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Mental health controversy of Donald Trump

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No other presidency in the history of U.S. presidents has generated more controversy in the mental health field than the presidency of Donald Trump.[1][2][3][4][5] Whereas questions about the mental health of Richard Nixon, Lydon B. Johnson, and Ronald Reagan were raised during their presidencies, Trump is unique in having created a heated debate among mental health experts since well before he took office. A historic number of mental health professionals started speaking up about a president's mental health issues before his inauguration,[3][6][7][8] the American Psychiatric Association (APA) expanded ethical guidelines to silence these professionals in unprecedented ways,[9][10][11] and at least one group of mental health professionals revolted against “the gag rule” they said it imposed.[12][13] Everything from personality disorder[4][14] to dementia[15] to all-out psychosis[16] were speculated. A breakthrough happened when Bandy X. Lee, professor of psychiatry and violence expert at Yale School of Medicine, went a step further to say that diagnosis was not the issue but dangerousness.[17][18] She held a conference on the ethics of speaking up about dangerous public figures,[19][20] and organized 27 mental health experts, many of them renowned, to put their essays into The Dangerous Case of Donald Trump, which became an instant New York Times bestseller[21] — also unprecedented for a book of specialized knowledge by multiple authors.

2017 meeting of mental health experts[edit]

In April 2017, forensic psychiatrist Bandy X. Lee hosted a meeting at Yale School of Medicine regarding the ethics of discussing Trump's mental health, inviting some of the most eminent living psychiatrists such as Robert Jay Lifton, Judith Lewis Herman, and James Gilligan.[22][23] Surprisingly, only two dozen people attended, fearful that they may be targeted — either by a litigious president or by his violence-prone followers.[24] The discussion revolved around ethics,[25] given Lee's 20-year support of the so-called Goldwater rule,[26] which prohibits diagnosis of public figures without an examination and without authorization.[27] As a proponent of the rule, she strongly opposed its modification under political pressure.[28] She found the American Psychiatric Association's change of interpretation of the rule soon after Donald Trump's inauguration, to prohibit not only diagnosis but any opinion "about the affect, behavior, speech, or other presentation" of a public figure,[29] to be "alarming."[30] Concluding that their societal responsibility to protect public safety was more important than etiquette toward a non-patient, Lee published the proceedings in a public service book, The Dangerous Case of Donald Trump: 27 Psychiatrists and Mental Health Experts Assess a President,[31] including other renowned psychologists and psychiatrists such as Philip Zimbardo, Nanette Gartrell, and Dee Mosbacher.

Despite the sparse attendance at the meeting, the event was covered in four continents and multiple languages.[32][33][34][35][36] Later, thousands of mental health professionals from around the United States and the world got in touch with her to form the World Mental Health Coalition and asked her to be its president.[37][38] Another group of mostly non-professionals formed following the event, Duty to Warn, organized by psychologist John Gartner, which held rallies across the country and established a Super-Political Action Committee.[39][40]

A bestselling book[edit]

The Dangerous Case of Donald Trump became an unexpected New York Times bestseller when it was released in October 2017. Within two days, all major outlets were out of stock, and it took Macmillan, one of the largest publishers in the United States, weeks to catch up with the demand.[8] In an interview with Robert Jay Lifton, Bill Moyers stated, "There will not be a book published this fall more urgent, important, or controversial than The Dangerous Case of Donald Trump."[41] In an appearance with Bandy X. Lee and Tony Schwartz, Lawrence O'Donnell said, "This is an historic work in the history of American psychiatry."[42] The Washington Post named it "The Most Courageous Book of the Year,"[43] saying, "The stand these psychiatrists are taking takes courage, and their conclusions are compelling."[44]

The editor had all authors agree to refrain from diagnosing and to base their statements on evidence and not on politics, even though Lee warned that politicization was "inevitable."[25] Authors and the editor also decided to forego any profit and donate revenues to the public good in order to avoid all financial conflicts of interest.[28]

