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.