Being involved in global violence prevention and dealing with genocides, gender-based violence, civil wars, and suicides, the last thing on my mind was domestic partisan politics. Yet the issue invaded my world the morning after the 2016 presidential election, starting at 8:00 a.m., when my phone was ringing off the hook and emails were flooding in from civil society organizations, patient advocacy groups, lawyers, students, activists, civil servants, and documentary filmmakers — mostly those I had engaged with over prison reform in this country — all afraid of the violence that was to come.
And they were right. In the midst of answering those calls, I had to ask myself: If I have devoted my career to studying, predicting, and preventing violence, could I turn away now, in the face of potentially the greatest risk of violence we could ever confront?
At that time, a former colleague from Harvard, Dr. Judith Herman, had written to President Obama, along with two other brave women, Drs. Nanette Gartrell and Dee Mosbacher, asking that the president-elect undergo a neuropsychiatric evaluation. I started composing letters myself, but those around me, while unanimously agreeing that the situation was dangerous, would not put their names to any letter. They were essentially afraid that they would spend the rest of their careers fighting for their licenses in light of a vindictive, litigious president, or that they may have to fear for their and their family’s lives in light of his violence-prone followers. I thought to myself that this was not good, that we needed to break the ice, and perhaps a conference would do it. Therefore, I organized a town-hall-style discussion with a panel at my institution, the Yale School of Medicine.
Foremost on my mind was ethics—on what basis should we speak (or am I missing something?), and how can we speak ethically and responsibly? There was this ethical guideline we informally call “the Goldwater rule,” which discourages psychiatrists from diagnosing public figures they have not personally examined and received authorization to do so. It is simply a repetition of good standards of practice: you don’t diagnose anyone without a personal examination, and once you have a diagnosis, you keep it confidential. But what was alarming was the fact that the American Psychiatric Association, shortly after Donald Trump’s inauguration, had expanded it far beyond just diagnosing to making any comment of any kind, be it on objectively observable behavior, speech, or affect—even in an emergency—elevating it to a status that no other ethical rule had held before. In other words, it was made into a gag order.
Never mind what history has shown us regarding the obvious results silencing relevant voices has under dangerous regimes. The question we addressed was, if there were a restriction on our speech about a public figure, like a patient (because a public figure isn’t a patient), then shouldn’t there be situations where there is a positive obligation to speak, as with a patient (since even confidentiality, as sacrosanct as it is in psychiatry, has exceptions)? To answer this question, I invited top members of my field, each of whom I had known for at least 15 years and could attest to their exemplary ethical stances from other dark times: Drs. Robert Jay Lifton, Judith Herman, James Gilligan, and lastly, a colleague from my division who was on the American Psychiatric Association’s ethics committee, Dr. Charles Dike.
At the end of the conference, our conclusion was that we had a duty to warn and that the dangers were too great: the public was in the process of believing that the new president was finally “settling in” and about to “pivot” to normalcy. Meanwhile, even though we had held the conference in a large auditorium, the audience did not exceed two dozen—but hundreds tuned in online, confirming that the sparsely populated auditorium was because of fear, rather than lack of interest — and as the meeting received national and international attention, eventually thousands of mental health professionals got in touch with me. I realized that this was unprecedented, that we had a medical consensus not only among those of the same specialty but among mental health professionals globally, and from that arose the National Coalition of Concerned Mental Health Experts, now the World Mental Health Coalition.
Meanwhile, various Congress members began to get in touch with me, and I initially consulted with them privately over the phone. One influential former Majority and Minority Leader said he would like to arrange for me to testify before all of Congress and proposed early September, when Congress would have just returned to session. For various political and other reasons, this did not happen, and both September and October passed.
Immediately after the conference, the publishing house Macmillan had contacted me, when we put the proceedings of the conference into a trade book. When it was released in early October, it became an instant New York Times bestseller—unusual for a multi-authored book of specialized knowledge. It spoke to the public’s hunger for understanding. In the book, The Dangerous Case of Donald Trump: 27 Psychiatrists and Mental Health Experts Assess a President, we warned that his condition was more serious than people assumed, that it would grow worse with actual power, and that he would eventually become uncontainable. By the end, it was on the bestseller list for seven weeks and the Washington Post dubbed it “the Most Courageous Book of the Year.”
By November, when Special Counsel Robert Mueller’s first indictments were released, the president began to show signs of deterioration. Two White House officials got in touch with me about their concerns over his “unraveling,” but with so few mental health professionals speaking up, I did not wish to be confined by confidentiality rules. Hence, I referred them to the emergency room, hoping that this might lead to the recruitment of another psychiatrist. I was unable to obtain information afterward, however, and nothing came of the incident.
