Profile of a Nation

Profile of a Nation:
Trump’s Mind,
America’s Soul
By Bandy X. Lee, MD, MDiv

World Mental Health Coalition, Inc.

New York, NY
A World Mental Health Coalition Book

Profile of a Nation: Trump’s Mind, America’s Soul

Copyright © 2020 by Bandy X. Lee, M.D., M.Div.
All rights reserved. Printed in the United States of America.

www.worldmhc.org
www.bandylee.com

Cover Design by Stacey L. Pritchett

Special consultant Mark A. Bruzonsky

Library of Congress Cataloging-in-Publication Data available upon request.

ISBN 978-1-7355537-4-0 (softcover)

ISBN 978-1-7355537-5-7 (ebook)
To my fellow Americans, yearning to be free
 Contents

Preface
Introduction
A Profile of Donald Trump
A Profile of Trump Supporters
A Profile of the Supporting Environment
Recovering America’s Soul
Afterword
References
About the Author
 Preface

This is an unprecedented report meant for unprecedented times. It seeks to

keep with the principles and standards of psychiatry over format of typical
presentation, since, for an extraordinary situation, trying to keep with
appearances can also lead to distortion. It is written because, if not for
dealing with a global mental health emergency, wherein at stake could be
nothing less than humanity’s survival, I do not know what psychiatry is
good for. The public will understand this, as it has from the moment it made
the request….
So how did a clinician consultant and academic psychiatrist with no
background or interest in politics come to speak up nationally about the
president? I often say politics invaded my area of expertise, and that would
be true. I was in forensic psychiatry, with an almost twenty-year career
working with violent offenders. I consulted widely on prison reform and
collaborated with governments and international organizations on public
health approaches to violence prevention.
In the context of my work increasingly turning global, with an eye
on preventing genocides, gender-based violence, and civil wars, domestic
U.S. politics was the last on my mind. Yet I was unexpectedly summoned
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 because of my work
with a high-profile prison reform project in New York City. They were
contacting me because they were 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?
It was the morning Donald Trump was elected to the presidency.
Growing up in New York City, I knew of him as a libertine tabloid
personality, a failed businessman, and somewhat a crook, but I did not
consider him necessarily dangerous. He came to a Broadway producer
friend of mine while in his early twenties, trying to get into show business,
but as he was only interested in the credits and the showcasing of his name,
my Tony Award-winning friend told him off: “Go back to real estate!” (My
friend regrets this advice to this day, for he believes his words may not have
been without influence at a pivotal point.) A handful of other friends, all
women, had direct encounters with him and, despite being from higher
society than he, experienced uniformly hurtful, degrading treatment with
gratuitous humiliation mixed into their otherwise simple, passing
interactions. Still, I may have considered him an odious personality but not
dangerous.
Then, in 2015 I saw him televised during one of his direct
interactions with followers, and by now a seasoned psychiatrist who saw
things differently, I recognized the personality patterns and the interpersonal
dynamic I specialize in treating among offenders of violence—and this was
very dangerous. Still, I was too preoccupied with personal affairs at the
time, taking care of my mother who had gone from a seeming perfect state
of health to passing away in less than a year. Glioblastoma is what Senator
John McCain and Vice President Joseph Biden’s son, Beau Biden, also had,
and its course is swift. While my mother had followed politics, it was never
my area, and I had just returned from another trip abroad after her departure
—until the citizen calls came on the morning after the election. Still, things
seemed remote, even otherworldly. My mother had been far more socially
conscious than I, and my public role was about to coincide with my
determination to take on her legacy.
At that time, a former colleague from Harvard, Dr. Judith Herman,
had written to President Barack Obama, along with two other psychiatrists,
Drs. Nanette Gartrell and Dee Mosbacher, asking that the president-elect
undergo a neuropsychiatric evaluation. Delighted to find like minds, I
reconnected with Dr. Herman after more than a dozen years and became
acquainted with her colleagues, with whom I formed invaluable friendships.
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 the litigious and vindictive
president, or that they may have to fear for their and their family’s safety in
light of his violence-prone followers. I thought to myself all the more that a
breaking of ice was necessary and decided to organize a conference at my
institution, the Yale School of Medicine.
 Foremost on my mind was ethics—how can we meet our societal
responsibility, while speaking ethically and responsibly? I wished to give
consideration to an ethical guideline we informally call “the Goldwater
rule,” which encourages activities that improve the community and better
public health by educating the public when asked about public figures—
only without diagnosing. It was simply a repetition of good standards of
practice. But what was alarming was the fact that, shortly after Donald
Trump’s inauguration, the American Psychiatric Association expanded the
caution not to diagnose without a personal examination and not to publicize
a diagnosis without authorization—to cover far beyond just diagnosis. From
now on, restrictions would apply to any comment on any objective
observation—even in an emergency, without exception. No other ethical
guideline held such absolute status. In other words, it was turned into a
prohibition, a gag order, that now abandoned the affirmative obligation of
“the Goldwater rule,” which included educating the public and improving
community health, not to mention all other core medical obligations such as
placing safety first—all in subordination to privileging a public figure!
Never mind what history has shown us regarding what silencing
relevant voices does under dangerous regimes. This change was shocking
enough for me to drop everything in order to speak up. The question I
wished to address was, if there were a restriction on our speech about a
public figure, like a patient (since a public figure isn’t a patient), then
shouldn’t there be situations where there is a positive duty 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 fifteen years and could attest to their
exemplary ethical stances from other dark times: Dr. Judith Herman,
certainly, and also Drs. Robert Jay Lifton and James Gilligan, and Dr.
Charles Dike, a colleague from my division currently on the American
Psychiatric Association’s ethics committee, whom I invited to speak first.
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. We, however, knew too much about human behavior for any
conclusion other than that Donald Trump’s disturbances would place the
country and the world in existential danger—not to mention be a threat to
governmental institutions, social norms, and, ultimately, the fabric of the
country. In other words, that psychological dangerousness in the most
powerful office on the planet would translate into social, cultural, and
geopolitical dangerousness was only a matter of time.
Even though we had held the conference in the largest auditorium of
the School, the audience did not exceed two dozen. This “failure” soon
turned into the realization that hundreds had tuned in online, confirming
that there was great interest but also considerable fear—and as the meeting
received national and international attention, eventually thousands of
mental health professionals from all over the country as well as from
multiple continents got in touch. I quickly realized that this was historic,
that we had a medical consensus, and from that arose the National Coalition
of Concerned Mental Health Experts, now the World Mental Health
Coalition.
Immediately after the conference, an editor of Macmillan Publishers
contacted me, as we were just putting together the proceedings of the
conference into a public-service 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. We could see that it spoke
to the public’s hunger for understanding. The book was The Dangerous
Case of Donald Trump: 27 Psychiatrists and Mental Health Experts Assess
a President, intended for the sharing of expertise as a public service and
donation of all revenues to the public good. In it, 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.”
Meanwhile, various Congress members who heard of the conference
began reaching out. Initially, I consulted with them privately over the
phone. One influential former Majority and Minority House Leader said he
would like to arrange for me to testify before the whole Congress and
proposed early September, when the Congress would have just returned for
session. For various political and other reasons, this did not happen, and
both September and October passed.
By November, Special Counsel Robert Mueller, who had been
appointed to investigate Russia’s role in influencing the 2016 presidential
election, released his first indictments, and the president began showing
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 compromise my educative role
by taking him on as a “patient”. Hence, I elicited only limited information
and referred them to the emergency room, hoping that this might lead to the
recruitment of another psychiatrist. When I called the on-call psychiatrist
after the referral, however, he was hostile and made clear he did not wish to
get involved; no matter the condition of the president, his main concern was
to be left alone. This is another regret I have: I underestimated the
reluctance to apply standard psychiatric procedures, simply because it
concerns a president. Why, is a president not a human being who deserves
care like everyone else? Is he not an equal citizen within a republic?
If I had been more experienced in the media world at that time—in
other words, knew what I do now—I would have requested a public
statement from the two gentlemen, or an appearance in the media with me
to spell out our concerns to the public. I was still thinking in terms of
choosing between the roles of provider and educator. Of note, people have
asked me if either of them seemed to be the famous “anonymous” White
House official who wrote a New York Times opinion piece and later a book;
I have said no, since the anonymous official was initially confident in his
and other insiders’ ability to handle the situation, whereas the two
gentlemen who got in touch with me were more correct in their estimation
that they could not.
In early December 2017, impatient of hearing about no movement
regarding my congressional testimony, former Assistant U.S. Attorney
Sheila Nielsen arranged for me to meet with a dozen Democratic Congress
members of 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, informed, 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. Surprisingly, they looked to us! They
stated that they had little power, but if we continued to educate the public as
we had been, from a professional point of view, then they might be able to
garner the public’s support to do something. They confided that they knew
of Republican lawmakers who were also very concerned about the president
but doubted they would act on those concerns, and so this would be the only
way. They turned out to be right: even fears that the president would trigger
“World War III,” as one Republican senator put it, did not prevent
Republican lawmakers from rallying behind him when it became time to
pass tax legislation.
Therefore, 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 waiting for Republican Congress
members to consult with me and went to the press. For several days, I was
interviewing for fifteen hours a day without a break, and invitations came in
from all the most prominent prime time programs on CNN, MSNBC,
network television, and even Fox News. I put aside all other tasks to attend
to this national need, while the president’s mental health was the number
one national conversation and in the news every day. I declined the biggest
shows that could only promise five to ten minutes of discussion, however,
to allow for a slower, more serious buildup of discussion that did not
sensationalize—another decision I would regret later. I regretted this
because, just as it seemed we were getting somewhere, the American
Psychiatric Association (APA) stepped in and made public accusations I
thought I would never encounter: claiming we were practicing “armchair
psychiatry,” using psychiatry as a “political tool,” and doing for “self-
aggrandizing purposes.” The irony of these attributions was that it was
violating its own, stricter version of “the Goldwater rule” that it adopted
with the Trump presidency, prohibiting not just diagnosis but making any
comment of any kind on public figures, without a personal examination and
without authorization—and I was a public figure at this point! What was
puzzling apart from its claim to know my innermost intentions was that its
arguments did not make any sense from an ethical or scientific point of
view. The highly acerbic, seemingly unprofessional attacks also seemed
unbecoming of a professional organization. Later, I would come to learn
that this is characteristic of institutions that choose to side with power over
principle. By this time, numerous chairs of psychiatry departments and
other prominent psychiatrists from around the country had reached out to
me with compliments and gratitude, but the APA’s position halted their
ability to come forth publicly. Is this how it goes, no matter how wrong the
leadership of the professional establishment is? I wondered to myself. And I
wonder to this day what might have happened if all these figures in power
positions felt free to come out in unison; it was a much riskier proposition
now.
By the fall of 2018, the nation was reeling after the deadliest anti-
Semitic attack in U.S. history and an extraordinary “pipe bomber” sending
sixteen explosives to prominent Democrats, including the former president,
former vice president, and former presidential candidate, as well as critics
of the president. The obvious immediate source? The incendiary rhetoric of
a president who would do anything to sway mid-term elections. By then,
white supremacist killings had already more than doubled, hate crimes
jumped 226 percent in counties that hosted his rallies, mass shootings rose
to an all-time high, and gun deaths more generally rose to their highest in
twenty-five years, not to mention widespread schoolyard bullying in his
name, a more hostile civic life, and a more divided country with common
threats of a civil war to defend the president. This is all without mentioning
the creation of thousands of young orphans and bereaved families at the
U.S.-Mexico border, the emboldening of despots around the world as they
committed human rights abuses and murders of journalists with impunity,
the heightened risk of war in many unstable regions, and a renewed nuclear
arms race.
Crises only deepened through 2019, which began with the longest
government shutdown in U.S. history, because of the president’s insistence
on funding for a wall on the southern border, creating needless hardship for
800,000 federal employee families. Public pleas for us to speak more never
ceased to pour into our web site despite the drying up of media inquiries.
Meanwhile, the World Mental Health Coalition had grown multifold in size,
with membership from four continents, and it incorporated into a nonprofit
organization with officers and a full board of directors.
The new Democratic-majority House of Representatives was sworn
in in January 2019, but it did not proceed immediately with impeachment as
expected. In March 2019, with the release of the second edition of The
Dangerous Case of Donald Trump, now updated with ten more mental
health experts to make thirty-seven, we held an interdisciplinary conference
to bring attention to the need. Thirteen top experts from the fields of
psychiatry, law, history, political science, economics, social psychology,
journalism, propaganda studies, nuclear science, and climate science came
together in unprecedented ways to explain how the president was unfit from
each of their perspectives. Renowned economist Jeffrey Sachs moderated
the event, which was held in the National Press Club Grand Ballroom, and
C-SPAN broadcast it. Attendees, stunned at the caliber and sheer number of
illustrious experts on a single panel, stated that the lack of news coverage
was “shocking.” Some asked: “What does it say about our country that a
monumental, unparalleled event such as this is attracting no attention?”
With only political pundits commenting on a matter requiring of
expert-level knowledge, a malignant normality set in, providing fertile
ground for pathology to spread. What ensued was psychological
conditioning for the continual gutting of institutions, the replacement of
career personnel with unqualified flatterers, and the catering to a president’s
emotional needs at the expense of public good, until presidential powers
were used only to expand personal power. The lack of media coverage did
not match the flood of public inquiries to our web site.
We tried our best to perform our professional societal duty. When
Special Counsel Robert Mueller released his report on a two-year
investigation into the Russian government’s interference in the 2016
elections and the role of Mr. Trump’s campaign in it, we issued our own
“report on the Mueller report.” Attorney General William Barr had
preempted its public release with his own summary of the report, falsely
interpreting as it an exoneration of both conspiracy and obstruction of
justice. An alarmed special counsel issued a letter that attempted to correct
the interpretation, requesting that his own summary be released, but the
psychological conditioning for dismissal was already complete. Mr.
Mueller’s report, when released a month later, revealed an alarming pattern
of numerous attempts at or requests for cooperation from the Russians,
regardless of whether or not there was a formally agreed-upon conspiracy,
and a dozen counts of obstruction that merely could not be prosecuted while
the president was in office, but it did not matter. The attorney general had
paved the way for the president’s ability to claim: “total exoneration.” If
Mr. Mueller’s report was not usable for prosecution, it allowed us the
perfect information to perform a mental capacity evaluation, which we did
as a public service: it contained within it abundant, high-quality reports
from coworkers and close associates of direct interactions with the
president, under sworn testimony. Drs. Edwin Fisher, Leonard Glass, James
Merikangas, James Gilligan, and I formed a panel to prepare the report:
“Mental Health Analysis of the Special Counsel’s Report on the
Investigation into Russian Interference in the 2016 Presidential Election.”
This assessment showed, definitively, that the president did not meet any of
the standard criteria for rational decision-making, and therefore lacked the
basic mental capacity to discharge the duties of his office. We offered a
chance for the president to interview with us if he believed himself fit, but
while we learned that he received our communication, he did not respond
within our timeframe. We therefore went ahead and published our
recommendations that: (a) the president be removed from access to the
nuclear codes; and (2) his war-making powers be curtailed.
However, without inroads into a public conversation, our report
went ignored. We had planned a town hall with several Congress members
the day before Mr. Mueller’s Congressional testimony in July 2019, but his
last-minute postponement of it gave us only the option to hold it online. We
organized a conference at Yale Law School in September 2019, with former
Chief White House Ethics Counsel Richard Painter as speaker, only to learn
that the Law School, having gradually changed from a public interest focus
to power-centeredness over the sixteen years I had been teaching there, was
quite hostile. It may not even have been possible without the sponsorship of
former Dean Robert Post, a champion of free speech and academic
freedom. Then, everything changed later that month. A whistleblower
revealed that the president had allegedly abused his powers and the
governmental purse by pressuring Ukrainian President Volodymyr Zelensky
to investigate the front-running Democratic presidential candidate’s son,
Hunter Biden, so that it could be used for campaigning advantage. In
response, Speaker of the House Nancy Pelosi, who had long resisted calls
for impeachment, finally announced an impeachment inquiry.
Upon this news, we had to get to work. While we had long
encouraged early impeachment for behavioral management reasons,
proceeding now after a protracted delay, after having allowed the president
to balloon in his false sense of omnipotence and impunity, was dangerous.
In early October 2019, Drs. Stephen Soldz, Fisher, and I, along with more
than 250 mental health professionals, sent in an urgent letter to the
Congress warning of the president’s psychological dangers. Three days
later, he ordered the withdrawal of troops from northern Syria, without
warning and catching our European allies by surprise, that caused the
massacre of our Kurdish allies and destabilized the region. In early
December 2019, Drs. John Zinner, Jerrold Post, and I, along with over 800
mental health professionals, sent in another warning against proceeding
with impeachment without guardrails. One month later, the president
ordered the assassination of a top Iranian general, Qassim Soleimani,
without justification, taking us to the brink of war with Iran. We still tried,
issuing a final warning from the World Mental Health Coalition of the need
urgently to contain his psychological dangers, but the House proceeded to
the end without consulting with us, voting to impeach and then handing
over the articles of impeachment, which we had already advised were too
few and should be held onto. As a result, the House’s hesitations only
enraged him and failed to contain him when the Senate acquitted him
through a sham trial without witnesses or evidence. Once he was clear, the
president went on a revenge spree against those who lawfully testified
against him, while pardoning and hiring war criminals before declaring
himself the law of the land.
Our final warning came less than two weeks before the first case of
the novel coronavirus was to be detected within the United States. Now, the
same danger we were warning against turned into a domestic threat: a
president who fights facts and reality for psychopathological reasons was
now in charge of leading the nation through a deadly pandemic. Not only
had he defunded the Centers for Disease Control and Prevention (CDC) and
dismantled the pandemic response teams that had been lauded throughout
the world, out of pathological envy of his predecessor, he had fired the CDC
team in China whose job it was to detect and prevent the very kind of
respiratory infectious disease as was to arise in China just months later.
While China began its response similarly as the United States—stifling
expert voices, spreading misinformation, and helping the virus to gain a
tenacious hold—it quickly changed course when the rapid spread of the
virus threatened both its international standing and its control over the
population at home. The United States, on the under hand, showed no such
versatility and, with the pandemic occurring at a moment of peak
perception of impunity and fewest moderating forces against the person in
charge, quickly superseded China in infections and deaths.
Donald Trump went as far as to call the pandemic a Democrats’
“hoax”, resisting widespread testing, and pushing for policies that would
artificially prop up the economy while putting lives at greater risk—until
the United States became the world’s pandemic epicenter. Once he made
this misstep, there was no going back, for he could never admit an error and
never take responsibility. He did everything possible to refuse providing
personal protective equipment, to delay invoking the Defense Production
Act, and to resist the testing, tracing, and isolating that was the only means
for control in the absence of a vaccine or a cure. No amount of medical,
financial, or military resources would halt the avoidable loss of hundreds of
thousands of lives, tens of millions of jobs, and one of the greatest
economies in the world. At the time of this writing, deaths from the
pandemic are approaching 200,000 in the United States—an overwhelming
majority of which public health experts say was avoidable—with no sign of
waning. All the countries surrounding China, with far less notice and fewer
resources, have managed to contain it, and almost all European countries
have done better than the United States. None of this has been surprising
but is the exact result we expected from the evidence we outlined in The
Dangerous Case of Donald Trump and a result that was essentially
inevitable based on our mental capacity evaluation of the Mueller report.
Equally unsurprising is his response to one of the largest people’s
movements in Black Lives Matter. His psychological need for “total
authority” and inability to tolerate criticism or even differing opinion has
made him quick to portray largely peaceful protesters as “professional
anarchists, violent mobs, arsonists, looters, criminals, rioters, Antifa, and
others.” Even as there has been no proof of what he calls “Antifa-led”
violence, but rather only of opportunists and his own followers, he has used
the occasion for unleashing federal forces on several cities—even as local
authorities implore Congress to make it illegal to send them where they are
unwelcome. Even the police force has been a shocking instigator of
violence, responsible for 125 documented violent acts against protesters
throughout the country over an 11-day period. And as the president calls
journalists “truly bad people with a sick agenda,” the U.S. Press Freedom
Tracker documented over 400 direct police harassment and attacks of
reporters at protests, many of whom have suffered permanent injuries, over
the span of two weeks. All this is consistent with the multiple ways in
which Donald Trump has directly inspired, incited, fueled, and laid down a
culture of violence, in line with his paranoia and violence-proneness under
stress.
As a psychiatrist, I believe there is no greater oppression than the
hijacking of the mind, and critical information at a critical time is necessary
to empower the public to be able to protect itself and to act while it is still
possible. It is always easier to prevent than to try to limit losses after a
problem has become barely containable. This is the reason for the current
volume. Some have questioned my ethical basis for speaking up, but
professionals are supposed to act on the principles of their field as their own
moral agents, not as technicians who follow fiats. The latter, a form of
ceding one’s autonomy, is a formula for becoming an instrument of
authoritarianism if not careful. I maintain that the humanitarian goals of
medicine and our practice of giving precedence to human lives and safety
above all else override any etiquette I owe a public figure. This is why the
Declaration of Geneva was established, and what the Nuremberg trials were
for; we were never supposed to privilege a powerful political figure who is
a not a patient above the foremost principles of medical ethics to which we
have pledged. The mind is considered tyranny’s battleground because
thought reform occurs through “milieu control,” or the control of
information in the environment. Most of this has been done through the
spread of false information, but we have the chance to change it through a
better understanding of truth.
 Introduction

On February 7, 2020, during a taped interview with Bob

Woodward, Donald Trump said: “This is deadly stuff…. You just
breathe the air, and that’s how it’s passed.”
Over the next month, in five cities around the country, Mr.
Trump held large indoor rallies with thousands of attendees.
On March 19, 2020, Mr. Trump told Mr. Woodward: “I
wanted to always play it down. I still like playing it down,
because I don’t want to create a panic” (New York Times Editorial
Board, 2020).
On the same day he said in public: “I would view it as something
that just surprised the whole world…. Nobody knew there would
be a pandemic or epidemic of this proportion.”
In the wake of the 2016 Ebola outbreak, the national
security council had drawn up a playbook on tracking, testing,
and stockpiling for a new virus. As late as in October 2019, an
internal federal government report warned how underprepared the
U.S. would be if it needed to tackle a new virus.
In January 2020, the president said the situation was
“totally under control.” Just six weeks later the U.S. emerged as
the new global center of the pandemic (Milman, 2020).
What does mental health have to do with it?

During Donald Trump’s presidency, the importance of mental health has

risen to the forefront of the public mind. “What is wrong with him?” was a
common question people asked since the beginning of his campaign, but
they were not referring to his physical health, nor his political ideologies.
The public was, in fact, far ahead of pundits, journalists, and even some
psychiatrists in their assessment of Donald Trump. So what does mental
health have to do with a presidency?
Mental health is fundamental to a well-functioning social and
political life, but it is something we often take for granted, and we seldom
stop to consider the mental health of our leaders. Yet, mental health issues
do not stop at the highest office of the land, and the president is not immune
from problems. Rather, the stakes are substantially higher if the same
problems affect someone with great influence and power, and the mental
health of a president is an especially important matter that affects everyone
in the public domain. The nuclear age, dramatically raised the stakes, with
the president of the United States able to decide within minutes how to
respond to a dire emergency. In the aftermath of the assassination of
President John F. Kennedy, Congress proposed the Twenty-Fifth
Amendment to the U.S. Constitution, which the states ratified to outline the
procedures for replacing the president or vice-president in the event of
death, removal, resignation, or incapacitation.
That a president’s ability to exercise good judgment could be
compromised became apparent when President T. Woodrow Wilson
suffered several “small strokes” while at the Paris Peace Conference in
early1919. He was under physician care but continued to represent the
United States during a time when his thinking was impaired. Much worse,
the stroke he suffered in October 1919 completely paralyzed his left side
and impaired him until his death in 1924. These months of inability became
some of the most significant in American history. When the Treaty of
Versailles between Germany and the Allied Powers was brought before the
Senate, the compromised president could not defend ratification that would
have brought the United States into membership in the new League of
Nations.
A similar situation occurred in the latter years of Franklin D.
Roosevelt’s presidency. Stricken by poliomyelitis in 1921, which left him
unable to walk, Roosevelt was impaired but able to serve in office. Whereas
he had met the challenges of the dictators of Germany, Italy, and the
Japanese militarists as commander-in-chief, he had the responsibility of
leading America through a global war while suffering from uncontrolled
severe hypertension. By his fourth election in 1944, he was in the late
stages of heart failure and cerebral vascular disease. The degree to which
these disorders contributed to his reluctance to “stand up” to Stalin at the
Yalta Conference of February 1945 is unknown. However, there is general
agreement that dementia led to his refusal to join British Prime Minister
Winston Churchill in a military operation to occupy Berlin, Germany, and
Czechoslovakia in advance of the Russians during the last months of the
war in Europe. Roosevelt died of hypertensive stroke soon after in April
1945 (Toole et al., 1997).
 With the global deployment of nuclear weapons following World
War II, the possibility that impulsive misjudgment could precipitate a
catastrophic disaster increased exponentially. While Harry S. Truman was
in the pink of health during his presidency, from 1945 to 1953, his
successor, Dwight D. Eisenhower, suffered a heart attack in 1955, intestinal
blockage and surgery in 1956, and a stroke in 1957, prompting him to make
“specific arrangements for the Vice President to succeed to my office if I
should incur a disability that precluded proper performance of duty”
(Eisenhower, 1965).
Acknowledging that even the briefest lapse in the president’s ability
to exercise executive power would be dangerous to the nation, Lyndon B.
Johnson said in a special message to Congress in January 1965:

A nation bearing the responsibilities we are privileged to bear for

our own security, and the security of the free world, cannot justify
the appalling gamble of entrusting its security to the immobilized
hands or uncomprehending mind of a Commander in Chief to
command (Johnson, 1965).
Senator Birch Bayh was soon thereafter able to achieve Congressional
approval of the Twenty-Fifth Amendment in 1965 and ratification by the
necessary thirty-eight state legislatures in 1967. While Sections One and
Two of the Amendment deal with succession, Sections Three and Four are
designed to maintain an active and empowered chief executive office if the
president is so physically or mentally impaired that his or her advisers judge
him or her to be unable to discharge its duties.
During Ronald Reagan’s term of office, there were occasions when
the provisions of the Twenty-Fifth Amendment might have been used.
Following an assassination attempt in March 1981, Reagan underwent
surgery under general anesthesia and, thereafter, was severely incapacitated
during parts of his recovery. Apparently, nobody suggested that the
president invoke Section Three when he reasonably could have done so,
and suggestions that the appropriate decision-makers invoke Section Four
were dismissed. When Reagan underwent cancer surgery in 1985, he
transferred powers to then-Vice President George Bush but reclaimed his
powers some nine hours later. Unfortunately, it now appears that Reagan,
while recuperating in the hospital, gave “final approval” to the devastating
Iran-Contra scandal that ended in humiliation for the president and his
entire administration. Section Four of the Twenty-Fifth Amendment is the
only section that has never been utilized, possibly because of the unpleasant
nature of involuntary separating the president from the powers and duties of
the office, by the cooperative action of the vice president and a majority of
the cabinet. Apparently, Reagan’s chief of staff briefly considered invoking
it late in Reagan’s second term when the president appeared at times to be
disengaged from the work of his administration (Gilbert, 2015).

What is mental health?

For human beings, our physical, mental, and social health are closely
interwoven and vital necessities. In recent decades, significant investments
have been made in education, screening, and treatment to manage physical
health conditions. Health education campaigns have focused on the links
between sun exposure and skin cancer, the importance of diet and exercise
in reducing the risk of cardiovascular disease, and the role of safe sex in
preventing the transmission of the human immunodeficiency virus (HIV).
Many people know the appropriate sources of professional help that are
available for physical health conditions, some of the treatments they might
receive, and the likely benefits of those treatments. They may also be
familiar with available complementary treatments and lifestyle changes
they might make. This knowledge can also be beneficial to those around
them; someone who has taken a first aid course to learn how to apply
cardiopulmonary resuscitation in an emergency may save a life.
We can contrast this situation with that for mental health conditions.
Many people do not recognize the signs and symptoms of mental disorders,
have beliefs about prevention and treatment that differ from those of health
professionals, and are not sure how to help themselves or someone else with
a mental disorder. Yet, mental disorders are very common. In any one year,
up to one-fifth of the population experience a mental disorder, and over a
lifetime, that number rises to one in three (Kessler et al. 2009). Depression,
anxiety, and other related disorders are among the leading causes of
disability (World Health Organization, 2008).
Mental health as a medical specialty field deals with the diagnosis,
treatment, and prevention of mental disease, to promote psychological
wellbeing, emotional balance, and resilience. It treats maladaptive
behaviors because of mood, thinking process, or perception. According to
the World Health Organization, mental health includes: “subjective well-
being, perceived self-efficacy, autonomy, competence, inter-generational
dependence, and self-actualization of one’s intellectual and emotional
potential, among others” (World Health Organization, 2001).
Disorders of the mind are just as serious and can be just as
debilitating as those that affect the body. They can also vary greatly: most
cause greater suffering inwardly, but others do outwardly. Some show
obvious symptoms, while others are more hidden. But because it affects the
mind, even though mental disorder prevalence rates are high, many people
either do not see the need or delay seeking help, often for many years. As a
result, mental health problems are not given anywhere near the same level
of importance as physical ailments, despite the growing awareness that
mental health is critical to the wellbeing of individuals and societies.
This lack of awareness has led to numerous misconceptions about
mental health problems, with many people being victimized for their illness
and becoming targets of stigma and discrimination. However, scientific
developments have shown that most illnesses are a combination of
biological, psychological, and social factors and that mental illnesses are
not set apart. Individuals should not be identified by their illnesses and
should not be accused of any moral failing because of their mental
affliction, as even the most severely impaired individual retains significant
free will and should be held accountable where appropriate.
Approaching mental health issues can be intimidating, but there is
perhaps no greater reward than the restoration of mental health—or at least
that is what patients in recovery say. Because of the unique characteristics
of that mental illnesses can exhibit, professionals in the area spend much of
their time educating, or, in the case of need for care, convincing patients
that they need it.

Forensic mental health

In addition to mental health, there is forensic mental health. This just means
that the mental health professional works at the intersection of mental
health and the law. Forensic psychiatry (one area of forensic mental health),
for example:
 is a subspecialty of psychiatry in which scientific and clinical
expertise is applied in legal … or legislative matters, and in
specialized clinical consultations in areas such as risk assessment
for employment” (American Academy of Psychiatry and the Law,
2005).

