by Bandy X. Lee
The physician, to whom life-and-death situations are entrusted, is expected to know when it is appropriate to act, and to act responsibly when warranted. It is because of the weight of this responsibility that, rightfully, the physician should refrain from commenting on a public figure except in the rarest instance. Only in an emergency should a physician breach the trust of confidentiality and intervene without consent, and only in an emergency should a physician breach the Goldwater rule. We believe that such an emergency now exists.
Test for Proper Responsibility
When we circulated our letters of concern, we asked our fellow mental health professionals to get involved in politics not only as citizens (a right most of us still enjoy) but also, specifically, as professionals and as guardians of the special knowledge with which they have been entrusted. Why do we think this was permissible? It is all too easy to claim, as we did, that an emergency situation requires a departure from our usual practices in the private sphere. How can one judge whether political involvement is in fact justified?
We would argue that the key question is whether mental health professionals are engaging in political collusion with state abuses of power or acting in resistance to them. If we are asked to cooperate with state programs that violate human rights, then any involvement, regardless of the purported justification, can only corrupt, and the only appropriate ethical stance is to refuse participation of any sort. If, on the other hand, we perceive that state power is being abused by an executive who seems to be mentally unstable, then we may certainly speak out, not only as citizens but also, we would argue, as professionals who are privy to special information and have a responsibility to educate the public. For whatever our wisdom and expertise may be worth, surely we are obligated to share it.
It doesn’t take a psychiatrist to notice that our president is mentally compromised. Members of the press have come up with their own diagnostic nomenclature, calling the president a “mad king” (Dowd 2017), a “nut job” (Collins 2017), and “emotionally unhinged” (Rubin 2017). Conservative columnist George Will (2017) writes that the president has a “disorderly mind.” By speaking out as mental health professionals, we lend support and dignity to our fellow citizens who are justifiably alarmed by the president’s furious tirades, conspiracy fantasies, aversion to facts, and attraction to violence. We can offer a hand in helping the public understand behaviors that are unusual and alarming but that can all too easily be rationalized and normalized.
An important and relevant question that the public has been asking is this: Is the man simply crazy, or is he crazy like a fox? Is he mentally compromised or simply vile? When he lies, does he know he is lying, or does he believe his own lies? When he makes wild accusations, is he truly paranoid, or is he consciously and cunningly trying to deflect attention from his misdeeds?
We believe that we can help answer these questions by emphasizing that the two propositions are not mutually exclusive. A man can be both evil and mentally compromised—which is a more frightening proposition. Power not only corrupts but also magnifies existing psychopathologies, even as it creates new ones. Fostered by the flattery of underlings and the chants of crowds, a political leader’s grandiosity may morph into grotesque delusions of grandeur. Sociopathic traits may be amplified as the leader discovers that he can violate the norms of civil society and even commit crimes with impunity. And the leader who rules through fear, lies, and betrayal may become increasingly isolated and paranoid, as the loyalty of even his closest confidants must forever be suspect.
Some would argue that by paying attention to the president’s mental state, we are colluding with him in deflecting attention from that by which he should ultimately be judged: his actions (Frances 2017). Certainly, mental disturbance is not an excuse for tyrannical behavior; nevertheless, it cannot be ignored. In a court of law, even the strongest insanity defense case cannot show that a person is insane all the time. We submit that by paying attention to the president’s mental state as well as his actions, we are better informed to assess his dangerousness. Delusional levels of grandiosity, impulsivity, and the compulsions of mental impairment, when combined with an authoritarian cult of personality and contempt for the rule of law, are a toxic mix.
There are those who still hold out hope that this president can be prevailed upon to listen to reason and curb his erratic behavior. Our professional experience would suggest otherwise; witness the numerous submissions we have received for this volume while organizing a Yale conference in April 2017 entitled “Does Professional Responsibility Include a Duty to Warn?”3 Collectively with our coauthors, we warn that anyone as mentally unstable as Mr. Trump simply should not be entrusted with the life-and-death powers of the presidency.
