BY MATTHEW PETTUS
Dr. Lee is a distinguished psychiatrist and expert on violence who has written books and held conferences on the mental health and stability of President Trump. Her actions throughout 2017 have subsequently created opposition from political and psychiatric professionals regarding the proper interpretation of the Goldwater Rule (a section of the APA’s Principles of Medical Ethics, that states it is unethical for psychiatrists to give professional opinions about public figures for whom they have not closely analyzed in person). Despite this opposition, Dr. Lee has significantly progressed this movement toward highlighting President Trump’s mental instability, by citing the dangers that a mentally unstable world leader could engender. Moreover, this brings about an important conversation regarding the perception of mental health in politics and society, as well as mental health as an epidemiological or global health issue. Dr. Lee clarifies that she speaks for herself and not for her division, department, or Yale School of Medicine.
How has your academic and intellectual experience contributed to your work today?
To give you some of my background, I am a forensic psychiatrist—a psychiatrist who works at the interface of psychiatry and the law—and a specialist in violence prevention. I started by treating violent offenders in jails and prisons, then designing violence prevention programs for them, and finally I was involved in prison reform and advising policy for several state governments. I also consulted with the World Health Organization’s Violence and Injury Prevention department, and for the last seven years have been leading a project group on violence prevention for researchers and implementers or policymakers. My work was largely global, and I had been teaching Immigration Legal Services at the Law School and Global Health at Yale College, and so I was never very interested in domestic partisan politics before. What woke me up was my phone ringing off the hook, and emails flooding in, beginning at 8 o’clock the morning after the election of 2016: civil society organizations, patient advocacy groups, students, lawyers, activists, documentary filmmakers, and staff from state governments were contacting me—all from fear of the violence that was to come—and they were right. I had to consider, if I have devoted my entire career to studying, predicting, and preventing violence, do I stop before the greatest risk of violence the human species could face? The answer was obvious to me. I never thought that I would become so central or that it would take so long, but I somehow had the right background for it: assessing risk, understanding violence, applying public health principles, working around the Goldwater rule—I had to consider this as a forensic psychiatrist who is frequently asked to diagnose minor public figures in court, for example, and I always kept with the rule—and serving as an expert consultant to Congress members. Forensic psychiatrists are trained to maintain boundaries, to comment only on areas of their expertise, and not to get involved in legal or political decision-making; these boundaries are what make it possible to serve as expert “witnesses” presenting objective evidence for cases that involve adversarial disagreement.
What do you believe the role of mental health is in global and public health, specifically in terms of politics?
Certainly, mental health has a greater role to play than it has. Psychiatry has traditionally been very focused on the individual, and I value person-centered care and the intimate meeting of humans as its unique strengths. However, knowledge gained about human beings in these ways could contribute greatly to a larger social, cultural, and society-level conversation, and I have written about this far before the current situation. Now, however, the need has become urgent, and there is an enormous amount of educating to do, since there is little awareness about the influence of psychological dynamics in society, or even that mental health issues are real. The political realm should not be immune, since there is no rule that says mental health problems stop at the office of the president, or whomever. Rather, the stakes are increased multifold if the same issues affect someone with great influence and power, now to mention the sole authority to launch weapons that are capable of destroying the world many times over. Like the rest of medicine, mental health has at its core the mission to prevent deaths and to save lives, and to improve the lives it saves. Like the rest of medicine, it has a duty to individual patients as well as to society, to extend care as well as to improve conditions in ways that prevent illness and suffering.
Global health and global psychiatry have definitely brought awareness. For example, core mental disorders remain consistent throughout a wide range of societies, but attempting to describe them through the lens of white, middle-class North American and European cohorts, however, leaves 80 percent of the world’s population with an “atypical” presentation. Without cultural knowledge and interchange among society, we would miss all these. We have seen the isolation that comes from dubbing “posttraumatic stress disorder” an individual problem in the context of wars, conflict, and migration. Without understanding it as a societal problem, the way many cultures do, we could miss the opportunity to be helpful. Worldwide, as mental disorders have become the leading cause of disability, we could not meet the growing demand for psychiatry without addressing the problem with cultural sensitivity and at population levels, using public health methods.
I personally have applied knowledge of mental health to policymaking rather than politics. There is a lot one can do in terms of preventing violence, for example. Now, violence has nothing to do with mental illness, even though mental health professionals deal with both. It is important to note that mentally ill individuals are no more violent than the general population and are more likely to be victims than perpetrators of violence, while most violent individuals do not have a diagnosable mental illness. Rather, I often use violence rates as a measure of the public mental health of a society, a social “mental disorder,” if you will. We know, for example, that the election of an impaired leader is not unrelated to the generally poor state of public mental health, which made such a leader attractive. How did this state come about? Through poor distribution of mental healthcare, education, and material resources—all of which affects the psychological health of the population. We have empirical data for this: structural violence, or inequality, is the strongest predictor of violent death rates, which again I consider to be a measure of a society’s health. This means that changes to public mental health, and prevention of disease, are best made through policy. By not addressing policy as a health issue, we have allowed governments to continue to institute policies that harm public health, until we have arrived at this critical state.