A psychiatrist in this setting uses psychiatric expertise to help inform legal,

criminal justice, and governmental systems. The word “forensic” derives
from the Latin word for “the forum” or the court system of Ancient Rome.
The forum was also where public speeches, gladiatorial matches, and
commercial affairs happened. Most importantly, it was a place where ideas
were exchanged, and different disciplines could meet and work together to
solve problems.
The modern-day justice system is not very different. Legal
professionals and mental health professionals—psychiatrists, psychologists,
and social workers—often work closely together. Mental health expert
witnesses especially play a large role in the judicial process. For example, a
trial lawyer may invite an expert witness to evaluate if there is
psychological damage to an injured party; an immigration lawyer may
consult an expert to see if trauma can explain inconsistencies in a story, or a
public defender may solicit an expert into whether mental health issues
were involved in a crime. Additionally, an employer may call upon an
expert consultant to perform a risk assessment or fitness-for-duty evaluation
if an employee were posing a threat to the safety of himself or herself and
others at work.
Expert witnesses, like fact witnesses, provide evidence that is
admissible in court. This is because expert or professional opinion—unlike
personal opinion, which is not admissible in court—is based on the expert’s
scientific, technical, or other specialized knowledge, applied to the facts of
a case using reliable principles and methods. Expert witnesses have a
responsibility to provide documentation, to educate about their area of
expertise, and to make the information accessible. This way, lawyers,
judges, or public and private governing bodies can obtain information in
areas that are outside their own knowledge base. The public was looking to
mental health professionals for similar information when it reached out to
me in large numbers, as both a psychiatrist and as an expert on violence, the
morning after the 2016 presidential election. Mental health experts may, in
turn, influence law and policy through teaching in law schools, public
education, and public health methods.

Mental health in the public domain

What happens when a mental health problem afflicts a president? First, it is

important to distinguish between mental incapacity and mental illness.
Mental illness per se does not make a person unfit for duty, just as one can
be unfit for a job without having a diagnosis of mental disorder. Abraham
Lincoln famously suffered from debilitating depression, which may even
have helped him to be a better, more empathic leader. Similarly, Theodore
Roosevelt’s hypomanic moods made him an exuberant and influential
personality. In fact, a study of U.S. presidents between 1776 and 1974
shows that almost half of U.S. presidents suffered from some kind of mental
disorder (Davidson et al, 2006). It is reasonable, therefore, to assert that
mental illness is a president’s private business, as long as it does not impact
on their ability to discharge the duties of their office.
Mental capacity, however, is a different matter. It is a requirement
for fitness, and it does not require a diagnosis. Forensic mental health
professionals conduct mental capacity evaluations all the time: capacity to
stand trial, capacity to sign a will, and capacity to perform the duties of
one’s office are all very common. Capacity evaluations for employment, in
particular, are routinely required for law enforcement or military personnel,
and even doctor and lawyer groups are beginning to mandate capacity
evaluations, necessitated by the rising average age of practitioners. Anyone
who exhibits signs of incapacity can be referred for an evaluation by the
employers or the courts, which in turn call upon an independent forensic
mental health professional. Dangerousness to self or others, or risk
assessment, is another evaluation that mental health professionals carry out,
and a positive result usually means automatic disqualification from
employment. If the mental capacity of a president is in question, the first
order should be to consult an independent forensic mental health
professional like any other situation. This seldom happens, however, and
the White House physician is often the reason why. A White House-
employed physician, often also a military officer subordinate to the
commander-in-chief, is not eligible to perform fitness-for-duty
examinations on one’s employer or superior. Capacity evaluations are done
for the benefit of employers—which, in the case of a president, would be
the people—not the patient. Dangerousness assessments, similarly, are done
for potential victims or authorities protecting them and not those posing
danger. Yet, outside referrals are rare, and public confusion about diagnosis
versus functional assessment leaves much in the hands of the president’s
personal physician, who has historically done much to cover up any signs of
incapacity, and very little to serve the public.
Mental health, like every other medical discipline, involves clinical
and public health practice. While clinical practice involves diagnosing and
treating one patient at a time after individuals have already become ill,
public health and preventive medicine involve population-level
interventions that help keep people healthy and prevent them from falling ill
in the first place. While both approaches are necessary, prevention is
increasingly emphasized as we enhance our understanding and accumulate
more information on how to stop illness, injury, and suffering before they
occur. For this reason, our code of medical ethics states: “a physician must
recognize responsibility to patients … as well as to society” (AMA, 2016).
Our responsibility to society takes the form of preventing illness and injury
in a healthy population, stopping illness from spreading if contagious, and
lessening their progression if already pervasive. From this perspective,
mental health professionals have a positive obligation to protect the public
if we have reason to believe, based on our experience and research of the
most dangerous individuals in society, that a public figure, through his
words, actions, and influence, represents a danger to public health and
safety.
Suffering from a lack of mental health alone may not be a problem
for a presidency. However, a lack of mental capacity is very dangerous, for
it means that the president and commander-in-chief, whatever the reasons,
cannot properly conduct their duties. This would be problematic for any
job, but for the most powerful office on the planet, on which millions, if not
billions of lives depend, it is a catastrophic emergency. Psychological
dangerousness is also a serious problem. While many presidents have been
dangerous because of “warlike” dispositions or faulty policies,
dangerousness for psychological reasons means that dangers could be
produced for reasons that are not only erratic but completely irrelevant to
politics. Having both mental incapacity and psychological dangerousness,
furthermore, means that attempts to cover up one’s incapacity could spark
unnecessary conflict and cause society to descend into violent chaos.

“The Goldwater rule”

“The Goldwater rule” was an obscure guideline before the Trump

presidency—so obscure in fact, that few scholars studied it and many
psychiatrists had not even heard of it. Having been considered outdated
since the day it entered the books, and its premise invalid since 1980, when
diagnostic practices changed, it would not be an exaggeration to say that it
was not abolished only because of it was too obscure to be bothered with.
Then, everything changed with the Trump presidency.
Through massive public campaigns, the American Psychiatric
Association made “the Goldwater rule” a household phrase, and it became
the unfortunate barrier to not just APA members, but all mental health
professionals’ ability to contribute. What is it? The “Goldwater scandal,” as
some have described it, arose following a survey by Fact magazine in 1964.
After Republicans nominated Barry Goldwater for president, Ralph
Ginzburg, the editor of the magazine, sent a questionnaire to 12,356
psychiatrists, asking: “Do you believe Barry Goldwater is psychologically
fit to serve as President?” His questionnaire included some information
about Goldwater’s personal history, which included a statement about
“nervous breakdowns.” With this prejudicial framing, 2,417 psychiatrists
responded, and while more than half said they did not know enough or
thought Goldwater was fit, 1,189 opined poorly or irresponsibly, stating he
was “schizophrenic” and “severely paranoid.” With less than 10 percent
commenting irresponsibly, it should not really have been news, but the
magazine sensationalized it in a special issue with the headline: “1,189
Psychiatrists Say Goldwater is Psychologically Unfit to be President!” After
a landslide loss, unsurprisingly, Goldwater was furious. He successfully
sued Ginzburg and his magazine for defamation. The jury awarded him $1
in compensation, $25,000 in punitive damages against Ginzburg, $50,000 in
punitive damages against Fact magazine, and the magazine went out of
business.
 Although it was not directly implicated in the lawsuit, the APA was
also embarrassed by the situation, and under pressure from the American
Medical Association (AMA), a powerful lobbying force in Washington at
the time that had long supported Republicans, including Goldwater, it made
a move to discipline its members. The result was what is now informally
called “the Goldwater rule.” In the years that followed, it became clear to
everyone who knew Goldwater that he was neither mentally ill nor unfit.
However, if the concern were over science or standard of practice, the
problem should have been irresponsible diagnosis, not the act of
commenting. But, because the circumstances leading to the adoption of the
rule had more to do with political compromise and preserving the
profession’s public image, the focus remained on keeping members of the
profession quiet (Stone, 2018). Although not commenting on matters of real
concern should be of equal professional irresponsibility as commenting on
matters of unconcern, scientific or ethical rigor was not the focus. The
awkward placement in the code of ethics is revealing: it is stated as an
encouragement to educate the public regarding public figures for the
purpose of public health—just without diagnosing. But an “ethics”
guideline arising out of a political compromise was perhaps bound to be
politically abused: with the current presidency, the part that discourages
diagnosis was expanded to prohibit all comment on any aspect of a public
figure under any circumstance, including national emergencies.
This alarming act, occurring two months after Donald Trump’s
inauguration, caused many of us to revolt and name it a “gag rule” (Glass,
2017). First, the “rule” is a misnomer to start, since the preamble of the
profession’s ethical code makes it clear that its guidelines are principles, not
rules, to which the individual professional must apply moral agency to
circumstance, as all ethical decision making requires. However, alarmed at
the number of mental health professionals speaking up about the new
president, the APA decided to reinterpret the guideline. Two important
changes happened: first, the expansion of “professional opinion” to cover
not just diagnosis but any observation of any kind that one can make as a
professional. Second, it eliminated the profession’s public health
responsibility in relation to public figures. These were significant changes,
since not just any opinion counts as “professional opinion” for the courts,
and there are plenty of useful insights professionals can provide outside of
making a diagnosis—which is not even necessary outside a treatment
relationship. By eliminating any public health responsibility, under all
circumstances—even a national emergency (APA, 2017a)—it was requiring
its members to go against the core principles of medical ethics, not to
mention the “rule” itself. “The Goldwater rule” falls under the guideline
that psychiatrists “recognize a responsibility to participate in activities
contributing to the improvement of the community and the betterment of
public health” (APA, 2013b). By creating a “gag order,” it was requiring
psychiatrists to violate the purpose of “the Goldwater rule,” the profession’s
primary responsibility to society, and the modern Hippocratic oath called
the Declaration of Geneva (World Medical Association, 2020). This
universal pledge by every health professional in the world since 1948 was
instituted in response to the experience of Nazism, clarifying that the
humanitarian goals of medicine are contrary to either silence or active
cooperation with a destructive regime. And as an absolute prohibition
without the possibility of moral agency, the gag order was arguably no
longer an ethical principle, but an edict.

The duty to warn and to protect

Like every other ethical guideline since Ancient Greek times, ethical
deliberation involves weighing two or more competing obligations.
Therefore, one of the problems with “the Goldwater rule” is that it has no
countervailing rule. Before we go into this, there are other problems that
have to do with messaging. Whereas it is perfectly acceptable for a private
trade association to have its own rules, it is not acceptable to overreach with
a campaign of misimpression, if not misinformation, that “the Goldwater
rule” applies universally. The APA is the only known mental health
association in the country, if not the world, to have this rule, and its
membership is just 6 percent of practicing mental health professionals in the
United States, according to the Department of Labor’s Bureau of Labor
Statistics (Bureau of Labor Statistics, 2019). Many, including myself,
resigned from the APA in 2007 upon the revelation that it was taking about
30 percent of its income from the pharmaceutical industry—and its policies
reflected this through an increase in support of pharmacotherapy over
patient rights, which it had previously advocated more strongly. Now, the
association was potentially harming public health through the spread of
misconceptions about its “Goldwater rule,” causing the public to confuse it
with the Health Insurance Portability and Accountability Act (HIPAA), or
patient confidentiality laws. Meanwhile, it used the public figure’s non-
patient status to make this rule more stringent than patient confidentiality,
stating that a “duty to warn” does not apply, based on the narrow Tarasoff
doctrine of a doctor-patient relationship.
Society is one of our primary responsibilities, and we not only have
a duty to warn and to protect it in the case of potential victimization, but a
duty to enhance public health and well-being more generally even in the
absence of immediate danger (Kroll and Pouncey, 2016). The independence
of the APA has also come into question, for it receives federal funding, and
admitted to changing “the Goldwater rule” to protect federal funding
(Gersen, 2017). The federal government has rewarded it substantially since
its public campaign (Kendall, 2020). It is not unreasonable to believe,
therefore, that its acceptance of federal funding has to do with its odd policy
of privileging governmental figures over the public’s health, and the
sidelining of the professions best suited to answer the public’s questions
about mental problems that are quite clearly of national consequence
(Grohol, 2019).
The duty to warn and to protect patients and society is built into our
professional responsibility, but this responsibility was expanded to non-
patients with the case of Tarasoff v. Regents of the University of California,
which was decided in 1976. In 1967, Prosenjit Poddar, a graduate student
from Bengal, India, came to the University of California at Berkeley. In the
fall of 1968, he met Tatiana Tarasoff at folk dance lessons in the
International House where he resided. They saw each other about once a
week until New Year's Eve when Tarasoff kissed him. Poddar interpreted
the kiss as a symbol of the seriousness of their relationship. When he
explained this to Tarasoff, she replied that he was wrong and that she was
interested in dating others. This rejection caused Poddar to undergo a severe
emotional crisis during which he became withdrawn, ignored his studies,
often stayed alone, and wept frequently. His condition continued to
deteriorate until he began to visit a campus psychologist. Sometime later in
the summer, when Tarasoff was apparently on vacation to Brazil, he
confided to the psychologist that he was planning to kill her when she
returned.
 The psychologist believed Poddar and notified the campus police,
requesting that they have him committed. They briefly detained him, but he
was released because he appeared rational and promised to stay away from
Tarasoff. The patient terminated therapy because of attempts to hospitalize
him. At the order of the psychologist's superior, a psychiatrist, no further
steps were taken to commit Poddar or to warn Tarasoff. In late October,
Poddar went to Tarasoff’s home with a pellet gun and a butcher knife. He
shot her with the pellet gun, and as Tarasoff ran from the house, Poddar
followed, catching her and stabbing her repeatedly and fatally with the
butcher knife. Tarasoff’s parents brought suit against the psychologist, his
superior, the campus police, and their employer, the University of
California, for failure to warn them, Tatiana, or anyone who could have
reasonably been expected to notify Tatiana of the dangers and for
negligently failing to confine Poddar.
A ruling by the California Supreme Court of California in 1974
stated that mental health professionals have a “duty to warn” non-patients if
they are potential victims of threats their patients made, or if their patients
otherwise displayed behaviors that could pose a “serious danger of violence
to another.” A rehearing of the case in 1976 expanded it with the provision
of a “duty to protect.” In other words, if a therapist should have made the
prediction that his or her patient posed a danger to another person, on the
basis of professional standards, he or she “bears a duty to exercise
reasonable care to protect the foreseeable victim of that danger” (Tarasoff v.
Regents of the University of California, 1976).
It is important to emphasize the three clarifications that the Tarasoff
ruling made: (a) that a duty to protect (and to warn in the case of danger)
that already exists with patients and society expands to include non-patients
in the case of danger; (b) that a therapist cannot claim “no responsibility”
toward a non-patient; and (c) that patient confidentiality is not absolute,
especially in situations of a threat to safety or survival. In contrast to the
Goldwater rule, which is based on one litigation against a third party fifty-
six years ago, the Tarasoff doctrine has been relitigated about one hundred
times, directly involving treaters, and has been codified in forty-four U.S.
states, as well as increasingly across the world as a standard of care. While
U.S. states are not permitted to adopt the Goldwater rule as it would violate
the First Amendment, the Tarasoff doctrine, with each litigation, has
expanded beyond the patient-provider relationship (Johnson et al., 2014). In
other words: “the victim was not my patient,” “the information did not
come from my patient,” or, in the case of universities, “the perpetrator was
not a direct patient,” are arguments that no longer hold (Regents of the
University of California v. Superior Court of Los Angeles County, 1970). In
this context, if “the Goldwater rule” were (even if less strict) an analogy to
patient confidentiality and consent, the Tarasoff doctrine would have to
serve as an analogy to a duty to warn and to protect society—even if society
were not our direct, primary responsibility, which it is.

Mental health in politics versus politicization of mental health

We need to make a distinction between using our mental health credentials

for political purposes and applying mental health principles in the political
realm where relevant. Under Nazism, the former was encouraged, and the
latter discouraged. As a result, not only psychiatrists, but most German
clergy, professors, lawyers, doctors, and other leading thinkers became
passive if not active enablers of some of the worst atrocities in their nation’s
history. In the short run, it may have ensured their personal safety or
political expediency, but not their collective wellbeing as a society. Not
meeting their obligations, in the end, served no one. Because of this
experience, the World Medical Association (1948) issued its Declaration of
Geneva to clarify that silence in collusion with a destructive regime was
just as incompatible with the humanitarian goals of medicine as active
collusion. Infamous Nazi, Soviet, and Chinese abuses of psychiatry,
whereby psychiatry falsely diagnosed in order to imprison dissidents in
hospitals, or otherwise served a destructive state over patients and society,
are instances of active collusion that we must distinguish and avoid.
The American Psychiatric Association’s turning the obsolete
“Goldwater rule” into an absolute decree of silence, apparently to be in
good graces with the present administration, is an unfortunate instance of
passive collusion. Its public misinformation campaigns, defying science and
evolving practice, and attacking independent professionals, or groups of
professionals who would speak up, even when they are not members and
oppose its new interpretation of “the Goldwater rule,” is arguably active
collusion. While in the beginning there were scores of member protests,
resignations, and demands for a vote, with time many professionals fell in
line, fearful of possible negative impacts on their careers if they spoke out
against the official policy.
The media took to heart what should have been a voluntary
guideline for only 6 percent of mental health professionals, not adopted by
any licensing board, and on which the APA itself has not dared discipline
any members through official channels: dozens of lawyers stood ready to
challenge the APA if it had done so. They colluded in the silencing of
professionals by canceling all invitations (one network did so over fifty
times), preventing fully completed interviews from going to print, and
editing out of dozens of articles only the words of experts—such that
almost none would reach the public through major sources in two-and-a-
half years. As with the conflict between membership and leadership of the
APA, reporters, and editors often seemed to be in conflict. No doubt the fact
that “the Goldwater rule” began with a lawsuit against a magazine, not
against practitioners, and the fact that we were dealing with a very litigious
president, played a role. Even though defamation lawsuits are intended to
be for cases where the allegations are false, truth no longer mattered. The
misconception of mental health as a nebulous, subjective area, instead of
the scientific field that it is, persisted. Hence began a “malignant
normality,” as Dr. Robert Jay Lifton describes in his foreword to The
Dangerous Case of Donald Trump (Lee, 2019b), where those who are best
positioned to comment on the greatest threat to public health and safety are
silenced and darkness descends upon a nation, initiated by the very
association that is supposed to enlighten the public on mental health.
We are now at a very dangerous point. Just as we predicted with The
Dangerous Case of Donald Trump, the president has turned out to be more
dangerous than the public ever could have known on its own, has grown
more dangerous with time, and is about to become uncontainable. Just as
we alerted would be the case, the APA’s distortion of ethics has turned out
to be worse than the change of ethics its psychological counterpart, the
American Psychological Association effectuated during the Iraq War in
order to facilitate governmental plans of torture. At the time of this writing,
the United States has lost almost 200,000 lives as a direct result of the
president’s dangerous mental state, which was entirely predictable—and
predicted—and therefore preventable. Without insight into mental health
principles and interventions, an enabling and spreading of pathology was
inevitable. Mental health adheres to medical neutrality, which means that
the description of a situation must be commensurate with the actual need,
not attenuated or withheld because of political pressures. In medical
assessments, there is no room for politics. Yet because of the APA’s
politicization of psychiatry, a mental health issue in a dangerous political
figure was allowed to be “normalized” into social, cultural, civic, and
geopolitical dangers. This document is to counter some of those adverse
effects so that the public might protect itself. Whereas I had not laid down
any detailed analysis when I compiled The Dangerous Case of Donald
Trump, I do so here to help this very end.

Criterion for commenting on a president

To justify this profile analysis, I will first prove dangerousness. Dangerous

risk assessment and management have become central to the current mental
health practice of almost all areas. It has also become among the most
important activities defining professional responsibility. Mental health
professionals may diagnose rarely, but dangerous risk assessment must
occur with every encounter. Once assessed, it is the basis for limiting a
person’s freedom in our civil liberties-favoring society, which allows
exceptional latitude for behavioral variation. When one is dangerous, that
behavior impinges on the freedom and safety of others. When law permits,
even require, that mental health professionals and physicians detain people
against their will, they must demonstrate that those people are a danger to
themselves or others for mental health reasons, or are gravely disabled and
unable to care for themselves. The same goes for revealing confidential
information — professionals must be ready to present evidence and solid
reasoning on the risk of danger, which is a medical emergency.
What does it mean to be a danger to others for mental health
reasons? It is important to separate mental symptoms from things such as
poor judgment or opinions and points of view that differ from one’s own,
which the law clearly permits. In the United States, it must be a disturbance
of cognition, emotional regulation, or behavior that is driving the pattern of
dangerousness. Additionally, the magnitude of the perceived harm must be
considerable. Is it that feelings are being hurt? Or is there actual injury
being perpetrated? Are there patterns of behavior and statements of intent
that reasonably indicate that harm is imminent? Does the person carry
weapons or any other instruments of harm?
Stipulating here the high standard of imminent danger to self or
others as a condition for speaking up about a public figure—even though
the actual threshold for speaking about a non-patient public figure should be
lower and even protected speech—we will adopt this as the minimum
standard. Any standard that goes higher risks unduly endangering the
public, which has vastly greater priority than a public figure, to whom we
do not have a primary professional responsibility. It is arguably more
important to point out if the leader of the United States is not mentally or
emotionally stable, the threshold for assessing the risk of violence should be
lower than that of the average citizen.
The president, in a position of great power and making critical
decisions, should theoretically meet higher standards of mental stability.
Despite these greater requirements, our response is the opposite, hampered
by common misperception: the president is supposed to be the nation’s
protector; how can he be unwell and harmful? In an extreme case scenario,
he would be unwilling to admit of any disturbance—which is a feature of
grave disability—what do we do then? If we did not act, would we continue
to deny until we were at a point of no return? Those who dare apply these
mental health principles to the First Citizen may find themselves at risk of
losing their jobs, their livelihoods, or even their personal safety—because
of either the president, or the segment of the population currently
empowered by the very symptoms that make him so dangerous. If
successful, these actions would drive the latter around the emotional bend.
As president, Donald Trump has control over the executive branch and its
agencies; is commander-in-chief of the military; has unilateral authority to
launch nuclear weapons capable of destroying the world many times over
(which the secretary of defense authenticates but cannot veto). For the
leader of the free world, inappropriate words alone may create a snowball
effect that ultimately results in devastating harm to others (Jhueck, 2017). A
complex web of factors requires consideration, which is why public
education is essential, in collaboration with other professionals, such as
politicians, lawyers, and social psychologists.
The MacArthur Violence Risk Assessment Study has a number of
indicators for whether an individual will commit future violence. Examples
include a past history of violence, a criminal or substance-abusing father,
personal substance abuse, having a generally suspicious nature, and a high
score on the Novaco Anger Scale. We look at “actuarial” data, as outlined
in the Violence Risk Appraisal Guide: did the person live with both
biological parents to age 16? Did the person have discipline problems in
elementary school? Does the person lead a parasitic lifestyle, exploiting
others for financial gain? Personality traits such as glibness with superficial
charm, a grandiose sense of self, seeking stimulation in constant activity,
and pathological lying, conning, and manipulation all factor in. Lack of
remorse, shallow affect, and lack of empathy are additional warning signs,
as are poor behavioral controls, irritability, verbal abuse, and sexual
promiscuity. Juvenile delinquency between the ages of thirteen and
eighteen, and signs of carelessness and criminal versatility, are also things
we look for. With respect to categories of mental disorder, perhaps
counterintuitively, major illnesses such as schizophrenia have a lower rate
of harm to others than personality disorders. Sociopathy or psychopathy, as
measured by a screening version of the Hare Psychopathy Checklist, is the
most strongly associated with violence among risk factors studied
(Monahan et al., 2001). Psychopathy is a constellation of personality traits
that may manifest with emotional detachment, interpersonal manipulation,
social deviance, impulsive lifestyle, and antisocial behavior (Cleckley,
1941; Hare, 2003).
The ensuing list includes just a sample of incidents in the public
record before and since his presidency. It is only a small fraction taken from
a vast body of data, but all that is needed for dangerousness is a
preponderance of evidence. Since no one can predict future dangerousness
with absolute certainty, the identification of factors associated with
potentially dangerous behavior is sufficient, and this creates an
overabundance of information for one book; each topic could become the
potential theme for an entire book in its own right, and the number of topics
would easily fill a library. But this much information is not necessary; it
suffices that we have enough to demonstrate dangerousness, which triggers
the next step: a mandatory evaluation and a complete assessment with
recommendations for further management. Until then, we err on the side of
safety. The intent here is to show that there are sufficient indicators of
acceptable quality and reliable records to reach a reasonable conclusion of
Donald Trump’s pattern of “danger to others.”
 Of note, dangerousness is not the same as a psychiatric diagnosis,
but it is an evaluation mental health professionals perform more often than
diagnosis. Most people with “mental illness” are not dangerous, and most
dangerous people are not diagnosable with mental illness. Only about one
percent of the perpetrators of homicide in this country are found to be “not
guilty by reason of insanity.” The rest are declared by our courts to be
subject to “criminal responsibility” for whatever act they committed.
Donald Trump may or may not meet the criteria for any number of
diagnoses of mental disorders defined in the Diagnostic and Statistical
Manual of the American Psychiatric Association (2013a), but that is
irrelevant here. Even the presence of “insanity” seldom leads to an insanity
defense, given the considerable free will people retain, even in cases of
debilitating mental affliction. Dangerousness assessments do not require
and are often not obtainable from a personal interview, for dangerous
individuals are likely to deny, minimize, or attempt to conceal the facts that
identify them as dangerous. The most reliable data usually come from the
person’s family and friends, police reports, criminal histories, medical,
prison, or judicial records, and other publicly available information from
third parties. In Donald Trump’s case, we have many opportunities for
direct observation in real situations in real-time, including his public
speeches, interviews, and constant “tweets,” which express his numerous
threats of violence, incitements to violence, and boasts of violence that he
himself has acknowledged committing repeatedly and habitually, in
addition to the collateral reports of others who have directly interacted with
him (Gilligan, 2017). The evaluation of dangerousness is what is most
relevant to public health, which mental health professionals assess precisely
through the kind information presented here.

Documenting dangerousness

During a rally in Wilmington, North Carolina, Donald Trump stated,

“Hillary wants to abolish, essentially abolish the Second Amendment….
And by the way, if she gets to pick her judges, nothing you can do, folks.
Although [for] the Second Amendment people, maybe there is, I don’t
know.” A reporter covering this incident was moved to say: “While the
remark was characteristically glib, it finds Trump again encouraging
violence… suggesting either an armed revolt or the assassination of a
president” (Blistein, 2016). Former Head of the Central Intelligence Agency
(CIA) General Michael Hayden told CNN’s Jake Tapper: “If someone else
had said that outside the hall, he’d be in the back of a police wagon now
with the Secret Service questioning him” (Diamond and Collinson, 2016). It
is true also for medical and mental health professionals: if a patient had said
that, an emergency certificate would have been signed, and the person taken
to the nearest emergency room for further evaluation. A common
explanation by defenders of his aggressive remarks in public settings is that
what he said was a joke. This does not change the dangerousness of the
remark but rather flags as a concern his deeming the remark so lightly as to
consider it as a joke, which could be indicative of an even greater
pathological risk that requires evaluation.
Donald Trump has on other occasions asked why we have nuclear
weapons if we cannot use them. In an interview with Chris Matthews on
MSNBC, he said: “Somebody hits us within ISIS, you wouldn’t fight back
with a nuke?” When Matthews remarked: “the whole world [is] hearing a
guy running for President of the United States talking of maybe using
nuclear weapons. No one wants to hear that about an American president,”
Trump replied, “Then why are we making them?” Another MSNBC host,
Joe Scarborough, reported that Trump asked a foreign policy advisor three
times: “If we have them, why can’t we use them?” (Fisher, 2016).
Donald Trump also urged that five innocent African-American
youths be given the death penalty, years after it had been proven beyond a
reasonable doubt to have been committed by someone else. In 1989, he
spent 85,000 dollars placing ads in New York’s four daily newspapers
calling for the return of the death penalty so that the youths who had been
wrongfully convicted of raping a woman in Central Park could be given the
death penalty. He was still advocating the same penalty in 2016, fourteen
years after DNA evidence and a detailed confession had proved that a serial
rapist had actually committed the crime (Burns, 2016).
At political rallies, Donald Trump urged his followers to beat up
protestors so badly that they would have to be taken out on stretchers. An
editorial in the New York Times quotes the following: “I’d like to punch him
in the face, I’ll tell you.” “In the good old days this doesn’t happen, because
they used to treat them very, very rough.” “I love the old days. You know
what they used to do to guys like that when they were in a place like this?
They’d be carried out on a stretcher, folks.” “If you see somebody getting
ready to throw a tomato, knock the crap out of them, would ya? Seriously.
Just knock the hell out of them. I will pay for the legal fees, I promise you.”
He even complained that his supporters were not being violent enough
(even though many had assaulted protesters severely enough to be arrested
and tried for assault and battery): “Part of the problem and part of the
reason it takes so long [to remove protesters], is because nobody wants to
hurt each other anymore” (New York Times Editorial Board, 2016). He even
seemed to sense that his followers did not mind or may even be attracted to
his violence: “I could stand in the middle of Fifth Avenue and shoot
somebody, and I wouldn’t lose voters” (Diamond, 2016).
The infamous “Grab ’em by the pussy” video, which Access
Hollywood’s Billy Bush recorded in September 2005, includes comments
from the newly-married Donald Trump when he sees actress Arianne
Zucker outside the bus where he is being recorded: “I better use some Tic
Tacs, just in case I start kissing her…. You know I’m automatically
attracted to beautiful—I just start kissing them. It’s like a magnet. Just kiss.
I don’t even wait” (Fahrenthold, 2016). During the course of the video, he
boasts of even more disturbing and assaultive things he has done to women.
Therapists of mental health across the country reported having to expand
their practices “with women who experienced sexual abuse when younger
… being re-wounded, re-traumatized” (LaMotte, 2016).
A great danger to vulnerable groups as well as the potential for
human rights abuses arise from an inability to tolerate criticism and
perceived threats to his ego. Claims of unearned superiority and delusional
levels of grandiosity were present since the start of his campaign (Gamboa,
2015). The flip side of that is often paranoia, a sense of entitlement, and the
potential for dangerous outbursts of rage if one’s inflated self-image were
challenged in any way. The compulsive need to shift blame can lead to
scapegoating and persecution. As anticipated, reports of hate crimes with
racial or ethnic bias jumped the day after Donald Trump won the election,
with greater reports of hate crimes on November 9 than any other day in
2016 (Williams, 2018). Derrick Johnson, president of the National
Association for the Advancement of Colored People (NAACP), noted: “The
acceptance of intolerance that has been condoned by President Trump and
many others across the country has simply emboldened individuals to be
more open and notorious with their racial hatred” (Eligon, 2018).
 Social psychologists at the University of Kansas conducted a study
on prejudice that surveyed almost four hundred Donald Trump and Hillary
Clinton supporters. They measured perceptions of social norms and
people’s own levels of prejudice toward nineteen social groups, shortly
before and after the election. Some groups were targeted by the Trump
campaign (such as Muslims and immigrants) and some were not (such as
atheists and alcoholics). There was an increase in the acceptability of
prejudice against groups Donald Trump targeted but little shift against
untargeted groups, which meant that the Trump presidency produced a new
normative climate favoring several prejudices that the authors label, “the
Trump effect.” Research suggests that individual expressions of prejudice
and potential violence depend highly on perceived social norms, and
Donald Trump had changed those norms (Crandall et al., 2018).
Assessment of dangerousness since the Trump presidency must
therefore take into consideration these changes of norms. In other words, a
dangerous presidency is bound to normalize and institutionalize many
dangers, making them seem acceptable precisely because a president is an
authority figure who sets norms and not just meets or breaks them. This fact
makes him dangerous beyond what can immediately be studied or be
directly observed.

