Here's why it is necessary to speak out about Trump's psychological dangerousness and lack of mental capacity

31 December 2020

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Dr. Bandy X. Lee was interviewed by presidential historian Joshua Kendall, whose most recent book is First Dads: Parenting and Politics from George Washington to Barack Obama (Grand Central, 2016). His journalism has appeared in the New York Times, Boston Globe, Los Angeles Times, Wall Street Journal, New Republic, Politico, and Times Literary Supplement, among other publications. He interviewed Dr. Lee, forensic psychiatrist and editor of The Dangerous Case of Donald Trump, as first of a two-part series in light of the growing controversy over the president's mental health.

Kendall: I'm taken by the depth of your psychological understanding of Donald Trump and by the accuracy of your predictions. Mary Trump's recent memoir about her uncle validated just about everything you and your co-authors wrote over three years ago. And in your new book completed over the summer, you wrote: "Now with an election looming, he will likely refuse to concede the results, call the election a fraud, and refuse to leave office." This is exactly what is happening right now. In contrast to journalists who approach Trump based on what they know about politics and past presidents, you approach him based on your experiences with patients. Tell me about your work in forensic psychiatry.

Lee: Thank you. Yes, a forensic psychiatrist works at the interface of psychiatry and the law, which is what I have done for over 20 years. My particular area of specialization has been violence prevention. I have treated violent offenders as well as worked at the population level through public health and policy recommendations. Predicting episodes of violence at the individual level is very difficult, almost random, because even the most violent individuals are not violent most of the time. Predicting and preventing violence at the societal level, however, is more precise, since probabilities translate into percentages, and the past few decades have yielded abundant research. I often state that violence is a societal disorder for this reason. I was able to understand Donald Trump easily, since I have treated about a thousand individuals of a very similar psychological structure. I was also able to conceive in public health terms the psychological influence he would have on society, in addition to his being, as president, a "barometer" of societal mental health.

Four years into the Trump administration—after we have repeatedly seen the president deny reality—by, for example, describing Covid-19 as a hoax that would go away after the election and by challenging without any evidence the results of the 2020 election—vast numbers of Americans are convinced that Donald Trump is weighed down by serious psychiatric problems. For example, a dean at Yale's School of Management recently described Trump in Fortune as "secluded and deluded," noting that he now has "the mindset of a mad monarch." In 2020, it seems as if it is almost impossible to talk seriously about Trump without flinging around psychiatric terms. But you were way ahead of the curve. Right after his surprise victory over Hillary Clinton in 2016, you had little doubt that he lacked the mental fitness to be president and began corresponding with fellow psychiatrists about how best to make your voices heard. You wrote in your 2017 book that you were worried about "[the] potential violence that could result from the presidency, from hate crimes to nuclear war." What was it about Trump's words and deeds that caused you such alarm?

I tried to stay true to my clinical judgment, based on having encountered many patients just like him through my work in jails and prisons, and knowing how such personalities can beguile, manipulate, and whip up frenzied, irrational support, as is common among leaders of street gangs. A population that has little awareness of psychology is particularly vulnerable to control. Observing his interactions with his supporters at rallies allowed me to gauge precisely his degree of fragility, manipulativeness, and violence-proneness, and his followers' responsiveness. While I was strictly an academic and clinician, I consulted regularly with policymakers and governments, which habituated me to keeping strict boundaries. Medical neutrality means a health professional should not change medical judgment or response according to political considerations—and we have a duty to human health and life. Society is also our primary responsibility, tantamount to our responsibility to patients.

As you noted in the title of your bestseller, The Dangerous Case of Donald Trump, your argument that Trump is unfit to serve as president revolves around his psychological dangerousness. What exactly is psychological dangerousness, and how can it be determined? And in your new book, you have asserted that Trump lacks the mental capacity to serve as president. What is mental capacity, and how can it be determined? While psychological dangerousness and lack of mental capacity are not the same thing as mental illness, are they at all related to it? Like Mary Trump, do you say that he likely suffers from a string of psychiatric disorders—including narcissistic personality disorder and antisocial personality disorder? How are such diagnoses made?

While many people kept looking for a diagnosis, I saw our role as educating the public that a diagnosis is not important, that the president is not our patient, and that there are more relevant matters to public health than diagnoses. Diagnosis is primarily for individual treatment, and is an intricate process. An interview is not always helpful—external observation and collateral information are preferred for dangerous individuals—but medical records are obligatory. Brain scans and electroencephalograms are almost always used to rule out medical conditions, unless we have extensive history. But even if we diagnosed, it says nothing about dangerousness or unfitness, which are of foremost concern to public health. Violence risk is determined almost actuarially, with a checklist of specific information and external characteristics—all of which have long been available on Donald Trump. Most importantly, past violence points to future violence, and his verbal insults, boasts of sexual assault, and incitement of violence were all signs of dangerous risk. Dangerousness alone makes one unfit for a job, but we performed a full assessment of mental capacity, which is basic for fitness. The Mueller report provided intimate, firsthand accounts by close associates and coworkers—which is the best kind of information to have for capacity evaluations—in abundance under sworn testimony. So, with exceptional rigor, we were able to show that he failed every criterion. This means he would be unfit for almost any job, not just president, and our standardized assessment could count as evidence in any court—which anyone can still take up.

