To this day, Yale psychiatrist Bandy Lee remains shocked by what happened on the evening of October 16, 2017.
It was a little more than a week after the release of her instant New York Times best-seller, The Dangerous Case of Donald Trump: 27 Psychiatrists and Mental Health Experts Assess a President, and Lee was scheduled to speak at the Weill Cornell Medical Center in New York City.
At a three-course dinner a couple of hours before the talk, Lee got a first hint that something was awry. In an apologetic tone, Lee’s host, Brenda Berger, an assistant clinical professor of psychiatry at Columbia University, informed her that the department chair, Jeffrey Lieberman, would be on the program along with Lee and one of her co-authors, James Gilligan, a professor of psychiatry at New York University. According to Lee, a flustered Berger acknowledged that once Lieberman insisted on being added as a speaker, she had been powerless to stop him.
“We were never consulted about whether this change was OK with us,” Lee says. “And then Lieberman shows up in a white lab coat! That’s something that I haven’t seen before or since—not in the wards nor anywhere else,” says Lee, the author of a textbook on violence, whose quarter-century-long career in psychiatry has also included a stint as an intern at Bellevue and as the Chief Resident at Massachusetts General Hospital. “And in his flamboyant way, Lieberman stated everything that he felt was wrong with the book and accused us of being completely unethical.”
Before the standing-room-only crowd, Lee and Gilligan both gave 20-minute lectures in which they fleshed out the central argument of their book—that Donald Trump is not mentally fit to be president. This conclusion is not based on a particular mental health diagnosis, but on an assessment of Trump’s dangerousness. As forensic psychiatrists, Lee and Gilligan are often asked by the courts to decide whether violent criminals are likely to re-offend—say, if a batterer is likely to beat his wife or children again upon returning home. “Dangerousness is dependent not on the person, but on the situation,” says Lee. “The book resulted from our conviction that we have a duty to inform Americans about the extreme danger that President Trump poses to the nation’s public health.”
In his unexpected rebuttal, Jeffrey Lieberman, whose one-year term as president of the American Psychiatric Association (APA) ended six years ago, compared the two guest speakers to Nazi and Soviet psychiatrists who relied on bogus diagnoses to punish enemies of the state. His comments revolved around their alleged violation of the so-called “Goldwater rule,” which the APA incorporated into its ethical guidelines in 1973 and which prohibits members of this influential trade association—to which neither Lee nor Gilligan happens to belong—from diagnosing public figures.
“Lieberman was not responding to what we actually said,” says Gilligan. “We never diagnosed Trump. I think we were set up because his talk appeared to have been written out beforehand. And his white coat captured his arrogant attitude toward us. In his harsh and insulting language, he was implying, ‘I’m the scientific authority and the two of you have no credibility.’”
Silenced in a Time of Crisis
With over 50,000 Americans already dead from the coronavirus pandemic, many Americans are terrified that their increasingly erratic president poses a serious threat to the public health of the nation. When filmmaker Rob Reiner tweeted last week,”It’s very simple. Donald Trump’s mental illness is causing Americans to die,” he got over 104k likes. While Lee and her co-authors locate the problem not in mental illness per se, but in psychological dangerousness, they have been warning about Trump’s potential to harm Americans for over three years. Remarkably, even during this national emergency, their voices are rarely heard in the mainstream media. The reason is that Jeffrey Lieberman and other senior leaders at the APA managed to enlist the help of The New York Times to convince most news organizations that their perspective itself is so dangerous that it must be silenced.
How did this ostracism happen? Why did Lieberman and the APA set out to muzzle Lee and her co-authors? And whose interests were ultimately served when some of America’s most thoughtful psychiatrists were silenced by their own profession?
The New York Times Falls in Line
Lieberman’s invective at Lee’s book talk constituted just one rung in a carefully orchestrated public relations campaign against Lee and her co-authors. That fall and winter, Lieberman and senior officials at the APA kept up the pressure. Lieberman also cranked out a series of articles in both academic journals and the popular press and sat for numerous interviews on national TV. This biological psychiatrist, best known for his numerous studies on antipsychotics, also added a dose of online trolling. For example, in a middle-of-the-night tweet on January 7, 2018, Lieberman challenged Lee’s expertise simply because he assumed she was only an assistant professor; along with that demeaning comment, he also expressed his agreement with a psychiatry professor at Stanford University that the Goldwater rule needed to be bypassed in order to “do something” about Lee and “the grave risks” she posed.
A couple of days later, the APA issued a press release that articulated a new, stricter version of the Goldwater rule. And a few days after that, The New York Times lined up with the APA against Lee, publishing both an editorial in support of the new Goldwater rule and an op-ed by Lieberman in which he accused Lee of engaging in “clinical name-calling.”
