Can we stop 'diagnosing' Trump?

American mental health professionals are undertaking a campaign to have the mental health of President Donald Trump assessed with a view to his removal from office. In a video published to social media yesterday, Dr. Bandy Lee, a forensic Psychiatrist at Yale University claims that President Donald Trump’s personal characteristics make war with nuclear weapons “a serious risk”. Earlier this year Lee and colleagues published a book “The Dangerous Case Of Donald Trump: 27 Psychiatrists and Mental Health Experts Assess a President.”

"The psychiatrists and psychoanalysts attempting to use their position to unseat a harmful public figure risk reducing mental health concerns to a slur... Assessing danger is different from making a diagnosis."

She and a group of colleagues in psychiatry and psychology “concerned for the safety and survival of humankind” call for an emergency psychological evaluation “just like any other military officer or civilian serviceperson.”

The psychiatrists and psychoanalysts attempting to use their position to unseat a harmful public figure risk throwing people with mental health difficulties under the bus, reducing mental health concerns to a slur and sowing doubt about the motives of the psychiatric professions in the minds of the public.

Higher duty?

Implicit in the position of Lee and colleagues is the assumption that their professional standing will make a more convincing case than any other ethical, moral, political or legal case for the removal of Donald J Trump from office. Lee has argued against the Goldwater Rule, the principle that precludes mental health professionals from speculating about the mental health of those they do not treat stating that in the case of Trump there is a higher duty to warn.

Speaking of why she and colleagues think Trump is dangerous, Lee says: “The signs are numerous. Just a few examples include verbal aggressiveness, history of sexual assault, incitement to violence at his rallies, attraction to violence and powerful weapons and taunting of hostile nations with nuclear power... Impulsivity, recklessness, paranoia, a loose grip on reality where real consequences matter little, a lack of empathy for others and a constant need to burnish a sense of power to fight inner feelings of worthlessness.” [Editor's note: Donald Trump has not been charged with sexual assault or incitement]. 

"Trump’s policy agenda, his casual dismissal of the concerns of those of ethnicities other than white, his war on affordable healthcare, his chaotic approach to foreign affairs, his kneejerk racism, sexism and animus against women, trans people and people of colour all effect mental health."

Lee justifies this position by likening it to more usual medical moral obligations: “When we see someone having a heart attack in the street we cannot just walk away we have to treat the person as a patient, even without consent,” she says in the video. “The equivalent in psychiatry would be seeing someone behaving erratically in an airport or on a subway, when someone could get hurt.

"We have a duty to report, a duty to warn and a duty to protect when someone is a danger. Assessing dangerousness is different from making a diagnosis. In fact a diagnosis is irrelevant when someone is dangerous. We need to contain them, remove them from access to weapons and fully evaluate them.”

It is a legitimate extension of the duty of psychiatric professionals to consider and advocate for policy and conditions that aid the health and wellbeing of their patients and contribute to the mental health of the population at large. Trump’s policy agenda, his casual dismissal of the concerns of those of ethnicities other than white, his war on affordable healthcare, his chaotic approach to foreign affairs, his kneejerk racism, sexism and animus against women, trans people and people of colour all effect mental health.

Risks and rewards

It is not incompatible with professional ethics to make political recommendations. Mental health professionals in the UK have had similar dilemmas around the impact of austerity policies on the mental health of the population and have come to a range of collective and individual conclusions. It is more risky to directly advocate for the removal of a President.

While Lee is at pains to point out that this is not about diagnosis; the nuance of that position is likely to be lost on the general public. We know that Trump and his supporters are not above the use of mental illness or disability as slur. We also know that Trump has a history of using phrases like ‘nutjob’ or ‘mentally sick’ to describe those with whom he disagrees. Why should those who are supportive of Trump see what Dr Lee and colleagues are doing as any different to this offensive mudslinging? It is easy to imagine that mental health as a public concern may come off worst in the interaction, legitimised as a weapon used to discredit opponents, its practitioners suspect, the needs of people further ignored.

The American Psychiatric Association reviewed and updated its position on the Goldwater Rule this year stating: “Patients who see a psychiatrist, especially their own psychiatrist, offering opinions about individuals whom the psychiatrist has not examined may lose confidence in their psychiatrist and/or the profession and may additionally experience stigma related to their own diagnoses... Basing professional opinions on a subset of behaviour exhibited in the public sphere, even in the digital age where information may be abundant, is insufficient to render professional opinions and is a misapplication of psychiatric practice.”

Lee and colleagues have observed the same difficult-to-believe events, the same objectionable behaviours and the same offensive and worrying statements as the rest of the world. They are taking this action because they do not believe that established set of checks and balances will prove sufficient to limit the damage Trump may cause. In doing so are taking a gamble not only with their own professional standing, but with that of their profession and the people who may need its help.

We have been working hard to break the link in the public imagination between 'mad' and 'bad' and to establish the right of people who experience mental health difficulty to the best possible life. Trump, on the evidence of his own actions and own statements is morally reprehensible: psychiatric language does not increase the power of that judgement.

Trump can just be bad, without his mental health entering into our assessment. Exceptional times may well require exceptional actions. The actions of Dr. Lee and colleagues walk a fine line between professional arrogance and bravery. The possession of good motives does not preclude you from malign results. The worry is that people who experience mental distress and mental health difficulty might be the collateral damage in this very big war for the future of the United States and the world.

Mark Brown writes extensively on mental health and is the former editor of 1 in 4 magazine, created for and by people with mental health needs. @markoneinfour