Dangerous new norms

Over the three-and-a-half years of Donald Trump’s presidency, we have

watched white supremacist terrorism become much more mainstream. As of
2019, white nationalist hate groups in the U.S. had surged 55 percent since
the Trump presidency, according to the Southern Poverty Law Center
(2020). The perpetrator of a massacre in August 2019 in El Paso, Texas,
where twenty-six were killed, much like the man who plowed his car into a
crowd of protesters after a white supremacist rally in Charlottesville,
Virginia, in 2017, the 46-year-old who attacked a Pittsburgh synagogue in
2018, and the Australian man who killed 51 people at two mosques in
Christchurch, New Zealand, in 2019, drew inspiration from violent white
supremacist ideas, if not from Donald Trump himself (Beckett and Wilson
2019). While the Federal Bureau of Investigation (FBI) and the Department
of Homeland Security (DHS) made attempts to give the threat of deadly
white supremacism priority and to shift strategies, senior members of the
Trump administration such as Stephen Miller, long allied with anti-
immigrant hate groups, have hampered efforts. Perhaps one of the more
shocking, related legacies of this administration is the traumatic separation
of small children from their migrant families at the U.S.-Mexico border
(Associated Press, 2019).
Mass shootings and other forms of violence have increased to
unprecedented levels. In 2019, there were 417 mass shootings in the U.S.,
according to data from the nonprofit Gun Violence Archive (GVA, 2020),
which tracks every mass shooting in the country. GVA defines a mass
shooting as any incident in which at least four people are shot, excluding
the shooter. The group also tracks mass murders as defined by the FBI—
incidents in which at least four people are killed; 31 of the mass shootings
were mass murders. The year 2019 had the highest number of mass
shootings in any year since 2014, when the GVA started its count, with a
progressive increase each year. Individual violence has also seen a rise: a
nationwide review by ABC News has identified at least 54 criminal cases
where Donald Trump was invoked in direct connection with violent acts,
threats of violence, or allegations of assault (Levine, 2020). A review of
police reports and court records found that perpetrators in at least twelve
cases hailed Donald Trump in the midst, or the immediate aftermath of
physically assaulting innocent victims, in another eighteen cases cheered or
defended him while taunting or threatening others, and in another ten cases
cited him and his rhetoric in court to explain their violent or threatening
behavior. By contrast, ABC News could not find a single criminal case filed
in federal or state court where an act of violence or threat was made in the
name of President Barack Obama or President George W. Bush. There has
also been a 226 percent spike in hate crimes in counties that hosted his
rallies (Feinberg et al., 2019). Violent behavior is known to be especially
susceptible to shifts in culture and to spread by contagion (Slutkin, 2017).
At the time of this writing, the U.S. announced that it was pulling
out of the Open Skies Treaty, the third withdrawal from an arms control
agreement under the Trump presidency. The Trump administration also
debated conducting the first U.S. nuclear test explosion since 1992, which
would reverse a decades-long moratorium on such actions (Hudson and
Sonne, 2020). In this manner, regardless of stated intentions, and as
expected of his long-standing, expressed attraction to violence and
aggressive posturing, he has made the world a much more volatile and
unsafe place. The destructive power of the U.S. arsenal apparently thrills
him, as he has boasted about the size of his nuclear “button” (Baker and
Tackett, 2018), a mystery “super-duper” missile he claims he has (Lye,
2020), and “the mother of all bombs” that once “dazzled” him (Wright,
2017). His flamboyant summitry with Kim Jong-un notwithstanding,
analysts believe that North Korea poses an even greater threat, such that we
may need to abandon the decades-long insistence that North Korea drops its
nuclear program, entirely for lack of options (Bierman, 2020). His
abandonment in 2018 of the historic nuclear deal with Iran, against
international uproar, has escalated animosity as well as the possibility that
Iran will begin production of nuclear weapons. And his withdrawal from
the Intermediate-range Nuclear Forces (INF) treaty in 2019 has the
potential to trigger an unlimited nuclear arms race with Russia.
The U.S. did not sign the United Nations treaty on the Prohibition of
Nuclear Weapons, which 122 nations adopted in July 2017 (Associated
Press, 2017), the Senate never ratified the 1996 Comprehensive Test Ban
Treaty, and the 2010 New Start Treaty is due to expire in February 2021,
but there is no indication of an intention to reinforce any of them (Borger,
2020). In addition, the Trump administration has proposed to develop new
low-yield nuclear capabilities and pushed forward on a 1.7 trillion-dollar
plan to maintain and upgrade the U.S. nuclear arsenal. In May 2020, the
American Nuclear Policy Initiative (ANPI), a task force of former
government and non-governmental experts, released a detailed, objective
analysis by the title: “Blundering toward Nuclear Chaos: The Trump
Administration after Three Years” (Wolfsthal, 2020). Overall, after bringing
the world to the verge of various crises in South America, the Middle East,
Europe, and Asia and alienating traditional allies, the world is closer than
ever closer to the possibility of devastating wars and a nuclear war. The
abrupt withdrawal of U.S. troops in northern Syria that incurred a massacre
of Kurdish allies and the unprovoked, illegal assassination of top Iranian
General Qassim Soleimani during his impeachment proceedings are perfect
examples of the reckless decision-making that demonstrate Donald Trump’s
extreme dangerousness to society (Sonne et al., 2020).
Finally, the utterly disastrous handling of the novel coronavirus
pandemic illustrates Donald Trump’s psychological dangerousness, not just
through commissions but through deadly omissions, repeatedly, brazenly,
and recklessly. In addition to depleting or disbanding every aspect of
pandemic preparedness, he ignored ominous, classified warnings about the
danger through the first critical months, allowing the disease to spread
freely throughout the U.S. by actively downplaying the threat, falsely
stating: “we have it totally under control,” calling it the Democrats’ “new
hoax,” and “like a miracle, it will disappear” (Qiu et al., 2020). He caused
the need for extreme lockdown measures and the subsequent economic
collapse, and at the time of this writing, the death toll is nearly 200,000.
Despite only having 4 percent of the world’s population, the U.S. has
maintained a quarter of the world’s coronavirus deaths with no policy
change that would allow for abatement. Rather, evidence has emerged that
he deliberately lied about the deadliness of the virus, while knowing full
well the risks posed to the public (Costa and Rucker, 2020). The death toll
will undoubtedly be far greater because he pulled out of the World Health
Organization, in his attempt to shift blame for his failures, undermining
critical global cooperation and defunding the world’s pandemic response
capability (Peters 2020). His devaluation of science, fight with reality,
reckless disregard for human life, and neutering of the Centers for Disease
Control (CDC) are responsible for depleting pandemic preparedness,
ignoring intelligence and sidelining the experts, and politicizing a public
health issue in ways that have vastly worsened a deadly pandemic (Saletan,
2020). As a result, the United States has become the world’s epicenter of a
pandemic, isolated through widespread travel bans and unique among
advanced economies to be so stricken with a plague. With accompanying
economic devastation, “deaths of despair,” and growing violence, the
Trump presidency is now entering what may well be the most dangerous
period of all.

Dangerous weapons and power

Access to weapons is a crucial part of a dangerousness assessment. The

president of the United States has 1750 nuclear warheads at his or her
disposal and has the authority to order these weapons to be launched even if
our country has not yet been attacked (Kristensen and Korda, 2020).
Weapons fired against the United States from a submarine would take about
twelve minutes to hit Washington, DC. Missiles fired from most continents
would reach the U.S mainland in around thirty minutes. For these reasons,
the president of the United States has the unfettered authority to launch
nuclear weapons at any time for any reason. There is no formalized way of
preventing this unless the commander of the U.S. Strategic Command, who
has been given the order to launch, explicitly disobeys that order. The
nightmare scenario of an unstable, impulsive, blame-shifting, and revenge-
obsessed individual having mere minutes to make the kind of monumental
decision is of the gravest possible concern and is a risk that defies
rationality.
All this is on top of outsized war-making powers that the president
has at his disposal. Despite the isolationist rhetoric and the stated aim to end
“endless wars,” Donald Trump has ramped up warfare on many fronts.
Strikes in Somalia have increased eightfold since his presidency (Turse,
2020), loosened rules of engagement have killed even more civilians, and
thousands have died in needlessly brutal operations in Iraq and Syria as a
result of slackened targeting standards (Cooper, 2017). As commander-in-
chief, he has gone out of his way to encourage war crimes and even to
celebrate those who commit them (Cole, 2019). Recently, we learned that a
direct clash between U.S. and Russian troops in northern Syria had been
ongoing for months without congressional authorization. This is the same
president who continued U.S. participation in Saudi Arabia’s war in Yemen
even after Congress voted to stop it and affirmed that it was
unconstitutional (Hueval, 2020). In May 2020, after bringing the nation to
the brink of war with Iran just months earlier, he vetoed the Iran War
Powers resolution, a bipartisan effort to rein in presidential authority to use
military force against Iran without congressional approval (Carvajal, 2020).
The ability to make policy is as important a consideration as access
to weapons in dangerousness assessments, where applicable. Because
dangerousness is more situational than person-oriented, various factors need
to be considered, such as the individual’s ability to cause harm through
secondary influence or authority, such as policies that are well-established
to stimulate violence or cause direct harm. Whereas these aspects have been
more nebulous in the past, three decades of scholarly research in violence
prevention allow for rigorous prediction. In many ways, violence prediction
has become much more precise with policy changes (Ouimet, 2012) than
with individual behavior, as the latter is largely circumstantial, dependent
on the setting and social contacts of the moment Some of the greatest harm
can be inflicted through policy: the climate is a perfect example. Experts
have warned that another decade on our present course, we will have likely
passed a point beyond which catastrophic harm is unavoidable (Harvey,
2019). In addition to leading the nation out of the Paris climate accord,
Donald Trump and the former industry executives and lobbyists placed in
control of the Environmental Protection Agency and the Department of the
Interior, spent four years rolling back auto emissions standards, opening the
Arctic National Wildlife Refuge to drilling, rejecting stronger air pollution
standards, and weakening the National Environmental Policy Act, which
has served as the foundation of environmental protection in the United
States for a half-century. Having opened the pathway to everything from
pipelines to the destruction of natural habitats, he is said to have done more
to damage the environment than any president in history (Loeb et al, 2020).
Every increase in global temperatures already translates into death and
misery for millions around the world, but we are now speaking of the
potential extinction of the human species, as well as many others. This
would not be possible without access to policymaking by a dangerous
individual.
Whenever danger is suspected in an individual, the first thing we do
before the involuntary assessment is to remove the individual from access
to weapons or other means of inflicting grave harm. An individual in a
powerful office can be dangerous not only through access to destructive
powers but through absence, such as the lack of mental capacity.

Mental incapacity

Verbal, behavioral, and policy-based violence are not the only forms of
danger; whether a president has the mental capacity to serve in his office is
also a critical question that needs answering. Special Counsel Robert
Mueller’s Report on the Investigation into Russian Interference in the 2016
Presidential Election (2019), which was released to the public in redacted
form on April 18, 2019, provided a wealth of relevant information
regarding the president’s mental capacity, or his ability to function in office.
It was also unique for other reasons. Until then, all the information that was
available, regardless of abundant quantity or sophisticated quality—real-
time, often candid video and audio recordings of responses to real events in
real-time, over decades; thorough investigative reporting by some of the
most respected journalists of the most trusted newspapers; books,
interviews, and tell-all accounts by a range of those who have closely
interacted with him; and persistent, unfiltered and undisciplined stream-of-
consciousness Twitter comments—could still be dismissed as unorganized,
unvetted public information. Information in the Mueller report, however,
was verified with the accuracy and expertise of the highest-order criminal
investigations and represented the most relevant information for a capacity
evaluation, being of reports by his close associates and coworkers who
directly interacted with him. And unlike a diagnostic exam, a functional
exam depends most heavily on a person’s colleagues’ reports on his actual
performance at his job, not on a personal interview.
Mental capacity is about possessing the mental soundness that is
necessary to fulfill a task. It is deemed that the office of president requires,
at minimum, the ability to make sound, rational decisions based on reality
and the ability not to place the nation in grave danger. The final
determination of “competency” is a judicial decision usually made by the
courts, while capacity is a medical assessment that forensic psychiatrists
and other mental health professionals make as expert witnesses to present to
the courts to aid them in making their legal decisions. Similarly, presidential
fitness is a political decision, but just as the courts routinely rely on mental
health professionals’ assessments for fitness for duty, political bodies
should not be denied access to the same medical and professional
information and expertise from which the judicial system benefits. A panel
of top psychiatrists and psychologists joined me in assembling our analysis
as a public service, and what follows is just a sampling of illustrations,
which can be read in full elsewhere (Lee et al., 2019).
A capacity evaluation involves the test of three main components:
(a) comprehension, or the ability to take in information and advice without
undue influence from delusions or excessive emotional needs; (b)
information processing, or the ability to appreciate and make flexible use of
information and advice; and (c) sound decision making, or the ability to
weigh different options and to consider consequences based on rational,
reality-based, and reliable thinking without undue influence from
impulsivity, delusions, magical thinking, or fluctuating consistency and
self-contradiction. When it comes to serving in a high governmental office,
constantly repeating demonstrable untruths despite a consensus that these
violate easily verified, objective, factual reality, and often following by
denying that those statements were made in the first place, even when they
were made in public and have been recorded on tape and video, would
obviously be disqualifying. Other important standards may be added, such
as capacity for trust, discipline and self-control, judgment and critical
thinking, self-awareness, and empathy (Gourguechon, 2019), but we decide
here to deal only with the bare minimum.

1. Compromises in comprehension

The Mueller report (2019) outlines how the Russians systematically and
sweepingly attacked America before and during the 2016 election. The
president’s refusal to acknowledge the severity of these attacks, his
investment in a certain “reality”—that the Russian attack was insignificant
—and his resistance against advice that challenges his established notions,
show a compromise in his ability to comprehend and to absorb important
information. When the highly-respected White House lawyer, Don
McGahn, failed to meet the president’s demands that he tell Acting
Attorney General Rod Rosenstein to fire Special Counsel Mueller, and then
to “put out a statement denying that he had been asked to fire the Special
Counsel” (Mueller, 2019), he became the object of ridicule (“Lawyers don’t
take notes”) and headed for the exit. His advisors similarly and repeatedly
blocked the president from acting impulsively and self-destructively,
preventing him from committing a crime. These reports illustrate a
president who is: (a) predisposed to rash, short-sighted, and dangerous acts,
without consideration of consequences, motivated by self-protection to the
degree that shows him incapable of considering national interest; and (b)
surrounded only by the most informal and personal resistance around him to
curtail those acts, until the pressure of his predisposition pushes out the
advisors.

2. Faulty information processing

The report sheds light on the extent to which Donald Trump lies to his staff
and his colleagues. This trend is so obvious, and yet also so unusual among
public servants that it raises a question of serious mental pathology: namely,
does he actually believe the obvious untruths that he utters (in which case
we would need to ask whether he is suffering from delusions), or, does he
know that they are untrue but utters them anyway (in which case he is
deliberately and consciously lying in an attempt to manipulate others into
advancing his financial, political, or psychological interests and needs,
which in severe form can be manifestations of an antisocial or
sociopathic/psychopathic disorder). Either instance constitutes faulty
information processing.
His combative style of ridiculing his opponents, or a “hit first and
ask questions later” approach—as in, “low-energy Jeb,” “little Marco,” or
“crooked Hillary”—enabled the candidate Donald Trump to avoid rational
and evidence-based debates over actual policy positions. He has also shown
predatory skills, being remarkably talented at deciphering his opponents’
vulnerabilities and brazenly talking down challenges. He lures and
“hypnotizes” his followers through factually untrue assertions that he may
make up one day and then deny the next, through a primitive form of
cognition that is called “magical thinking” or “wishful thinking.” It is a
form of cognition that follows “the pleasure principle” (adhering to
whatever makes one feel good, or at least less distressed, and appears to
gratify one’s wishes), rather than “the reality principle” (which will often
frustrate or be incompatible with one’s wishes). This kind of brashness is
often a reaction to one’s own vulnerability, and the reality of human
weakness and uncertainty, also shown in the president’s intolerance for
investigative reporting, which he calls, “fake news” and “the enemy of the
people.” Our deepest concern is that when reality smothers his accusations
and neutralizes his assaults, he will then resort to his most dangerous and
violent strategies.

3. Interferences to sound decision making

Angry outbursts in the president are documented with an alarming

frequency, intensity, and lack of control. Former White House Chief
Strategist Steve Bannon described the President’s anger upon learning of
Attorney General Jeff Sessions’ recusal, “as mad as I’ve ever seen him,”
and he “screamed at McGahn.” In response to Comey’s confidential
briefing to congressional leaders on the existence of the Russia probe in
March 2017, notes taken by Annie Donaldson, then McGahn’s chief of
staff, state: “POTUS in panic/chaos.” Others reported that the president was
“beside himself,” “became very upset and directed his anger at Sessions.”
Hicks described the President as “extremely upset by the Special Counsel’s
appointment…. she had only seen the president like that one other time,
when the Access Hollywood tape came out during the campaign.” And
when he hears of the appointment of the special counsel, he exclaims: “Oh
my God. This is terrible. This is the end of my Presidency. I’m fucked”
(Mueller, 2019). It is notable that the nature of the provocation is always
threats to self, not because he is furious that a staff member or cabinet
secretary had bungled an important legislative or foreign policy initiative.
There is no, “What are we going to do? This will undermine all our plans
and policies,” but his responses are a virtual admission of guilt, remarkable
for the extent to which the president is preoccupied with himself without
room to consider the welfare of the nation.
Recklessness can be seen in the instances in which the president
acted against the advice of others, including the White House lawyer,
McGahn. Following Comey’s March 2017 meeting with congressional
leaders, at which he disclosed the existence of the Russia probe, the
president twice called Comey directly, notwithstanding guidance from
McGahn to avoid direct contacts with the Department of Justice. The
president initiated several efforts to have him removed or at least to limit
his powers. In the first instance, he raised issues about Mueller’s supposed
conflicts of interest. These were generally dismissed by McGahn, Bannon,
and others. McGahn pointed out that advancing these arguments could add
evidence of an attempt to obstruct the special counsel. In spite of this, the
president’s personal attorney contacted the special counsel’s office asserting
the alleged conflicts. Four days later, the president called McGahn and
directed him to have Rosenstein fire Mueller, something that McGahn had
no intention of doing. In a second call the same evening, the president told
McGahn: “Call Rod, tell Rod that Mueller has conflicts and can’t be the
Special Counsel” (Mueller, 2019). McGahn prepared to resign before the
president backed down.
In parallel sequence, the president directed Lewandowski to contact
Sessions and to have him assert that the president had done nothing wrong
and that the special counsel’s authority would be limited to “investigating
election meddling for future elections” (Mueller, 2019). Scheduling
conflicts delayed Lewandowski’s opportunity to meet with Sessions. A
month later, when the president asked Lewandowski about progress,
Lewandowski asked Rick Dearborn, a senior White House official, to serve
as an intermediary and gave Dearborn a typed version of the statement the
president had dictated for Sessions, but Dearborn never acted on it.
In both instances, the president directed actions to be taken, the
dismissal of Mueller as special counsel, and the limitation of the special
counsel’s role by an unrecused Sessions, which were avoided only by the
passive resistance of those he directed. The combination of reckless
decisions, false denials, and threatened vengeance against those who kept
his recklessness in check, illustrate a dangerous pattern of impulsive harm-
doing which, when challenged, is only redirected in more threatened harm.
Above all, in a post-Richard Nixon era, knowing that that former president
was forced to resign because of his firing of law-enforcement officials who
were facilitating or even just permitting the investigation into his behavior
to proceed, constituted an obstruction of justice, a rational person
presumably would have considered the consequences of such actions. The
president himself discovered that the firing of “nut job” Comey did not
“take the pressure off,” (Smith, 2017) but only brought on a new special
counsel with new investigations into him that did not work to his advantage.
Ousting moderating forces that he would have done well to listen to, only a
few capable staff now remain in spite of the president.
Conclusion

Mental capacity, especially decisional capacity, is the most important

mental health evaluation for assessing a president’s ability to discharge the
duties of his or her office. Like dangerousness, it is a separate evaluation
from the diagnosis of mental disorder and does not mean one has a mental
illness. It means that should a crisis arise—from a pandemic to nuclear war
—the person would not be able to make the necessary decisions to handle
the situation. It does not preclude criminal-mindedness; rather, the
combination of mental incapacity and criminal-mindedness can create some
of the most dangerous kind of leadership possible. The special counsel’s
abundant documentation of clear and pervasive, cumulative patterns, under
sworn testimony, allowed for a top-quality assessment of the president’s
impaired capacity, in which he failed every criterion. In other words, he was
found incapable of making responsible decisions free of impulsivity,
recklessness, suspiciousness, or absorption in self-interest that precludes
attention to the national interest. He was found incapable of weighing
consequences before taking action, without detachment from reality,
creation of chaos and danger, and cognitive and memory problems. In
addition, the counsel recorded extensively and in detail criminal intent (a
“guilty mind”) in the presence of wrongful action (a “guilty act”) in relation
to obstruction of justice, which demonstrates criminal responsibility and
indictability. We added in our report “proneness to place himself and others
in danger,” as an additional criterion to determine fitness for duty—since
dangerousness alone disqualifies—and this returns us to the assessment
earlier in the chapter. Thus, having proven Donald Trump’s dangerousness
from multiple angles, I have exceeded my most rigorous threshold for
proceeding with more detailed analysis, so as to help the public better
understand, and protect itself from the very real threat that Donald Trump
poses.
 A Profile of Donald Trump

Commenting on a president

While it is unethical to speak about matters one has insufficient

information about, it is also unethical to withhold an assessment on which
one has more than enough information—especially when societal safety is
at stake. Particularly disturbing is the total absence of a request for
assessment on the part of the authorities, despite the severity of the
president’s disturbances, the obviousness to which he presents a danger, and
the degree to which the public has been clamoring for expert input.
Bringing attention to mildly significant mental problems in a high office
could be detrimental and should be carefully considered. However, failure
to disclose serious mental problems in such an office, especially in a
democracy, where the electorate must be informed to make the right
choices, could have catastrophic consequences. Whatever the reason for this
gap, to fill this void is one of the purposes of this study. First, we must
establish a level of knowledge. In April 2019, when presenting Grand
Rounds to a group of Harvard psychiatrists and other mental health
professionals, they stated during the discussion: “We know more about this
president than we do about any patient we have ever treated.” I would
agree. And if we have a duty to report, to inform, to warn, and to protect
society against any knowledge of danger we have about a patient, how
much greater is it for a nonpatient, toward whom we have no confidentiality
requirements?
What we have to offer in this case is not the information we have
access to but the perspective we bring, given our years of training, decades
of clinical observations and interest, and more than a century of scientific
research investment and evidence. I bring training from Bellevue and
Massachusetts General Hospitals in New York City and Boston
respectively, two decades of practice in maximum-security prisons in
various parts of the country, and over one hundred peer-reviewed
publications, including a textbook on public health approaches to violence
prevention. The profile I present here is not political but grounded in
applying these perspectives to the individual in the context of society. In
addition, I have had in-depth personal conversations with Donald Trump’s
ghostwriter and his niece, to gauge the reliability of the public information
that they provide, as well as draw upon further intimate information. At the
same time, throwing out labels such as “narcissistic personality disorder” or
“antisocial personality disorder” is marginally helpful at best, since
diagnosis is not so much about inclusion as it is exclusion. In other words,
there is a greater likelihood that attempts to diagnose will simplify and
minimize the situation by closing off inquiry into the actual scope and true
complexity of the problem. Using phrases that mean very little to the
general public does not achieve much. Instead, we must encourage a
nuanced discussion aimed at establishing and understanding the true danger
to public health. This is the ultimate litmus test: how will this discussion
help to improve public health and safety? Will it enhance understanding and
empower the public with knowledge, and will it help steer the course in a
positive and life-affirming direction? Study is important to achieve the
desired outcome since a leader’s behavior is not just dependent on personal
characteristics but on how the people respond to and interact with him.

Donald Trump as he sees himself

In late 2018, Donald Trump made an extraordinary suggestion after a

dispute with his hand-picked Federal Reserve chairman for raising interest
rates:

I have a gut, and my gut tells me more sometimes than anybody

else’s brain can ever tell me (Sullivan, 2018).

It was not only an unusual statement for the leader of the Free World to
make but a strikingly precarious approach to take when engaging in high-
stakes negotiations as with North Korea over nuclear disarmament. Donald
Trump seemed to believe that following his “gut” would serve him better
than any preparation, deliberation, or listening to the wisdom of his career
advisers. Without any experience, underlying knowledge, or even curiosity,
he walked into conversations with potentially hostile world leaders, stating:
“We will see what happens. Whatever it is—it is” (Guild, 2018). He took
the same approach with the crisis of the coronavirus pandemic: “One day—
it’s like a miracle—it will disappear…. We’ll see what happens,” he said in
February 2020, as the virus raged through communities (Bump, 2020).
When confronted six months later with the fact that a thousand Americans
were dying a day, he said: “They are dying. That’s true…. it is what it is”
(Cole and Subramaniam, 2020).
Later, we learned his motivations through journalist Bob
Woodward’s recordings in March 2020: “I wanted to always play it down. I
still like playing it down because I don’t want to create a panic.” In public,
just three weeks earlier, he went as far as to say that Democrats were using
the coronavirus outbreak as a “new hoax” to damage him. And yet on
another occasion in March 2020, he said: “This is a pandemic…. I’ve felt
that it was a pandemic long before it was called a pandemic” (Rogers,
2020). This is not the pattern of someone trying to solve a problem behind
the scenes and attempting to calm the public; it is the pattern of someone
who wishes to minimize a problem even as others are worried about it, and
then justifies to himself that he, too, was worried all along and denies the
decisive role he played in impeding efforts to stop it. He later stated: “I
don't take responsibility at all” (Oprysko, 2020).
It makes little difference to public health whether he consciously
understood the seriousness of the pandemic and was lying, or was trying to
impress the journalist with the rational-sounding explanation that he did not
“want to create a panic,” when in reality he cared little for the
consequences. His actions remain the same, leading the country into a vast
underestimation of a deadly problem, while he not only refused to act but
actively undermined the efforts of others. Central to his persuasion of his
followers is that he “knows more about anything” and “understands better
than anybody,” regardless of the topic, the proof of this being that he is
president (Britzky, 2019). “When somebody’s the president of the United
States, the authority is total. And that’s the way it’s got to be,” he said in a
press briefing (Sheth, 2020).
His self-aggrandizement had shown through in remarks once made
while praising his own “trade war” against China: “Somebody had to do it.”
Then, while looking to the heavens, he said: “I am the Chosen One.” Earlier
the same day, he had retweeted a right-wing pundit’s flattering, messiah-
flavored comments: “The Jewish people in Israel love him like he’s the
King of Israel. They love him like he is the second coming of God”
(Breuninger, 2019). Suggestions that he was sent by God, and that he has a
particular mission to perform flatter him as he feeds into the world view of
evangelical Christians (Kobes Du Mez, 2020). Just what he has to offer,
other than a feeling of ascendency and power, is rather vague, but this does
not concern him greatly because the praise he receives satisfies his “gut”.
And it does not seem to matter where the flattery is coming from. More
recently, he endorsed QAnon, a virtual cult and a potential domestic
terrorist threat that, according to the FBI, reveres him: “I don’t know much
about the movement other than I understand they like me very much, which
I appreciate,” he said in a press briefing (Liptak, 2020).
Such personal statements abound. “No one knows the system better
than me,” he said on his first campaign trail. “That’s why only I can fix it.”
He painted a dire state of affairs in the United States and the world—
instability abroad and crumbling infrastructure at home—and blamed these
problems on career politicians. “This is [their] legacy…. Death, destruction,
terrorism, and weakness.” To Americans shaken by violence at home and
around the world, he promised: “Safety will be restored.” He would replace
Obama-era health care with the kind that is “affordable and accessible for
all.” He would overhaul tax laws and get rid of regulations that would
“make our country rich again” (Jalonick and Daly, 2016). These were some
examples of the sweeping ways in which, without experience or a plan, he
would “make America great again.” His belief in his power bordered on
feelings of omnipotence and delusions of grandeur.
He prides himself on being tough, stating: “The world is laughing at
us, at our stupidity,” something he mentioned more than fifty times between
2011 and 2016 when he was elected. In 2014, he tweeted: “We need a
President who isn’t a laughing stock to the entire World. We need a truly
great leader, a genius at strategy and winning. Respect!” His primary theme
as a candidate whenever he discussed foreign affairs or international trade
was that China was laughing at us, Europe was laughing at us, the Taliban
was laughing at us, OPEC was laughing at us, and the world was laughing
at us. Once he became president, he promised, the laughter would stop. “We
don’t want other leaders and other countries laughing at us anymore, and
they won’t be,” he said. Yet, two years later, the Washington Post remarked:
“literally not a single person on Earth gets laughed at more than Donald
Trump”—and a video captured Canadian Prime Minister Justin Trudeau,
French President Emmanuel Macron, British Prime Minister Boris Johnson,
and others doing just that at the NATO summit (Waldman, 2019).
 Nevertheless, there can be little room for doubt over Donald
Trump’s belief in his greatness. What are the sources of this belief? Some
have attributed his confidence to the fact that he believes in his superior
“gut” to guide him through a course of action. He said there was no need to
prepare for trade negotiations with the Chinese president because: “I know
it better than anybody knows it, and my gut has always been right.” He said
on another occasion that his decisions about which candidates to endorse
were based on: “very much my gut instinct.” He claimed his 2016 campaign
strategy came from multiple sources, including: “Yeah, gut,” but also “from
my heart.” He said in 2011, “my gut tells me” President Barack Obama’s
birth certificate may have been forged. His gut also told him to do “The
Apprentice.” He has over the years touted the primacy of the gut: “Go with
your gut…. You have to follow your gut…. Develop your gut instincts and
act on them…. I’ve seen people that are super genius, but they don’t have
that gut feeling” (Milbank, 2018).
Consequently, Donald Trump does not attribute his abilities to any
real knowledge or intellectual capacity. “I love the poorly educated,” he
once said during a victory speech (Hafner, 2016). He has long belittled
science, except when there is an opportunity to boast about himself. During
a visit with doctors and researchers at the Centers for Disease Control and
Prevention (CDC) at the onset of the coronavirus pandemic, he announced:
“Every one of these doctors said, ‘How do you know so much about this?’
Maybe I have a natural ability.” Before winning the presidency, he had
publicly questioned science by expressing skepticism about vaccines, and
by suggesting that climate change was a hoax fabricated by China. Once in
office, he systematically downplayed or ignored science to weaken
environmental health and global warming regulations. He disbanded expert
advisory boards and either suppressed or altered findings that warned of the
dangers of pollution and global warming. As the new viral outbreak
engulfed the nation, he repeatedly muzzled, sidelined, and pushed aside his
public health experts (Friedman and Plumer, 2020). Those who contradicted
his preferred narrative were either removed from their positions or had their
funding withdrawn (Goldberg, 2020a).
It may indeed seem as though Donald Trump acts under some secret
guidance that gives himself and others the feeling of magical infallibility:
his ability to sense the needs of a crowd and to spellbind them, his Harry
Houdini-like escapes from troubles that would have sunk anyone else, or
his ability to build a Teflon presidency centered around what can only be
described as obvious criminality. Armed with bravado, bluster, boundless
audacity, and ruthlessness, thriving in the tumult of his creation, he has until
now, exhibited an extraordinary knack for recasting obvious losses into
strange wins, accustomed to the prodigious safety net of his wealthy father
or of the bankers and lenders of New York City. His supporters allow him to
live large on their dime until the point at which letting him die would
mortally wound themselves, and he effectively occupied and used his hosts
to grow bigger until he was not only “too big to fail” but “too big to jail”
(Kruse, 2019). This is, in a sense, how he has scrounged the U.S.
presidency and has held onto it to escape any prosecution or accountability.
He sees his approach as a binary choice. He told New York magazine
in 1994:

Hey, look, I had a cold spell from 1990 to ’91. I was beat up in
business and in my personal life…. But you learn that you’re
either the toughest, meanest piece of shit in the world, or you just
crawl into a corner, put your finger in your mouth, and say, “I
want to go home” (Horowitz, 1994).

