A Funny Thing Happened on Our Way to Alerting the Public …

… About one of the greatest mental health emergencies in the history of this nation.

We would not even have thought twice about it: we see a danger, and we report. For a danger as great as a threat to all human civilization, especially in a public servant who is in place to protect the people, of course the public had the right to know. Every mental health professional assesses danger, in every person one sees, every day, and passersby on the street are not exempt, as we have a professional duty to respond to emergencies. Having devoted decades to studying and treating violence-prone individuals almost identical in presentation to the president, I believed I had an extra advantage in recognizing the dangers, and hence extra responsibility. But it did not take a specialist in violence to see what I saw: many of my colleagues felt the same way. I thought, therefore, that if enough of us spoke, our professional organizations would help consolidate our message.

The opposite happened. One among many mental health organizations and the only one to have the so-called “Goldwater rule,” the American Psychiatric Association (APA), came out with a surprising “reaffirmation” of this obscure rule that many psychiatrists had not even heard of, since it was considered outdated since the 1970’s and all but invalid since 1980 when our diagnostic system entirely changed. We went from diagnosing based on introspection to observation around this time, and reliance purely on interviews gave way to depending heavily on others’ reports. I still respected this rule, for it had an underlying purpose — public health — and a place in the larger context of ethics. However, the APA, digging out this informal “rule” (clarified as a “principle” in the actual code), created a new gag order: this time, it prohibited not just diagnosis but any comment whatsoever on a public figure, and elevated it to a status no other ethical guideline had ever enjoyed —that is, there were to be no exceptions, even in a national emergency. This meant that, in order to keep with the absolute prohibition, we would have to violate the ethics code of the American Medical Association (AMA), the universal pledge of the Geneva Declaration, and the Hippocratic Oath — to protect a public figure!

A public figure is not our primary responsibility. The preamble of the AMA code specifies that we have a “responsibility to patients … as well as to society,” and while public health is one of our primary duties, we have no obligation to a public figure other than as a part of our duty to public health. Yet the APA effectively played on the public’s mistaken impression that psychiatrists treat patients only in private offices and eliminated our public health role, while elevating the public figure to patient status, making “the Goldwater rule” seem as binding as patient confidentiality (yet it also tried to have it both ways: it permitted no “duty to warn” in the case of danger, stating that there is no patient-provider relationship in this case; but if it had not eliminated our societal responsibility, it would have been a primary duty, not an exception as with a patient!). Most laypeople now believe “the Goldwater rule” is the law, when it is arguably against the law, as it conflicts with the First Amendment of the U.S. Constitution. I was shocked to learn thereafter that the APA receives federal funding, which obviously compromises its private status, and the CEO even admitted in a closed meeting that the change of rules was to protect its federal support.

This was still in March 2017. Now I know that to bank on power over truth is a typical response under this administration. But before I witnessed Attorney General William Barr’s getting ahead of the messaging through a media campaign, violating legal norms and ethics, when he was supposed to represent the law, to side with power (he misrepresented Special Counsel Robert Mueller’s report in April 2019), I did not know this was possible. I did not know that a professional organization could seize control of the messaging through a media campaign, violating its own professional norms and ethics, when it is supposed to represent the profession, to side with power. A political compromise from the start (entered after psychiatrists commented on Senator Barry Goldwater’s presidential bid in a way that contributed to his landslide loss), the eponymously named “Goldwater rule” was bound to be politically abused.

The APA’s actions can be personified in one figure, a past president of the APA, whom I will call Dr. L—. I first encountered him when he forced himself onto a panel that was planned months ahead of time, which he apparently believed he could do because he was chairman of the department. A senior colleague and I were to speak, and never in my 20-year career had I met or imagined a chairman who would so brazenly impose himself on the day of a panel to which we were guests, without even notifying us, seemingly bulldozing over the two thoughtful, younger woman organizers who apologized to us profusely. The disrespect was already very telling, but he increasingly revealed himself a professional counterpart of the president he would avidly defend. He presented himself as a paragon of ethics but knew nothing of what was in the book he scathingly criticized: The Dangerous Case of Donald Trump: 27 Psychiatrists and Mental Health Experts Assess a President, a collection of essays in which we had compiled the concerns of some of the most upright mental health professionals in the country who had spoken up fearlessly in other dark times. Since he was relying on the impression that we broke “the Goldwater rule” when we had not, at least in its original conception, he got everything wrong and was humiliated before a large audience. News of his blunder traveled up and down the coast among psychoanalytic societies, and I even received messages, apparently in glee, from those I do not know: “You demolished him!”

