Yale Psychiatrist on 'The Dangerous Case of Donald Trump'

On November 9, 2016, Dr. Bandy Lee’s phone became inundated with calls and emails.

To the surprise of much of the world, Donald Trump had just been elected president of the United States, and Lee’s friends, students, and colleagues were concerned.

A forensic psychiatrist at the Yale School of Medicine, Lee specializes in violence prevention. She does not consider herself a political person, and had paid little attention to the presidential election before that morning.

What she had seen, though, disturbed her.

“Within even the first minute or two I was concerned about the interactions that he was eliciting from his followers,” Lee told The Globe Post, noting Trump’s aggressive and sometimes violent rhetoric.

Also concerning to Lee and some of her colleagues was Trump’s own mental condition. What seemed like “wacky” outbursts to many were, in fact, signs of potential cognitive decline and personality disorders to the trained eye.

Feeling a sense of professional responsibility, Lee organized a conference with some of the nation’s leading mental health professionals. The meeting served as a forum for a “rigorous” discussion about whether they had a duty to warn the public about the concerns they held privately.

Out of the conference came “The Dangerous Case of Donald Trump: 27 Psychiatrists and Mental Health Experts Assess a President,” a book edited by Lee and originally published in 2017.

The publication of the book was controversial, as critics accused the authors of breaking the American Psychiatric Association’s “Goldwater rule,” which says it’s unethical to offer a professional opinion on a public figure unless you’ve personally conducted an exam on them.

But Lee rejects those claims, saying the APA has twisted the rule’s original meaning and rendered it a “gag rule” aimed at “silencing professionals.”

In the time since the book was published, Lee believes Trump’s mental state, as well as the public health of America as a whole, have both declined. Worse still, she said the decline is likely to accelerate without intervention.

The interview has been lightly edited for length and clarity.

Q. At what point did you first begin to have concerns about the president’s mental health and why did you feel compelled to speak out publically about those concerns?

Lee: First of all, let me say that my views are my own and don’t represent those of my institutions. The first time I noticed some concern was watching glimpses of television broadcasts of Mr. Trump’s rallies and his interactions with the public. Those were the moments that concerned me. So I would say within even the first minute or two I was concerned about the interactions that he was eliciting from his followers.

I was actually taking care of a family member at the time so I didn’t really pay much attention to the campaign until the morning after the election. I was inundated with phone calls and emails from members of the public and civil society organizations and lawyers and students – those who knew of my expertise in violence prevention – and they were calling me because they were very concerned.

Now, I never thought of the political realm as my area. But upon reflection, I realized that if I had devoted my 20-year career to preventing violence, then would I not get involved in a situation where I saw the potential for the greatest possible violence? And so that is when I thought that I needed to do something.

Q. A lot of ordinary people seem to believe that Trump is “crazy.” They might casually remark to friends or family that he’s “nuts” or that he’s “out of his mind” or something along those lines. But from a clinical standpoint, what specific concerns do you have about the president’s mental state?

Lee: Yes. Well, I first need to clarify that I’m not really as concerned about Mr. Trump’s personal mental health as I am about his effects on the public’s health and safety. So the extra case I might be able to bring is both clinical psychiatry – what I can observe in the individual – as well as preventive psychiatry, which is a part of public health. And so it’s actually more the latter that I was interested in – his effect on the public.

So what was concerning was his aggressive language, which usually means that there’s physical violence not far behind – his boasting of sexual assaults, his endorsement of violence in his speeches, his attraction to violence and powerful weapons which he had expressed throughout his campaign as well as through his presidency. And also finally during his presidency, he has taunted allies and enemies alike, even nuclear powers. All those are signs of danger and danger is what makes this an emergency situation and the need for an evaluation urgent.

“The likelihood is that [Trump] has several different conditions, not just one.”

Q. One of your colleagues, John Gartner, from Johns Hopkins Medical school wrote in the book that Trump is a “malignant narcissist.” I think a lot of politicians – maybe even all politicians in some people’s minds – could be accused of narcissism. But at what point does something like narcissism become more than just a personality trait and something that’s actually potentially pathological?

