Joshua C. Kendall

It's imperative to speak out about Trump's lack of mental capacity and psychological dangerousness: mental health expert

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 the second of a two-part series, on what can be done to prevent another autocrat from threatening American democracy. The first part of the interview series can be read here.

Kendall: As poets going back to Homer have observed, many human beings have tragic flaws; and we all act irrationally at times in ways that may cause harm to ourselves and to others—even those we love. So what differentiates Trump from other far-from-perfect leaders? As you know, a couple of years ago, a past president of the American Psychiatric Association wrote an influential op-ed in The New York Times, arguing that there was nothing wrong with Trump psychologically. As he suggested: "It's entirely possible that he simply has certain personal qualities we don't find ideal in a leader…. That he is, in a word, a jerk." Why do you dismiss this explanation?

Lee: There is a quote by Blaise Pascal I often recited in my adolescence: "The heart has its reasons, which reason does not know." The poets see what most of us do not. I went into psychiatry because it seemed the way to alleviate the most suffering, but little did I know that almost all human problems are solvable by figuring out our hearts—since, once we cease to be our own barrier, very few problems are left. Hence, perhaps the one role mental health professionals can play, the minimal contribution we owe society, is to distinguish for the lay public signs of pathology in this powerful realm, and to call attention to and not to give power to them so that we can avoid the most terrible tragedies.

Hence, it is especially egregious that a psychiatrist would normalize serious signs. Yet his is the only full-page opinion by a mental health professional the New York Times has published on the president. I and some of the most renowned psychiatrists and psychologists in the country submitted over 200 op-eds to the Times—all of the opposite opinion—to no avail. Members of the public complained about the said op-ed for years: "You never say anything in public, but when you do, it's worse because you say he's 'just a jerk'!" I have to agree it is harm. Psychiatrists and the American Psychiatric Association (APA) benefited financially and otherwise for "protecting" the president by minimizing his defects, and the distortions of psychiatric reasoning and ethics were something I never thought I would see in my career—which a major newspaper, rather than investigate, helped.

It seems as if your psychological analysis also applies to the pathology that characterizes other people in positions of power besides just Donald Trump, such as the bosses of media companies who sexually exploit their employees—say, Harvey Weinstein—and the drug company executives—say, the leaders of Purdue Pharma, the opioid manufacturer—who knowingly kill people in order to increase their profits. Why has this sociopathic behavior—called "malignant normality" by psychiatrist Robert Jay Lifton, one of the contributors to your first book on Trump—become increasingly common? And why do you think major media outlets were so slow to come to terms with Trump's malignant behavior?

"Malignant normality" began under this administration with the APA's modification of "the Goldwater rule," which essentially allowed pathology to spread without checks and to supersede reality. Having dangerously disordered leaders leads to this result. My observations over the last two decades have been that more and more corporate and political leadership resembled the prisoner population I trained to treat, even as prisoners themselves were becoming more "normal" as a result of mass incarceration. As power becomes concentrated, especially the kind that comes with impunity and legalized corruption, it functions as bait for sociopathic personalities. Sociopaths make up just 1 to 4 percent of the overall population but take up 20 percent of leadership positions, according to one study. In other words, if we preferentially vote criminal personalities into office, then we have a system that increasingly governs with "alternative" principles that squander and destroy rather than produce and create. The media outlets are a part of these larger societal trends, not a ballast against them. Their presentation of problems as entertainment keeps within the good graces of power structures and funding sources, but real problems requiring real solutions are inconvenient.

In your new book, Profile of a Nation, you use your experience in prison psychiatry to describe Trump's relationship to his base. Describe the psychological dynamics of this intense bond. You write, "If considered individually, most of [Trump's] followers would not be diagnosed with mental health problems…. As a group, however, [they] display a mass psychology of irrationality and impairment." Why do you think this is so? You argue that Trump's removal from office should reduce the potential for violence among his most ardent supporters. But even if Trump quietly leaves the White House in January, the nation will still face the major stress of a raging pandemic for at least a few more months. Over 3,000 Americans are dying a day, and then there is the likely economic toll of increasing unemployment, poverty, homelessness, and hunger. As we know from history, such deep economic turmoil can fuel a desire for authoritarianism.

I often bring up the phenomenon of "shared psychosis," because it is underrecognized. It is the transmission of mental symptoms through intense emotional bonds, especially common in prison or state hospital settings. When individuals with severe symptoms that go untreated hold a dominant role in a gang or in the family, previously healthy persons come to look as if they have the same disorder as their leader. Only after extracting the pathological person and eliminating exposure do you have reduction of symptoms and return of others to their baseline. This takes care of the most powerful and puzzling, emotional part, but it is not all. We need also to address the cognitive indoctrination and cultic programming through right-wing propaganda, especially if Donald Trump manages to establish a shadow presidency. You are right to point out the psychological injury that results from socioeconomic deprivation, not to mention the trauma from this presidency, which we have hardly begun to recognize. For healing, I usually recommend three steps: (1) removal of offending agent (the influential person with severe symptoms); (2) dismantling systems of thought control, which advertising and marketing have become, now heavily adopted by politics; and (3) fixing the socioeconomic conditions that give rise to poor collective mental health in the first place.