Continued high demands for the book led to an expanded edition with ten additional mental health experts,[45] which includes notable professionals such as Stephen Soldz, Ellyn Kaschak, Lise Van Susteren, and Nassir Ghaemi. It was released in March 2019 in conjunction with a major interdisciplinary conference at the National Press Club.[46] The conference featured 14 top experts not only of psychiatry but of law, history, political science, economics, social psychology, nuclear science, and climate science to "share the specific ways in which psychological dangerousness in a president has translated into social, cultural, and geopolitical dangerousness."[47] Panelists included former CIA psychiatrist Jerrold Post, economist Jeffrey Sachs, former Chief White House Ethics Counsel Richard Painter, fascism expert Ruth Ben-Ghiat, political historian Gar Alperovitz, nuclear weapons expert Scott Ritter, and Pulitzer Prize-winning investigative journalist David Cay Johnston. The event was organized by the World Mental Health Coalition and was covered by C-SPAN.[48]

Congressional oversight[edit]

Since the Yale meeting, several Democratic U.S. Congress members got in touch with the organizer Bandy X. Lee, with the intention to have her testify before the Congress,[49] but when this did not happen, a former assistant US attorney arranged for her to meet privately with a dozen personal contacts.[50][51] By the end, she had spoken to more than 50 Congress members,[52] all Democrats except one "incidental" Republican.[53] They all agreed that, being a minority party, there was not much they could do.[51] Lee decided to refrain from further contact so that Republicans would have a chance to reach out to her, but none of them did.[54] Thus, when Special Counsel Robert Mueller's report was released 15 months later, Lee convened a panel of leading mental health experts to evaluate Donald Trump based upon his behavior as detailed in the Mueller report.[55][56][57] Their definitive conclusion: Trump is mentally unfit, a threat to the United States and the world, and as such should have his powers severely restricted.[58][59] Several Democratic members of Congress invited Lee and other mental health professionals to Capitol Hill in July 2019 to present their findings at what they hope will be a bipartisan congressional meeting.[58][60] Apart from this, Lee and colleagues, including former members of the Carter commission for an expert panel for the 25th Amendment,[61] have formed a working group to create an independent, nongovernmental panel solely of medical experts — consisting of three psychiatrists, one clinical psychologist, one neurologist, and two internists — that can be available for consultation by any political body, should the need arise.[62][63]

Opposition[edit]

There has been fierce criticism. The American Psychiatric Association intervened in unprecedented ways to publicize APA Ethics Code 7.3, informally called "the Goldwater rule," which states that "it is unethical for a psychiatrist to offer a professional opinion unless he or she has conducted an examination and has been granted proper authorization for such a statement."[27] It did not emphasize, however, the overarching principle of the rule, which states that "A physician shall recognize a responsibility to participate in activities contributing to the improvement of the community and the betterment of public health" and that "a psychiatrist may share with the public his or her expertise about psychiatric issues in general" when "asked for an opinion about an individual who is in the light of public attention."[27] Furthermore, in March 2017, it reversed its trend of limiting the Goldwater rule over time (at one point it even discussed abolishing it)[64] to expanding it.[29] While it used the Goldwater rule to criticize contact with lawmakers, it failed to mention that APA Ethics Code 7.1, which comes before the Goldwater rule, states, "Psychiatrists are encouraged to serve society by advising and consulting with the executive, legislative, and judiciary branches of the government."[27]

Trump himself pushed back by stating he was a "very stable genius"[65] who has "one of the great memories of all time."[66] White House Physician Ronny Jackson, who was later removed from his position,[67] defended the president by declaring his employer and commander-in-chief "fit to serve" based on a 10-minute dementia screen.[68] Media personality Gina Louden appeared, calling herself "Dr. Gina" and stating in a controversial interview with Sean Hannity that Trump was possibly "the most sound-minded person to ever occupy the White House."[69] The most vocal critic among psychiatrists has been past APA President and Chair of Psychiatry at Columbia University Jeffrey Lieberman, but despite calling Lee and her colleagues' work "tawdry, indulgent, fatuous, tabloid psychiatry" for diagnosing,[70] which they carefully tried to avoid,[31] he was exposed in later reports as having diagnosed the president himself.[71][72]