In early December 2017, impatient to hear of no movement regarding my congressional testimony, former Assistant US Attorney Sheila Nielsen arranged for me to meet with a dozen Democratic Congress members from her own contacts. I asked Dr. James Gilligan, a foremost violence expert, to join me, and we found that the lawmakers were eager beyond expectation: one senator even stated that it was his most awaited meeting in eleven years! Overall, I was impressed that our country had such seemingly capable and concerned leaders; I was immensely humbled when one of them called me his “hero.” Nevertheless, they said that, while they shared our concerns, they did not feel they could do anything, being in the minority party, but rather looked to us. They stated that they knew of Republican lawmakers who were also very concerned but doubted they would act on those concerns. But even fears that the president would trigger “World War III,” as one Republican senator put it, did not prevent them from rallying behind him when it came time to pass tax legislation.
This is why, in January 2018, when the president tweeted that his “Nuclear Button…is a much bigger & more powerful one” than North Korean leader Kim Jong-Un’s, I gave up on waiting for Republican Congress members to consult with me and took on an educative role for the public. I revealed to the press my meeting with the Congress members, and from then on, for several days, I was interviewing for fourteen hours a day without a break, barely having time to go to the bathroom, and having my first meal of the day at 10:00 p.m. But I put aside all other tasks to attend to this national need, while mental health issues were in the news every day.
However, just as after the release of the book, when the American Psychiatric Association (APA) issued a public statement that there was no “duty to warn” applicable outside of a preexisting relationship with a patient, it now issued a public statement obviously directed at me alone, stating that “armchair psychiatry” and “politicizing psychiatry” were not allowed—even though I did not diagnose but was commenting on public health and was consulting with Congress members according to their own guidelines for public service.
Other outrageous things happened: A former president of the APA, whose words the APA’s public statement seemed to echo, seized all the cable news opportunities I myself turned down to keep the discussion nuanced and blatantly misrepresented the book to accuse it of saying the opposite of its actual content. (He obviously had not read the book.) I had resigned from the APA over ten years ago due to its excessive ties to the pharmaceutical industry, but I was dismayed to find, together with this past president, that it was promulgating misconceptions and plunging the public into further ignorance. Later, a high-ranking officer admitted that it modified the Goldwater rule in order not to lose federal funding. By this time, numerous other members had resigned from the APA in protest of this modification.
As a psychiatrist, I believe there is no greater oppression than the hijacking of the mind. While this has been occurring for at least a couple decades through state-sanctioned propaganda masquerading as “news” (e.g., Fox News), the APA’s control of the flow of information in the name of “ethics,” precisely at a time when mental health professionals are most needed to address a national mental health crisis, attests to the importance of our voice. Thought reform works through the process of “milieu control,” or the control of information and communication in the environment. This is the reason why the mind is considered tyranny’s battleground.
I was inundated with hostile attacks and death threats via Twitter, email, and phone, on some days numbering over a thousand. Like Dr. Christine Blasey Ford, who went into hiding after her testimony against Brett Kavanaugh’s appointment to the US Supreme Court, I too went into hiding for a month, unable to get to my office or to step outside without a disguise. I lost half my hair and gained twenty pounds from the stress. During these times, I drew courage from the asylum seekers that my students at Yale Law School represented; many of them endured watching their family members killed before them, being imprisoned, tortured, and gang-raped — all for speaking up or for being perceived as a political threat. Suddenly, all this was a bit closer than before.
When the threats stopped, however, it was an even greater letdown; it was a sign that our voices had become irrelevant and the powers that be had won. The media continued to cover only the after-effects of the dangers — such as the extraordinary “pipe bomber” who sent sixteen explosives to prominent Democrats and critics of the president, or the deadliest anti-Semitic attack in US history that occurred in relation to conspiracy theories directly traceable to the president—while only worsening the problem for all the fixation on Donald Trump.
Now, a year since I was interviewing with the media every day, I have not earned an income for twelve consecutive months and have depleted all my savings, took off two hours for Christmas and ten minutes for the New Year, and my six-year-old niece and four-year-old nephew have grown so much I barely recognize them. Yet the APA has not transitioned to taking a more responsible leadership role, and a multilateral chorus of mental health professionals has not formed as I had hoped would happen, while the psychological dangers continue to escalate into geopolitical ones.
In the midst of this, the camaraderie and mutual support among many of the authors, the National Coalition, and the public have been indispensable. I will not forget how, when I returned to my office after that month of hiding, I found waiting for me a mountain of letters, thank-you cards, pictures of children, books, chocolate, poems, jokes, stories, and words of encouragement—all from the general public who had heard of the threats I’d received and far more heartfelt than intimidation could ever be. It served as a reminder to me that this is the true voice of the people and is why this work is so important. I hope you will join me in it. ■
Bandy X. Lee, MD, MDiv, is a forensic psychiatrist at Yale School of Medicine. She has consulted globally and nationally on violence prevention and prison reform. She has an extensive publication record, including opinion-editorials, peer-reviewed articles and chapters, and fifteen edited books including the New York Times bestseller The Dangerous Case of Donald Trump: 27 Psychiatrists and Mental Health Experts Assess a President (Macmillan, 2017). She has most recently authored the textbook Violence (Wiley-Blackwell, 2019) and does clinical work in correctional and public-sector settings.