Lee: First of all I need to clarify Dr. Gartner is not my colleague. And although he ended up in the book that I was editing, in the book itself I made sure that he would not diagnose the president. But I know he has gone around and given diagnoses.

We actually parted ways since he’s been doing that. But all the authors of the book that I collected – which are some of the most renowned figures in psychiatry and psychology – we have been trying to abide by ethical guidelines not to diagnose the president because the diagnosis is a very specific act that requires a lot of information, including usually a personal interview or the best effort to conduct a personal interview.

We don’t have a lot of information, although we are very seriously concerned. In fact, to diagnose the president would under undermine the severity of what he is presenting with because the likelihood is that he has several different conditions, not just one. So to say that he is a malignant narcissist or has narcissistic personality disorder undermines the real seriousness of what we are seeing and is also irresponsible.

On the other hand, we are advocating that he undergo an evaluation which would be the medical standard of care when someone is posing a danger.

Q. I would like to get into some of those ethical questions a little later. But for now, in terms of just some of [Trump’s] observable behaviors and observable personality traits – is there an important distinction between a personality trait and something that becomes a pathology? Generally speaking, where it that line?

Lee: Yes, absolutely. That distinction is important. Which is why that is probably one of the key distinctions that mental health professionals can contribute. Since most pathological signs are actually extreme versions of the normal, it’s usually not something entirely invented and new.

So most people would interpret pathological signs as a range within the normal of what they’re familiar with. Human normalcy encompasses a huge range of variation and therefore there’s a great deal that’s included within normal personality or style or choices. And to distinguish patterns of disease, you have to know something about the diseases and that’s where clinical experience becomes important and scientific data on the reliability of what you see. So it takes a good deal of training to distinguish what is abnormal from what is normal.”

“[Trump] has grown markedly more dangerous. In terms of the worsening of public mental health, his followers have become more irrational and more prone to believing conspiracy theories.“

Q. Another person that contributed to the book, Lance Dodds at Harvard, wrote that Trump’s “sociopathic characteristics are undeniable.” So without getting into the realms of making a diagnosis, generally what are the potential dangers associated with sociopathic characteristics in individuals?

Lee: Yes, I allowed him to include that term because it points to a societal disorder. And that’s something that we can observe and it depends more on the person’s behavior toward others or behavior in society. Sociopathy is often a dangerous trait.

In fact, most mental illness, by the way, is not dangerous. Most mentally ill individuals are actually more likely to be victims than perpetrators compared to normal individuals and most violence or dangerous behavior is done by those who do not have traditional mental illness diagnoses. Therefore to equate mental illness with danger is erroneous. But there are certain syndromes that are more dangerous than others and one of them would be sociopathy.

Q. Since this book came out in 2017, has the president’s behavior grown in any way more concerning to you?

Lee: Certainly there has been considerable decline and more recently, many people have noticed his cognitive decline. I think that’s actually demonstrable over a period of years because we have video recordings of his being able to complete sentences being able to use complex words being able to organize paragraphs. Increasingly, he’s not able to be coherent in terms of making complete, coherent sentences, not repeating words, not looking for words, not repeating concepts and not trailing off of his initial train of thought.

These kinds of things are actually specific signs of cognitive decline. You can see that even recently he called Tim Cook of Apple “Tim Apple.” He called Venezuela a company. He mistook his father’s birthplace for his grandfather’s. He said “oranges” instead of “origins.” And out of the blue, he said “I’m very normal.” So these are indicative of his own mind recognizing problems with him. That’s why he calls himself a “very stable genius,” and very normal. He may believe that, but most of the mind’s processes are unconscious. There’s a part of your mind that recognizes that something is not going well and blocks you from realizing that. That’s why these defensive declarations are coming out.