Mary Trump, his niece, and a clinical psychologist told me:

Even though my grandfather died twenty years ago, whenever

Donald is talking about he is the best, he is the greatest, whenever
he is starved for attention and compliments and the rally crowds,
what he is really doing is speaking to his audience of one, which
was my grandfather, and saying, “You know, Dad, I am the best, I
am the winner, do not kill me” (Lee, 2020b).

In other words, you need to be the toughest killer on the block or die.
A staggeringly fragile ego lurks behind the façade. Many trace his
bid for the presidency itself 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 (Roberts,
2016). He has spent his entire adult life plastering his name on skyscrapers
and casinos, obsessed with his image, and spending perhaps the greatest
amount of time as president monitoring television coverage of him, angrily
accusing, “Fake news!” or “Enemy of the people!” simply for accurate,
unflattering reporting (Sullivan, 2020). Perhaps most shockingly, when the
coronavirus pandemic hit, governors had to grovel to him to receive
medical equipment, and those who he refused had their entire states “going
through hell as a result” (McCarthy, 2020).

Donald Trump as the public sees him

When we try to paint a portrait of Donald Trump as the public sees him, we
must not forget that propaganda distorts a large part of their view. Millions
of people have seen him in staged rallies and press conferences, but most of
their information comes from media sources, which have diverged with
time into highly conflicting narratives, divided into two camps: whether
they support him or not. Reporting has also become split, dependent on
whether they believe him or not. In other words, his awkwardness,
belligerence, and even antisocial tendencies have come to be experienced as
endearing, reassuring, and alternately sympathy-evoking and awe-inspiring,
depending on the framing.
He is, at first glance, an alert and oriented, tall but mildly obese
Caucasian man who appears his stated age or perhaps slightly younger. He
is well-groomed with an elaborate hairdo and bulky, ill-fitting suit with an
exceptionally long red tie. His posture is forward-leaning, whether sitting or
standing. His eye contact is often uneasy and fleeting when around others in
a room, where he can oscillate between the attitude of a scolded child
(especially around other world leaders) or a belligerent commander
(especially around reporters). He gesticulates often as if playing an invisible
accordion and, unlike most people, appears most comfortable when
addressing large crowds, especially stadiums full of them. His speech is
often loud and voluminous, rarely letting others speak in his presence, but
otherwise normal in rate and rhythm. His expressed emotion is often labile
if not volatile, able to transition from being charming to being aggressive on
a moment’s notice, but is highly dependent on his audience. His thought
process is often loose, jumping from one topic to another through free
association, which others have described as “bumbling, tangential, and
bordering on the nonsensical” (Shpancer, 2020). His thought content is
often detached from reality, bordering on delusion, but we will delve further
into this in the analysis.
Physical descriptions of him in the media hardly fail to notice his
hair, as far back as in 1984: “His sandy hair is probably a bit long by
standards of the corporate world,” a newspaper profile stated politely of the
then-38-year-old. “With the sides slicked back just a bit.” Three decades
later, the hairdo of the leading Republican presidential candidate became a
topic of conversation in its own right: “Is it swirled or swooped? Animal or
vegetable? (Mineral?) Burnt sienna or orange Creamsicle? Recently,
Gawker published an extensive investigation asserting that the whole
concoction might actually be a $60,000 weave” (Hesse, 2016). The Chicago
Tribune called him:
The braggart with the ducktail who would be president…. It is the
most famous ducktail in America today, the hairdo of wayward
youth of a bygone era, and it’s astonishing to imagine it under the
spotlight in Cleveland, being cheered by Republican dignitaries.
The class hood, the bully and braggart … is the C-minus guy who
sat behind you in history and poked you with his pencil and
smirked when you asked him to stop. That smirk is now on every
front page in America. It is not what anybody—left, right or
center—looks for in a president. There's no philosophy here, just
an attitude (Keillor, 2016).

Early remarks on his dress were not flattering, either. “He’s known
for a swaggering businessman’s style that offers little in the way of a
statement on personal aesthetics or even rarefied taste,” one article said.

His suits … are cut from conservative but quality fabric yet lack
an attention to fit. They are always a little too roomy, the sleeves
a tad too long. So much so that they look cheap—or more
diplomatically, they look a lot like the mass-market suits that bore
his name and were once sold at Macy’s until the department store
shuttered the line after his derogatory remarks about Mexicans.
Trump’s tie always seems to hang just a little too far below his
 belt, which makes a perfectly fine four-in-hand look not quite
right. He makes ties look sloppy (Givhan, 2015).

Not looking fastidiously tailored is possibly how he aims to appeals to the

average voter, not as a man with his name plastered on assorted buildings
who touts his wealth, but as an ordinary, angry middle-management guy. He
lacks the confidence or subtlety to settle with a discreet elegance without a
searing, fire-engine red tie, for instance. People have asked: “Why does
Trump wear suit jackets that are (literally) two sizes too big?” And an
article has answered: “It might have something to do with his attempts to
look bigger and therefore more powerful” (Croffey, 2016).
Indeed, his electoral success owes a great deal to a large portion of
the population placing importance on having a strong leader and to their
perception that he looked the part. Morning Consult/Politico exit polls
showed the importance of the presidential candidate appearing to be strong.
It was twice as salient a factor in the 2016 election, with 36 percent, against
18 percent in 2012, saying that having a strong leader was particularly
important. The image Donald Trump projected was of a nationalist
strongman, which resonated with those whom globalization had
marginalized. The notion of a “strong leader” has been interpreted as “one
who maximizes his (or her) personal power; dominates his government,
political party and a wide swath of public policy; and asserts his right to
make all the big decisions.” In projecting himself as a near-messianic
figure, disregarding his lack of political experience but ridiculing even his
own party and declaring, “I alone can fix it,” he promised at his
inauguration ceremony to determine not only the course of the United
States but also of the world “for many, many years to come” in a “historic
movement the likes of which the world has never seen before” (Brown,
2017). The realities that the audience turnout fell far below that of Barack
Obama in 2009, and that he failed to impress most Americans—notably the
voters who chose his opponent by an excess of three million votes—did not
get in the way of his rhetoric. Indeed, that he would never have won but for
the vagaries of an anachronistic electoral college system would not enter
into his discourse.
Perhaps it was his obvious fragility or the serious nature of the
office he holds that caused much of the mockery and teasing from the major
media to diminish following the shock of his winning the presidential
election. On the other hand, the myth of his strongman image grew from the
peripheries into the mainstream: “Donald Trump: Finally Someone with
Balls” t-shirts became common at his rallies, and research by the
Washington Post revealed that he appeared to appeal to men with “fragile
masculinity,” those who were secretly insecure about their manhood.
Research shows that men often feel pressure to look and behave in
stereotypically masculine ways—or risk losing their status as “real men.”
Socialization of these expectations begins in early childhood and can
become unforgiving standards that make some men worry they are falling
short. The political process can become a way for fragile men to reaffirm
their masculinity, and this became so in the United States in 2016 more than
in previous years; by supporting a “tough” politician with aggressive
policies, they could reassure themselves and others of their own manliness
(Knowles and DiMuccio, 2018). Hence, the apotheosis of the fragile man,
awkward, thin-skinned, self-conscious, and unsure of himself, managed to
become through his public persona the epitome of manhood for many.
In addition to the lure of his psychological defenses, hypnotist
Richard Barker claims hypnotic techniques are one of Donald Trump’s most
powerful weapons. Mass hypnosis has been around for a very long time,
including in politics and religion, but “Donald Trump has mastered it,”
Barker argues. He uses mass persuasion and suggestion, even though he is
“not a very good public speaker,” but his magical powers in commanding
attention lay almost entirely in his ability to sense what a given audience
wants to hear and then to manipulate his speech in such a way to arouse the
crowd’s emotions. Like a seismograph for crowds, he senses with an agility
that no conscious strategy could match, to act as an amplifier of the most
secret desires, the least permissible drives, and the sufferings and revolts of
those who felt left behind. “America was once great,” his frequent narrative
goes, and “we need to fight those that are taking our country away from
us.” By creating expectations, the audience knows what they are going to
get, and helping them to visualize brings them into a hypnotic trance. He
had been tireless on the campaign trail, and even afterward seemed to crave
giving speeches so much that he could not stop even after being elected. He
used repetitive phrases—“Lock her up!” or “Build that wall!”—rehearsed
his audience, and created message discipline. “He does all the things that a
hypnotist would do when you’re hypnotizing somebody,” the hypnotist
described (Kurtz, 2016).
 His brash rhetoric was something new, and a stark comparison to
most slow-tongued, carefully calibrated politicians. His brutal insult
comedy was a spectacle that people paid to see, and the executive chairman
of CBS himself admitted the campaign was a “circus” of “bomb-throwing.”
He said: “It may not be good for America, but it’s damn good for CBS….
Man, who would have expected the ride we’re all having right now?... The
money’s rolling in, and this is fun” (Bond, 2016). Through insults, chants,
entertainment, spectacles of violence, and the assistance of mass media, he
was thrusting himself onto the consciousness of thousands, holding
audiences under a hypnotic spell, whether they found him refreshing or
repulsive.
Before the election almost all of his speeches seemed to center
around the following three themes: (a) the corrupt “swamp” of Washington
that needed to be drained; (b) the illegal and criminal immigrants entering
from Mexico; and (c) how great he is and how he alone can fix it. His
rambling events, which sometimes stretched over an hour with only the
barest of notes to guide him, was a framework built around the same,
simple anchors that created comfort for their predictability. Indeed, people
liked what he did and would attend one rally after another to hear him
speak. It was not so much what he said that appealed to his audiences, but
how he said it, with the familiar rhythm of anecdotes, themes, and phrases
he habitually settled into. His heart and soul in the cause of national
aggrandizement, he dared to speak the truth and to defy the national
authorities as well as “the globalists.” His main message was as follows: he
is a winner, everyone else is a loser. By supporting him, they are winners,
too—and America needs winners (Berenson, 2016).
It was this version of Donald Trump that people saw firsthand: a
tireless speaker who rushed from one rally to the next, in states that often
felt neglected by the political elites, working himself to exhaustion on their
behalf. They do not see the man who owns or operates seventeen different
golf courses or properties around the world, including twelve in the United
States, two in Dubai, one in Ireland, and two in Scotland, as well as planned
courses in Indonesia. He plays only with friends and famous people,
including professional golfers, senators, and other political and diplomatic
personalities. These are only spotted visits since the White House goes out
of its way to bar the press from shadowing him when he goes to his clubs.
He golfed so much since taking office on January 20, 2017, that a “Trump
Golf Count” website was set up, and as of this writing was seen on his
courses or played golf elsewhere over 290 times, nearly 22 percent of his
time in office. His cost to the American taxpayer has totaled in the tens of
millions of dollars, and the Secret Service has spent at least 550,000 dollars
in third-party golf cart rentals and over 500,000 dollars to stay overnight at
Donald Trump’s properties, including his New Jersey country club (Golf
News Net, 2020).
Donald Trump’s image as a successful businessman helped carry
him to the White House, and a majority of Americans still believe he was
successful. Yet, in 2018 the New York Times reported that he inherited 413
million dollars from his father, largely through illegal tax dodges (Barstow
et al., 2018). In 2019, the news broke that the “very successful”
businessman had lost 1.17 billion dollars between 1985 and 1994, or more
money than nearly any other individual American taxpayer—such a
massive sum that he was able to avoid paying income taxes for most of
those years (Buettner and Craig, 2019). Despite being reminded of these
facts in a poll, however, 74 percent of Republicans still clung to the belief
that Donald Trump was successful when it came to business. A powerful
real estate tycoon feeds people’s imagination, as well as offers material for
the right-wing propaganda machine, which continued to portray him as a
superlative, if not superhuman, character. Many believed that he is the same
height and weight as professional baseball player Tim Tebow, and a full two
inches taller than Barack Obama, no matter the glaring evidence to the
contrary. They also seemed to believe he is as rich as he says he is, that his
tax cut was all about the middle class and cost him “a fortune,” and that he
could not release his tax returns because he is under audit, even though
there is no such rule. Even his lack of scruples in losing more than any
other taxpayer became a sign of his greatness: “If anything…. it’s pretty
impressive, all the things that he’s done in his life. It’s beyond what most of
us could ever achieve” (Cummings, 2019).

Donald Trump as his associates see him

To portray Donald Trump as his associates see him, we must take into
account a number of factors. We must consider not only the extent of these
associates’ interactions with him and the reliability of their reports, but also
how they compare with one another. In doing so, there is a vast amount of
material we could draw from. In fact, there is almost an overabundance of
information that has poured out from former colleagues, associates and co-
conspirators, as well as by one member of Donald Trump’s own family. The
sources that have been selected for consideration here include reports and
books by five people who provide, within their pages, firsthand accounts of
their experiences with the man. The first is Tony Schwartz, a ghostwriter
who spent eighteen months shadowing Donald Trump in order to write his
memoir. The second is John Bolton, a man who served as Donald Trump’s
national security advisor for seventeen months. The third is Michael Cohen,
who spent twelve years as Donald Trump’s lawyer and fixer. The fourth is
Bob Woodward, a journalist of presidents who conducted an extraordinary
eighteen taped interviews with Donald Trump. The last is Mary Trump, the
president’s niece, who spent a lot of time around the family. I have
personally met with, and interviewed, only three out of those five—Tony
Schwartz, Michael Cohen, and Mary Trump—but there is a high degree of
consistency between their reports across the board. This, in addition to the
consistency also shown when checked against other sources of information,
such as investigative reports and sworn testimonies, suffices for an
assessment of reasonable validity.
A ghostwriter

In order to protect the public, a personal interview is not always necessary

to assess the various effects and influences that a given public persona
might have. In many cases, collateral reports produced by others who have
interacted with that person are far more valuable. It was for this reason that
Tony Schwartz was invited to contribute to The Dangerous Case of Donald
Trump (2017), even if he was not to be numbered among the initial twenty-
seven mental health experts included in that publication. Schwartz was able
to offer what the mental health experts at that time could not: a piece that
recounted and reflected on direct personal experiences with Donald Trump.
Schwartz spent eighteen months between 1985 and 1987 getting to know
Donald Trump better than almost anyone outside the family: he camped out
in Donald Trump’s office, joined him on his helicopter, tagged along to
meetings, and spent weekends with him at both his Manhattan apartment
and his Florida estate. Thanks to Schwartz’s contribution to The Dangerous
Case of Donald Trump, we were able combine expert medical analysis with
experiential observation. Bringing those two elements together meant that
our assessment could claim reasonable completeness.
In his piece, Schwartz did not pull any punches. His breakthrough
book, The Art of the Deal (Trump and Schwartz, 1987) earned him forty-
eight weeks on the New York Times bestseller list. Schwartz’s assessment of
how it was written is: “I put lipstick on a pig,” he told the New Yorker. It
was because of that book that Schwartz had also decided to speak up during
the 2016 presidential campaign. He believed The Art of the Deal had caused
many Americans’ to foster a false conception of Donald Trump’s character.
Indeed, the book presents Donald Trump as a charmingly brash
entrepreneur with an unfailing knack for business: “It pays to trust your
instincts” (Trump and Schwartz, 1987), he states at one point, boasting of
the “secret” of his success. Schwartz knew, however, that beneath that
appealing, if possibly abrasive, façade lay a pathologically impulsive and
dangerously self-centered individual. This is an assessment that also finds
support in a statement made by Roy Cohn, Donald Trump’s personal
lawyer, a man who had, in the 1950’s, assisted Senator Joseph McCarthy in
his vicious crusade against Communism. Cohn, at the end of his life, dying
of AIDS, had this to say about Donald Trump: “Donald pisses ice water”
(Mayer, 2016).
 This coldness and self-centered attitude are particularly evident in
Donald Trump’s relationships with other people, as observed by Schwartz.
Donald Trump spent very little time with his family and appeared to have
no close friends. People were disposable in his world, Schwartz claims,
because for Donald Trump, “it was all about what you could do for him.” In
addition to that, Donald Trump had “no attention span,” the result of which
was “a stunning level of superficial knowledge and plain ignorance.” While
it drew upon an entirely different set of data, Schwartz’s criticism of Donald
Trump in 2016 was such that it agrees closely with our assessment as
mental health experts: “I genuinely believe,” he stated at the time, “that if
Trump wins and gets the nuclear codes there is an excellent possibility it
will lead to the end of civilization” (Mayer, 2016).
Schwartz’s first meeting with Donald Trump was not one that he
would have predicted. Its unlikely prompt was an unflattering piece that
Schwartz had written for the New Yorker, in which he described Donald
Trump as a ham-fisted thug trying to drive out rent-stabilized tenants from
his Central Park South building through harassment. After the piece was
published, Donald Trump sent Schwartz something closely akin to a fan
note. Schwartz was, understandably, shocked: “Trump didn’t fit any model
of human being I’d ever met. He was obsessed with publicity, and he didn’t
care what you wrote.” This characteristic manifested itself time and time
again later, when Schwartz was ghostwriting the memoir. Finding it
difficult on occasion to pin down a fidgety and easily-bored Donald Trump,
Schwartz started to eavesdrop on his phone calls instead. Rather than being
angered by this, and Donald Trump loved the attention. Indeed, according
to Schwartz, if Donald Trump “could have had three hundred thousand
people listening in, he would have been even happier.” All of this ties in
with what Schwartz recalls of Donald Trump’s habit of “playing people” in
these calls: manipulating them by flattering, bullying, and occasionally
getting mad, but always in a calculated way. At the end of a call, instead of
saying goodbye, Donald Trump’s customary sign-off was “You’re the
greatest!” At one point, Schwartz noted in his journal: “All he is is ‘stomp,
stomp, stomp’—recognition from outside, bigger, more, a whole series of
things that go nowhere in particular” (Mayer, 2016).
Not only did Schwartz’s eavesdropping reveal some of the ways in
which Donald Trump relates to others, it also exposed a number of
inconsistencies. “Lying is second nature to him,” Schwartz told the New
Yorker. “More than anyone else I have ever met, Donald Trump has the
ability to convince himself that whatever he is saying at any given moment
is true, or sort of true, or at least ought to be true.” Indeed, far from being a
successful tycoon, he lied strategically and misled the press. Moreover,
when his lie was uncovered through reporting by the Village Voice, Donald
Trump’s conscience was seemingly completely unaffected. When
challenged about the facts that had come to light, he would double down,
repeat himself, and grow belligerent. While this was the case, Schwartz
could not simply portray Donald Trump, in his memoir, as a hateful “one-
dimensional blowhard” (Mayer, 2016). As such, when writing the book, he
created euphemisms, putting into Donald Trump’s mouth phrases such as:
“I play to people’s fantasies…. People want to believe that something is the
biggest and the greatest and the most spectacular. I call it truthful
hyperbole” (Trump and Schwartz, 1987).
While he always abhorred Donald Trump’s “willingness to run over
people, the gaudy, tacky, gigantic obsessions, the absolute lack of interest in
anything beyond power and money,” Schwartz now greatly regrets the fake
charm that he created and ascribed him in the memoir. Having watched
Donald Trump pile one hugely expensive project atop the next, like a circus
performer spinning plates, Schwartz would go home and say exclaim to his
wife: “He’s a living black hole!” The countless hours spent with Donald
Trump were “draining” and “deadening,” and to Schwartz his bid for the
presidency seemed merge seamlessly into that continuum. After having
spent decades as a tabloid titan, in Schwartz’s mind Donald Trump’s plan
for the future was clear: “the only thing left was running for President. If he
could run for emperor of the world, he would” (Mayer, 2016).
A national security adviser

Adding to the portrait of Donald Trump by Tony Schwartz is John Bolton’s

book, The Room where It Happened (2020). Bolton’s account is one of
someone who actually worked with Donald Trump, and worked not with
revulsion but in uncommon agreement. Bolton was of the same mind as
Donald Trump on many matters of national and international significance,
including on the controversial withdrawal from the Iran nuclear deal.
Bolton was widely criticized for choosing to release certain information
only in his book, apparently for its sales, rather than to testify before the
House of Representatives and possibly contribute to the president’s
impeachment (Flood, 2020). The Room Where It Happened nonetheless
provides valuable insights. Most importantly, perhaps, it reveals the degree
of alignment between Bolton and Donald Trump, despite some differences
regarding policy. What Bolton provides us with, then, is a unique
perspective on Trump from someone who was not just a governmental
insider who is alarmed at the behavior he has witnessed, but a psychological
insider who can use his own resemblance to the president to turn on him.
The same factors that make Bolton such a valuable source, however,
also make his writing potentially difficult to interpret. Reading The Room
Where It Happened, it is important to keep in mind and to balance two
things: the author’s narcissistic tendency to use the advantage of special
insight and information in the his favor, and the inherent competitiveness
that prompts the depiction of the opponent in a poor light so that the author
might appear in a better one. To provide a fair assessment of Bolton’s own
reliability would perhaps require a book-length study. Certainly, taking into
account all the things already mentioned, Bolton is possibly the least
reliable of the associate sources considered in this chapter. Despite this,
however, he still provides many compelling and useful insights for this
analysis.
Bolton, we must be clear, is no hero and no martyr. Sometimes his
agenda was even more extreme than that of the president himself. His
experience, though, is extensive and undeniable: former U.S. assistant
attorney general for Ronald Reagan; assistant secretary of state for
international organization affairs in the State Department; undersecretary of
state for arms control and international security affairs; brief, recess-
appointed, ambassador to the United Nations; and, finally, national security
advisor to Donald Trump from April 2018 through September 2019. This
wealth of experience in and around government is, therefore, an important
consideration when trying to understand Bolton’s following assessment of
Trump: “I don’t think he’s fit for office. I don’t think he has the competence
to carry out the job” (Bolton, 2020).
That Bolton perceives Trump to be lacking in competence and
clarity of thought is evident throughout his book. He describes his thought
process when it comes to matters of governance and policy as being “like
an archipelago of dots, leaving the rest of us to discern—or create—policy.”
By Bolton’s account, the possibility of a grand spectacle often lures the
president, without consideration of other factors. This tendency, Bolton
claims, saw Donald Trump enter into tough negotiations with foreign
leaders while in possession of only a minimal understanding of the stakes.
The further consequences of this can be seen in his signing of a toothless,
vague, agreement with North Korean leader Kim Jong-un in Singapore and
in his siding with Russian President Vladimir Putin rather than the U.S.
intelligence community. Bolton also claims that, at one point, Donald
Trump casually advocated withdrawing the U.S. from NATO for no other
reason than to “do something historic” (Bolton, 2020). In this manner,
Bolton’s account corroborates our standardized mental health assessment
from April 2019: that Donald Trump lacks mental capacity, the basic
requirement to be considered fit and competent for just about any job, let
alone the presidency.
The Room Where It Happened is full of deeply critical and
unflattering anecdotes concerning Donald Trump, but the most telling are
the ones that are not present: the ones that the White House redacted. When
it became apparent, in January 2020, that Bolton had written and was going
to publish a book, the White House sent Bolton’s lawyer a cease-and-desist
letter. This letter demanded that the book not be released without the
removal of “voluminous amounts of classified information” and whose
publication constituted a “national security risk.” Subsequent to the issuing
of that letter, William Barr’s Justice Department also filed a federal lawsuit
requesting that the judge block the release of Bolton’s book. The reason
behind both of these legal actions soon became clear, as Vanity Fair
obtained some of the details subject to redaction: they are deeply
embarrassing for Donald Trump, illustrating his naked politicization of
America’s foreign policy. In one of the unredacted passages that was
leaked, Donald Trump is depicted begging for China’s assistance while the
2019 G20 dinner: “Make sure I win…. Buy a lot of soybeans and wheat and
make sure we win” (Sherman, 2020), said the would-be strongman,
desperate for re-election, abasing himself before Xi Jinping.
That behavior toward Xi is telling. As a needy supplicant, Trump
does not criticize the ruthless leader he finds himself conversing with.
Indeed, according to Bolton, when Xi explained why China was building
concentration camps for the country’s minority Uighur population, Donald
Trump actually told Xi that he approved of this brutal violation of human
rights. By Bolton’s account, Donald Trump actually told Xi to “go ahead,
you’re doing exactly the right thing.” Earlier in the same passage, Bolton
also writes that, during a phone call to Xi ahead of their G20 meeting,
Donald Trump said, “I miss you,” before adding: “this is totally up to you,
but the most popular thing I’ve ever been involved with is making a deal
with China…. Making a deal with China would be a very popular thing for
me’” (Sherman, 2020). For this reason, people have hypothesized that
Donald Trump was particularly eager to praise Xi at the start of the
pandemic: “China has been working very hard to contain the Coronavirus.
The United States greatly appreciates their efforts and transparency,” he
said on January 24, 2020 (Ward, 2020). He made this statement at the same
time as the Chinese authorities were detaining a doctor who, since
December 30, 2019, had been trying to alert them to a virus that by then had
spread around the world (Shih, 2020).
In addition to these insights about relations with Xi and China,
Bolton’s book also confirms many crucial elements of the Ukraine scandal
that was central to the impeachment case brought against the president in
December 2019. Bolton provides firsthand evidence of the fact that Donald
Trump conditioned the provision of 391 million dollars in security aid to
Ukraine on its first agreeing to publicly announce investigations into
supposed wrongdoing by Democrats, including former vice president,
Joseph Biden. In other words, he sought to use taxpayer money as leverage
to extract help from another country for a partisan political campaign: a
quid pro quo that House Democrats claimed to be an abuse of power. As
this proved to be a key issue within the impeachment hearings, and as
Bolton clearly possessed evidence relating to the case, his actions at the
time are questionable. During the hearings, Republicans dismissed the
accusation on the basis that testifying witnesses offered only secondhand
evidence, but Bolton was present in the room and could have provided
firsthand evidence. An extra layer of complexity is also added by the fact
that Bolton would, in his book, later state that he saw Trump’s inventions in
Justice Department investigation against foreign companies, in order to
“give personal favors to dictators he liked— to represent “obstruction of
justice as a way of life” (Baker, 2020).
A personal lawyer and fixer

Michael Cohen did not merely work for Donald Trump and, out of all those
who have spoken out publicly against the president, he was the closest to
him. Reflecting back on their relationship, Cohen claims that he got to
know Donald Trump better even than the president’s own family. This, he
argues, was because he was able to bear “witness to the real man, in strip
clubs, shady business meetings, and in the unguarded moments when he
revealed who he really was: A cheat, a liar, a fraud, a bully, a racist, a
predator, a con man.” The value of Cohen’s account is twofold: it is told
from the perspective of not only an onlooker but also an eager participant,
now paying the price as federal inmate number 86067-054. In his book,
Disloyal: A Memoir, Cohen (2020) provides a credible account of his own
internal tensions: on the one hand, knowing that the president is corrupt and
totally unsuited to the job; on the other, supporting Donald Trump due to a
feeling of kinship for the man for whom he had stiffed contractors, sued
creditors, and ripped off realtors for over a decade. “I care for Donald
Trump, even to this day,” Cohen admits, “and I had and still have a lot of
affection for him.” Former insiders of cults or abusive relationships are
valuable to anthropologists and psychological professionals alike. Indeed,
these individuals provide some of the most intimate insights into what
really happens within the destructive subculture or relationship but also
place it in context.
Cohen’s fate after his split from Trump was similar to that of many
defectors from gangs, or escapees of abusive relationships, even if it
afforded greater opportunity for grandiose and dramatic statements. “The
President of the United States wanted me dead,” is how Cohen begins his
book. He does, however, then proceed to clarify that the statement is not
one that Trump himself would ever issue:

Or, let me say it the way Donald Trump would: He wouldn’t mind
if I was dead. That was how Trump talked. Like a mob boss,
using language carefully calibrated to convey his desires and
demands, while at the same time employing deliberate indirection
to insulate himself and avoid actually ordering a hit on his former
personal attorney (Cohen, 2020).
What Cohen describes here is, to a large degree, congruent with what we
have witnessed of Donald Trump in public: he has repeatedly incited his
followers to acts of violence against those he opposes or dislikes, or who
have criticized him, while avoiding the assumption of responsibility. Cohen
himself used to be one of those followers, ensnared by the malevolent
charm of a mob “Boss” who gave directions for his dirty work obliquely,
always leaving room for deniability. From the twenty-sixth floor of Trump
Tower, Donald Trump would summon Cohen to fix messes of his own
making: buying the silence of women with whom he had had affairs, or
managing disgruntled contractors and any others whom Donald Trump had
cheated. If Donald Trump operated in a manner at times akin to a mafia
godfather, his performance as a father was less accomplished: his neglected
children were starved of his love and were “forever trapped in a cycle of
seeking his approval” (Cohen, 2020).
If Disloyal contains many such revelations about Donald Trump’s
behavior and attitude toward those around him, it also brings into stark
relief his always contentious relations with Russia. As Cohen recounts,
building a hotel in Moscow had been one of Donald Trump’s objectives for
almost four decades. Accordingly, as his run for the presidency kicked off
in December 2015, Cohen reached out and made contact with Vladimir
Putin’s press spokesman, Dmitry Peskov. The resulting situation had both
seen and unseen elements: Donald Trump publicly praised Putin on the
campaign trail while Cohen secretly tried to bring Trump Tower Moscow to
fruition. All of these actions were, of course, known to Donald Trump,
because of his need to be in charge of everything. By Cohen’s account,
Donald Trump did indeed collude with the Kremlin, but it was not the
sophisticated collusion his critics imagined and hypothesized. Instead,
Donald Trump’s treason, if it can be called that, was of a much more
pedestrian, me-first nature. Sharing with Putin a loathing for Hillary
Clinton, Donald Trump would willingly accept any Russian help—hacking,
spies, trolls, and oligarchs bearing gifts—so long as it benefited him
personally. Donald Trump sucks up to Putin largely because he loves
money, believing the one-time KGB colonel to be the world’s richest man,
worth a trillion dollars—much in the way Cohen was infatuated with the
former real estate mogul, supposed billionaire, and star.
In trying to answer the question as to why he would risk everything
to serve such a gargantuan con man, Cohen helps us to understand the
insider’s experience of following Donald Trump. Living in the heart of the
president’s world, Cohen was intoxicated by a fantastical cocktail of power,
strength, celebrity, and complete disregard for the rules. Reflecting on his
ultimate seduction by power, at one point in his memoir Cohen likens
himself to character of Gollum from The Lord of the Rings. Moving more
clearly from the realm of fantasy, however, he also suggests that he might
be viewed as micro version of the situation currently occurring on a macro
scale: Donald Trump mesmerizing America’s media, and seducing and
duping half of its population. Indeed, Cohen is insistent on the fact that the
U.S. population, more so than the Russians, facilitated Donald Trump’s rise
to power and who may yet keep him there. The cocktail Cohen imbibed has,
however, caused a hangover of equal strength: the “weird kind of pleasure
in harming others in the service of Donald Trump” that he once enjoyed
now causes him “eternal shame” (Cohen, 2020).
If Cohen is now open about his own actions and responsibilities, he
also makes clear that he was not always working alone. Indeed, he work
closely, on occasion, with David Pecker, the then CEO of American Media
and publisher of the National Enquirer. Most notably, the two men
cooperated with one another to smother the stories that emerged concerning
Donald Trump’s extramarital relationships with Stormy Daniels, an adult
actress, and Karen McDougal, a Playboy model. These actions came to be
particularly significant for Cohen personally: his own paying off of Daniels
was an illegal campaign expense that helped put him in jail. Despite, or
perhaps because of, the coverups, corruption, and lying, Cohen admits that
Donald Trump has an arsenal of dark gifts. By Cohen’s account, the
president is in possession of talent, charisma, and pure ruthless ambition, as
well as what he perceives to be an innate ability to tap into and exploit
voters’ deep prejudices and fears. In using these so-called gifts, Donald
Trump thinks nothing of the consequence of his actions, living constantly in
the present tense, a sort of “shark” that survives only through continuous
motion, confident in his own instincts to guide the way. Cohen’s own self-
destructive descent into a world where this takes place, into “Trumpland”,
foreshadows that of the nation, according to his “part survivor’s memoir,
part revenge tragedy” (Harding, 2020).
A presidential journalist

Bob Woodward made his name with Carl Bernstein through All the
President’s Men (1974), where they laid out the history of the Watergate
scandal. Woodward might not be the most psychologically-minded
interviewer, but his book Rage (2020) is extraordinary because of the
existence of accompanying tapes, allowing recorded glimpses into intimate
conversations. The subject of Rage is Donald Trump and, over the course of
eighteen on-the-record, recorded, interviews from December 2019 through
August 2020, it presents an incredible account of the president in his own
words, as well as in Woodward’s. In this respect, the written work is
fascinating in its own right, but it is perhaps the recordings that offer us the
greatest insights. Listening to the exchanges between the two men, it is
possible to gauge the subtle cadences and affective charges that shape the
logical progressions of the interviews. At times, Donald Trump appears
serious and focused, while simultaneously divulging stunning details about
his handling of the coronavirus or a new secret nuclear weapons system. In
other interviews, however, he is more frivolous, such as when he gives
Woodward a tour of a small office that he calls “the Monica Room” (a
reference to the affair between Monica Lewinsky and Bill Clinton). What is
clear in all instances is that Trump is clearly trying to impress his
interviewer.
Making these interviews still more striking and important is the fact
that they are ones that Donald Trump himself requested. Indeed, he went
out of his way, and against the explicit advice of his aides, to do so. Donald
Trump’s aides had prevented him from speaking with Woodward for his
earlier book Fear (2018); after learning of this, the president then asked
Woodward to interview him, seemingly under the conviction that he could
charm a more flattering account from the journalist. This impulsive
behavior and thought process is captured in intimate detail in the
impromptu calls that Woodward would often receive from Donald Trump,
commonly after nine or ten o'clock at night. As such, regarding the
revelations of Rage, the White House’s standard response to unfavorable
stories about the president—branding them as “fake news—second-hand or
corrupted with other agendas—is untenable. Here, Donald Trump indicts
himself with his own voice, over and over, apparently without realizing it.
 A wealth of information makes it difficult to decide which of
Donald Trump’s interviews with Woodward, or which sections of which
interviews, should be looked at here. One particularly telling exchange,
however, has Trump discussing Covid-19. Speaking with Woodward, the
president states clearly the extent to which he recognized the severity of the
threat posed by the worst global pandemic in a century. “It goes through air,
Bob. That’s always tougher than the touch…. It’s also more deadly than …
even your strenuous flus,” Donald Trump tells Woodward, before
continuing with a slightly different emphasis: “You know, people don’t
realize, we lose 25,000, 30,000 people a year here.” He then proceeds to
again state that the novel virus causes five times the mortality and calls it
“deadly stuff” (Gangel and Herb, 2020). All of this stands in direct contrast
to his public dismissal of the seriousness of the virus, his repeated
hampering national efforts, and his cavalier disdain for masks: surely
contributing factors to the carnage that the virus has caused in the U.S.,
with millions infected and almost 200,000 dead.
There are other exchanges Woodward documents in Rage that seem
even more untethered from reality. At one point, for example, Donald
Trump claims he has “done more for the Black community than any other
president than Abraham Lincoln” (Woodward, 2020). This is a statement
that is in no way supported by the manner in which his department of
justice has aggressively and perversely criminalized and terrorized people
of color (Maxwell and Solomon, 2018). It does not even always accord with
Trump’s own words. As the protests over the police killing of George Floyd
spread across the country and around the world, Woodward tells Donald
Trump about how he, as a privileged white person, has only recently
grasped the need to understand and address the anger and pain of Black
people. Having said that, Woodward then asks Donald Trump whether he
has also experienced a similar epiphany. The president is clear in his
response: “No. You really drank the Kool-Aid, didn’t you? Just listen to
you. Wow. No, I don’t feel that at all.” Somewhat reversing the issue,
Donald Trump then proceeds to complain about something else he is not
getting: “I have done a tremendous amount for the Black community. And
honestly I’m not feeling the love” (Gangel and Herb, 2020). On that point,
his feeling, or lack thereof, is a genuine one: only 10 percent of black voters
supported Donald Trump.
 The same hubris that led Donald Trump to believe that he has done
so much for black Americans, amongst whom unemployment is now at 13
percent, also manifested itself in other aspects of his life and dealings.
Perhaps most strikingly, it shaped his unhinged relationship with the North
Korean dictator, Kim Jong-un. Getting Kim to give up his nuclear weapons,
a long-held goal of the U.S., Trump believed he could achieve solely
through the use of his own persuasive powers. Part of this attempt at
persuasion took place in twenty-seven letters between the president and
Kim that Donald Trump reportedly refers to as “love letters.” Significantly,
he gave Woodward access to these letters; Woodward notes that the tone of
the correspondence between the two leaders is indeed akin to that used by
“suitors”. The actual real-world significance of this, however, appears to be
negligible. Donald Trump met with Kim three times—in Singapore, Hanoi,
and in the DMZ between North and South Korea—but he has been no more
successful than his predecessors in getting North Korea to dismantle, or
even to dial back, its nuclear program. Indeed, the tone of the
communication between Donald Trump and Kim might well have been
carefully engineered by the latter. In his book, Woodward reports that CIA
analysts “marveled” at the letters, remarking on how skillfully their author
appealed to both “Trump’s sense of grandiosity” and his desire to be seen
taking “center stage in history” (Woodward, 2020). What is evident from
this is that North Korea, like many other nations, has had a rigorous
psychological profile of the U.S. president, whereas the U.S. itself is
lacking one.
At one point in an interview, Woodward asks Donald Trump a direct
question concerning what it was like to meet with Kim at their first summit,
held in Singapore. The response that he receives, both in its tone and its
focus, provides a great insight into nature of the president’s approach to
matters of such political gravity: “It was the most cameras I think I’ve seen,
more cameras than any human being in history”—indeed, even more
cameras than he had seen at the Academy Awards. He proceeds to brag
about how Kim “tells me everything,” seemingly impressed by the
dictator’s brutality. “He killed his uncle and put the body right in the steps
where the senators walked out. And the head was cut, sitting on the chest….
Nancy Pelosi said, ‘Oh, let’s impeach him.’ You think that’s tough? This is
tough” (Woodward, 2020).
 The interviews with Donald Trump make Rage a remarkable
account, but Woodward did not only interview the president. The journalist
also spoke at length with the former secretary of state, Rex Tillerson, and
the former director of national intelligence, Dan Coats. Corroborating what
many others have said, Coats describes to Woodward Donald Trump’s
problematic relationship with the truth: “To him a lie is not a lie. It’s just
what he thinks. He doesn’t know the difference between the truth and a lie.”
Tillerson, in his interview, took objection to the president’s choice of staff,
stating that he found what he saw as the chummy dealings between Jared
Kushner and Israeli Prime Minister Benjamin Netanyahu, “nauseating to
watch” and “stomach-churning.” The former secretary of defense, James
Mattis, also claims an ambivalent and distant relationship with the
president: “I never cared much what Trump said…. I didn’t get much
guidance from him, generally, other than an occasional tweet.” Despite this,
Woodward also reports that Coats and Mattis had a phone call on May 25,
2019, in which they agreed there might come a time when it would be
necessary to publicly state that Donald Trump was dangerous and unfit to
be president. This was just the same conclusion that we had arrived at
through our mental capacity evaluation just a month earlier, on April 25,
2019. Woodward may well be more prone to direct reporting than to
conducting analysis, and yet he, too, draws a conclusion from his
interviews. Toward the end of Rage, he writes: “Trump is the wrong man
for the job” (Woodward, 2020).
A niece

In terms of trying to gather the most interpretive collateral information, a

credible mental health professional’s account of their childhood is of great
value. Such an account has been provided by Donald Trump’s only niece,
Dr. Mary Trump. The quality of information that an individual like Dr.
Trump is able to provide allows for a more in-depth analysis of the subject’s
ingrained personality structure. Especially for someone in a position to
exert extensive, and especially adverse, influence on society, it gives us key
insight into the reasons why their behaviors are so powerful and how they
can spread to others. As a general rule, the more biologically-determined
mental illnesses such as schizophrenia or depression result in a person
posing even less danger to others even than if they had no illness. By
contrast, developmental defects can be very dangerous and yet often go
undetected, or, worse, they are misrecognized and improperly celebrated 
to the detriment of society. As a result, it is important to identify both early
childhood events and also enduring later patterns that might indicate the
presence of, or predisposition to, personality problems. The availability and
reliability of collateral sources of information determine the depth to which
we are able to probe in such a process. If the sources are reliable and
credible, we may have the ability to ask them not only for facts but also
reactions and resources that they might be able to offer. This holds true
particularly in cases in which the defects being analyzed cause suffering not
to the person who possesses them but to others with whom they come into
contact: a condition we call ego-syntonic (the symptoms do not bother their
bearer), as opposed to ego-dystonic (the symptoms bother their bearer). Dr.
Trump meets those criteria and, most importantly, she has provided a
credible analysis based on intimate household observations. That analysis,
delivered toward the end of Donald Trump’s first term in office,
corroborates and completes our own independent public health analysis,
made by some of the nation’s foremost mental health experts at the start of
the presidency.
When I interviewed Dr. Trump, in order to establish her reliability,
or the extent to which she demonstrated critical self-awareness and realistic
appraisal, I asked her: “When did you realize it was not you and your father
who were ‘a mess’ (her uncle’s portrayal of them) but Donald Trump
himself?” She answered with a good degree of insight:
 It took a really long time because you grow up in this atmosphere
that seems totally the way it is…. I think getting disinherited was
kind of a tipoff, [and] throughout my training as a clinician, I
learned a lot about how to look at systems like families and
pathologies and developmental issues, et cetera. Distance and
training … helped a lot (Lee, 2020b).

She then added further to her credibility by commenting on some of the

difficulties she faced when writing the book. “It was not until I started
writing the book,” Dr. Trump told me, “that I really got in touch with some
things that I, honestly, wish I had not had to” (Lee, 2020b). Listening to her,
I was satisfied that she was both a valuable and a reliable source.
In her book, Too Much and Never Enough (2020), Dr. Trump
provides an account of her uncle’s childhood. She describes how, as a
toddler, Donald Trump was deprived of the most essential ingredient
required for healthy emotional growth and life: parental care. According to
the book, “Donald’s main source of comfort and human connection was
taken from him” when he was not yet three years old, following a
harrowing incident that occurred in the Trump family’s mansion. That
incident centers around Donald Trump’s mother: there was night in which
his twelve-year-old sister, Maryanne, discovered her lying unconscious on
the bathroom floor in a pool of blood. The cause of this was severe
postpartum complications resulting from the birth of her youngest child,
Robert, which would see the mother of five repeatedly hospitalized over the
subsequent six months. “Having been abandoned by his mother for at least
a year, and having his father fail not only to meet his needs but to make him
feel safe or loved, valued or mirrored,” Dr. Trump argues that, during that
early period, “Donald suffered deprivations that would scar him for life.” In
her assessment, this situation was “an epic tragedy of parental failure.”
Donald Trump’s mother never truly recovered, and nor did her relationship
with her son. His father, strikingly, showed utter indifference, if not
annoyance, toward his wife’s expressions of discomfort or pain; he would
often cut her off, saying “Everything’s great. Right, Toots? You just have to
think positive” (Trump, 2020).
As a child, Donald Trump, unsurprisingly, came to display the
classic early signs of serious problems with aggression and psychopathy. By
the time he was thirteen, as Dr. Trump claims, “Donald’s misbehavior—
fighting, bullying, arguing with teachers—had gone too far.” What had
started as name-calling and teasing had escalated into physical altercations.
His father did not necessarily mind the acting out itself, but the fact that it
had now become both intrusive and time-consuming bothered him. At the
suggestion of fellow board members, he sent Donald Trump to the New
York Military Academy as a way to rid himself of the trouble and leave
himself free to attend to what he considered to be more important matters.
The future president experienced his father’s action as another
abandonment, and it became the foundation for his further development into
being what Dr. Trump describes as a “petty, pathetic little man—ignorant,
incapable, out of his depth, and lost to his own delusional spin.” This spin,
we learn, is essentially all that Donald Trump has learned: relentless and
incongruous puffery. Despite being fundamentally infantile and mentally
unstable, Donald Trump styled himself a stable genius, even though all
evidence pointed, and continues to point, to the contrary. In doing so,
regardless of the outcome, his father would back him up. The result of this,
according to Dr. Trump, was that as Donald Trump’s “failures mounted
despite my grandfather’s repeated—and extravagant—interventions, his
struggle for legitimacy, which could never be won, turned into a scheme to
make sure nobody found out that he’s never been legitimate at all.” To
achieve this, he successfully utilized the media to spread his hype, until
finally even the banks fell for it. In this manner, from his adolescence in
reform school to his coddling in the Oval Office, Donald Trump can be seen
to have essentially been “institutionalized most of his adult life” (Trump,
2020).
For Dr. Trump, her uncle’s aforementioned relationship with various
banks is, in some way, both emblematic and indicative. Analyzing that
relationship, she concludes that the banks’ “willingness (and then their
need) to foster his increasingly unfounded claims to success hung on the
hopes of recouping their losses.” But, of course, they would never manage
this. Dr. Trump argues that this parallels the manner in which the president
has been equally effective in drawing in numerous enablers, opportunists,
and supporters until they too have become trapped. “Honest work was
never demanded of him,” she says, “and no matter how badly he failed, he
was rewarded in ways that are almost unfathomable.” Viewing the current
situation this this critical lens of personal experience, Dr. Trump is now
terrified that the U.S. this will devolve into “a macro version of my
malignantly dysfunctional family.” She argued that, having grown up in a
family environment in which a “killer” instinct was revered, Donald Trump
views cruelty as “a means to distract both us and himself from the true
extent of his failures.” The potential consequences of this for the public at
large are not positive: “He’ll withhold ventilators or steal supplies from
states that have not groveled sufficiently,” Dr. Trump posits, suggesting that
what the president “thinks is justified retaliation is, in this context, mass
murder.” She is similarly clear when it comes to the reason as to why she
decided to write about her uncle: “Donald, following the lead of my
grandfather and with the complicity, silence and inaction of his siblings,
destroyed my father. I can’t let him destroy my country” (Trump, 2020).
This is damning: her father, the president’s older brother, apparently the
most empathic and self-reliant member of the family, died at the age of
forty-two of alcoholism, prompted by their abuse.
 A Profile of Trump Supporters

A public health issue

As I wrote in the introduction of The Dangerous Case of Donald Trump,
despite its title, Donald Trump is not the main focus of the book. Rather, to
understand his presidency as a national public health issue, we need to
understand his followers as well as the state of the nation that gave rise to
his presidency. Then, we need to study the larger context that he has
influenced by virtue of his position. Coauthor Dr. Thomas Singer calls
attention to the link between Trump and the American collective psyche.
Trump “mirrors, even amplifies, our collective attention deficit disorder, our
sociopathy, and our narcissism” (Singer, 2017)—but this would not serve as
a diagnosis as much as a recognition of our own pathology. The ascendancy
of an individual with grave impairments does not occur in a vacuum, and
we are now at a pivotal point where we can either improve the situation or
further impair it. Hence, this chapter is devoted to understanding a part of
that larger picture: his followers.
Just as normalizing the president’s psychology is dangerous, so too
would be attempting to normalize the psychology of his followers. This
does not mean that each follower of the president will exhibit abnormal
psychology; on the contrary, it is more likely that each person will be quite
normal when separated from the president and other followers. A group
psyche is not the same as the sum of the psychology of individual members,
and the themes and conflicts of groups are not the same as our personal
struggles, although they interact. The group psyche is a part that lives inside
every one of us as individual carriers and sharers in whatever group
dynamics of which we are a part. As with individuals, problems can arise
within groups that are recognizable and follow distinct patterns. It is worth
noting, for example, the various factors at play for the more or less 40
percent of the population that comprises Trump’s enduring “base” to act,
think, and believe as it does, and we should not ignore how some of this
diverges from healthy, rational, and well-informed ways. When such a large
portion of the population deviates from health, it becomes a public health
problem that should be dealt with through the language of public health,
since individual analysis has no mechanism for dealing with persons who
are nevertheless “normal” for conforming to the subculture.
 The first observation is that it appears that he can do no wrong in the
eyes of his followers. In the words of one of his followers: “President
Trump has accomplished more positive things for this nation in less than
two years than the last three have accomplished in twenty plus years….
Could you please list one thing the demwit party has done for the black
people in America?” (Azpiazu and Ocner, 2018). Later, the assertions
become more belligerent: “I am here tonight to tell you—to warn you—that
this election is a decision between preserving America as we know it and
eliminating everything that we love,” said Charlie Kirk, a young Trump
acolyte opening the Republican National Convention (Wehner, 2020).
During a deadly pandemic, his followers can be seen putting their
lives and health in danger, not for the good of the country, the economy, or
even themselves and their family. It is simply so that their leader can get a
media adrenaline rush from Fox News and other right-wing media coverage
of protests heeding his call to “liberate” their various states against social
distancing and other public health policies that are meant to protect people
(Mitchell, 2020). When Donald Trump would resume his rallies, many
would show up not wearing masks or practicing social distancing as they
chant: “We! Love! You!” (Karni, 2020). This is an extraordinary
demonstration of fealty, one that is not lost on a president who seems
acutely aware that his best chance of staying in power—and out of jail—
relies on his ability to mobilize his supporters. Unfortunately for both the
president and his loyal supporters, many of those most loyal to him will be
sick or dead because of these actions. They are literally willing to die for
the show of support for their leader.
This fealty shows in the willingness to take a dangerous substance—
one that might kill them—if Donald Trump stated it would be good for
them, such as when he announced that he was taking hydroxychloroquine to
ward off the coronavirus. Convinced that their president would never lead
them down a dangerous path, people all over America have been asking for
the medicine, despite the growing number of lupus and arthritis patients
complaining they were unable to fill their prescriptions amid shortages. It
did not matter to Donald Trump’s followers that medical experts and his
own U.S. Food and Drug Administration warned against the drug’s
dangerous side effects, or that it could cause lethal heart problems. They
dismissed studies showing that hydroxychloroquine does not work against
Covid-19. When Donald Trump suggested during a televised news briefing
that ingesting disinfectants might help treat the virus, the following eight
day period saw an increase in accidental poisoning by 121 percent
compared to April of 2019 (Kluger, 2020), and at least one instance proved
that someone “drank a product because of the advice he’d received”
(O’Laughlin, 2020).
While the dynamics between Donald Trump and his followers are
complex, they can be summarized in four stages. First, there is the
narcissistic symbiosis, wherein similarly-impaired personalities are
attracted to one another and unattracted to health. Second, there is cultic
programming, whereby followership of Donald Trump is systematically
coordinated and cultivated through psychological conditioning. Third, there
has formed what I will call a battered nation syndrome, whereby followers
are psychologically abused but too invested to leave. Finally, there is shared
psychosis, or the natural spread of symptoms that results from prolonged
exposure to an impaired person in an influential position.

Narcissistic symbiosis

We have seen how brazen actions—calling Mexicans rapists, bragging

about sexual assault, provoking war with Iran, causing tens if not hundreds
of thousands more Americans to die, and collapsing the world’s greatest
economy—have failed to produce a serious dent in the president’s
popularity. Even a rapidly diminishing vocabulary, wandering off, and
forgetting his son’s name—all serious signs in a man whose father died of
Alzheimer’s disease—are nothing compared to Joe Biden’s relatively
insignificant stumbles (Carr, 2020). Why might this be?
There is a considerable amount that has been written about this
magnetism and the political psychology of leaders and followers. The great
German sociologist Max Weber (1922) first introduced the concept of
charismatic authority, describing it as compelling forcefulness on the part of
the leader’s personality. Psychoanalyst Dr. Irvine Schiffer (1973) describes
how leaders—especially charismatic leaders—are at heart the creation of
their followers. Psychiatrists started to focus on the follower dynamic after
the mass suicide at Jonestown, a settlement of the People’s Temple in
Guyana, where followers of the Reverend Jim Jones drank poisoned Kool-
Aid (Flavor Aid) at his direction in 1978 (Ulman and Abse, 1983). The
realization that leader-follower relationships involve important emotional
attachments paved the way for the application of attachment theory: leaders
often function for their followers, “like parents … whose role includes
guiding, directing, taking charge, and taking care of others less powerful
than they” (Popper and Mayseless, 2003). Former CIA psychiatrist Dr.
Jerrold Post (2019) has described how narcissistically wounded individuals
are drawn to a narcissistically impaired leader in a charismatic leader-
follower relationship like a “lock and key.”
According to Post, crucial psychological aspects of the leader, like a
key, fit and unlock certain psychological aspects of their followers. A sense
of grandiose omnipotence of the leader is especially appealing to his or her
needy followers. This is different from “reparative charismatics,” or a
healthy relationship that is drawn together by a need to heal their nation’s
wounds. Rather, destructive charismatic leaders make use of their
followers’ defects, employ absolutist polarizing rhetoric, and draw their
followers together against an external enemy. The followers may be
psychologically healthy but rendered temporarily needy by societal stress,
or developmentally mirror-hungry, secretly yearning to merge with another
when an idealized figure appears. In Narcissism and Politics: Dreams of
Glory, Post notes that: “in times of crisis, individuals regress to a state of
delegated omnipotence and demand a leader who will rescue them, take
care of them” (Post, 2014).
In The Spellbinders, Ruth Ann Wilner (1984) surveyed the vast
literature on charismatic leader-follower relationships, and found that there
have four characteristics in common:

1. The leader is perceived by the followers as somehow superhuman.

2. The followers blindly believe the leader’s statements.
3. The followers unconditionally comply with the leader’s directives for
action.
4. The followers give the leader unqualified emotional support.

Clinical work with individuals of narcissistic pathology, studies of

individuals who join charismatic religious groups, and psychodynamic
observations of group phenomena provide persuasive support for the
psychological makeup we observe in individuals who are susceptible to this
charismatic relationship—the lock of the follower for the key of the leader.
The development of “the wounded self” results in these two personality
patterns that are important for charismatic relationships.
Post (2019) illustrates two seemingly juxtaposed manifestations of
“the wounded self”: “the mirror-hungry personality” and “the ideal-hungry
personality.” These are the templates for the complementary portions of the
charismatic leader-follower relationship. The first is the “mirror hungry”
personality. Donald Trump has a mirror-hungry leader personality, which
feeds off of the adoration of his followers in the charismatic leader-follower
relationship he has established. This personality pattern results from “the
injured self” whose grandiose façade feeds off of confirming and admiring
responses, to protect against the inner sense of worthlessness and lack of
self-esteem. To nourish the famished self, the individual feels compelled to
display the self to evoke the attention of others. However, no matter how
much positive attention one receives, one is never satisfied, continually
seeking new audiences as a source of attention and recognition one craves.
This constant need for new attention led the high-profile businessman
Donald Trump to seek an increasingly prominent celebrity status,
culminating in his hit TV reality game show “the Apprentice” in the 2000’s.
However, as the attention he received from this show could not satisfy him,
he sought a new source of attention by running for president of the United
States.
Central to the mirror-hungry leader’s ability to elicit admiration is
the skill in conveying a sense of grandeur, omnipotence, and strength.
Ambitious and charismatic individuals who can convey this sense of
grandiose omnipotence are drawn to the spotlight. There, they attract
individuals seeking idealized sources of strength, by offering a feeling of
conviction and certainty to those who are consumed by doubt and
uncertainty. This was evident in Donald Trump’s support from rural areas
and the working class, where his motto to “make America great again” had
a strong resonance. Despite a lack of any concrete policy, his extravagant
claim that, “I’ll be the best jobs president God ever created,” appealed
especially to those who were struggling and felt abandoned by previous
administrations.
Mirror-hungry leaders are drawn to large crowds, where the roar of
admiration becomes intoxicating. It was evident during Donald Trump’s
campaign how much he thrived on followers shouting his name at large
rallies. This is why even after the election ended, he continued to hold giant
rallies across the country; after more than three hundred rallies in 2016
alone, he held nearly one hundred more during the first three years of his
presidency (Kruse, 2020). He continues to need these expressions of
admiration from his followers as compensation for his deep-seated
insecurity and self-doubt.
In the spotlight, they offer a feeling of conviction and certainty to
those who are consumed by doubt and uncertainty. Ideal-hungry follower
personalities from rural areas and the working class especially, found
greater resonance with the grand-sounding motto: “make American great
again.” Despite a lack of any concrete policy, the extravagant claim that,
“I’ll be the best jobs president God ever created,” appealed especially to
those who were struggling and felt abandoned by the political class.
These rallies have been vital for his supporters as well. There is a
quality of mutual intoxication and dependence on both sides, whereby
Donald Trump reassures his followers by filling their void, who in turn
reassure him of his self-worth. In the words of the infamous pipe-bomber
Cesar Sayoc: “the first thing you [hear] entering Trump rally is we are not
going to take it anymore, the forgotten ones…. It was fun, it became like a
new found drug” (Karimi, 2019). Donald Trump was able to tap into the
existing rhetoric of the white supremacist alt-right in the United States,
which is a form of idealizing the self by denigrating others—be they
foreigners, Latinos, Muslims, and many other groups—to help ward off
deep feelings of inferiority. These are “ideal hungry” individuals who view
themselves as worthwhile only as long as they can relate to individuals
whom they can admire for their prestige, power, unlimited success, beauty,
or brilliance. The hypnotic lure of the charismatic leader is compelling for
the ideal-hungry follower. The wounded follower feels incomplete by
oneself and enduringly seeks to attach to an ideal other. Thus, there is a
powerful, almost chemical attraction when the mirror-hungry charismatic
leader and the ideal-hungry charismatic follower meet. Donald Trump
thrives on the adoring mirroring response of his followers, and he provides
them with a sense of completeness and security, like lock and key, in a
psychological symbiosis.
This does not mean that all those who voted for Donald Trump are
narcissistically wounded individuals. The phenomenon of the charismatic
leader-follower relationship is likely too complex to lend itself to a single
overarching psychological model. However, the enduring psychological
power of the Trump phenomenon relies on his appeal to wounded
individuals seeking leadership that can act as a heroic rescuer. While
elements of these narcissistic transferences are present in all charismatic
leader-follower relationships, ones that induce and rely on the regression of
followers are particularly dangerous (Post, 2019a).
A leader’s stance of total certainty is very attractive to wounded
followers who are besieged by doubt. For them, preserving grandiose
feelings of strength and omniscience does not allow for expressions of
weakness. “Splitting”, or the separation of unpleasant aspects of oneself
that are either projected onto “the other” or otherwise disowned, is central
to maintaining the illusion and allows for no uncertainty. The leader, of
course, is also trying to ward off his or her doubt through defensive
posturing (Kohut, 1985).
There is the “me” and the “not me,” good versus evil, strength
versus weakness, “winners” versus “losers”. This results in the belief that
they are the source of the problem, they are evil, and to eliminate them is to
eliminate our problems. Psychoanalyst Phyllis Greenacre observed that to
be effectively charismatic it is a great asset to possess paranoid conviction.
Indeed, the combination of charisma and paranoia led to some of the most
fearful excesses of human violence in history (Robins and Post, 1997).