In March of 2017, as you and other prominent psychiatrists began speaking out about Trump's mental state, the American Psychiatric Association reaffirmed its support for a formerly obscure clause in its ethical guidelines called the Goldwater Rule, which states that "member psychiatrists should not give professional opinions about the mental state of someone they have not personally evaluated." What is the Goldwater Rule and what purpose was it intended to serve? And even though this ethical rule applies only to psychiatrists who belong to the APA, it has been used to silence all mental health professionals—even psychologists and social workers—from offering their professional opinion about what might be driving the president's behavior. But isn't there something useful about the Goldwater Rule? Does it not help reduce the stigma often associated with a mental health condition? If mental health experts can point out leaders' emotional difficulties, wouldn't people with emotional problems be less likely to seek treatment and to confide about their condition?

The March 2017 revision is what got me started. I gauged, at a public-health level, that silencing experts would result in the spread of mental pathology, an inability to apply correct interventions, and therefore vast suffering and societal damage. I am sad to say, this is exactly what happened. "The Goldwater rule" in the narrowest sense was set up to caution against commenting on things that one could not rigorously—primarily, diagnosis. However, having originated as a political compromise, it was bound to be politically abused. Misapplying it as a "gag order" under the Trump administration and forcing a media culture of making no experts available, commentary by people who knew nothing of what they were talking about became rampant, defeating the stated purpose of the "rule". You are also right in that, through public campaigns, the APA gave the impression that its trade-association "rule" was universal, when it covers only 6 percent of practicing mental health professionals, whom it probably cannot discipline anyhow because of the First Amendment. Instead, it resorted to misinformation campaigns that changed the nation's "informational milieu." The effect under Donald Trump has been catastrophic, leaving a population defenseless during perhaps the greatest mental health emergency in the nation's history, especially in a deadly pandemic made multifold worse because of his mental impairments.

The assertion that commenting on a public figure's mental health would increase stigma does not hold up. If anything, scientific research clearly shows that open discussion and education reduce stigma, and pretending that mental problems do not exist causes patients to blame themselves and not to seek treatment. Besides, I do not see how allowing mental compromise to play out in full severity before the public, contributing to great harm from a lack of treatment, is not stigmatizing. The APA, by playing up public misconceptions and prejudices and—in effect—stigmatizing the whole mental health field as the only field in which the public cannot hear from experts, canceled the progress from decades of mental health awareness efforts. Sharing specialized knowledge about a public servant who poses a danger to the public empowers the public to hold those in power accountable. Stripping the public of access to the best available knowledge is ipso facto anti-democratic, not to mention harmful to public health. Never in my career have I witnessed such travesty by a health association.

In March of 2020, the non-profit that you lead—the World Mental Health Coalition—issued a "Prescription for Survival," which stated that Donald Trump should be removed from office, whether by impeachment, the 25th Amendment, or any other available mechanism. Sure, you were right that, by then, it was already clear that Trump was botching the nation's response to the pandemic. But we live in a democracy, and Donald Trump is a duly elected president. And while you may disagree with the Republicans in the Senate who voted against removing Trump from office after the House impeached him late last year, senators are also duly elected representatives. So what do you say to Americans who worry about giving mental health experts the power to overturn the will of the people?

Using psychological tactics to misinform the public and to manipulate it to act against its interests is not permitting the people's will. Facts and the best available knowledge, or expertise, are supposed to facilitate informed decisions. Early education and persuasion through the sharing of information is especially important with a mental health crisis, just like a pandemic, since to wait until an untrained public appreciates the full extent of the crisis on its own will be too late. This is why society invests in training specialists. Having devoted our lives to a specific field, we can detect dangers in our respective areas with greater precision, and this is the minimum we owe society. We do not intervene in politics, but we have a responsibility to say if something is not purely politics. When elected officials do not merely present a different ideology or approach but cause widespread mass deaths, devastate the economy, and reform people's thoughts so that they cannot protect their own self-interest, these leaders are no longer offering political options but are a public health hazard. When a president presents with dangerous mental symptoms that, unlike military personnel or other critical positions, are not screened in advance, then it is incumbent on independent mental health experts to speak up about problems. It was not our place to say how they should be removed, but it was within our purview to state that the dangers need to be removed for public health and safety, whatever the means—and this is still the case today.

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