what psychiatrists had said about him during his presidential campaign.
The magazine had sensationalized a survey of psychiatrists it had sent out, saying that “1,189 psychiatrists” diagnosed Goldwater as unfit to be president, even though it should have been no news — this was less than 10 percent of psychiatrists the magazine had surveyed. The rest refrained or spoke responsibly. But Goldwater won a lawsuit against the magazine in court. It embarrassed the profession, so after that the APA instituted this clause.
The Goldwater rule used to be so obscure, most psychiatrists hadn’t even heard of it. It is certainly not a priority compared to other things like public health and public safety, or the survival of our patients and the larger society. We are responsible for safety and wellbeing first, whereas the Goldwater rule is more about etiquette — or at least the APA said so before Mr. Trump came along. Shortly after inauguration, the APA turned it into an absolute rule where there would be no condition under which you would override it.
This alone is very alarming because it’s a change of a rule under a certain administration in response to apparent political pressures, in the opposite direction of science and evolving practice. The conference that I organized in early 2017 was meant to have a discussion about this, about the ethics of speaking up around the situation of a dangerous public figure. Hundreds of mental health professionals were already getting in touch with me. So I collected abstracts and put together the most significant essays into a book.
The book was an instant New York Times Bestseller — it seems like the public was hungering for this information — and yet mental health professionals were not allowed to educate on this issue. We still get dozens of messages from the public every day, asking us to speak more. The American Psychiatric Association, which is federally funded and pharmaceutical industry-dependent, took active and aggressive steps against us, denouncing us in a public statement each time: right after the publication of the book, and right after I revealed that I had spoken with Congress members (even though I was strictly following their own guidelines to be of public service by consulting with the three branches of government).
I actually resigned over 10 years ago from the APA because of their pharmaceutical industry ties. They’re heavily funded by the pharmaceutical industry and I felt that their ethics were compromised because of that.
So the fact that they were trying to silence us so aggressively, I might add, was very alarming. I never imagined they would apply professional ethics in a way that seemed so unethical and politically-motivated.
CW: Allow me to play devil’s advocate for just a moment. You mentioned that the Goldwater rule is more of an etiquette, and should not be enforced to the extent the APA took it. Do you worry about the opposite, on the rule being almost ignored? Should a person who maybe has a less worrisome mental health issue, say clinical depression or anxiety, be worried if they have a political career for their future in mind, and what’s the difference between that person and what you want to see happen with regard to this current president?
BL: The principle that the Goldwater rule falls under is that psychiatrists are to participate in activities that better the community and promote public mental health. And so if [a psychiatrist’s actions] go against that, then they should not speak up.
I’m actually a strong proponent of the original Goldwater rule. I’m a forensic psychiatrist, which means I’m constantly asked by courts to testify on public figures, and I have refrained from diagnosing them for 20 years simply because that’s the standard of medicine I like to practice.
The Goldwater rule is actually superfluous because the standards already say that, without personal examination, you should not diagnose. Confidentiality also requires that you usually do not reveal the diagnosis publicly.
But we are not talking about personal mental health here but a public health issue. What really needs to be the focus is medical judgment and medical need when there is a clear and present danger to the public. There is a primary responsibility on the part of medical professionals to protect patients and society — not public figures, not political interests, not even the reputation of the profession. All these come after our primary duties. So if we think about society and the risks to society, then I believe it is important to speak up.
CW: I want to shift focus to Donald Trump specifically. Many of your colleagues didn’t see a need to speak out about a politician’s mental health until he came along. The president has referred to himself as a “stable genius” at times. What signs to you see that may contradict his assertions?
BL: Even the fact that he is asserting himself as a stable genius is a warning sign. Mental impairment actually includes, when severe, the inability to see that something is wrong with yourself. In fact, one can almost make it a rule that the sicker you are, the more you will resist even considering the possibility of your being impaired, and avoid evaluations or treatment at all costs. The sickest individuals avoid doctors and hospitals the most.