The brutal murder of George Floyd in May alerted many Americans to the problem of structural racism that continues to permeate American society. In your new book, you argue that structural racism is just part of a larger problem that you term "structural violence." What are the other key components of structural violence, and what forces have contributed to it and helped to maintain it? How can combating this scourge strengthen our democracy?

Structural violence is a central theme in my textbook on violence, as it is responsible for more deaths than all suicides, homicides, and wars combined. Having completed the text before this presidency, I do not even mention dangerous personalities but go straight to the societal conditions, including structural racism, that give rise to dangerous personalities in the first place. I hence focus a great deal on democracy as a solution in addition to being a critical manifestation of societal health. A colleague at Columbia University and I did an empirical study of 43 low-, middle-, and high-income countries, from 1960 to 2008, looking at the influence of democratization on violent death rates. We thought we would see an initial rise in violence and then a stabilization in newly democratizing societies, since we included only suicide and homicide (government statistics on state violence are unreliable). Astonishingly, violence only mostly rose over time. We eventually realized that the simultaneous adoption of unequal capitalism with democracy was causing the perpetuation and even worsening of structural violence. Structural violence, such as socioeconomic inequality, is the most potent cause of behavioral violence, including gender or racial violence. Based on my two decades of treating violent offenders and preventing violence at the societal level, I recommend reducing inequalities as urgent for the healing of our nation—which Joe Biden's administration is likely to attenuate but not solve.

Over the last few years, you have consulted frequently with John Feerick, a former dean of the Fordham University School of Law, who helped Senator Birch Bayh of Indiana draft the 25th Amendment. Passed by Congress in 1965 and ratified by the states in 1967, this Amendment allows for an incapacitated president to be removed from office. You have said that one thing you learned was that the Vice President was not expected to be the person who invoked it. How is the Amendment supposed to work? Did Feerick think much about mental fitness at the time? Do you think it could be used to remove a president due to a lack of mental capacity? Do you worry that it will be used against Joe Biden once his term begins?

Yes, after we spoke at some of the same conferences, he invited me to speak to his students at Fordham, and I invited him to speak at Yale. Even before we met, he said presidential incapacity can only be broached by "those who have knowledge of what's going on and maybe needing assistance, at times, of doctors." He said that, in the case of psychiatric issues, input by mental health experts may need to come first, since "psychiatric conditions … may be hard to apprehend." This is very true: a famous scholar of psychopathy illustrated how dangerous conditions can carry a "mask of sanity." Dean Feerick's close collaborator John Rogan also added: "The objective for mental health professionals is not diagnosis from afar but rather to educate the citizenry about these conditions so as to promote deliberative democracy." The vice president agrees when other opinions press upon him, since doubts about his motives may arise if he initiated. When approached to give recommendations for Rep. Jamie Raskin's new bill for a Commission on Presidential Capacity for the 25th Amendment, I explicitly excluded the American Psychiatric Association as a source for panelists because of its inability to act independently under the Trump administration. While it may still lobby itself in, several other colleagues, including APA members, also recommended its exclusion.

Over my career of teaching at Yale Law School for 15 years, I have lamented the general trend toward interpreting legal texts only by their written form, extracting them from their historical and societal contexts. President Lyndon Johnson specifically addressed Congress when stating that the nation could no longer gamble security to an "uncomprehending mind of a Commander in Chief," which in turn led to Sen. Birch Bayh to author the 25th Amendment. Hence, I do not understand why there is still a debate as to whether it covers psychiatric issues. I again fault the APA for contributing to the misconception that mental health stands apart from other areas of health, just so it could single out mental health as the only field the public could not hear from experts about.

As for Joe Biden, the more expertise and research are highlighted, the more it should help him, I believe, since medically insignificant signs related to stuttering—which may be outwardly dramatic but have no serious cognitive implications—seem to have been played up for partisan reasons. Given the propensity to view everything, including mental health, through a political lens and as a potential "weapon", some grounding in reality seems appropriate.

What are your own plans for the future?

I hope finally to end my interlude of speaking publicly, perhaps just after the release of a book I just completed, tentatively titled, Healing of a Nation, which is a sequel to my Profile of a Nation. It draws on my experience of applying psychiatric principles to public health and society while collaborating with sociologists, anthropologists, economists, political scientists, and policymakers through the World Health Organization since 2002.

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

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.