In his Times piece, as in his remarks at the Weill Cornell Medical Center a few months earlier, Lieberman claimed that her position had antecedents in the abuse of psychiatry by totalitarian regimes. Psychiatry had a checkered past, he wrote, which included its “collusion in Nazi eugenics policies, Soviet political repression and the involuntary confinement in mental hospitals of dissidents and religious groups in the People’s Republic of China.” When asked about this argument, Lee says, “What Lieberman glosses over is that we are not using psychiatry to support a destructive regime, but to challenge a leader who is too mentally impaired to give America the leadership it needs.”
Nevertheless, the efforts by Lieberman and the APA, together with the New York Times editorial, have effectively marginalized the voices of Lee and her co-authors, who include such esteemed psychiatrists as Robert Jay Lifton, author of The Nazi Doctors: Medical Killing and the Psychology of Genocide (1986) and Judith Herman, author of Trauma and Recovery: The Aftermath of Violence (1992). Whereas a few months earlier, several influential publications such as The New Yorker questioned the usefulness of the Goldwater rule in the Trump era, now other mainstream media outlets began to treat Lee as an unethical psychiatrist who “should know better”—to cite the wording in the Times editorial—than to talk publicly about Trump’s mental state. “In early January, my inbox had been flooded with invitations to appear on national TV,” says Lee. “But that stopped almost immediately. And since then, dozens of TV producers have invited me to be on their shows, but have always ended up canceling at the last minute.”
The Return of the Goldwater Rule
To understand how Lieberman and the APA managed to flex the Goldwater rule to muzzle Lee and her collaborators, we have to go back to exactly what psychiatrists said about Republican Senator Barry Goldwater in the run-up to the 1964 presidential election. That fall, FACT, a muck-raking magazine, published a special issue that was based on a survey sent out to all 12,000 or so members of the American Psychiatric Association. Of the approximately 2,400 psychiatrists who responded, about half determined that Goldwater was “psychologically unfit” to be president. Unfortunately, few comments were fact-based; epithets like “lunatic” and “sadistic” were flung around a lot without any context, as were various crude Freudian terms such as “anality” and “latent homosexuality.”
After losing the election to Lyndon Johnson, a furious Goldwater successfully sued the magazine for libel. In an effort to recover from this public humiliation, the APA made that 1973 addendum to its professional guidelines, declaring that “it is unethical for a psychiatrist to offer a professional opinion unless he or she has conducted an examination and has been granted proper authorization for such a statement.”
As Lee stresses, over the next few decades, just about everyone in America forgot about the Goldwater rule—even most psychiatrists. “To my surprise, when the APA reaffirmed it in a release in March of 2017, the organization subtly shifted the emphasis from protecting public health to protecting public figures,” she says. “In the original version, psychiatrists were encouraged to educate the public as long as they did not formulate a diagnosis. But now, any comment about a public figure is prohibited in all circumstances, even in a public health emergency.”
In the first half of 2017, even before Lee’s book was published, Lieberman had begun waging a PR campaign to prevent psychiatrists—even those who are not APA members—from saying anything about Trump’s mental health. His first major move was a paradoxical one. In order to advocate for the importance of the Goldwater rule, he violated it. Enlisting the help of seven colleagues whom he has described as “experts in disorders of the brain (neurologic and psychiatric),” he did the very thing that he has repeatedly described as unethical. Based on readily available biographical information, Lieberman and his colleagues both diagnosed President Trump and published their findings in a popular magazine.
The resulting article, which appeared in September of 2017 in VICE, under Lieberman’s byline, repeated the very same half-century-old error that it was designed to fix. It’s an inside-out version of the sensationalistic 1964 FACT article that is also steeped in psychiatric pseudoscience. Instead of wild psychoanalysis, Lieberman analyzed Trump through the lens of biological reductionism. Instead of unfounded assertions about Goldwater’s flagrant pathology, readers get reassurances about Trump’s relative normality.
In their assessment of Trump, Lieberman and his fellow biological psychiatrists displayed the conceptual framework that Caleb Gardner and Arthur Kleinman, in a recent editorial in the New England Journal of Medicine, cited as an example of the failures of modern psychiatry. “Checklist-style amalgamations of symptoms,” concluded the two Harvard psychiatrists, “have taken the place of thoughtful diagnosis.”
In his VICE article, Lieberman made no attempt to understand Trump, the person; instead, he relied exclusively on DSM checklists. And the “diagnostic” conclusions that he reached would surprise many Americans who have read biographies of Trump.
For instance, he starts off by asserting that Trump’s childhood was “non-traumatic.” As numerous journalists and biographers have discovered, Trump’s bonds with both his parents were frayed, and that’s a key reason why they shipped him off to military school at the age of 13. As Politico has reported, his mother suffered a near-fatal illness when he was two years old that had long-term consequences for his emotional development. Likewise, as The New York Times has noted, his authoritarian father was emotionally abusive to his children—a fact that may well have contributed to his elder brother’s tragic death from alcoholism at the age of 43.