Cultic programming

There is always a villain—and a hero—at a Trump rally, and that is exactly

what his audience expects—along with his insults, bravado, and takedowns
of liberals and other enemies. The venue may be Council Bluffs, Iowa, Erie,
Pennsylvania, or Topeka, Kansas, but the formula is always the same.
Donald Trump’s supporters remain as enthusiastic as ever, standing for
hours in the hot sun or the pouring rain, exploding into thunderous applause
when he took the stage. They wave the same signs, they wear the same hats,
and chant the same refrains, “Build that wall!” and “Lock her up!” even
years after his election. Lines to get into these rallies wind around buildings
and twist through alleys for at least a mile (Colvin, 2018). “I think it’s
amazing what he’s doing, I really do,” says Tami Gusching, 32, in Fort
Wayne, Indiana. “I love the aggression that he has and the power behind
him” (Sikich et al., 2018). “I’m just totally, madly in love with him,” says
Peggy Saar, 64, from Rochester, Minnesota (Colvin, 2018). “It’s a love
fest!” says Randal Thom, 58, at a rally in Springfield, Missouri, gesturing to
a stranger. “I might not know this guy’s name, but I know three things about
him: He loves the country, he loves the president, and he bleeds the color
red” (Rogers, 2018). Who are these people, and why do they support and
even adore Donald Trump, despite his having shown himself as attention-
seeking, self-important, dishonest, vindictive, entitled, lacking in insight
and accountability, and completely devoid of remorse and empathy?
Cult expert Steven Hassan (2019) sees Trump supporters—63
million strong—as a patchwork of diverse yet distinct groups, each with
varying levels of allegiance. They range from fervent followers among
Christians and the alt-right, who see Donald Trump as a change agent who
can forward their agendas, to traditional Republicans who vote the party
line, to pro-lifers, National Rifle Association (NRA) members, and the poor
and out of work. Some are old, fearful, and angry, and like how Donald
Trump’s rhetoric renders emotional legitimacy to their feelings. Others are
wealthy with “practical” motivations capable of walling off the harms that
arise from Donald Trump’s tax cuts for the rich and his government
deregulations. Donald Trump’s campaign was an unrelenting recruiting
machine, using the same rhetoric and techniques of cults, according to
Hassan. “Our movement is about replacing a failed and corrupted political
establishment, with a new government controlled by you, the American
people,” began a 2016 Trump campaign ad. “The only people brave enough
to vote out this corrupt establishment is you, the American people,… and
we will take back this country for you, and we will make America great
again” (C-SPAN, 2016).
There are hierarchical structures and systems of thought reform that
work to generate cultic programming to those who are susceptible. At the
top are White House staffers, some of whom are family members, a core
group who are in regular contact with Donald Trump. Cults typically
employ a coterie of aides who are loyal and subservient to the leader,
carrying out directives and instilling doctrine. Each moderating force is
replaced until the leader is surrounded by “yes men” and “yes women” who
“let Trump be Trump.” The psychology behind it can take the form of
obsession with loyalty. Donald Trump makes it a point, for example, to test
those around him and to keep his inner circle exclusive to loyalists and
devoted staff—and family. His former political aide Manigault Newman
and his former “fixer” Michael Cohen both describe leaving Donald
Trump’s orbit like escaping a cult—“the cult of Trumpworld,” as the former
puts it (D’Antonio, 2018). A “cult leader,” is how Lev Parnas, an associate
of Donald Trump’s personal attorney Rudolph Giuliani, describe Donald
Trump (Gregory, 2020). A similar structure can be found among distinct
groups of Trump followers:
Eight out of ten white evangelicals voted for Donald Trump
(Martinez and Smith, 2016). Of his followers, those who attend church are
generally more receptive to minorities than those who do not, but some
churches have encouraged tribalistic impulses, especially the New
Apostolic Reformation (NAR). Desiring to turn America into a Christian
nation and claiming to receive direct revelations from God, its leaders have
appropriated Donald Trump, casting him as a figure of deliverance. This is
not a rare belief: according to a Fox News poll, nearly half of Republicans
believe Donald Trump has been chosen by God to be president (Bump,
2019).
Another segment of his base is the white working class. Donald
Trump cultivated this marginalized and disenfranchised, disengaged group
of Americans that Hillary Clinton largely ignored, and they were key to his
election victory in 2016. He flaunted his wealth in a way that endeared him
to them, claiming to have made his fortune with hard work, savvy
negotiating skills, and by beating the “establishment” at its own game.
During the first presidential debate, Donald Trump bragged that avoiding
federal taxes made him smart (Mangan, 2016). He cast himself as an
outsider, an underdog who understood working-class malaise and would
“drain the swamp” of political elites to bring change for “the forgotten
man” and “forgotten woman.” He enthralled his audience and spoke their
language, playing to their wants and needs. He blamed their situation on
“global elites” who have “robbed our working class and stripped our
country of its wealth and put that money into the pockets of a handful of
large corporations and political entities” (Newburger, 2018). He also gave
them a good story—a vision of a new America that he alone could “fix”. Of
course, his interactions with them are always limited to crowds, and his
speaking numbs his listeners to the point where they are willing to believe
almost anything he says. He courts and entertains them at one moment and
frightens them the next by building up “enemies” who are responsible for
all their problems. His words whip up emotions, and somehow he always
seems to say what the majority of his audience are already secretly feeling
but unable to verbalize. He is acutely tuned into the audience’s responses,
which energize him. As a result of this reciprocal relationship, his
ascendance to power emotionally intoxicate him and his audience alike.
His once-unlikely followers, the Republican Party, are now under
his thumb. While Donald Trump had initially promised a more liberal
platform, saying he would preserve and defend social security, renegotiate
the North American Free Trade Agreement (NAFTA), pull back on Iraq and
Afghanistan, and support LGBTQ rights, he reversed himself, pushing a
pro-life, pro-gun, anti-immigration, anti-globalist, and climate change-
denying agenda. They held their noses and voted the ticket to get a
Republican elected, but now the Republican Party is widely seen as the
party of Donald Trump, or “Trumpublicans”, in large part because of the
web of influence the media, religious and populist groups, and large
corporations have spun—helping Donald Trump win the presidency.
Donald Trump’s approval rating with Republicans has never gone below 77
percent, according to Gallup. In July 2020, it was 91 percent, actually up
four points since before the coronavirus pandemic (Gallup, 2020), as I
projected would happen, from defensive compensation (Lee, 2020a).
Jews make up only about 1.8 percent of the adult population, about
5.9 million people (Brandeis University, 2020), but there is a powerful
minority of mostly Orthodox or ultra-Orthodox voters who support Donald
Trump. These are largely closed groups who obediently follow what they
believe to be traditional Jewish values. The rabbi functions as a guru,
interpreting the tradition and directing beliefs, attitudes, and practices. In
some groups, women are encouraged not to work but to have as many
children as they can, to run the household, and to care for their husbands
and family. Children are sometimes homeschooled or sent to parochial
schools where they receive both secular and religious education. They are
often intolerant of homosexuality, against abortion, and unquestioning of
what they are told to believe or do. These characteristics of insular groups
can make them susceptible to cultic programming.
Of all the factions in Donald Trump’s base, the alt-right is perhaps
the most dangerous. They are responsible for the tragedies in Charleston,
South Carolina; Charlottesville, Virginia; Pittsburgh, Pennsylvania; El Paso,
Texas; and Christchurch, New Zealand. Though the perpetrators seem to
have acted alone, they are increasingly connecting using an informal global
network, often through the dark web (Ailworth, Wells, and Lovett, 2019). In
an online manifesto, the perpetrator who attacked two New Zealand
mosques, killing fifty people and injuring fifty others, said he drew
inspiration from Donald Trump’s rhetoric. White supremacist and
nationalistic thinking have existed for centuries in the United States, but
Donald Trump’s words and deeds—his “America First” sloganeering, his
apparent excusing of violence, his racist remarks, and his bullying—have
electrified the radical right (Potok, 2017). Arno Michaelis, a founding
member of the racist skinhead band the Centurian, who is now an activist
and an outspoken critic of white nationalism, describes how hate groups
like the Ku Klux Klan actively campaigned for him, organizing and paying
for robocalls for Donald Trump. He advises that the president “stop
espousing rhetoric that strikes chords with people who are afraid of
immigrants” (Bonn, 2019). A person with violent tendencies resonates with
others who have the same tendency.
In a 2019 Gallup poll, 43 percent of American households reported
owning guns (Saad, 2019)—that is 55 million households with 393 million
guns (Karp, 2018). The NRA claims 5.5 million members (Gutowski,
2019). Donald Trump campaigned on a broad pro-gun agenda, which he
maintained after the mass shootings at the Marjory Stoneman Douglas High
School in Parkland, Florida, which killed seventeen students and teachers,
and in Las Vegas, after fifty-eight deaths and hundreds more injuries. The
NRA spent more than 30 million dollars in 2016 on behalf of the Trump
campaign (Open Secrets, 2016), a staggering sum compared to 2012 when
the group spent about 13 million dollars trying to elect Mitt Romney and to
unseat President Barack Obama—becoming a decisive factor in Donald
Trump’s victory. Richard Feldman, a former NRA lobbyist, believed in
2017 that the NRA was at a crest in power, while Republicans controlled
the Congress and Donald Trump controlled the White House. At the NRA’s
leadership forum in Atlanta that year, Donald Trump became the first sitting
president since Ronald Reagan to address the Association (Luo, 2017).
QAnon started in 2016, soon after the “Pizzagate” hoax, when it
alleged that Hillary Clinton was running a pedophilia ring out of the
basement of a pizza parlor. It is a webbed network of conspiracy theories
surrounding a person who identified himself as having, “Q Clearance,”
meaning top-secret security clearance, claiming that there is a secret group
working to oust Donald Trump from office. According to conspiracy theory
experts, Donald Trump has breathed life into the theme that he is an
outsider who Democratic lawmakers are trying to drag down because the
change he brings to governing threatens them. Its assertions have also
grown more bizarre over time: many now believe that Donald Trump is
fighting a satanic “deep state” of global elites involved in pedophilia,
human trafficking, and the harvesting of life-extending chemicals from the
blood of abused children. “Q” signs are frequent at his rallies, he often
“retweets” its messages, and he has now tacitly endorsed QAnon, stating
that its followers “love our country” and “like me very much,” even after
the FBI has identified it as a domestic terrorism threat (Smith and Wong,
2020). When reality requires the president to resort further and further into
conspiracy theories to counter the onslaught of unwanted facts, his
maladaptive tendencies are bound eventually to support extreme and
dangerous distortions. In other words, Q’s growth, now international, is a
natural consequence of Donald Trump’s predisposition for conspiracy
theories: his first big step into politics was his alleging that President
Barack Obama was not born in the United States, thus making his
presidency invalid. “We have a current president who uses conspiracy
rhetoric arguably more than any other president in modern history,” said
political psychologist Dr. Joanne Miller. In 2020, liberal research firm
Media Matters tracked fifty QAnon supporters running for Congress, which
suggested adherents of a fringe theory were feeling emboldened to come
out of the shadows under Donald Trump’s leadership (Phillips, 2020).
For Donald Trump and his followers, his rallies provide a place of
solidarity and safety (Hassan, 2019). A reporter who attended five rallies in
eight days calls them: “the crucible of the Trump revolution, the laboratory
where he turns his alternative reality into a potion to be sold to his
followers” not as, “We the people,” but “We my people.” Tucked into the
love, however, he sensed a menace, as if to say: “I love you people,…
because you hate my enemy” (Pilkington, 2018). To the question of what
America would be like in 2050 if Clinton had been elected president, retired
teacher David Stewart, 66, answered: “Taxes and unemployment would go
through the roof, the economy would collapse, there would be riots for food
and water.” If Donald Trump were not in charge? Retired building foreman
Rick Novak, 57, said: “People are going to get killed…. Gang wars. We are
going to get gang wars between white and black, whites and Mexicans. We
could have our own little Vietnam, right here.” As Donald Trump fanned
their fears, they expressed their love for him. When he snarled angrily
about, “kicking the criminals, the drug dealers and the terrorists the hell out
of our country,” the gratitude of his people was visceral.
Yet what he creates is far from security. On October 27, 2018, two
hours after he posted a rant against “invaders that kill our people,” Robert
Bowers, 46, entered a synagogue in Pittsburgh, pulled out an AR-15 style
assault rifle, and at least three handguns, and killed eleven Jewish
worshippers (Pilkington, 2018). As Donald Trump railed against his
enemies, Cesar Sayoc, 56, sent sixteen homemade explosives to prominent
Democratic politicians and media figures, including former President
Obama, former Vice President Joe Biden, and former Secretary of State
Clinton, with the belief that Donald Trump’s critics were “dangerous,
unpatriotic, and evil” (Jacobo, 2019). In March 2019, Donald Trump said in
an interview: “I can tell you I have the support of the police, the support of
the military, the support of the Bikers for Trump – I have the tough people,
but they don’t play it tough — until they go to a certain point, and then it
would be very bad, very bad” (Wise, 2019). A week later, fifty people died
after a shooter attacked two Mosques in New Zealand, explicitly citing
“common purpose” with Donald Trump (Al Jazeera, 2019).

“Battered nation syndrome”

If the unwavering support of Donald Trump is because of susceptibility to

cultic programming, what explains the passivity of the rest of the nation?
Do people still not recognize that Donald Trump is lacking in the emotional
maturity, the intelligence, the preparedness, or even the basic sympathy a
time of crisis? After more than 19,000 documented lies (Kessler et al,
2020), impeachment, repeated acts of corruption, subversion of justice, and
even after the disastrous mishandling of the coronavirus pandemic, his
political invincibility, and seemingly uncompromising support can be
confusing.
Harper West (2017) described the nation as being in an abusive
relationship with Donald Trump, much like the case example she drew from
her practice:
 Justin can be harshly critical, calling [Amelia] a “fat loser” and
her home-cooked meals “a disaster.” But if she asks even
reasonable questions, he lashes out at her: “You’re always so
negative and critical.” If she states a fact he disagrees with, he
accuses her of making up “fake” stories. Despite Justin’s family
and financial security, he is joyless and scowls much of the time.
Amelia is mystified how the most minor disagreements
seem to escalate into major arguments. I ask if Justin can
apologize or admit fault. “Oh, never,” she says. “He’s very
stubborn. It’s always my fault. I call him ‘Justifying Justin’”….
Justin has lied so frequently that Amelia has become
concerned she is “losing her mind” or has a poor memory, aided
by the fact that Justin accuses her of these faults. He insists that
she forget his mistakes, but brings her mistakes up repeatedly
during arguments…. She hesitates to confront him because she
has learned that it leads to escalating arguments with no
resolution. She is always the one to compromise (West, 2017).

Abusive personalities seek out submissive people who are willing to

be controlled and manipulated. In order to hide their feelings of inadequacy,
abusive individuals often adopt an aggressive, dominating persona and, in
positions of power, surround themselves with a coterie of family and
sycophants who avoid questioning them for fear of angry retribution. They
rarely admit to weakness or vulnerability because they believe this would
subject them to the same kind of abuse and control that they perpetrate on
others. Victims of abuse in turn may be blind to these flaws because they
replicate an abusive personality they experienced in childhood, and the
relationship pattern feels normal, even safe. This may help us to understand
why his followers blindly support him and why reporters and Democratic
leaders do not oppose him with conviction.
A “battered nation syndrome” can be conceived after the “battered
woman syndrome” or “battered man syndrome” that has been described in
domestic violence situations, where the “battered” partner comes to form
avoidance or numbing of emotions, cognitive difficulties, problems relating
to others, and personal image problems (Walker, 2017). The mental health
fields have extensive experience with victims who remain loyal to callous
and abusive personalities, for the same reasons that politicians and the
public seem to display with Donald Trump. Many people stay in abusive
relationships because they are ashamed to admit they made a poor choice.
With each passing crisis that Donald Trump has mismanaged, his followers
seem to be even more fervent in their support, despite the adverse effects
they suffer as a result.
As hard as it may be to believe, this kind of die-hard support often
appears among those who are embarrassed to admit they made a mistake in
voting for him. Shame causes some people to deny and double down on
their decisions, rather than admit an error in judgment. Donald Trump also
exhibits extremely poor shame tolerance. Abusive personalities, often as the
result of childhood attachment traumas, have low self-worth and are overly
sensitive to shaming experiences, such as being criticized, making mistakes,
or failing in any way. This shows up in an inability to be accountable or to
admit an error: Donald Trump’s “Sharpiegate” is a relatively benign
example; the coronavirus pandemic response a deadly one. Attempts to
offload blame can also lead to severe levels of direct violence.
Others in the nation are not blind to his flawed behavior but idolize
him for what he has: impunity from criticism. Other bullies desperately
wish to spout off opinions and not be challenged or questioned. They roar
their approval at rallies when Donald Trump intimidates and dominates
others, because they, too, wish to abuse those who are weaker. They see
nothing wrong with Donald Trump’s lashing out in rage or blame but rather
applaud it. In his entitlement, over-confidence, and bloated ego, they see
themselves and feel vindicated. Seeing authoritarian, immoral, and
unethical behavior in a successful billionaire and president allows them to
conclude that these are not faults, but positive attributes.
Abusers intimidate through the degrading of others. Donald Trump
uses his size, aggressive handshake, domineering body language, shoe lifts,
and even his bright red “power necktie” to intimidate. U.S. Representative
Adam Schiff likely knows he is not “shifty,” and White House reporters
know that the descriptions of them as “fake” or “dishonest” are untrue, but
he or she is often too shocked to be able to respond. Abusers rely on subtle
putdowns to weaken the victim’s confidence, and onlookers steer clear, or
shower him with praise, to avoid the same fate.
Members within abusive cults often act against their self-interest,
such as by giving away their money, property, children, or rights to a cult
leader. In the same way, abused spouses may quit their jobs, relinquish
financial security, or give up contact with family and friends at the demand
of their abusers. Provoking fear is something abusive personalities do to
secure fervent supporters. When fear “hijacks” the human brain, we lose
our ability to think rationally and become preoccupied with short-term
physical or emotional survival in a way that does not lend itself to thinking
comprehensively about complex, long-term problems (Anda et al., 2017).
Fear causes us to take cognitive shortcuts, and slogans such as, “Build the
wall!” further hinders the consideration of more realistic and nuanced
solutions to problems.
Passive reactions to abusive behavior occur because of the ease with
which abusers prey on the trust of their victims. Humans are a social
species, and most of us enter relationships eager to be liked, engaging in
prosocial behaviors. Trust allows us to direct the energy and abilities that
we would have been spent warding off enemies, toward building
relationships, high-functioning societies, and civilization. Antisocial people,
however, play by a different set of rules. If we expect love and trust from
them, we will be constantly confused and disappointed when we get back
humiliation, emotional abuse, and betrayal.
A desire to keep trying leads victims to stay in abusive relationships
and causes many Americans to downplay and hope for more presidential
behavior from Donald Trump, despite repeated disappointments. Just as
abuse victims have difficulty comprehending that someone who says, “I
love you,” would cause them harm, Americans find it difficult to believe
that a president who has taken an oath to “preserve, protect, and defend”
would choose to harm a nation and its sacred institutions, destroy
peacebuilding alliances, and subvert the social order. It violates moral
standards and our very world view to admit that a leader would work solely
for personal gain at the expense of the public.
As with all abusers, without external limits, Donald Trump will
likely continue to prey on people’s expectations of trust and desire for
stability, and our fruitless craving for a capable leader. He will continue to
sow distrust and fear, manufacture chaos, and play-act at leadership. Just as
abuse victims may need the strength, wisdom, and support of others to help
them leave their abuser, the nation needs political leaders, journalists, and
intellectuals with the strength of character to confidently call out what they
see (Lee, West, and Washington, 2020). Without this, an emotionally
battered people can easily succumb to the human tendencies to submit,
freeze, and fall into a helpless “battered nation syndrome.”

Shared psychosis

I once treated a family around the outskirts of Boston that believed outer-
space aliens were invading their neighborhood. The father was a
construction worker, the mother a former clerk, and the five children ranged
in age from eight to sixteen. They seemed respectable in public, but at home
they worried that an alien force had taken over their neighbors, heralding
the end of the world. They thought they were the only “sane” ones left and
needed to save themselves before the alien invaders besieged them too.
The mother, a domineering personality, chastised the only
nonbelieving member, her sixteen-year-old daughter. She had called the
emergency room when her parents started barricading doors and sleeping
with knives by their beds. Her call was on the earlier side for untreated
cases like this. Fear or terror might have escalated into an aggressive attack,
as they falsely believed themselves under assault. The mother, identified as
the “primary” patient, or the cause of “family psychosis,” or folie à famille,
was taken to the emergency room and then hospitalized. Within a matter of
days, both the patient and the entire family dramatically improved.
While there are many medically unjustifiable misconceptions we
have about mental pathology, none is perhaps as consequential as the denial
that it can be contagious. Just like the novel coronavirus, the
transmissibility of mental symptoms should not be taken lightly. Indeed, its
contagion could be more efficient than other forms of infection, since it
does not require physical exposure but only emotional bonds.
Weakened hosts, an environment that facilitates transmission, and a
lack of awareness that it is even possible make individuals highly
susceptible. Predisposing personalities, cultic programming, and trapped,
prolonged exposure as in the case example above create the optimal
conditions for the spread of symptoms. Furthermore, poor mental health
contributes to denial, and therefore those who are the most affected are the
least likely to admit that anything is wrong.
The transmission of mental symptoms and behavior is especially
common in public-sector hospital and prison settings, where untreated
symptoms among influential or dominant individuals can become severe
and spread among family members, criminal co-conspirators, gangs, and
other tight-knit groups (Guivarch et al, 2018). Infectious disease specialist
Gary Slutkin of Cure Violence has long advocated that violence be
considered an infectious disease whose spread we can interrupt. Research
has established evidence for the contagion of international terrorism and
suicide. Conceiving violence as a societal disorder requiring public health
interventions, population-level, has been very productive, allowing for
prevention at a massive scale. It has also helped the world move away from
the misleading association of mental illness with dangerousness.
Three conditions are necessary for the spread of mental symptoms:

1. Severe pathology in an influential figure

The transmission of mental symptoms has been given different names:

induced delusional disorder, shared psychosis, folie à deux, trois, quatre,…,
or millions—depending on the number affected—or mass hysteria when
affecting a whole population. All describe the same phenomenon, but none
are satisfactory. The latest, induced delusional disorder, focuses on the most
commonly transmitted symptom, delusions, but does not cover other
possible symptoms, such as mood. Shared psychosis captures the
syndrome-like severity, but is a misnomer because it often does not involve
actual psychosis. Folie à deux, or “madness in two,” is perhaps the most
preferred but a foreign phrase. Finally, “mass hysteria” describes well the
frenzied quality that arises from the sharing of symptoms among crowds,
but often does not actually involve symptoms of “hysteria”, or histrionics.
The important feature is that mental symptoms are not confined to the
person; they take hold and spread across interpersonal boundaries, just as
they initially take over one portion, and then eventually the whole of the
mind of an individual.
Severe psychopathology in an influential figure, therefore, transmits
to others or a group, until the exposed persons or groups come to feel, think,
and behave as if they had the same disorder as the primary person. Unlike
normal social dynamics, where enthusiasm, common purpose, or even
outrage can be “infectious” but individuals retain their uniqueness, the
spread of pathology is especially efficient and deleterious, taking over the
personalities of those involved.
 Shared psychosis at the societal level has been documented since the
Middle Ages and scientifically studied in detail in the mid-twentieth
century following the downfall of Nazism. A country or a group, seemingly
“seized” by irrational fears of persecution, may attack other, relatively
powerless groups. Often dramatic and yet easy to miss, it can absorb
persons of otherwise sound mind when they have prolonged exposure to a
severely impaired individual, usually of influence or authority, who goes
untreated. While the sixteen-year-old in the above case example managed
not to succumb, she underwent castigation and shunning. Above all, denial
among those affected will likely be vehement to the degree that the
symptoms are severe (we see this among Trump supporters who avoid
consideration of the possibility by calling any such insinuation, “Trump
Derangement Syndrome” or “TDS”, thereby deflecting the issue onto the
inquirer) (Zorn, 2018).
Transmission happens more readily in vulnerable persons, but those
who succumb are not necessarily of unsound mind to start. Delusions of
persecution or general paranoia are the most common to transmit, but even
bizarre beliefs, such as the primary person being of divine origin, are not
rare. Exposure to actual delusions is unlike exposure to strategic lies or
simple misinformation; they are more infectious because the primary person
is genuinely convinced of them and the emotional pressures for others also
to believe them is stronger. For example, when an influential figure holds
the paranoid belief that a serious viral pandemic is a “hoax”, orchestrated
by one’s enemies to bring down one’s presidency, it can be more
emotionally persuasive than any reality and is difficult to correct.

2. Group members with high emotional investment

Another condition for the spread of mental disease is emotional investment.

Folie à deux describes shared madness within a pair, but here we will focus
on folie à groupe, or the spread of mental symptoms in a group. The group
can be a household (folie à famille), a prison dormitory or cell-block, a
religious or other highly emotionally-bonded group, a community, or a
nation. Members may have a high emotional investment in the primary
person because of family relations, gang affiliation, similar symptoms to
start, blackmail, or other threats—these add to the conditions but are not the
symptoms themselves. Symptoms can also compel the conditions that
strengthen bonds: causing others to lose their bearings through
“gaslighting” (Stout, 2005); the generation of an alternative narrative
through an addiction to “tweeting”; orchestration of an alternative belief
system through the need to deny reality; intolerance of uncertainty leading
to pressures of conformity; and an insatiable need for adulation driving
addiction-inducing, hypnotic rallies—all create ideal conditions for
transmission. In other words, cultic programming and shared symptoms are
a feedback loop.
Induced delusions function like primary delusions: they are both
equally resistant to evidence and truth. The cognitive distortions, delusions,
and other mental symptoms can emotionally overwhelm normal responses
to the same situation. Some individual members may be more vulnerable
than others, but with strong emotional bonds and prolonged exposure,
fighting submission becomes more difficult. Those who do may experience
great pressure, as a result of the primary individual’s irrational symptoms,
or ostracism by the group, and may eventually give in or give up. Riding
the emotional force of pathology, these dynamics can be overwhelming—
and because of the disorder that the primary person carries, it might be
more aptly called a “transmitted cultural disorder.”