In your opinion, how does President Trump’s position in society pose a public health risk?
As you know, the Bulletin of the Atomic Scientists moved the hands of their “Doomsday Clock” closer to midnight. The clock is now the closest to the symbolic hour of apocalypse as in 1953, at the height of the Cold War. The direct reasons that the Bulletin’s president (https://thebulletin.org/sites/default/files/2018%20Doomsday%20Clock%20Statement.pdf) cites are: “reckless language in the nuclear realm [heating] up already dangerous situations [and] minimizing evidence-based assessments regarding climate.” Additionally, the Bulletin’s statement notes: “This is a dangerous time, but the danger is of our own making.” We can speak of the various ways in which Mr. Trump in the office of the presidency poses a public health risk: the unprecedented spike in hate crimes that continue to this day, the widespread schoolyard bullying that is done in his name, the escalating rates of gun deaths since his campaign, and the doubling of white supremacist killings, not to mention the changes in international norms regarding nuclear proliferation. Additionally, the American Psychological Association reported that the nation is experiencing its lowest state of psychological wellbeing in memory, but the threat of a nuclear Holocaust, of course, is our greatest and most imminent fear—and a very real one, as anyone who understands Mr. Trump’s psychological patterns could tell you.
If he were not President, would Trump still be considered an exception to the Goldwater Rule, as you have previously called him?
I actually do not consider that we are making an exception. We are calling him dangerous, which is more a description of the situation than a diagnosis of the person. Therefore, yes, it certain that he would be far less dangerous in a different situation of not in charge of the nuclear codes. We are not making an exception to the Goldwater Rule, as it is still possible to warn the public without making a diagnosis. However, you are right in that we generally break confidentiality and consent to respond to emergencies, as when an individual poses a threat to others or the public: health professionals are legally authorized, if not mandated, to report, to warn, and to take steps to protect potential victims, and to assume this as first priority in the interest of safety. We also may not choose whom to take or not take as a patient in an emergency. By parallel, we should also be permitted to break the Goldwater rule when the health and safety of the public were at stake. In fact, this exception is written into the rule by virtue of the principle it falls under.
How would you reconcile the Goldwater Rule with the political idea, “duty to warn”, and the medical contract, the Hippocratic Oath?
I believe it is important to keep with the Goldwater rule other than in an emergency, and even so, to keep focus on the public figure’s personal mental health to a minimum. In this way, I am a strong proponent of the rule. In this instance, I am mainly concerned about going against even the principle of the rule to silence a profession. Not so distant history tells us about how tragic that can be. In early twentieth-century Germany, sociologist Max Weber argued in a paper, “Politics as a Vocation,” that intellectuals should not utter any political opinions or say anything that could remotely be regarded as partisan. This became a precursor Goldwater rule for all intellectuals. As we know, under Nazism, not only psychiatrists but most German clergymen, professors, lawyers, doctors, and other leading thinkers became passive enablers of some of the worst atrocities under a dangerous political leader who led their country into the worst disaster in its history. The World Medical Association issued its Declaration of Geneva after the recognition that either silence or active collusion with a destructive regime run contrary to the humanitarian goals of medicine. These goals echo the principles underlying the APA code of ethics, the ethical code of American Medical Association, and the Hippocratic oath.
How would you evaluate the APA’s statement that psychiatry should not be used as a political tool?
I absolutely agree and call on the APA to comply by it! The dangers of turning a reasonable rule into a silencing mechanism, without members’ input and against their protest, and in ways that run counter to medical ethics should be obvious: in this case, it even contradicts the ethical principle it falls under. Many believe its actions are politically-driven in unethical and possibly illegal ways, and dozens of members have resigned, now including high-ranking officers of the APA. Basically, on March 16, 2017, two months into this administration, the APA issued a three-page reinterpretation of the Goldwater rule (https://www.psychiatry.org/newsroom/news-releases/apa-reaffirms-support-for-goldwater-rule) in unprecedented ways, without scientific or ethical basis. In fact, the science goes in the opposite direction, and before this administration, the APA treated the rule consistently with scholarship: as an obscure rule on its way out. All of a sudden, its new interpretation required that we counter the principle the rule falls under, and even the rule itself as it is written in the code. Basically, we are not just prohibited from diagnosing or giving a full professional opinion without all the information, but commenting in any way on any aspect of a public figure’s plainly expressed emotion, speech, or behavior, including in an emergency.