Lieberman ends up ruling out a host of possible diagnoses, including Bipolar Disorder, Attention Deficit Disorder, and incipient dementia because he could not find evidence that Trump meets all the DSM criteria. And he dismissed the possibility of a personality disorder because he claimed that character structure is not something that psychiatrists should ever even consider. “A diagnosis of Personality Disorder (narcissistic or otherwise), while plausible,” wrote Lieberman, “is of limited significance, as they lack well-established scientific validity.”
In contrast, Lee and her collaborators did not view Trump through this modern diagnostic lens. Their perspective is rooted in the neo-Freudian ideas of the psychoanalyst Erich Fromm, a Jewish refugee from Nazi Germany, who developed an intriguing theory about how the destructiveness of certain personality types can manufacture evil. For Fromm, psychopathology often has little to do with impaired daily functioning—say, being too anxious or depressed to go to work—which is a key yardstick in DSM diagnoses. As Fromm sees it, it is not uncommon for people in positions of power who appear normal to be deeply disturbed. As Robert Jay Lifton writes in the foreword to Lee’s book, “Our Witness to Malignant Normality,” in which he channels Fromm, “A dangerous president becomes normalized, and malignant normality comes to dominate our governing (or, one could say, our antigoverning) dynamic.”
Fromm’s insights are also found in many writers, from Homer on, who have depicted the tragic consequences of character flaws. For example, Shakespeare, as James Gilligan observed in his chapter in Lee’s book, “The Issue is Dangerousness, not Mental Illness,” was keenly aware of the subtle ways in which certain personality types engage in destructive behavior. Noting Trump’s tendency to incite violence by his followers, Gilligan quotes a line from Henry II, where the king encourages his minions to murder his enemy, Thomas Becket, by implication rather than by a direct command, “What miserable…traitors have I nourished and promoted in my household, who let their lord be treated with such shameful contempt by a low-born clerk?”
A couple of months after the VICE article, Lieberman published a scathing review of Lee’s book in Psychiatry News, a newsletter put out by the American Psychiatric Association. Despite his own recent VICE article, he once again insisted that any discussion by psychiatrists of a president’s mental health violates “our professional ethics,” adding that his own political ideology was not a factor in his defense of this particular president, as he had supported Hillary Clinton during the 2016 election. “Sadly, The Dangerous Case of Donald Trump,” he concluded “is not a serious, scholarly, civic-minded work, but simply tawdry, indulgent, fatuous, tabloid psychiatry.”
Lieberman’s personal media blitz, which also included a talk delivered in his signature white lab coat on Medscape, culminated in the APA’s decision to issue its release strengthening the Goldwater rule in January of 2018. In its key new tweak, the APA directly addressed media organizations, calling for an end “to psychiatrists providing professional opinions in the media about public figures whom they have not examined, whether it be on cable news appearances, books, or in social media.” The APA also attempted to expand the purview of its authority by “urging all psychiatrists, regardless of membership, to abide by this guidance in respect of our patients and our profession.”
Once The New York Times seconded the APA’s injunction against “armchair psychiatry,” any psychiatrist who spoke publicly about Trump’s dangerousness ran the risk of being quickly dismissed as the true danger to America’s public health.
Eager not to alienate APA members who might not agree entirely with their take on the Goldwater rule, Lee and her co-authors sought a rapprochement with APA leadership. This effort was led by psychiatrist Leonard Glass, a professor at Harvard Medical School, who had resigned from the APA after 41 years of membership in March of 2017 to protest the reimposition of the Goldwater rule. “We very much wanted to see if there was a way we could find a compromise,” says Glass. In the spring of 2018, Glass’s working group formulated a proposal that recommended keeping the Goldwater rule, as long as the APA could grant a few concessions such as affirming the duty of psychiatrists “to use our professional knowledge to educate the public on matters that fall within our areas of expertise like all other [medical] specialties.” That June, a letter signed by 22 psychiatrists calling for this rollback of the Goldwater rule was sent to the APA by Robert Jay Lifton. The response: radio silence.
Is the APA Protecting Guild Interests?
Having achieved their desired outcome, Lieberman and other senior APA officials have said little publicly about this matter since early 2018. And when asked to respond to the arguments raised by Lee and others in this article, Lieberman, communicating through his publicist, declined to comment.