In terms of dangerousness, he has grown markedly more dangerous. In terms of the worsening of public mental health, his followers have become more irrational and more prone to believing conspiracy theories, as he himself is. He has been accelerating in terms of his threatening violence or calling for violence. And now we see increasing incidents of mass shootings or acts of aggression where they are citing Mr. Trump as a direct inspiration or his conspiracies as a direct inspiration.

We can also see it in terms of the increased frequency in his tweets. That alone wouldn’t really say very much but a pattern as I said – he tweeted something like 52 times in 34 hours recently. And the content is much more vitriolic. It shows signs of extreme stress.

There was another period leading up to the midterm elections and now again recently leading up to the anticipated release of the Mueller report. And now that more subpoenas are coming up he is again showing deterioration. So we have seen a pattern of attacking people who criticize him or going into conspiracy theories or becoming violent or calling for violence when he is under stress, and we are seeing more and more of that.

Q. Do you believe that that kind of behavior is likely to continue or even potentially devolve further going forward?

Lee: That’s right. Untreated, without intervention, it’s likely to not only get worse but to accelerate. And I think it is very irresponsible to wait to do an evaluation. I don’t believe this can wait any longer.

“It is the American Psychiatric Association that deviated from its own ethical rule in order to silence professionals.”

Q. In writing this book, some say you and your colleagues have broken away from the American Psychiatric Association’s “Goldwater rule,” which says it’s unethical to offer a professional opinion on a public figure unless you’ve personally conducted an exam on them. How do you respond to critics who say what you’re doing is unethical?

Well, ethics are complex. First of all, we did not deviate from the Goldwater rule. It is the American Psychiatric Association that deviated from its own ethical rule in order to silence professionals. The book came out of an ethics conference that I held which was a rigorous discussion on whether there were overarching ethical principles that overrode the Goldwater rule, such as a duty to warn the public or to protect public health and safety. Our professional responsibility to the public is a primary responsibility, just like our primary responsibility to patients. That’s what is said in the APA’s own preamble to ethics. We have a primary responsibility to patients as well as to society. It doesn’t say secondarily to society. It doesn’t say secondarily to a public figure.

The Goldwater rule was set up to serve the public good. And so I actually agree. I’m a strong proponent of the Goldwater rule and have kept it for over 20 years of practice even though, as a forensic psychiatrist, I’m exempt from it. But I still have not violated it. And the reason is because when you are speaking about a public figure, it is important to be rigorous and to meet gold standards of diagnosis. That’s precisely why we avoid diagnosing a public figure.

On the other hand, we strongly believe that overarching responsibilities are more important than the lower level rules, especially to a non-patient. A public figure is not a patient and it’s not our primary responsibility. And frankly, the Goldwater rule is superfluous because good practice would cause us to keep with the Goldwater rule anyway. But it was put in place when no other association does that as a political compromise.

What happened during Barry Goldwater’s campaign was that the rather tabloid Fact Magazine put out a survey to 12,000 psychiatrists, and actually, less than 10 percent came back with irresponsible diagnoses and called him unfit. And this was of course exaggerated and publicized without saying that over 90 percent of psychiatrists were actually non-responsive or responsible in what they were saying so.

So actually, a non-event really – that such that a small portion would speak irresponsibly – came to be a huge embarrassment for the APA. And so they put in this rule. What we object to is the fact that they changed the rule, which we now call “the Trump rule,” to distinguish it as different from the original Goldwater rule.

In March of 2017, two months after Trump’s inauguration, they turned it into a gag rule by changing the definition of “professional opinion.” A professional opinion is like evidence or fact – it’s admissible in court as evidence. They turned it into any opinion of a professional. In other words, anything you say about a public figure of any kind can be asserted to be an opinion. A professional making any opinion would be an opinion of a professional. So that sounds like a fine distinction, but it should really alarm everyone because what oppressive regimes, what authoritarian regimes, love to do is to discount expertise and to silence relevant information so that people will be stripped of critical knowledge.