Some trace Donald Trump’s bid for the presidency to the 2011 White House Correspondents’ Association dinner, when he became the butt of jokes by President Barack Obama and “Saturday Night Live” comedian Seth Meyers. Humiliated by the experience, he swiftly left the dinner in a dour mood, and many who observed him said it seemed to trigger some deep yearning for revenge. “That evening of public abasement … accelerated his ferocious efforts to gain stature in the political world,” the New York Times wrote. I trace Dr. L—’s crusade against us and our efforts to the humiliation he suffered that October 2017 evening on the panel at the Uris Auditorium of Weil-Cornell Medical College.

Dr. L— went on to write five or six articles “doubling down” on his thesis, accusing us of being akin to Soviet or Nazi psychiatrists, which was ironic, given the kind of experiments he had performed. Obviously still not having read the book, despite this having been the reason for his public embarrassment, he missed that I, together with Dr. Judith Herman, explicitly state our purpose for dissenting against a destructive regime was to avoid being like the Soviet and Nazi psychiatrists, who became agents of the state. Still more ironically, he failed to notice that the author of our foreword — Dr. Robert Jay Lifton — was none other than the psychiatrist renowned for his documentation of Nazi doctor atrocities! As Dr. L— made rounds on the very television programs we ourselves declined, misrepresenting its contents as their opposite, he called our book “not a serious, scholarly, civic-minded work, but simply tawdry, indulgent, fatuous tabloid psychiatry,” when, if he had even opened the book, he would have known that all the great luminaries of the field, renowned and highly respected for their scholarship, were in there. Or perhaps he was jealous not to be included, as he intently presented himself as exemplary above all for keeping with “the Goldwater rule.” Yet, barely a month before the panel, he had diagnosed the president — and was among the only two psychiatrists I knew who have (the other was Dr. Allen Frances, who curiously has not been targeted despite explicitly breaking the rule, since his diagnosis favors the president). Nevertheless, we, who never diagnosed but merely pointed out danger signs and the need for an evaluation, were the only public targets of accusations because of these misrepresentations. And Dr. L—’s irresponsible words left an impression enough for White House doctor Ronny Jackson, who is removed from his position after questions of medical malpractice arose, to repeat them when questioned about us.

Still, the public was listening, and the media responding with great interest and thoughtfulness. By January 2018, when the president was highly unpopular with the public and threatening North Korea, media inquiries swelled into 15 hours of interviewing, every day, and invitations came in from all the most prominent prime time programs on CNN, MSNBC, network television, and even Fox News. I made the mistake of hesitating about any interview that was only a few minutes long, believing that the delicate nature of the topic could easily be distorted, and that a more nuanced buildup would be preferable to a sensational burst. But these are the very programs that Dr. L— seized upon, riding on our reputation to appear and then bludgeoning our message to gain publicity for himself as an “ethical” psychiatrist.

What I thought would be a prolonged public discussion came to a screeching halt when the APA put out an astonishing accusation of “armchair psychiatry,” of our using psychiatry as a “political tool,” and our doing so for “self-aggrandizing purposes” (the irony of these descriptions is that they are in violation of the APA’s current rule that prohibits not just diagnosis but any comment whatsoever, without exception, on public figures!). This was coupled with an extraordinary article by the New York Times editorial board stating that psychiatrists had nothing to offer the public and should not comment on the president, while publishing a lengthy companion editorial by Dr. L— stating that Donald Trump was “just a jerk” and therefore not much to worry about. What kind of newspaper determines what experts should and should not say? These are boundaries determined within the areas of expertise — yet it was clear who directed the newspaper, as clear as it was who shaped the messaging from the APA. In a “tweet” just a few days earlier, Dr. L— had said that it was “pathetic” of members of Congress to “exploit” a “naïve misguided psychiatrist for partisan political purposes,” referring to me, as he added: “maybe Dangerous Case will get her promoted.” I could recognize the source of the APA’s wording in terms of using psychiatry as a “political tool” and for “self-aggrandizing purposes” from his peculiar views (which seemed projection, since it had never occurred to us that we would gain anything other than risk our careers and possibly even lives if the situation truly worsened). The APA even repeated his error: not having forensic expertise, Dr. L— confused expert consultation with government (which I, as a forensic psychiatrist, do all the time) with politicization of psychiatry. The APA guidelines explicitly state, even before “the Goldwater rule,” that psychiatrists are “to serve society by advising and consulting with the executive, legislative, and judiciary branches of the government.” And that was exactly what I had done, independently and without political motive or anything to gain.