Judith Lewis Herman, M.D., is Professor of Psychiatry at Harvard Medical School. She is a renowned expert in the traumas of interpersonal violence and author of the now-classic Trauma and Recovery. She is a cofounder of the Victims of Violence Program in the Department of Psychiatry at Cambridge Health Alliance, a Distinguished Life Fellow of the American Psychiatric Association, and the recipient of numerous awards, including the Lifetime Achievement Award from the International Society for Traumatic Stress Studies.
Bandy X. Lee, M.D., M.Div., is Assistant Clinical Professor in Law and Psychiatry at Yale School of Medicine. She teaches at Yale Law School, cofounded Yale’s Violence and Health Study Group, and leads a Violence Prevention Alliance collaborators project for the World Health Organization. She is the author of more than one hundred peer-reviewed articles, editor of eleven academic books, and author of the textbook Violence.
Acknowledgments
We thank Nanette Gartrell, Dee Mosbacher, Gloria Steinem, Robin Morgan, Jaine Darwin, Frank Putnam, and Grace Lee, for their helpful editorial comments and assistance in the preparation of this Prologue.
References
American Medical Association. 2001. AMA Code of Medical Ethics: AMA Principles of Medical Ethics. www.ama-assn.org/sites/default/files/media-browser/principles-of-medical-ethics.pdf.
American Psychiatric Association. 2006. Position Statement on Psychiatric Participation in Interrogation of Detainees. www.psychiatry.org/File%20Library/About-APA/Organization-Documents-Policies/Policies/Position-2014-Interrogation-Detainees-Psychiatric-Participation.pdf.
______. 2013. Principles of Medical Ethics with Annotations Especially Applicable to Psychiatry. www.psychiatry.org/psychiatrists/practice/ethics.
______. 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.
Collins, Gail. 2017. “Trump Stays Buggy.” New York Times, March 17. www.nytimes.com/2017/03/17/opinion/trump-stays-buggy.html.
Dowd, Maureen. 2017. “Mad Trump, Happy W.” New York Times, March 4. www.nytimes.com/2017/03/04/opinion/sunday/mad-trump-happy-w.html?_r=0.
Frances, Allen. 2017. “An Eminent Psychiatrist Demurs on Trump’s Mental State.” New York Times, February 14. www.nytimes.com/2017/02/14/opinion/an-eminent-psychiatrist-demurs-on-trumps-mental-state.html.
Hoffman, David H., Danielle J. Carter, Cara R. Viglucci Lopez, Heather L. Benzmiller, Ava X. Guo, S. Yasir Latifi, and Daniel C. Craig. 2015. Report to the Special Committee of the Board of Directors of the American Psychological Association: Independent Review Relating to APA Ethics Guidelines, National Security Interrogations, and Torture (revised). Chicago: Sidley Austin LLP.
Lewis, Neil A. 2005. “Guantánamo Tour Focuses on Medical Ethics.” New York Times, Nov. 13. www.nytimes.com/2005/11/13/us/guantanamo-tour-focuses-on-medical-ethics.html.
Medvedev, Zhores, and Roy Medvedev. 1971. A Question of Madness: Repression by Psychiatry in the Soviet Union. New York: Vintage.
Risen, James. 2014. Pay Any Price: Greed, Power, and Endless War. New York: Houghton Mifflin.
Rubin, Jennifer. 2017. “Will Comey’s Request Push Trump over the Edge?” Washington Post, March 6. www.washingtonpos
t.com/blogs/right-turn/wp/2017/03/06/will-comeys-request-push-trump-over-the-edge/?utm_term=.65aa62ca0657.
Snyder, Timothy. 2017. On Tyranny: Twenty Lessons from the Twentieth Century. New York: Crown/Archetype.
Will, George F. 2017. “Trump Has a Dangerous Disability.” Washington Post, May 3. www.washingtonpost.com/opinions/trump-has-a-dangerous-disability/2017/05/03/56ca6118-2f6b-11e7-9534-00e4656c22aa_story.html?utm_term=.90f21a74dc93.
World Medical Association. 2006. Declaration of Geneva. www.wma.net/policies-post/wma-declaration-of-geneva/.
INTRODUCTION
Our Duty to Warn
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 d
evoted 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.