And that is what the APA was doing on behalf of this administration. The CEO of the APA already confessed that they did so in fear of losing federal funding. So we really have to think about where the association’s loyalty lies – what conflicts of interest it has – and the fact that it’s federally funded. I resigned from the APA over 10 years ago because they started taking a lot of funding from pharmaceutical companies. And their policies and their advocacies reflect that in that they are heavily pharmaceutical-treatment-oriented instead of the patient-oriented advocacy it used to do.

So now that it’s fearing losing federal funding under this administration, they have chosen to take this course in spite of a huge uproar among its membership and demands for a vote – demands to re-evaluate their new interpretation of the Goldwater rule – and they have not budged. So we find the APA’s action unethical and politically motivated, not our own, which is responding to a medical need

Q. The president has obviously spent many, many hours combined speaking on television and in public. And again, without making a diagnosis, do you feel that you can glean useful information just by observing his public behavior generally?

Lee: That’s actually a good point because one appearance in public could be an act and even just a few appearances would not really tell you whether it is a political presentation – that it does not reflect the person’s actual thoughts and behavior versus what is truly going on. But patterns tell you a lot. With this president, we have extremely longitudinal, voluminous, high-quality information in addition to almost unfiltered direct information on his immediate reactions to real situations in real time over extended periods of time in terms of his tweets and his video appearances and his decision making patterns.

The patterns would tell you whether it’s more likely to be strategy versus more likely to be patterns of disease and compromise and over time, you test your hypotheses. In fact, observing behavior over extended periods of time can be more reliable in a lot of areas than a personal interview. And so in fact, we know a great deal more about Mr. Trump than a lot of our own patients and a lot of mental health professionals say so.

So we can test that hypothesis – is it likely to be an act that he puts on for political reasons versus is it really his true presentation? Over time, one wins over the other one and it seems safe to say that this is his true presentation. It is more impairment rather than strategy, even though certain things look like strategy because pathology can be so powerful that it becomes very effective. Except it’s effective in driving toward damage and destruction and is not productive.

Another reason why we look at his public appearances is because we’re concerned more about the public. Regardless of his intentions, regardless of whether it’s strategy or pathology, he has a deleterious on the public.

Q. For many jobs where people are put in positions of power, candidates have to undergo some form of psychological evaluation before they’re hired. Does it strike you as problematic that there are currently no such requirements for the position of president, where the stakes are so incredibly high?

Lee: Exactly. This is what I what has been my chief concern. I have been emphasizing that all police officers and military personnel need to undergo psychological testing before they take on their jobs in the first place. And those who handle nuclear weapons have to go undergo especially rigorous testing and renew it every year. And yet the commander in chief, under whose sole authority nuclear weapons can be launched, does not undergo such a test.

Also in any job, when an employee is acting as erratically and is showing signs of instability and is acting as belligerently as he is, an employer would have demanded a capacity evaluation. Capacity evaluations are functional exams where you simply test if the person is able to do the job and they’re not unduly influenced by impulsivity or delusions or irrational thinking.

So if he were anyone other than the president, he would likely have been asked to undergo such an exam and not be allowed to return to work until he does. Capacity evaluations which are fitness for duty exams happen around the country all the time. They happen to even the highest CEOs. But currently, the highest, most consequential position does not require this and to not have this as part of the job requirement is a glaring omission.

Now we can still demand this. The people in the United States are the president’s employers. And so the people can demand this. There’s no exception in the law in terms of medical standard of care and right to treatment for a president. The president may be immune from legal charges but he’s certainly not immune from medical treatment.

More on the Subject

The quiet New Zealand city of Christchurch was struck by two deadly attacks on Friday, with 49 people killed and another 20 seriously injured after gun assaults on mosques as Muslims worshipped.

In his manifesto, the suspected shooter said he’s an admirer of U.S. president Donald Trump, saying he’s “a symbol of white identity and common purpose.”

Trump condemned the attack via Twitter, saying his “warmest sympathy and best wishes goes out to the people of New Zealand.