I resigned from the APA over a decade ago because of its growing ties with the pharmaceutical industry. Much corruption has resulted from this, undermining the profession’s reputation as well as its science and actual treatment efficacy. I was initially surprised that the APA would take the stance that it did with this administration and I assume in response to the influence of our book, The Dangerous Case of Donald Trump,which we wrote as a public service, donating all royalties to public health, and which became an instant bestseller—I believe as a result of the thirst on the part of the public. But I guess it is in line with the reasons for which I resigned. It also receives federal funding, which some insiders have cited to me as a reason. I am still very disappointed, since I take ethics seriously, and the APA is supposed to be setting guidelines for the entire profession, not just APA members. I believe that membership protest and the profession’s correction of its own guild is a healthy sign, necessary to prevent corruption and the use of psychiatry as a political tool. The American Psychological Association, during the Iraq War, went against members’ protests to modify its own ethical guidelines under political pressure, allowing for psychologists to design and participate in torture—and see what scandals have resulted.
Applying psychiatric knowledge to the political realm, on the other hand, can be done responsibly and should be done in public service, according to our ethical guidelines. In legal settings, forensic mental health professionals are frequently employed as expert “witnesses”, as I said earlier, and our findings are considered as evidence. The same can apply to branches of the government. Rather than medicine or psychiatry becoming politicized by entering the political realm, the influence can and should be the other way around: medicine or psychiatry, as scientific fields describing natural phenomena, have the ability to serve as a neutralizing ground for politics. Experts speak about medical matters only and do not venture into areas outside their expertise, such as in political decision-making. Politics itself should modernize to become more evidence-based, focusing on problems and effective solutions that have been proven, rather than following power or partisan struggles, and experts can help with this. Ethical guidelines actually instruct that we be of public service in this way, by consulting with the various branches of government. Unfortunately, there has been a conflation of this with the politicization of psychiatry, when the field itself makes a clear distinction—due to what I can only describe as a misinformation campaign by a past president of the APA, who should have been denounced as ignorant but was instead backed by the APA itself.
If President Trump were to undergo a mental health exam, what implications would the results of that examination have for the political world?
First, there are two exams we have been recommending: a neuropsychiatric evaluation and a capacity evaluation. The first regards Mr. Trump’s mental health condition and is his private affair, which he can choose to reveal or not. The second assesses his ability to function mentally in his office and is a different evaluation than that which is done for diagnosis and treatment. Usually the latter is the domain of forensic mental health professionals and should not be carried out by the treating physician. Psychiatrists or psychologists would do a standard evaluation of capacity fitted to the function or job, and then turn over the results to a legal, or in this case political, body, since issues such as incompetence or disability are legal decisions, not medical ones. However, the mental health expert’s role is important, as the legal, or political, bodies recognize that it is an area that requires the input of an “expert” and for the most part cannot be decided upon by non-professionals’ impressions alone. Of course, this is an available resource, which we strongly recommend, but not a required one, and even after experts have done the evaluation and made their recommendations, whether or not to make use of the results is entirely up to them. Hence, it may have no effect at all.
Nevertheless, the president, who has the ultimate responsibility for the use of the most dangerous weapons in the history of the world, and who has the sole capability to murder millions of people in an instant, should undergo a proper evaluation. A 10-minute cognitive screen is not a comprehensive exam, and nor was it even necessary for a 71-year-old who has demonstrated multiple psychological, cognitive, and neurological signs of serious impairment. What was in order was a comprehensive neuropsychiatric examination, scans of the brain, and a capacity evaluation. The Department of Defense has established reasonable procedures and precautions since 1993 to ensure that personnel who handle nuclear weapons are evaluated and monitored on a continuing basis. It seems reasonable at least to apply the same standards to the commander-in-chief who orders them.
Lastly, how do you think the role of mental health should be incorporated into the definitions or disciplines of global health and policy?
This is something I have been working on informally since the very moment I joined as a consultant to the World Health Organization, with its launch of The World Report on Violence and Health in 2002. Now as a leader of a project group for their Violence Prevention Alliance, I work in collaboration with many different disciplines, service sectors, and government officials to illustrate how mental health plays a role in nearly all domains of human affairs. I outline some of this in my upcoming textbook with Wiley-Blackwell, Violence: An Interdisciplinary Approach to Causes, Consequences, and Cures. We are discovering, even in areas such as political science and economics, that we cannot simplify human beings into rational actors, for example. Some sections of these fields have indeed dramatically changed their position from excluding any psychological aspects from their equation to giving them great importance. When I outline effective prison programs or the effects of social and economic policies on violent death rates in a society, a lot will be missed without applying the principles of mental health under the ecological model—and the reverse is true, of course. Recognizing the role, large or small, of psychological dynamics in all human affairs will allow us to deal with it better, rather than minimizing or denying its existence. This also applies to the domains of global health and policy. How to do it? For now, by including mental health professionals, just as we do epidemiologists, sociologists, anthropologists, economists, and political scientists, into the discussion—and mental health professionals should not be shy about sharing their special knowledge, either.
Yale Global Health Review 