Other signs include that it’s unclear he is capable of taking in important information and advice in a logical, reality-based way, or to consider consequences before making major decisions. This would be an issue of capacity that is related to fitness of duty. One would think that decisional capacity is fundamental or basic for a president.
The fact that he hasn’t shown reliable signs that he has that capacity (in fact, he’s showing numerous signs that he does not) is dangerous in his position of such great power.
In addition to that, as you had mentioned, he has a propensity for violence. When he is criticized or his position is challenged in any way, he very quickly goes into an attack mode — he attacks the person criticizing him or presents a version of reality other than the one that suits him. The more severe the symptoms are, the less one is able to accept reality and facts. He is almost living in his own reality as a result of his inability to tolerate generally accepted reality.
His history of being a violent person is also demonstrable. He has shown verbal aggressiveness, he has boasted of sexual assaults in the past, he has incited violence in his supporters, he has endorsed violence in key speeches, he has shown an attraction to violence and powerful weapons, and he has taunted a hostile nuclear power, as well as alienated allies. These are all signs pointing to a propensity for violence, because past violence is the greatest predictor of future violence.
CW: As we start off the new year, we’re facing plenty of challenges as a nation — some of them of the president’s own making. Trump’s behavior during the shutdown, his inconsistency on whether we’ve succeeded in defeating ISIS or not, and other issues come to my mind. Is 2019 going to be a kinder year to Trump, or are we going to see more signs of his erratic and disturbing behavior surface?
BL: I think it’s going to be a very dangerous year in which we will see an acceleration of the chaos and disturbances that have happened in the past. Regardless of where it’s occurring, what we’re observing are psychological phenomena. Psychological dangerousness in the office of the presidency will translate into geopolitical dangerousness.
We are at a very dangerous place because he has eliminated all moderating forces around him, with the resignation of General James Mattis; the shutdown that he has incurred because of the need for an irrational border wall; and the fact he is considering a declaration of an emergency at the border. We know that if the president declares a national state of emergency then incredible powers will be at his disposal.
Dangerousness is not a diagnosis as much as it is an assessment of the situation. We have to think about the situation of Mr. Trump still holding great power, which has grown over time.
But we know there is a lot of chaos at the White House, and in world affairs there is increasing chaos and instability where it is unknown when or where a war may break out next. There is simply no limit to which he would go to protect his own inflated self-image, to protect himself from the humiliation of an encroaching indictment or when he cannot say he is “winning” anymore. His mental challenges could cause him to use his powers as president to take unpredictable, extreme, and potentially dangerous measures. So we’re entering perhaps the most dangerous period of his presidency.
As a medical professional, it is quite distressing to see because the medical standard of care would have been to intervene much earlier. A thorough evaluation could reveal a diagnosis, and I think at this point it’s also important for the public to know, since they will be directly affected.
CW: Do you believe that future presidents, as well as this current one, need to undergo a fitness test before they are considered to serve? And how would you tie this towards potential usage of the 25th Amendment in the Constitution?
BL: I’d like to say that I’m a mental health expert and therefore I usually do not weigh in on political decisions such as the 25th Amendment. I can say that decisions such as disability, fitness-for-duty, capacity — these are legal decisions, and yet there would be no court that would declare any of these without appropriate medical expert input.
As far as your question about fitness-for-duty exams, the fact that military officials, and particularly those who handle nuclear weapons, undergo meticulous fitness-for-duty exams before they ever take their job, I think at least the same should be applied to presidential and vice presidential candidates, with yearly follow-up.
CW: Finally Dr. Lee, I want to ask, should we aim toward removing Trump from office before the 2020 election comes about?
BL: I think that is unavoidable. We can only expect the dangerousness to worsen and accelerate. If we had any concern at all about national security, or even the survival of the human species (given the technological powers that are invested in the president), with this level of mental instability, with greater dangers to come because of the impending [special counsel’s] investigation reports, without sufficient containment of the president, I believe removal would be in order.
All of this could be answered more precisely with an evaluation, of course, but I think Trump has shown enough to demonstrate he is in no state to continue his presidency for another two years.