3. An environment that fosters contagion

Conditions of isolation, either physically or through filtered information,

especially when they “immunize” against alternative viewpoints through
phrases such as “fake news” or “the enemy of the people,” combined with
constant, high levels of exposure to the symptomatic primary individual, is
the formula for the generation of shared delusions. The environment is,
therefore, extremely important in determining the level of contagion.
Many have remarked on the cult-like quality of the leader-follower
arrangement we see with Donald Trump and his supporters. The dynamic
alarmed my colleagues in the mental health profession enough to write
entire volumes (Lifton, 2019). Existing arrangements of “viral” social
media, profit-driven news programs that rely on ratings, and rallies that
reinforce herd mentality and conformity, all contribute to an unconscious
spread of symptoms.
How is the recognition of shared psychosis, or folie à groupe,
helpful? We know from the scientific literature that, when contact with the
inducing individual is removed, the shared symptoms usually subside just
as dramatically as they have appeared. If removal is not possible, we know
that reducing exposure can be helpful. We can prevent epidemics from
occurring in the first place by screening for mental impairment before
individuals take positions of influence. Further, we can take steps to protect
ourselves in the future by promoting public mental health and education
about mental disease, as well as reducing environmental “toxins” that
include propaganda, brainwashing, and filtered information. Knowing that
mental compromise can contribute to physical demise, and recognizing the
distinct, characteristic patterns of disease, we can better avoid mistaking it
for a normal choice or just another ideology that excites people.
 A Profile of the Supporting Environment

The mental state of a society

At the start of The Spirit Level, British epidemiologists Richard Wilkinson

and Kate Pickett (2009) eloquently describe what they understand to be the
overarching problem of our era:

It is a remarkable paradox that, at the pinnacle of human material

and technical achievement, we find ourselves anxiety-ridden,
prone to depression, worried about how others see us, unsure of
our friendships, driven to consume and with little or no
community life. Lacking the relaxed social contact and emotional
satisfaction we all need, we seek comfort in over-eating,
obsessive shopping and spending, or become prey to excessive
alcohol, psychoactive medicines and illegal drugs.
How is it that we have created so much mental and
emotional suffering despite levels of wealth and comfort
unprecedented in human history? Often what we feel is missing is
little more than time enjoying the company of friends, yet even
that can seem beyond us. We talk as if our lives were a constant
battle for psychological survival, struggling against stress and
emotional exhaustion, but the truth is that the luxury and
extravagance of our lives is so great that it threatens the planet
(Wilkinson and Pickett, 2009).
What Wilkinson and Pickett are describing is not just a subjective
impression. The actual numbers and statistics are just as devastating, if not
more so. The United States, for instance, is the country in which the effects
in question appear most pronounced, and it has the lowest life expectancy
among rich countries. Not only is that the case, but since 2014, the average
life expectancy in the country has been going down instead of up, unlike
any other rich, developed country (Woolf and Schoomaker, 2019).
Moreover, most of the deaths that are contributing to this lowering of the
average life expectancy are occurring among people in the prime of their
lives, between the 25 and 64. The common causes of death in these cases
include opioid addiction, obesity, alcoholic liver disease, and suicide.
These statistics do not fit with the prevailing ethos of the United
States. Americans have always been told that material success brings
happiness, but the actual results of that mantra look more like social failure
in the midst of plenty. Instead, it seems that what matters most for societal
mental wellbeing is not overall economic success but, rather, the way in
which economies are developed and how they are distributed. Societal
forces like income inequality and unstable employment have psychological
consequences, and these consequences in turn create ideal conditions for
diseases and deaths. As such, what Wilkinson and Pickett imply is that the
psychological breakdown of whole societies is the result of choices we
make, collectively, about how to organize our social, political, and
economic systems. That vital connection, however, seldom materializes
within broader political discussions. Indeed, as Wilkinson and Pickett
lament, “as soon as anything psychological is mentioned discussion tends to
focus almost exclusively on individual remedies and treatments. Political
thinking seems to run into the sand” (Wilkinson and Pickett, 2009).
In essence, then, there is an inability or an unwillingness to see the
direct link that exists between economic and political policies, on the one
hand, and a nation’s health and mental health, on the other. It is this
inability to perceive the situation as it is that sits, perhaps, at the heart of our
general dearth of actual, deeper understanding. This has not always been the
case, nor is it a universal phenomenon: in other cultures and time periods,
people have been more aware of these influences. When German physician
Rudolf Virchow (1848) investigated the typhus epidemic in the region of
Upper Silesia, Poland, in the mid-nineteenth century, he came to state the
following: “Medicine is a social science, and politics is nothing else but
medicine on a large scale.” What we can take from that assessment is that
tuning into our collective sense of wellbeing and understanding that we
have ability to both find problems and devise solutions, is a crucial part of
self-awareness. It is that degree of self-awareness that helps us to provide
our progress, and our thriving, with meaningful direction.
Accordingly, just as The Dangerous Case of Donald Trump was not
simply about Donald Trump but, ultimately, the nation’s state of mental
health that gave rise to his presidency, this profile is also about both
ourselves and the nation. In order to present and understand Donald
Trump’s presidency as a public health issue, we have examined his
followers. In doing so, we emphasize that in order to heal from pathology
we cannot “normalize” it or pretend that it does not exist. It is equally
important to note that pathology is not the person, and hence the aim here is
not to stigmatize or to blame individuals. Indeed, pathology is not
something that always localizes within the individual; instead, it may exist
in the spirit of the nation, which is something common to us all. What this
means is that the development and maintenance of national self-awareness
must also involve the observation of ourselves. It also means that whatever
unhealthy, dependent, and irrational traits we identify in Donald Trump’s
followers, these cannot be understood as being isolated aberrations. Rather,
these traits are a direct consequence of us all, of everyone in society, even
those who are not supporters of Donald Trump. It may well also be the case
that while those who are most vulnerable may succumb to the most
obviously maladaptive behavior, they are at the same time also the least
likely to have had a part in creating the unhealthy conditions that led them
to that place. In short, we all share responsibility.
To continue to speak collectively, our current prospects do not look
good. The greater social context and situation that Donald Trump has
influenced and reinforced through his position has brought us to a position
that matches disturbingly closely a description by political philosopher
Hannah Arendt (1973) in The Origins of Totalitarianism:

Never has our future been more unpredictable, never have we

depended so much on political forces that cannot be trusted to
follow the rules of common sense and self-interest—forces that
look like sheer insanity…. [Humankind is divided] between those
who believe in human omnipotence (who think that everything is
possible if one knows how to organize masses for it) and those for
whom powerlessness has become the major experience of their
lives (Arendt, 1973).
Arendt was speaking in reference to the early twentieth century and writing
in the aftermath of the Second World War, and yet the situation that she
outlines does not sound too foreign to us today. So, we must now ask, how
did the U.S. get to this current point? What are some of the national
characteristics that have led us to this place?
A class system

Until the 1980’s, the American experience was similar to other large
economies. As recently as 1975, the top 1 percent of the population gained
a similar share of the income in the U.S. as they did in countries such as
Canada, France, Germany, Italy, Japan, and the United Kingdom. This
changed in the subsequent decade. Since 1987 the share of the GDP that
went to the top 1 percent in the U.S. exceeded that of all those other
countries, year after year. The rate at which this change occurred was
remarkable. On average, throughout the 1990’s and 2000’s, the income
share for the top 1 percent in the U.S. kept rising at twice the rate seen in
the U.K., and it exceeded that of other advanced economies by an even
greater factor. By 2014, the situation in the U.S. was stunning: the top 1
percent of the population had captured 18 percent of income; this
represented a significant increase from the figure of 8 percent in 1975
(Alvaredo et al., 2015).
What can be seen if share of the U.S. GDP that is earned by the top
20 percent of the population is equally stark. By 2018, that 20 percent was
earning fully 52 percent of all U.S. income (Semega et al., 2019) while the
bottom 20 percent, by contrast, earned only earned 3.1 percent. Another
factor that, in connection to this, creates wealth inequality is the fact that
most low-wage workers cannot save money. These workers also receive no
health insurance, sick days, or pension plans from their employers. In
simple terms: they cannot get ill, and they have no hope of retiring. What
that results in is the creation of significant health care inequality. The poor
receive very little in this regard whereas the rich, since they get rich faster,
take away in ever larger piece of the pie. As the overwhelming majority of
people saw their share of the national income, and the benefits resulting
from that, shrink by 1 to 2 percent, the wealthiest 1 percent of people
increased their own share of the same by 10 percent. These statistics also
describe a decrease in economic mobility with U.S. society. The average
wage earned by a worker remained, essentially, the same despite there being
a 15 percent increase in their productivity and a corresponding increase in
corporate profits of 13 percent per year (Greenhouse, 2009).
Presented with these data, there are many vital questions that one
might ask. The one to address here, however, is the following: what kind of
effect has this economic situation had on average Americans and on
national culture? Since human beings are largely symbolic creatures, factors
such as income, wealth, and health inequality matter not only for the
economic wellbeing of society but also for its psychological wellbeing. The
influences of this situation manifest themselves in many ways. Tracing
some of them in their groundbreaking study of the psychology of social
class, the American sociologists Richard Sennett and Jonathan Cobb
focused on the lived experience of manual laborers and their families. What
Sennett and Cobb (1972) discovered through their research was the
existence of a class-based battle for status and respect. “The terrible thing
about class in our society,” they claimed, “is that it sets up a contest for
dignity” (Sennett and Cobb, 1972), and this is a contest that those on the
bottom rung of society must, by definition, lose. Psychologically, the
hardest part of being poor, according to Sennett’s and Cobb’s assessment, is
not the material deprivation itself but rather the sense of “injured dignity,”
or the loss of self-respect and pride in relation to others. Such a hierarchical
system of respect, status, and dignity thus necessarily creates an endless
process of shaming and self-doubt.
The often undignified nature of the lives American live on the lower
rungs of society is powerfully portrayed by Barbara Ehrenreich in Nickel
and Dimed. In that book, Ehrenreich describes her first-hand experience of
how, even in times of relative prosperity, many Americans live demeaning
lives: subsisting on a minimum wage, surviving in run-down motels, being
unable to afford good food, and on occasion sleeping in their cars
(Ehrenreich, 2001). By her account, the only way by which people in the
lowliest occupations can get by is through exceptional mental and muscular
effort, sometimes by working two or three jobs at the same time. A different
story, however, emerges in J.D. Vance’s Hillbilly Elegy (2017), more than a
decade after Ehrenreich’s work. What Vance describes is a dysfunctional
culture of substance abuse, knockdowns, fights, and a pervasive feeling
among people that they simply cannot get ahead in life no matter what they
do – an attitude that he terms “learned helplessness” (Vance, 2017). It is,
again, a bleak account: an entire region of the country gives up without
trying, the population bound together by a common feeling of victimhood
and a desire to blame others. The sense of demoralization that Vance
describes is, alongside depression, a psychological consequence of extreme
inequality, and these feelings deepen as the extent of people’s poverty
grows more extreme.
In the U.S., poverty, and extreme poverty, are serious issues within
society. In 2018, Philip Alston, the United Nations special rapporteur on
extreme poverty and human rights, published a remarkable report. What
Alston revealed was the extent of the poverty that exists within the U.S.:
roughly 40 million people live in poverty; almost 18.5 million live in
extreme poverty; and nearly 5.3 million spend their daily lives in Third
World conditions of absolute poverty. And these people all reside within the
borders of the richest nation in the world. Writing in the report, Alston
notes:

Successive administrations, including the current one, have

determinedly rejected the idea that economic and social rights are
full-fledged human rights, despite their clear recognition not only
in key treaties that the United States has ratified, such as the
Convention on the Elimination of All Forms of Racial
Discrimination, but also in the Universal Declaration of Human
Rights, which the United States has long insisted other countries
must respect. But denial does not eliminate responsibility, nor
does it negate obligations…. In practice, the United States is
alone among developed countries in insisting that, while human
rights are of fundamental importance, they do not include rights
that guard against dying of hunger, dying from a lack of access to
affordable health care or growing up in a context of total
deprivation (United Nations, 2018).
There are a number of factors that start to explain the somewhat paradoxical
situation that Alston describes. Firstly, the constant fight against feelings of
shame and humiliation is an important psychological contributor to the
extreme conditions in the United States. Americans are raised on the
Horatio Alger myth, named after a nineteenth-century U.S. novelist who
wrote numerous “rags to riches” stories. What this myth dictates is that
anyone can get rich so long as one is smart and works hard; the flipside of
that is, of course, that it also implies that if you are not rich then you must
be stupid and lazy. Secondly, another factor contributing the unique
situation within the U.S. is the fact that the whole economic system of mass
production is set up to stimulate people to want to get rich: people are
constantly bombarded with advertisements, marketing, and a flood of ever
newer consumer goods. Thirdly, the importance of the American Dream and
its pervasive influence cannot be underestimated. One of the defining
features of the American Dream is the belief that children, the next
generation, will have better opportunities and live better lives than their
parents. It is, perhaps, a beautiful dream but it is one that is increasingly
failing to become a reality. As economists Raj Chetty and colleagues (2017)
have shown, while the American Dream was realized for about 90 percent
of children born in 1940, it held true only for half of those children born in
1984.
To return to the Horatio Alger myth, it can be clearly shown that the
socioeconomic reality in the U.S. simply does not reflect the rags-to-riches
fantasy. In fact, the situation is quite the opposite. In recent years, several
large studies have found that, contrary to historic perceptions, the U.S. is
now less socially and economically mobile than the United Kingdom and
much of mainland Europe. In 2006, to answer the question “Do Poor
Children Become Poor Adults?” U.S. economist Miles Corak (2006)
reviewed more than fifty studies of nine different countries and ranked
Canada, Norway, Finland, and Denmark as the most mobile, with the
United States and Britain being tied at the other end of the scale. Similarly,
Swedish economist Markus Jantti and colleagues (2006) found that just 8
percent of American men at the bottom rose to the top fifth, compared with
12 percent of British men and 14 percent of Danish men. Moreover,
according to the Economic Mobility Project of the Pew Charitable Trusts,
about 62 percent of Americans raised in the top fifth of incomes stay in the
top two-fifths, while 65 percent born in the bottom fifth stay in the bottom
two-fifths (DeParle, 2012). This relative lack of mobility is, if anything,
getting worse. What an Economic Report to Congress in 2012 found was
that increasing income inequality was inexorably leading to lower economic
mobility (Lenzner, 2012). The conclusion? Inequality begets inequality.
Inequality in society, and particularly the juxtaposition of extreme
wealth against extreme poverty, is obviously not without consequence. This
contrast in economic status fuels the feeling that society embraces some
people but not all. Indeed, it is interesting to note at this point that the Latin
word for ‘lower’, as in of lower socioeconomic status, is inferior, and that
in Roman law the lower classes were termed the humiliores, or “the humble
classes,” after the word for ‘low’, humilis. This may seem like a minor, or
overly academic, observation, but the implications are significant. When the
notion that to be poor is to be inferior and humiliated is embedded within
language itself, it becomes very hard to feel any sense of pride or self-worth
whilst in such a position. The same applies, in reverse, for the opposite end
of spectrum. The Latin word for ‘higher’, as in higher socioeconomic
status, is superior, which is related to the word for pride, superbia, from
which the English word superb is also derived. The term for the upper
classes in Roman law was honestiores, or the “honorable classes,” after the
word honestus, or honest, decent, and virtuous. Comparing all of these
terms, and the way in which they are still present in our everyday language
and mode of thought, offers a clear insight into the nature of society. An
unequal society that systematically divides itself into those who are inferior
and those who are superior, into “losers” and “winners”, results in the
creation of a large proportion of the population who feel fundamentally
humiliated. Crucially, it is relative and not absolute poverty that results in
this sense of humiliation and shame: if everyone were poor, or had the same
resources, such feelings would not exist. It is the apparent difference in
wealth that is problematic, and when the poor grow poorer and the rich
grow richer at an accelerated rate the feelings of shame and humiliation
intensify further.
Therefore, there are major psychological consequences to these
features of U.S. society that produce a wide gap between aspiration and
possible achievement. These become opportunities for the development of
widespread and intense feelings of inferiority and humiliation that can even
lead to depression and despair. This phenomenon is discussed at length by
the economists Anne Case and Angus Deaton in Deaths of Despair and the
Future of Capitalism (2020). What Case and Deaton show is that deaths
from suicide, drug overdoses, and alcoholic liver disease are rampant
among less-educated Americans following the loss of a job, community,
and dignity. In assessing why this is the case, Case and Deaton blame the
policies and politics transforming the U.S. economy into an engine of
inequality and suffering. Speaking in no uncertain terms, they argue that the
“American economy has shifted away from serving ordinary people and
toward serving businesses, their managers, and their owners” (Case and
Deaton, 2020).
The observation that Case and Deaton make concerning the levels of
mortality and chronic illness in American society is highly relevant. The
correlation between income distribution and population health is
remarkable when considered on a global level but it is particularly striking
in the example of the United States. Despite its being the wealthiest nation
on earth, there are such disparities in income within the country that
conditions exist that allow for a lower average life expectancy than in other
developed countries (Kulkarni et al., 2011). Trends show that the increase in
average life expectancy within the U.S. has been slowing down over the last
four decades. While in 1980 the average life expectancy in the U.S. was
similar to comparable developed countries, since then it has increased by
only 4.9 years as opposed the average increase of 7.8 years seen in similar
countries (Organisation for Economic Co-operation and Development,
2020). It is within regions with high levels of unemployment that this recent
deceleration in the increase of life expectancy has been most marked. This
is especially significant given that the level of employment national has
been in a long decline. Whereas in the late 1960’s all but 5 percent of men
of prime working age, 25 to 54, had jobs, in 2010, 20 percent of those in the
same age bracket were unemployed. While things improved slightly as the
country recovered from the Great Recession, the change was not drastic: in
2018, despite the recovery 14 percent were still not at work. Furthermore,
since a fifth of that 14 percent were looking for work, they were not even
counted as being “unemployed” (Case and Deaton, 2020). Such a capitalist,
materialistic society equates “self-worth” with “net worth,” and the
suffering is measurable at national scale, in terms of shortened life-years.

A caste system

When a class system diminishes a person’s dignity in all of the ways

described, where, or what, can they turn to? In the face of this reduction of
personal worth and status, for those who are eligible, the United States
offers an alternative source of pride and self-esteem: caste. A caste system
is a rigidly stratified social framework into which persons are entered as
soon as they are born, and determines their position, or caste, determined by
immutable characteristics such as skin color or ethnicity. Perhaps the
paradigmatic example of such a system is the hereditary social class
structure of Hinduism. The traditional Hindu caste system determines
occupation, status in a hierarchy, and customary social interaction and
exclusion. The United States has a caste system of its own, as psychiatrist
Dr. James Gilligan (1996) has described our arrangement of racial
stratification. At the top of this hierarchy are the “WASP’s”, or White
Anglo-Saxon Protestants, and at the bottom are Black Americans, with
some Hispanic Americans and other minority ethnic groups closely
following. As in the Hindu system, to be of lower caste in the U.S. has real
ramifications: you can expect to be subject to social and cultural rejection,
to be regarded and treated as inferior, to be arrested and publicly
humiliated, subject to police profiling and brutality, in ways no white
person would be (Bult, 2020).
Suffering humiliation is one thing, but what political scientist
Hannah Arendt argues is that even worse than being humiliated is being
ignored. Arendt makes this observation in relation to the experience of
Black Americans under the eyes of their white co-citizens, both rich and
poor. “The institution of slavery,” Arendt states, “carries an obscurity even
blacker than the obscurity of poverty; the slave, not the poor man, was
‘wholly overlooked’” (Arendt, 1963). Many Black American authors have
evoked this sense of being ignored, of living in obscurity, when writing
about the experience of being Black in America. Notable among these
authors are W.E.B. Du Bois, who addresses the issue in Dusk of Dawn
(1940), and Ralph Ellison, whose novel, The Invisible Man (1952),
expresses the same point clearly in its very title. Evidently, poverty in the
U.S. is not limited to its Black citizens, but one reason why poor white
people have not been quick to revolt against their own economic oppression
is because, in terms of caste, Black Americans have always been there to
occupy a lower rung on the social ladder than even the poorest white
citizens. Essentially, as long as there is a group to look down on from your
own position, however lowly that might be, you can find a false consolation
for your inferiority in relation to others above you. This behavioral trend,
and its recent acceleration, has played a role in Donald Trump’s election to
the presidency. Robin DiAngelo’s White Fragility (2018) and Carol
Anderson’s White Rage (2017) describe the white ambivalence and
backlash against challenges to these assumptions.
What has just been described is, in essence, one of the reasons why
America’s pattern of racial terrorism keeps repeating itself: namely that the
system of white supremacy that spawns this terrorism remains intact. Toxic
as its central beliefs are, we cannot understand white supremacy merely as
being white individuals’ delusion of being inherently superior to Black
people. Indeed, there exists an institutionalized white supremacy whose
functioning does not rely on individual bigotry. This form of white
supremacy is, instead, a universal operating system that relies on deeply
entrenched patterns and practices to disadvantage people of color and
privilege whites consistently and universally. The multiple lynchings that
have taken place during the coronavirus pandemic perfectly illustrate the
relentless energy of the engine of institutional white supremacy as it
privileges some and destroys the lives of others. Black, brown, and
indigenous people have disproportionately been the victims of these
lynchings. This is occurring even as the same people are expected to risk
their lives in low-wage jobs in order to make life comfortable for everyone
else, while also suffering much higher rates of joblessness and poverty.
There is a difference between individual and institutional white
supremacism. The difference also manifests in their respective capacity for
destruction: the hidden aspects of institutional, systemic, racism have far
more destructive potential than overt actions of individuals. One reason for
why this is the case is that racism is a system of advantage and hierarchy
based on race, not merely prejudicial sentiments or beliefs (Wellman,
1993). Similarly, psychologists Drs. Steven Roberts and Michael Rizzo
(2020) also advocate that racism should not be understood solely as
individual people “disliking or mistreating others on the basis of race.”
While such attitudes and behaviors are part of racism, racism itself is a
broader, more complex, phenomenon: it is a system of advantage, a racial
hierarchy; in other words, it functions structurally as a caste system. On this
matter, they write that “just as citizens of capitalistic societies reinforce
capitalism, whether they identify as capitalist or not, and whether they want
to or not, citizens of racist societies reinforce racism, whether they identify
as racist or not, and whether they want to or not” (Roberts and Rizzo,
2020). This distinction between individual actions and instances of racial
violence has a particular contemporary relevance. It is important to be
aware of, and to think about, the recent high-profile murders of Black
American citizens in the hands of police officers, but we need to also
understand that these horrific events are the consequences of a larger
system.
A crucial element within this larger system is the criminal justice
system. The criminal justice system in many respects embodies the attitudes
of our society in general. Within this system, racial profiling is a particular
issue that refers to the practice by law enforcement of suspecting
individuals of wrongdoing based on stereotypes about their race rather than
on their observed behavior. The direct result of this practice is that, in the
U.S., people of ethnic minorities are far more likely to be arrested than
white people. Moreover, once arrested, these individuals are also more
likely to be convicted. Once convicted, people from ethnic minorities are
likely to face stiffer sentences than white people for the same crimes. In
particular, Black men in the U.S. are six times more likely to receive prison
sentences than white men, and almost three times more likely to receive
them than Hispanic men (U.S. Bureau of Justice Statistics, 2012). Black
Americans have also been hit the hardest by the introduction of tougher
sentencing laws: they account for 41 percent of the national prison
population while comprising only 13 percent of the population (West and
Sabol, 2008). This imbalance is also evident in the behavior of the police:
nationally, police are three times more likely to stop and search cars of
Black drivers than those of white drivers, and about two times more likely
to stop and search cars of Hispanic drivers than those of white drivers (Eith
and Durose, 2011). In addition to that, Black Americans are arrested for
drug use at three times the rate of whites, and for drug sale or manufacture
at four times the rate of whites, despite the fact that the level of drug use
and dealing is similar between both racial groups (Snyder, 2011).
The difference between the treatment of Black and white Americans
within the criminal justice system does not stop there. Black Americans are
twice as likely as whites to be imprisoned when convicted for the same
robbery charge, and the number of Black Americans on death row has
remained constant for thirty years despite the fact the homicide rate among
that section of the population has decreased. (Tonry and Melewski, 2008).
Despite the fact that both Black and white Americans are numbered equally
among homicide victims, four out of five executions that have taken place
since the reintroduction of the death penalty have involved cases in which
the victims were white (Baldus et al., 1990). Michelle Alexander, in The
New Jim Crow (2010) astutely notes what this entails or, indeed, implies
about society. She points out that mass incarceration functions as a system
of racialized social control: by gathering entire segments of minority
communities and branding them as criminals, the system relegates them to
permanent second-class status upon their release. The inferiority of this
status is very real: stripping former convicts of the right to vote, to serve on
juries, to be free of legal and employment discrimination, and denying them
access to education and other public benefits. The functioning of the
criminal justice system in this way has enabled the practice of what has
been termed “slavery by another name” (Blackmon, 2008): namely, the
leasing out of mostly Black convicts to work in abysmal conditions for
negligible or no income. In this manner, what is meant to be a system to
ensure justice becomes, instead, a vehicle that furthers injustice and
structural violence that systematically injure individuals and tear
communities apart.
While systematic racism is perhaps most visible in the criminal
justice system, it also takes place in many other areas of society: housing,
education, employment, health care, and the media. The forms of racism
that exist within each of these areas combine to reinforce one another, and
they often remain unseen until they become manifest in “incidental” events.
Such events might include occasions of unwarranted police brutality and
marches by white supremacist terrorist groups, like those that occurred in
Charlottesville, Virginia. While his response to such happenings has been
mute at best, Donald Trump has, on the other hand, called Black Lives
Matter protesters “professional anarchists, violent mobs, arsonists, looters,
criminals, rioters, Antifa, and … dangerous thugs” (Bidgood and Goodwin,
2020). His dehumanizing rhetoric has also frequently referred to non-white
immigrants as being “aliens”, “criminals”, “animals”, “rapists”, “killers”,
“predators”, and “invaders” (Fritze, 2019).
If all of those factors are considered, the mental health effects that
they have on members of minority groups, and Black Americans in
particular, might be more accurately described as being cultural rather than
individual. This emphasis is necessary because of the pervasive legacies of
slavery and the corresponding legal and tacit systems of racial oppression
that exist in the U.S. The notion of legacy of slavery is important, as
research shows that trauma is heritable and transgenerational (Dias and
Ressler, 2014). For this reason, Black psychologist Dr. Kevin Washington
(2019) asserts that post-traumatic stress disorder (PTSD) is a misnomer in
relation to Black Americans: the prefix “post-” suggests that the trauma is
finished, rather than ongoing. What Washington suggests is that a different
term is required. He argues that when an entire group or a culture in the
U.S. experiences a continuing trauma, whether it is in the form of police
brutality, poor health care services, environmental racism, “food deserts,” or
the pipeline-to-prison process, it would be more accurate to refer to this
trauma as “persistent enslavement systemic trauma,” or PEST. This term
recognizes the fact that while physical slavery lies in the past, enslavement
is something that assumes many forms: mental slavery persists into the
present and is, in many ways, more violent than its physical counterpart.
This is, to an extent, reflected in the way in which physical actions are
performed to achieve mental effects: the primary purpose of the physical
brutality is to cause psychic disruption, and by targeting an entire group of
people on all levels of existence, to maintain systemic subjugation. While
Washington focuses on the Black American experience, he cautions of the
potential for contemporary version of slavery with other races and
nationalities throughout the world. Native Americans have suffered
genocide and are still living through its aftermath, and there are also other
people of color—including Hispanic Americans, Middle Eastern
Americans, and Asian Americans—who have also been the targets of racial
segregation.
Racism, as it exists in the U.S., affords no simple understanding, as
has become clear by this point. Despite this, Roberts and Rizzo represent a
movement toward such an understanding by identifying seven factors
contributing to racism in the U.S.:

1. Categorizing people into distinct groups

2. Factions, which trigger ingroup loyalty and intergroup competition
3. Segregation, which hardens racist perceptions, preferences, and beliefs
4. Hierarchy, which emboldens people to think, feel and behave in racist
ways
5. Power, which legislates racism at local and national levels
6. Media, which legitimizes overrepresented and idealized
representations of white Americans while marginalizing and
minimizing people of color
7. Passivism, such that overlooking or denying the existence of racism
encourages others to do the same

In short, according to Roberts and Rizzo, the U.S. systematically constructs

racial categories, places people inside those categories, and then actively
segregates people on the basis of those categories. In so doing, it privileges
and empowers some people over others, reinforces those differences
through biased media, and then leaves those disparities and media in place.
Of the seven factors that they list, Roberts and Rizzo believe that perhaps
the most insidious is that of passivism, or passive racism, which depends on
there being apathy toward systems of racial advantage or a denial that those
systems even exist. Such apathy can result in no positive change, and in
order to correct systemic racism properly, one must do more and become an
“antiracist” (Kendi, 2019).
The question of how to do more, how to respond to such continuing
trauma, is equally complex. An important tenet of trauma therapy, however,
is to validate patients’ truths and personal experience of their subjugation.
Witness and testimony are vital: when they do not exist, or are not present,
people in crisis “become bounded, out of place and out of time” (Davis,
2014). As such, being believed and not having one’s experience denied is
crucial to anyone who has witnessed unspeakable horrors, or who has had
their world turned upside down through direct experience of torture, rape,
physical, or sexual abuse. The first step that for a person to be able to move
forward out of isolation and shame is the affirmation of the truth of their
experience. Without this affirmation, the work of healing cannot progress
(Teng, 2017).
This notion of the importance of validating and affirming an
individual’s experienced truths has also been making regular appearances in
discussions regarding another aspect of society that is both related and
relevant here. Gender discrimination can happen in a similar manner as
systematic racism and is also a serious and ongoing problem. Part of what
helps to perpetuate gendered violence and discrimination is the fact that
men find themselves able to ward off or negate feelings of shame, disgrace,
and dishonor so long as they can claim themselves to be superior to women.
The parallel here is with the attitudes of the poorest white people in the
U.S., who are able to accept their poverty only because the system enables
them to claim themselves superior to people of other skin tones.
This aspect of male identity is deeply rooted in culture. Distinction,
difference, and implicit superiority is central to the traditionally received
idea of manhood. In the conventional and stereotypical sex roles that
patriarchy prescribes, manhood revolves explicitly around the expectation
that men distinguish themselves from women. Again, it is useful at this
point to examine briefly the history of the word. In Latin, the term for
manliness and manhood, virtus, means “courage” and derives from vir, a
word that is used to mean both “man” and “soldier”. Our modern English
word “virtue” also derives from virtus, a linguistic trace that further reflects
the lingering contemporary presence of the qualities most valued by the
martial culture of Ancient Rome valued. By contrast, the Latin word for
“womanly”, muliebris, meant simply “unmanly” and was used as a
derogatory way of addressing men who did not meet the masculine ideal. In
other words, the idealized values and characteristics of courage, virtue,
manliness, and soldier-hood could all simply be defined as being “not
woman.” It is this pervasive and deep-rooted cultural indoctrination that
acts as one of the primary reasons why the women’s liberation and the
transgender movements are particularly threatening to what has hitherto
been a privilege from birth.

Indoctrination

Tyrants do not arise in a vacuum, and nor does tyranny emerge within the
world without announcement. Instead, tyranny is the result of a long period
in which elites cultivate an increasingly unbearable, oppressive
socioeconomic inequality that benefits only themselves, at least for a while
(Mika, 2017). If these oppressive, hierarchical, structures are to be
maintained, especially in a nation that at least nominally adheres to
democratic principles, then what is necessary is large-scale indoctrination.
In his work, Thought Reform and the Psychology of Totalism, psychiatrist
Dr. Robert Jay Lifton (1961) outlines the first criterion for thought reform
as “milieu control.” What he understands by this phrase is the control of
information and communication available within the social environment so
that, ultimately, the mind of an individual is also controlled. While drawing
an accurate distinction between education and subtle forms of thought
reform can lead one down a slippery slope, a major difference can be found
in terms of what is expected of individuals who have undergone the
processes. Whereas a thought-reformed person is expected not to question
or to examine critically the doctrine they have learned, an educated person,
by contrast, is encouraged to do exactly the opposite.
 The media are an invaluable tool for indoctrination. Indeed,
recognizing the importance of broadcast communication in influencing
public opinion and attempting to discourage partisan indoctrination, the
Federal Communications Commission (FCC) in 1949 came to adopt the
Fairness Doctrine (Houser, 1972), which allowed that the public interest
“can only be satisfied by making available … varying and conflicting views
held by responsible elements of the community” (FCC, 1949).
Implementing this regulation was always a difficult process but, in 1987,
Ronald Reagan used is presidential power to abolish it altogether (Pagano,
1987). The result of Reagan’s action was that AM radio was able to take
off, and the task of serving the public interest quickly transformed into that
of interesting the public. Education and other activities than required more
mental effort, such as the development of critical thinking, took a sideline.
Riding this wave was Rush Limbaugh, who, through rhetorical charisma,
succeeded in labeling the rest of the media as “biased”. Having managed
that, Limbaugh proceeded to articulate the need for right-wing media, a
media which in turn came to call refer to itself as “fair and balanced.”
A former media consultant who helped Richard Nixon win the
presidency (Sherman, 2017), papered over Ronald Reagan’s budding
Alzheimer’s and shamelessly stoked racial fears to elect George H.W. Bush,
Fox News CEO Roger Ailes may have done more than anyone else to pave
the way for Donald Trump’s presidency. Ailes recognized that, although
people like to think they are rational, they are actually driven by emotions
—anger, fear, nostalgia, even disgust. Journalist Tim Dickinson notes in
“How Roger Ailes Built the Fox News Fear Factory”:

To watch even a day of Fox News—the anger, the bombast, the

virulent paranoid streak, the unending appeals to white
resentment … is to see a refraction of its founder, one of the most
skilled and fearsome operatives in the history of the Republican
Party…. Fox News was a new form of political campaign—one
that enables the GOP to bypass skeptical reporters and wage an
around-the-clock, partisan assault on public opinion. The
network, at its core, is a giant soundstage created to mimic the
look and feel of a news operation, cleverly camouflaging political
propaganda as independent journalism (Dickinson, 2011).
The success of Fox News as a political propaganda machine can be in
countless instance. In the documentary film The Brainwashing of My Dad,
Jen Senko (Senko et al., 2015) vividly depicts her father’s right-wing
radicalization: beginning as he started listening to particular radio shows
during his daily work commute and growing markedly worse when he
started watching Fox News. His new fanaticism rocked the very foundation
of Senko’s family, but she discovered that this was not an isolated
phenomenon; similar changes were occurring with alarming frequency
across America. As a friend of my own once lamented to me: “we were
always worried about the effects television would have on our children,
when we should have been worried about the effects it would have on our
parents!” One of the effects of watching Fox News is not without a dark
irony: in 2012, a Fairleigh Dickinson University survey reported that Fox
News viewers were less informed about current events than people who did
not follow the news at all. This phenomenon became known as the Fox
News effect, and the program, like conservative radio, continued to
cultivate an audience that thrives on anger, to prove that liberals are evil,
and to otherwise deliver all of its reports with an emotional punch
(Poundstone, 2016). It is exactly this kind of communication and attitude
toward reporting that Donald Trump would later echo.
In Network Propaganda, Yochai Benkler, Robert Faris, and Hal
Roberts (2018) draw on their different backgrounds in law, sociology, and
media studies to show how manipulation, disinformation, and radicalization
have transformed American politics. They challenge the conventional
wisdom within Washington that holds that there is symmetry between the
two polarized political parties. Liberals and conservatives, they argue in
Network Propaganda, live in separate bubbles, where they watch different
television networks, frequent different web sites, and absorb different
realities. These two sides may operate in different spheres but, the book
argues, they should not be understood as being equal when it comes to their
evaluation of “news” stories, or even in their grounding in reality. Simply
put, liberals want facts whereas conservatives want their biases reinforced.
Liberals embrace journalism while conservatives prefer propaganda. The
authors conclude, on the basis of this, that “the right-wing media ecosystem
differs categorically from the rest of the media environment.”
The right-wing media ecosystem described in Network Propaganda
might, indeed, also be described as being systematic psychological
manipulation. According to the authors, false stories are launched on a
series of extreme web sites, such as InfoWars—the home of infamous
conspiracy theorist Alex Jones—“none of which claim to follow the norms
or processes of professional journalistic objectivity.” Those stories are then
transmitted to outlets such as Fox News and the Daily Caller. These
secondary outlets, as Benkler and colleagues observe, claim to follow
journalistic norms but often fail in their actual implementation. Notably, it
is shown that the same pattern is not mirrored on the left wing: there are no
significant media web sites on the left that parallel, in their content, the
chronic falsity of those on the right. Indeed, the upstream sources with an
allegiance to facts serve rather as a consistent check on the dissemination
and validation of the most extreme stories if they emerge on the left, in
ways that, equally, have no parallels on the right. The dynamic on the right
works to a particular end: it “rewards the most popular and widely viewed
channels at the very top of the media ecosystem for delivering stories,
whether true or false, that protect the team, reinforce its beliefs, attack
opponents, and refute any claims that might threaten ‘our’ team from
outsiders” (Toobin, 2018).
To understand how this process of indoctrination works, it is
necessary to consider its basic mechanisms. To that end, in Brainwashing:
The Science of Thought Control, neuroscientist Kathleen Taylor (2006)
brings a neuroscientist’s perspective to bear on the “extreme influence”
techniques that psychiatrists and psychologists have written about for
decades. Taylor points out the usefulness of thinking about brainwashing as
being a sequence of carefully planned, influential procedures that are
specifically designed to alter drastically the way people think and act. The
purpose of brainwashing is to alter identity, to rewrite it so that it serves the
imposed will of the brainwasher. Some forms of torture, such as sensory
deprivation and physical depletion, may hasten the effects of brainwashing,
but they are not essential and, in fact, may even render it less effective in
the long run. While torture makes obtaining compliance easier, it is, at the
same time, far less likely to bring about actual conversion. Taylor thus
exposes the vulnerability of our thoughts, beliefs, and behaviors as
advertisers, politicians, religious leaders, talk show hosts, telemarketers,
and other pundits constantly target us, seeking to capture first our attention
and then our beliefs.
 While media outlets such as Fox News might perform it most
explicitly, even mainstream media are not immune to implicitly effecting
thought reform. In Manufacturing Consent (1988), a scathing critique of the
idea that the mass media inform the public objectively, media scholar
Edward Herman and linguist Noam Chomsky present the notion that mass
media also works to influence opinion:

It is … difficult to see a propaganda system at work where the

media are private and formal censorship is absent. This is
especially true where the media actively compete, periodically
attack and expose corporate and governmental malfeasance, and
aggressively portray themselves as spokesmen for free speech and
the general community interest. What is not evident (and remains
undiscussed in the media) is the limited nature of such critiques…
(Herman and Chomsky, 1988).

