At the Close of Mental Health Awareness Month, the Mental Health Emergency of the President has Gone Unaddressed

As Mental Health Awareness Month draws to a close, the most major national mental health emergency has still gone unaddressed. I am speaking of the mental health, or lack thereof, of the president. It is a mental impairment that has been deadly through action and inaction, with just one aspect causing at least 36,000 deaths and which is now fueling a nation’s flames.

That the mental health field has been silent is unconscionable. A prominent psychiatric association campaigned not just to protect a public figure against public safety, but stopped independent psychiatrists from trying to fulfill their duties. It used its clout to silence not only its members but all psychiatrists and, through public campaigns, all mental health professionals. But if professionals are not allowed to do their independent thinking, then who in society is?

We know from the pandemic that the exclusion of expert input can be deadly. And before there was a viral pandemic, there was a mental health pandemic that the Trump presidency is acutely exacerbating. Renowned forensic psychiatrist Dr. James Gilligan, examining trends in violent death rates in the U.S. over more than a century, concluded that the Republican Party was a significant contributor, enough to be called a “party of death.” A rigorous empirical study ruling out other possible explanations still showed party effect: violent death rates roughly doubled under every Republican president and halved under every Democratic president, with few exceptions, over 110 years of U.S. history.

When we are no longer speaking of mere ideological difference but life and death, we are entering the realm of pathology, and all bets are off: we need experts. Lay pundits, no matter their good intentions, will only facilitate pathology by interpreting the abnormal in terms of what they know, which will underestimate and normalize the problem. Meanwhile, pathology will do what it always does: promote greater damage and death, regardless of the crisis at hand. The nature of mental pathology complicates further: it is highly efficient at subverting the order of real and unreal; at garnering irrational, fervent support; and at subsuming the institutions intended to contain it. Unless severe limits are set, such defects invite sycophancy, corruption, and widespread destruction, while leaving no chance for the rational. These familiar dynamics for the specialist will inevitably catch the public and the political actors off guard and leave them defenseless.

In this context, I would like to urge that the mental health field have more mental health awareness — especially the field of psychiatry. It could have more self-esteem, so that it may more resolutely represent its own ethical and practical standards. It does not have to adopt an extreme, ideological biological psychiatry, for example, to cater to the pharmaceutical industry, in contradiction to the bio-psycho-social perspective of our own training (only in strict biological psychiatry does nothing outside of a personal examination matter). It also does not have to protect an impaired president so as to preserve its federal funding (only as a psychiatric arm of the government does it need to prioritize protecting a public figure over protecting public health), and have it revealed later that a government that uses its purse to censor science has handsomely rewarded it.

It does not have to get mired in circular arguments: such as that we cannot offer mental health information because the 25th Amendment is a political process, which, in turn, allows those in charge to say the political process cannot be initiated because the mental health data are lacking. It does not have to give similarly absurd excuses: such as that we should not comment because we, as experts, cannot know anything without a personal examination, all the while claiming that the public has everything it needs without expert knowledge and without personal examination. It would not have members claiming they are the epitome of ethics for not diagnosing, while in the same breath offering a diagnosis that is favorable to the president — as if the intention of protecting the president could not be made clearer.

The self-consciousness is understandable. Coming from a family of doctors, I myself was exposed to it. My uncles would ask me: “A surgeon does a lot but knows very little, and an internist knows a lot but does very little. But a psychiatrist knows little and does little. Are you sure you wish to be a psychiatrist and not a surgeon?” It was a joke about psychiatry among the other specialties, and even my affectionate uncles were teasing me over it.

While I feel well-rewarded for pursuing a field that fascinated me, it points to an even greater need not to retreat. All studies point to the source of stigma as a lack of education. The psychiatric field, by silencing its members for fear that psychiatry might be looked upon unfavorably, instead of taking its rightful position among the medical specialties, has made matters worse.

Far from enlightening the public about what constitutes rigorous science, it accepted the popular but scientifically unfounded distinction between physical and mental health, whereby the former is real and the latter imaginary. Mental health expertise seemed to fall somewhere between superstition and common sense — which may be why the New York Times felt it could state that experts had nothing to offer the public and professionals of other fields could claim themselves experts after a fortnight of study. We would never assume “anyone” could do rocket science, and yet the human mind, which is more complicated than any rocket, seems up for grabs.

Rather than clarify that psychiatrists do not always diagnose but can make useful observations from a distance, the psychiatric establishment decided to label pejoratively all outside observation as “armchair psychiatry.” Instead of elucidating that psychiatrists also work in population-level prevention and have a public health duty, it decided to promote the prejudice that we only work in secret offices (which has never been true for me). Finally, rather than distinguishing between patient confidentiality, which is the law, and the etiquette of being cautious when speaking about a public figure, which is still a First-Amendment right, it has publicly conflated the two. This way, it could more easily condemn those who spoke up about the president as being “unethical” — all the while failing to disclose its lack of independence from the federal government.

All subsequent, token statements the psychiatric leadership has made, for greater access to mental health care, against the separation of children from families, in cautioning about the mental health effects of Covid-19, and now against racism, have a hollow ring when it has failed to address the catastrophic emergency of the president’s mental incapacity. My question is, will it raise its voice only on the side that is safe, or will it do so where it vitally matters, and may even make a difference? Psychological dangerousness in a powerful office has now devolved into what I have called democide, genocide, bioterrorism, and now a death wish — and far past is the time to beat around the bush.

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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