In sum, the New York Times, coupled with the APA’s actions, largely set the tone for the rest of the media, which adopted formal and informal policies not to air mental health experts. Several opinion pieces by myself or colleagues were accepted and then denied publication once they found out we were mental health professionals. Newspaper journalists, including for the New York Times, would include our quotes, only to find them selectively removed by editors. Producers invited me to over 50 programs, only to have them cancelled before appearance 100 percent of the time (now they no longer bother to invite, knowing that it will inevitably be blocked). Meanwhile, the public hunger that made our book an unusual New York Times bestseller — such that one of biggest publishers in the country took five weeks to replenish stocks in ways that would not run out in hours — only grew. Pleas for us to speak more poured into our web site as the president’s disturbances worsened and the public health consequences became more dire. In March 2019, when we had our interdisciplinary panel, with 13 national experts from all different fields, to discuss how the president was unfit from each of their perspectives, no news outlet would cover us, citing “the Goldwater rule.” It did not matter that none but one of the panelists was a psychiatrist — the APA’s public campaign had worked: its gag order had turned into a household phrase and was now taken to be universal.

On a side note, something curious happened in the summer of 2019, at the height of controversy over the president’s mental health after “Sharpiegate”: going back perhaps five or six months, all articles that cited me and my colleagues —around two dozen in outlets as varied as the Boston Globe and HuffPost, news web sites, and a popular video op-ed site were all altered to have the words “eminent”, “renowned”, and “top” uniformly removed before the word “psychiatrists” or “psychologists”, apparently to make us seem less significant. Some articles were several months old and had not changed before this incident, making it obvious that it was not the editors’ immediate decision. The reporters had not even been aware of the change and were as astonished as I. The video op-ed site had recorded a video of me around this time, but unlike the previous three, which were released within a couple weeks, this one would not be published for another four months: it was my comment on the APA’s manipulation of “the Goldwater rule.” Only after I badgered the group about it, did it finally publish the video, but only after leaving out my most important point, and maneuvering the order of my statements so that my approval of the original “Goldwater rule” comes last instead of first, appearing as if I am in approval of the new rule. This is not North Korea! was the first thought that entered my head in response. I asked directly if the APA had been in touch with them, and they could not even answer “no” but seemed in some kind of bind. This incident made me suspect all the more that the APA or Dr. L— may have been involved.

Regardless of whether or not that was the case, in March 2020, as people are tangibly and quantifiably losing their lives as a direct consequence of the president’s mental incapacity and mismanagement of the most serious pandemic in years, all is traceable to the interventions of the APA and Dr. L—’s personal crusade. The attention to mental health that was natural in January 2018, when dozens of Congress members were contacting me and much of the public was still able to listen to us, seems no longer possible now. Back then, it was a matter of course for news programs to invite mental heath experts to comment on a mental health issue, and much of the public was listening. Now, we have not only systematized the exclusion of expert commentary, but normalized the president’s pathology without comprehending how dangerous this could be. As in any autocracy, the most needed, relevant truth is the first to be suppressed, and while the president busily turns much of the government into a group of personal henchmen who are preparing to go after anyone who shows “disloyalty”, with additional hired “sting operations” for groups outside the government’s reach. His supporters are largely programmed to worship and to follow him, even as they march toward likely widespread deaths following his instructions not to heed experts or warnings about the pandemic. It is therefore after two years, in the face of a public health crisis as we had warned against since the beginning, that I am able to recount the funny but tragic event that happened on our way to alerting the public.

Addendum (11/24/2020): Dr. L— made clear in his public statements that he considered me to be “undistinguished” and insignificant. However, on a television program, when historian Michael Beschloss pointed out that my book contained “the most eminent psychiatrists” on the planet, he responded: “They’re not that eminent.” It took me a very long time to decipher this strange statement about obviously highly respected psychiatrists, but perhaps all the lying, reversing the content of our book to the public, and calling psychiatrists whom others refer to as “the greatest living American thinkers” “not that eminent” may indicate that he was jealous! After all, I never reached out to him to be included in the book — despite his having actually diagnosed the president — never would have conceived of him as eminent or especially respectable, and he himself was never called upon by Congress!

What leads me to this possibility is the fact that the American Psychiatric Association, too, “doth protest too much.” If ethical or scientific correctness were truly its goal, it would recognize the inconsistencies in its reasoning and admit its error, in the service of integrity, justice, and truth. However, two recent letters to the editor give me little hope: one is to the Washington Post by the president of the APA, and the other is to USA Today by the CEO of the APA. Their “doubling down” on their indefensible rationalizing and almost delusional-level mental acrobatics to justify an unjustifiable position reveals the institution’s priorities — being the same institution that once appointed Dr. L— president. Like any guilty party, it does not flinch at its casualties, even the 250,000 Americans who perished in the hands of a mentally-impaired U.S. president, whom it did everything to help.

Forensic psychiatrist, violence expert, president of the World Mental Health Coalition (worldmhc.org), and editor of "The Dangerous Case of Donald Trump.”

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