Numerous psychiatrists believe that the APA’s vehement defense of the Goldwater rule is disingenuous and that something else besides a sudden revival of interest in this ethical guideline accounts for its intransigence. In the fall of 2017, John Zinner, a psychiatrist at George Washington University, told The New Yorker that he had heard a “high official” of the APA acknowledge that its leaders were worried that if psychiatrists started criticizing Trump, the president might retaliate by reducing federal dollars for psychiatric treatment. Zinner is also quoted as saying that the Goldwater rule was laid down “really not out of ethical concern, [but…concern for] our pocketbooks.”
Likewise, NYU’s James Gilligan thinks that following the money might provide an explanation for the APA’s actions. “I wonder if the primary worry of academic psychiatrists like Lieberman may be the loss of NIH funding for their biological research,” he says. Trump’s sudden decision earlier this month to suspend the $500 million in funding that the US gives to the World Health Organization lends credibility to Gilligan’s hypothesis. This is clearly a president who uses the power of the federal purse to support his friends and punish his enemies in the scientific community. So perhaps a strict Goldwater rule is one way for the APA to make sure that it stays on amicable terms with Trump.
If this is, in fact, the APA’s strategy, it appears to be working. As the APA noted in a release at the end of 2019, it is pleased with Congressional funding for psychiatric research during the Trump administration, which now includes $2 billion a year to the National Institute of Mental Health (NIMH)—up $155 million from the previous year. And over at Columbia University, where he heads up the New York State Psychiatric Institute (NYSPI) as well as the medical school’s psychiatry department, Lieberman also continues to be the beneficiary of considerable funding by the feds, even though the NYSPSI was slapped with a roughly $10 million fine for overcharging NIH in 2016. According to the latest publicly available figures, in 2018, the NYSPI received about $64 million in NIH grants and, in 2019, the psychiatry department at Columbia another $17 million.
The Loser in All This: The American Public
Though Lee has largely been frozen out of the mainstream media for the past couple of years—say, by the op-ed pages of The New York Times and The Washington Post and by the major cable news networks—she continues to speak out as much as she can. Last spring, she published a second edition of her book, which features an additional ten contributors. At around the same time, she and her co-authors, along with thousands of mental health professionals from around the world, formed the World Mental Health Coalition, which seeks to educate the public about the dangerousness of President Trump. She also maintains an active presence on Twitter; the webzine Salon continues to write about her efforts.
A discussion of the pros and cons of the World Mental Health Coalition’s prescription for America, which focuses on the need to remove Trump from office—via some constitutional mechanism, such as by invoking the 25th Amendment, for example—goes beyond the scope of this article, which seeks only to highlight how a few major movers and shakers at the American Psychiatric Association have shaped the national conversation about Trump’s mental fitness. Unfortunately, even though Lee’s ideas are popular among many rank-and-file psychiatrists and psychotherapists—in December of 2019, for example, over eight hundred signed a petition sent to Congress about Trump’s rapidly deteriorating mental health—the insistence by the APA’s leaders that essentially all mental health professionals, even psychologists and social workers, have an ethical duty to remain silent continues to serve as the de facto law of the media landscape.
As Richard Painter, who worked as the chief White House ethics lawyer during the presidency of George W. Bush and co-wrote a chapter for the second edition of Lee’s book, stresses, most media outlets readily assume that the American Psychiatric Association formulates its policies based on an assessment of what is likely to be in the best interests of the American people. “But journalists forget that the APA is a guild, and professional guilds—like the APA or the American Bar Association—tend to focus on protecting their members. These guilds often do everything in their power simply to help lawyers or psychiatrists earn a better living,” he says.
Harvard psychiatrist Leonard Glass argues that doctors in other medical specialties are often called upon to provide some insight into the health status of a celebrity without conducting an examination. “When Hillary Clinton fainted during the 2016 campaign, cardiologists were asked about what might have caused it,” he says. “If Tom Brady were to suffer a high ankle sprain, many reporters would immediately seek the professional opinion of orthopedic surgeons on the possible extent of the quarterback’s injury.”
As the American people face the devastating toll of the coronavirus pandemic, they are vigorously debating whether their president is psychologically fit to lead the country in the weeks and months ahead. The silencing of Lee and her collaborators by Lieberman and the APA detracts from the ability of the mainstream media to conduct this vital discussion. And today, looking back at the public relations campaign against her book, key questions have yet to be definitely answered: Why did Lieberman and the APA seek to silence the voices of these distinguished psychiatrists who study dangerousness? Was the potential loss of federal funding the main driver? Was it perhaps also done for reasons of ego and power, with Lee and her collaborators getting too much attention?
But the most pressing question now is this: Is it time for the APA to modify or even suspend the Goldwater rule? As the nation grapples with a series of previously unimaginable long-term threats to the health and well-being of its citizens, can America afford to be guided by a guild that silences experts who could provide insight into the mind of a president who may be exacerbating this crisis?
MIA Reports are supported, in part, by a grant from the Open Society Foundations