Silence in the media[edit]

Multiple reporters have noted the absence of discussion of this topic in the media.[73] The role of the media and the American Psychiatric Association have been powerful in shaping public discourse.[30] Whenever mental health professionals would speak to the media, the APA would make forceful public statements until the media could no longer invite them. When Bandy X. Lee spoke about her meeting with Congress members, the APA immediately accused her of "armchair psychiatry," of using psychiatry as a "political tool," and appearing in the media for "self-aggrandizing purposes."[74] Invitations to prominent news programs almost instantly stopped,[75] and the APA's statements gave conservative media the ammunition to target Lee and anyone else who would question the mental health of the president.[76][77][78] Surrounding the National Press Club meeting, Lee and multiple others were invited onto CNN and MSNBC to speak about the event, and all were canceled just hours beforehand, surprising some regular commentators.[79] While trying to procure press coverage, the World Mental Health Coalition learned that half the media organizations believed the Goldwater rule was some kind of law that applied to more than just voluntary members of one psychiatric association among many.[79][80]

The New York Times Editorial Board explicitly shuns psychiatrists,[81] outside the small handful willing to say the president is "just a jerk,"[82] he "does not have narcissistic personality disorder,"[83] or that psychiatrists have nothing to offer the public.[84][54] According to Lee, CNN has communicated a specific policy of not publishing opinions of mental health experts.[54] Mental health experts organized their own event for Mental Health Awareness month.[85] Much of the content of the National Press Club meeting revolved around the need to hear from psychiatrists and psychologists,[48] and recently notable constitutional scholars stated that the 25th Amendment can be "useless,"[86] or at least difficult,[87][88] in the absence of independent mental health professionals' input.

Debate over the Goldwater rule[edit]

Bandy X. Lee and her organization of mental health professionals have made an explicit statement on the Goldwater rule in their defense: "By inflating the 'do not diagnose' part while suppressing the 'educate to better public health' part, the [American Psychiatric Association] created a gag rule that has protected a destructive government. We object to this politicization of psychiatric ethics and placing a public figure (who is not a patient) over public health and safety (our primary responsibility)."[38]

In mental health practice, safety comes before confidentiality, as exemplified by the increasingly important "duty to warn" and "duty to protect" statutes,[89] which have been codified in multiple states, while the Goldwater rule remains a guild rule because of its conflict with the First Amendment.[10] Many consider the Goldwater rule outdated and scientifically refuted,[90][91] given that diagnostic methods have changed entirely since the rule's inception, from being introspection-based to a strictly observation-based system.[92][93] Remote diagnosing has become prevalent with telepsychiatry,[94] and an increasing number of studies show that a personal examination is not necessary for accurate diagnosis.[95] Records reveal that even the APA itself discussed eliminating the rule before Donald Trump's presidential campaign.[96] Resignations and protests from within the APA have been notable,[97][98][99] while an informal poll showed that an overwhelming majority of psychiatrists were in favor of changing the rule[100] and another mental health association (the American Psychoanalytic Association) clarified that its members were not beholden to the Goldwater rule.[101][102] Finally, in June 2018, two APA distinguished life fellows and 20 other mental health professionals submitted a Goldwater rule revision proposal,[103] but to this day the APA refused to acknowledge even receiving it.[104]

Lee argues that the Goldwater rule is not the place to begin, since it is of lesser priority than the Declaration of Geneva, which is a universal pledge considered to be the modern Hippocratic oath, adopted by the World Medical Association.[105] The Declaration clarifies the humanitarian goals of medicine, which implies that supporting a destructive regime, either through silence or active participation, would be a violation of that pledge.[31]

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