Herman and Chomsky continue to trace how money and power are able to
determine which news is fit to print, to marginalize dissent, and to allow the
government and dominant corporate interests to shape messages to the
public. They identify five “filters” that contribute to this distortion of the
news:

1. Ownership. Media firms are big corporations, often part of huge

conglomerates whose end game is profit, to which critical journalism
takes second place.
2. Advertising. The primary income source of the mass media transforms
their audience’s attention into a product that they sell to advertisers.
3. Sourcing. Journalism cannot be an effective check on power because it
relies on access to news sources, which means complicity with
governments, corporations, and other powerful institutions that may
revoke the privilege at any time.
4. Flak. Powerful institutions might counter inconvenient stories by
discrediting or demonizing their authors through flak (a term deriving
from the German word for antiaircraft fire).
5. Common enemy. To manufacture consent, you need an enemy—
communism, terrorists, or immigrants—to help corral public opinion
and to frighten the population into submission.
These filters work both individually and also in interaction with one
another, providing each other with a certain degree of reinforcement. To
reach the public, the raw material of news must first pass through these
filters; when it emerges at the other side, all that remains are the residues
deemed acceptable by the powerful structures and parties involved. As
these structures determine the premises of discourse, the angle of
interpretation, and what is newsworthy in the first place, they have the
effect of operating what essentially amounts to a vast propaganda
campaign. It is not easy to think about ways to avoid or navigate this issue
successfully. The filters that Herman and Chomsky identify are built into
the system in such a fundamental way that alternative bases for a different
system of news and media are hardly imaginable.
In addition to control of content, there is growing control of process
that has become deleterious. Social media, through opaque algorithms that
filter information and encourage addiction, researchers have pointed out
how social media work to distort reality, to boost conspiracy theories, to
move users to more extreme content and positions, and to incentivize the
outrageous and offensive. These proprietary algorithms determine what a
person sees without information or consent. Media platforms use them
without accountability, while political operators can game the arrangement
by creating ecosystems of links and platforming one another. They now
“hack” the social brain in ways that work like a drug. One of Facebook’s
founders, Sean Parker, said that Facebook’s goal was to “consume as much
of your time and conscious attention as possible,” and that it did so by
giving users “a little dopamine hit every once in a while, because someone
liked or commented on a photo or a post or whatever. And that’s going to
get you to contribute more content, and that’s going to get you … more
likes and comments.” The point was to create “a social-validation feedback
loop … exactly the kind of thing that a hacker like myself would come up
with, because you’re exploiting a vulnerability in human psychology”
(Podur, 2019). The growing sophistication makes the influence on society
ominous. In the face of this, it might have been helpful for the mental health
professions to mitigate the harmful effects, but instead of using their
knowledge to heal, in the societal sphere, they would fall silent.
Silence on the part of professions

The reason that the mind is tyranny’s battleground in its pursuit of power is
because the most potent weapon of the tyrant is the mind of the oppressed
(Biko, 1978). It is for this same reason that journalists and intellectuals are
often the first targets of an oppressive society. The extent to which critical
voices are silenced is, equally, a good measure of a society’s collective
mental health, self-reliance, self-awareness, and capacity for change. In the
era of Donald Trump, perhaps the most critical silencing of intellectuals has
been the move to stifle mental health professionals’ input, just at a time
when mental health became a critical national concern. The American
Psychiatric Association’s (APA’s, 2017a) modification of an ethical
guideline to prevent any comment on a political figure by mental health
professionals, at the start of Donald Trump’s presidency, might well be in
our day the first sign of encroaching tyranny and of the institutional
tightening of information control that Herman and Chomsky (1988) speak
of.
Before going further into the details and significance of the APA’s
action, however, let us first turn to the early twentieth century. It was at that
point, over a century ago, that neurologist and founder of psychoanalysis
Sigmund Freud helped enhance our understanding of the nonrational human
mind. One of the reasons why Freud’s work was so radical and influential
was that it fundamentally challenged one of the assumptions people like to
make: that human beings are rational creatures. What Freud worked to
show, however, was that lying beneath the surface of our conscious minds
are feelings and drives, often sexual and aggressive, that could control our
behavior, unless we brought them to conscious awareness. This newfound
knowledge proved to be so effective for individual therapy, it was harnessed
also for social, political, and commercial engineering (Hassan, 2019).
Indeed, it was the belief of reporter and psychological writer Walter
Lippmann (1922) that the public needed active guidance, and this was
because of the limited time and opportunities available to learn everything
necessary to form public opinions. World War I proved a testing ground for
new ways of influencing the way the public thought in this regard. During
the conflict, the U.S. government, wishing to sway public opinion in favor
of the war, called in Freud’s nephew, journalist and “father of public
relations” Edward Bernays, to help promote the idea that American
participation in the war was necessary to make the world “safe for
democracy.” Witnessing how mass psychology could be controlled like
“flipping a switch,” Bernays understood that he could also make people buy
ideas or products by appealing to their emotions and desires. In doing so, he
became the first person to apply psychological principles to propaganda and
advertising, and effectively spawned the modern era of consumerism. In
Propaganda, Bernays (1928) spelled out the science of shaping and
manipulating public opinion, and he termed this science “the engineering of
consent.”
Unfortunately, his findings would be mobilized to control the
masses to the benefit of the few. The ruling class understood that the more
deprived and the unhealthier the masses are, the more controllable they
would be and decided that it was easier to manipulate them psychologically
than to improve actual conditions. The use and misuse of psychological
techniques for political or commercial purposes is extensive and has had a
net harmful effect on society’s grounding mental health. By contrast, there
has been little use of these same techniques to be helpful and to contribute
to societal betterment. Just as the free press had to yield its position in
society to political propaganda and commercial media, which made
relentless use of psychological manipulation, so did intellectuals, notably
health professionals and mental health professionals, had to yield their field
to politicians and the corporate interests behind them. One cannot argue that
the public is better off, or better represented, as a result of its having lost
both the free press and access to the best available knowledge, or best
health care. Knowledge empowers the people, and hence its squelching can
never help but the body that is trying to control them.
The divide between intellectuals and politics is not a new
phenomenon. Even during the height of intellectualism in America, it was
often observed that the “best brains are not attracted to the government
service” (Ahmad, 1970). In cases in which the U.S. government temporarily
borrows the service of intellectuals, these individuals are not able to
function independently. This marks the U.S. as distinct from most other
countries, including the U.K., possibly the nation’s closest cousin when it
comes to the way in which experts, such as mental health professionals, are
consulted. In the U.S., when experts are brought in to work for the
government, they have assigned jobs to do and they are not free to speculate
in an intellectually uninhibited way. At best, if the government desires to
have them, intellectuals may function as advisers. When it comes to issues
of mental health, then, the problem is clear: a government most in need of
consultation is the one least likely to seek it. If one of its own were mentally
afflicted in dangerous ways, it would most likely hire experts who would
help hide it. Within the context of the current administration it was,
therefore, incumbent on the mental health community to meet its
independent professional societal responsibility through the only means it
had available: public education.
Such a delivery of public education did not, however, fully
materialize in the Trump era. It is at this point we must return to the APA.
Regarding the general failure of the mental health community to perform its
ethical duties to their full extent, it is difficult adequately to assess the
enormity of consequences the APA set in motion when, either under
governmental pressure or of its own initiative, it decided to collude with
power over truth. The specific method it used to do so was by reinterpreting
“the Goldwater rule,” into a kind of “gag rule” that silenced an entire
profession (Glass, 2017). Its new position had little ethical, scientific, or
practice-based validity, and a vast majority of professionals who were
speaking up were not members under its jurisdiction: only about 6 percent
of practicing mental health professionals are APA members, according to
the Bureau of Labor Statistics (Grohol, 2019). Hence, what the APA did
was to defend and enforce its position through public campaigns and by
promoting its guild rule as if it were universal, or worse, some kind of law.
Through its vast lobbying clout, it also enlisted the media, starting with the
New York Times, and soon all the major media fell in line (Kendall, 2020).
By doing so, it engineered a public opinion where one had not previously
existed: that the public did not wish to hear from mental health
professionals about the mental health of the president.
Only, it was untrue: as insiders of the whole affair, many of us know
that the situation was more complex (Fingar, 2020). Through frequent
contact with the public through an organization of mental health
professionals that formed to step in where we believed that the APA had
failed in societal leadership, we knew that vast numbers of people not only
wished to hear from mental health professionals but were clamoring
constantly to hear from us with the question: “Where are the psychiatrists?
Where are the psychologists?” (Lee, 2019c). Not only that, the exceptional
success of The Dangerous Case of Donald Trump, a book by mental health
professionals that became an instant and unprecedented New York Times
bestseller for a multi-authored book of specialized knowledge, was a clear
indication of public demand. Countless members of the APA also resigned
even from leadership positions because they disagreed with its new rule.
Many of those former members of the APA subsequently joined our
organization, specifically in opposition to the APA’s complicity with the
government. It is currently unknown exactly what proportion of
psychiatrists within the APA disagree with the new rules, because the APA
refused to do a poll or to hold a discussion. A potential indicator, however,
is an informal poll that another organization—the American College of
Psychiatrists—conducted. The results showed an overwhelming majority of
psychiatrists disagreeing with the current version of “the Goldwater rule”
(Bosworth, 2018). Among the dissenters was a past president of the APA,
Dr. Steve Sharfstein, who holds heroic stature for resisting pressures the
organization experienced under the Bush/Cheney administration to endorse
and assist in torture. Moreover, despite the pressure that the APA applied on
other organizations, the American Psychoanalytic Association (APsaA)
issued an explicit memo to its members stating that “the Goldwater rule”
did not apply to them and that they were free to comment (Begley, 2017).
Within our organization, the World Mental Health Coalition, there
are many who believe that the APA was singularly responsible for blocking
important education that may have helped the public to protect itself and
possibly to avert losing thousands of lives. Five months into the pandemic,
for example, we were able to create a blow-by-blow account of how exactly
mental health professionals foretold the president’s mismanagement of the
coronavirus pandemic, based on his psychological makeup (Lee, 2020c).
Our message that the situation was predictable and preventable could not
effectively reach the public, because the APA’s change of “the Goldwater
rule,” whose purpose was to protect public health, now protected a public
figure at the expense of public health, arguably violating all core tenets of
medical ethics. Conscientious, independent professionals, unable to gain
any attention from the media, were inhibited from speaking their conscience
(Lee et al., 2019). Given this situation, we stated early on that the APA’s
distortion of ethics to suit the Trump administration would cause more harm
than the APA’s psychological counterpart, the American Psychological
Association, did to change its ethics guideline to facilitate and design
government programs for torture (Risen, 2015). This is because any stifling
of speech regarding widespread danger to society was bound to cause far
more devastating harm than one thousand torture victims, as bad as that had
been. Almost 200,000 deaths later from Covid-19 at the time of this writing,
this would be hard to argue.
 Recovering America’s Soul

Political personality profiling

A renowned scholar recently contacted me with an inquiry:

I’d be interested to know the way that this famous study is viewed
in your field. I read it yesterday for the first time and found it to
be remarkable, with eerie echoes to the present. Langer’s main
point seems to be Hitler’s neurotic insecurity and guilt and the
way they manifested in Hitler’s need to prove his superman status
to himself and others, to the point of global destruction. It seems
far too close to the ‘stable genius’ for any comfort (Personal
Communication, 2020).

The “stable genius” found here to be similar in some of his characteristics

to that disturbing historical reference is, of course, Donald Trump—
according to his own description of himself (Diaz, 2018). The “famous
study” the scholar refers to is the “OSS Hitler Psychological Portrait” by
Dr. Walter C. Langer. The sense of there being a disturbing similarity
between the portrait set out in that study and today’s president is one that is
commonly experienced. Other responses I have received from those who
have read Langer’s study include, amongst many more: “uncanny in
resemblance” and “I thought I was reading about Trump!”
The author of that psychological portrait, Langer, was an American
psychoanalyst. In 1943, the Office of Strategic Services (OSS), the
precursor of the modern Central Intelligence Agency (CIA), commissioned
him to produce a highly confidential, accurate, psychological study of
Hitler. Undertaken at the height of World War II at the special request of
General William J. Donovan, head of the OSS, Langer’s psychological
analysis became an important point of reference for Allied leaders. The
accuracy of the analysis contained within the study received contemporary
validation: it predicted Hitler's suicide in 1945. Later, in 1972 and nearly 30
years after it was first prepared, Langer’s work was published as The Mind
of Adolf Hitler and became a bestseller.
 It is reflection on the value and insight of Langer’s work that many
members of the public have been asking for a similar “profile” of Donald
Trump, and hence my small attempt has now been developed into this
current book. “If a profile on a dangerous political figure from the outside
was useful,” people have said to me, “then a profile on a dangerous political
figure from the inside is even more urgent and necessary, since we are more
vulnerable.” Others have argued: “What advantage do we have if the rest of
the world, including all our enemies, have a correct perception of our
president, while we are the last to know?” This report is a response to such
urgings, but above all the purpose of a profile is to have a better
understanding so that we can solve a problem—and what greater problem
does America face than that of its mentally-compromised president? It is
also finally written in dedication to that person who persisted in his
insistence that I was one of the few who could and would do this, and to
whom I owe a tremendous personal debt for his role in my struggles to
provide warnings about the dangers of Donald Trump.
Langer was, himself, keenly aware of the value of his study,
including its perhaps unrealized potential as a pioneering model that could
have been utilized in relation to subsequent significant geopolitical events.
In a later introduction to the bestselling report, he wrote:

I may be naïve in diplomatic matters, but I like to believe that if

such a study of Hitler had been made years earlier, under less
tension, and with more opportunity to gather first-hand
information, there might not have been a Munich; a similar study
of Stalin might have produced a different Yalta; one of Castro
might have prevented the Cuban situation, and one of President
Diem might have avoided our deep involvement in Vietnam
(Langer, 1972).

If Langer recognized the usefulness of his study, so too did others. Indeed,
such recognition led the American Psychiatric Association (APA) to
establish a task force that was meant, among other things, “to arrive at
proposals with respect to ethical guide-lines for the writing of …
psychobiographies and psychiatric profiling” (1976). Creating a team that
had just such an objective, the APA at that point clearly did not doubt
psychiatrists’ ability to know anything and to arrive at conclusions in the
absence of a personal examination, as it would later assert to be the case
under the Trump administration. In fact, quite the opposite situation and
view prevailed. Langer’s analysis and the assistance it provided the OSS
were considered to be so useful, so valuable, that Dr. Jerrold Post, a
distinguished APA life fellow, launched the CIA’s Center for the Analysis
of Personal and Political Behavior. That center was essentially a profiling
division that would in turn see the creation of a new subspecialty within
psychiatry: the profiling of political figures, and I have learned much from
him through personal contacts and our collaborative work. He contributed a
chapter to the second edition of The Dangerous Case of Donald Trump
(Lee, 2019b), which was to form a basis for his own book, Dangerous
Charisma (Post, 2019b). He helped me with the release of The Dangerous
Case’s second edition, through a major, multidisciplinary conference at the
National Press Club in March 2019. The conference, entitled, “The
Dangerous State of the World and the Need for Fit Leadership,” brought
together thirteen leading experts from the fields of psychiatry, law, history,
political science, economics, social psychology, journalism, nuclear
science, and climate science in unprecedented ways on the unprecedented
topic of how the president was unfit from each of their perspectives (C-
SPAN, 2019).
Political profiles have become a tradition of at least seventy years.
Known studies alone are multiple. In the 1950’s, the CIA commissioned an
analysis of the Vietnamese leader and revolutionary Ho Chi Minh based on
remote observations. Then, in 1961, the CIA profiled Soviet Premier Nikita
Khrushchev in advance of his meeting with President John F. Kennedy in
Vienna. According historian Michael Beschloss, the process of reading up
on his Soviet adversary and counterpart got Kennedy hooked on CIA
personality profiles, and he reportedly viewed them as “salacious secrets
about foreign leaders.” Seventeen years later, in 1978, President Jimmy
Carter asked the CIA to prepare psychological profiles on Israeli Prime
Minister Begin and Egyptian President Sadat in advance of the Camp David
talks. Following that summit, Carter expressed pleasure with the dossiers
that the CIA had provided: “After spending 13 days with the two principals,
I wouldn’t change a word,” he said, seemingly impressed by their accuracy.
As the situation in Libya in the early 1980’s caused concern for the Reagan
administration, the CIA tried to make sense of the erratic actions of Libyan
strongman, Moammar Qaddafi. Similarly, in 1990 on the eve of the Gulf
War, another strongman leader, Saddam Hussein, was also the subject of a
“comprehensive political psychology profile,” which the CIA’s Post
presented to the House Armed Services Committee. The following year, the
Agency also drew up a classified psychological profile of Haitian President
Jean-Bertrand Aristide, whom a military coup had just ousted. That same
profile would prove instrumental in withdrawing American support for the
exiled leader during the Clinton administration, after preparing to restore
him to office in 1994. Finally, an even more recent example comes from
2008, when a Pentagon study went as far as to diagnose Russian President
Vladimir Putin with “autism”. The Office of Net Assessment’s Body Leads
project asserted that scrutiny of hours of Putin footage had revealed him to
have “Asperger’s Syndrome, an autistic disorder which affects all of his
decisions” (Gilson, 2015).
Many things can be taken from that historical survey of some of the
CIA’s actions, not the least of which is that the agency has a long history of
producing political and psychological profiles of international figures. It is
also evident that the CIA has often engaged in diagnosing foreign leaders
from afar for the benefit of American politicians and diplomats, and,
moreover, that the APA has fully cooperated with such diagnoses. Such
operations are not, however, unique to the U.S. and its intelligence
agencies; in fact, some other countries’ unusually deft handling of Donald
Trump suggests a successful use of similar techniques. The reason behind
my mentioning, here, of such reports is not to assert any similarity between
the profile I am producing and those agency-commissioned ones but the
opposite: I wish to make clear that the purpose of my report is strictly
public health and safety from a medical perspective, and not to diagnose
where convenient to power structures, such as the CIA, while prohibiting
diagnosis where inconvenient to those structures, such as with “the
Goldwater rule.” That diagnosis is ill-advised without having full access to
the person’s medical records and, in some cases, a personal examination, I
accept. However, the APA has promulgated in public the notion that
diagnosis without a personal examination is under all circumstances
unacceptable and unethical—even when essential to society’s protection—
while in other settings it has itself fully engaged in diagnosis—even when
harmful to society—when a personal examination is never possible but
distance-diagnosis is well-suited to authority. This is the distinction I would
like to draw, if only to separate myself from medically untenable but
politically advantageous positions.
The profile I am providing here is also distinct from those surveyed
above in that it tries to give context by bringing a public health and
ecological perspective to it. A frequent error of American psychiatry is to
see individuals as separate from their environment, more so under the
influence of pharmaceutical industry-driven biological psychiatry. First, the
profile acknowledges that we are facing not a foreign adversary buta
domestic one who has access to all the nation’s levers of power and secrets.
Second, without the CIA or any other authoritative organization requesting
an evaluation, it witnesses the medical needs of the moment, with multiple
arms of government that are supposed to be checks on the president
incapacitated, for whatever reason, and turning a blind eye. Third, rather
than being commissioned to work on issues behind the scenes,
psychological professionals instead find themselves at a roadblock, unable
to advance without authorization, blacked-out from the media and actively
restrained by one of their professional associations, especially one of its
past presidents, who has made false accusations (Lieberman, 2017), even as
he was later found to have violated “the Goldwater rule,” not we (Begley,
2018). And, finally, rather than feeling reassured that their elected leaders
will protect them, the public has instead, as a direct result of Trump’s
presidency, experienced unprecedented rises in stress and anxiety, including
retraumatization, suffering from mental consequences without being given
explanations as to why. The stifling of mental health experts’ voices has
only exacerbated the situation, and the presidency’s psychological toll on
the nation already become immense, even before the disastrous
mismanagement of the coronavirus pandemic and subsequent economic
collapse. At the time of this writing, widespread suicides, homicides, and
“deaths of despair” are projected (Well Being Trust, 2020), but only the tip
of the iceberg has been seen.
The danger that the country currently faces, then, is both intimate
and imminent in nature. As such, and in consideration of the tradition of
political personality profiling, the psychological study of any such
individual who poses a danger to society on that scale is to be viewed as
being both relevant and important. To allow psychological profiles only of
foreign enemies and not of domestic leaders is to place ourselves in a
situation characterized by a twofold danger. If a foreign enemy were to
possess a profile of our leader while we ourselves did not, then they might
be able not only to work against us from the outside but also to collude with
a domestic enemy to destroy the nation from within. With that in mind, it
can be seen as a terrible misfortune that the APA has colluded with the
Trump administration to enable the silencing of independent mental health
professionals when it comes to discussing matters pertaining to political
figures. As a consequence of that fateful decision, Americans have been
kept in the dark and rendered defenseless at a critical time, suffering
massive harm and casualty as in no other war than World War II and the
Civil War. Institutions such as the APA exist to fulfill a purpose, and they
should not use their resources merely to protect themselves and to cover for
one another’s errors at the expense of the society they are supposed to
serve. From the start, “the Goldwater rule” was more a political
compromise than an ethical guideline, perhaps bound to be politically
abused. It is in defiance of this unethical action, by an organization that is
presumed to uphold professional ethics, that I have embarked on this
profile, “Trump’s Mind, America’s Soul.”

A profile of the nation

That our nation is sick and on a suicidal path is now no longer deniable.
This is the case both literally, in terms of the grossly inadequate steps to
contain the coronavirus pandemic, and figuratively, in terms of the country
having brought itself to the brink of fatally undermining core democratic
institutions. As the coronavirus has continued to claim a thousand lives a
day in the U.S., while most other economically-advanced countries have
brought deaths down to double or even single digits, the international
community might wonder whether we have lost our collective minds. By
the end of 2020, the projected number of Covid-19 deaths in the U.S. is
projected to exceed 400,000 (Lewis, 2020). Even more ominous, perhaps, is
the psychology of the nation that Donald Trump is shaping: how can one
man bring about such a wretched, plague-ridden, and pariah status out of a
nation the world once envied, however inaccurately, as a shining example
of democracy and economic flourishing? Human beings are adaptable, and
when we elevate a mind that embraces base impulses and wanton
criminality, this rapidly becomes the standard, after which rapid decline is
almost automatic. Donald Trump’s delusions of grandeur have been allowed
to swell through his three-and-a-half years in office to such a degree that
defeat or voluntary departure from office, especially in the face of criminal
charges, will have become inconceivable for him. Additionally and
commensurate to this, his followers have been conditioned to take any
defeat of their strongman leader as a “coup”, and even to refuse to accept as
legitimate proper election results. Given than he has now coopted a number
of government institutions, having replaced career officials with loyalists,
we can be certain that those inside and outside his administration will be
working heavily to distort, to delay, and perhaps even to distract away from
any result other than their desired one, using all means possible.
The pressing question is this: how do we improve from here? How
do we move away from pathological rule, further descent into chaos and
lawlessness, and fracture of society bound for destruction? The first step
forward comes through a thorough understanding, through an accurate
formulation. To do this, we must: (a) correctly name the problem; and (b)
correctly understand the situation. Naming the problem, as simple as it
sounds, is something we have not been able to do. Consider how many
excuses we have heard about why we need not hear from experts about a
mental health problem, how it is not a mental health problem, and how
Donald Trump is a “symptom” and not a problem? He is a symptom,
certainly, but he is also an important cause and an immediate offending
agent that must be removed for there to be healing. It is rather this kind of
either-or thinking that makes us incapable of mobilizing all our resources
and cooperating, when it is of critical importance. Denying that a mental
health problem is a mental health problem is precisely proof of a mental
health problem (I know that is a mouthful, but it is the very nature of mental
health problems to affect the mind that would otherwise be capable of
recognizing what the problem is). Given this characteristic, naming the
problem as one of mental health is 99.9 percent of the struggle. Of note,
mental health problems are not solely individual but ecological. We need
not, and should not preclude societal considerations or coexisting problems
of criminality—that we would do better to think of the whole at once for a
better understanding—is the very thesis of this book. As such, we are now
able to embark on the creation of a psychological formulation of the
situation. This formulation is presented below and consists of three key
parts: a formulation of Donald Trump, a formulation of his followers, and a
formulation of the nation as a whole.
Formulation of Donald Trump

Mr. Donald J. Trump is a 74-year-old married white male with five children
from three marriages. He is currently the president of the United States, a
role whose public nature is in keeping with that of the many highly visible
jobs he has held in the past. We do not have access to his medical records,
and so are unable to provide a definitive diagnosis, but are able to refer to
information about him from numerous reliable sources, including firsthand
reports by those who have observed him directly and longitudinal
information over decades. This type of information is far more valuable
than a personal interview in evaluating conditions that are of interest to
larger society—such as personality disorders, dangerousness, and unfitness.
He exhibits numerous worrying behaviors and symptoms that include the
following: (a) pathological narcissism; (b) sociopathy; (c) difficulty with
impulse control; (d) frequent mood swings; (e) histrionic traits; (f)
dependent traits; and (g) declining cognitive function. If there were more
room within this profile, the list might extend further. On the basis of the
evidence available, a number of full evaluations that do not require a
personal interview have already been performed. The result of one of those
was an assessment of psychological dangerousness, for which he
abundantly met criteria; this would ordinarily warrant further, involuntary,
evaluation and would disqualify him from any job until he is proven no
longer to be dangerous. Similarly, a mental capacity evaluation, based on
highly reliable information presented in the special counsel’s report,
evidenced a failure to meet any of the required criteria for rational decision-
making, which would also disqualify him for almost any job, let alone
president. Cause for further concern is a potential neurological asymmetry
with apparent right-sided weakness and forward-leaning posture, whether
sitting or standing. This asymmetry may also be related to conditions that
are contributing to his difficulties with attention and impulse control; all
this has been observed within the context of a family history of Alzheimer’s
Disease. Furthermore, multiple sources, including his own niece, have
alluded to an undiagnosed learning disorder, which may have contributed to
Trump’s behavioral problems as a child and his capacity as an adult.
He has not had any known suicide attempts or psychiatric
hospitalizations, but he has consistently struggled to manage on his own,
meeting with multiple bankruptcies, criminal charges, and serious public
scandals such that he has required extraordinary institutional support
throughout his life—in the form of millions of dollars from his father, from
multiple banks, and now the federal government. Earlier in his presidency,
it was suggested that he, who has the ultimate responsibility for the use of
the most dangerous weapons in the history of the world, and who has the
sole capability to murder millions of people in an instant, should undergo an
evaluation for the multiple, serious psychological, cognitive, and
neurological signs he showed. Rather than give him a proper
neuropsychiatric workup, however, Dr. Ronny Jackson, now disgraced and
removed from his position as White House physician, performed in January
2018 a 10-minute cognitive screen, on which Donald Trump apparently
scored 30 out of 30, but this is a test that full-blown Alzheimer patients
have been found to score perfectly (Trezpacz et al., 2015), and hospitalized
schizophrenia patients to score in the normal range (Gierus et al., 2015),
such that Alzheimer research groups have recommended that the test not be
used for ruling out dementia. Hence, unfortunately, a much-needed
comprehensive exam was skipped.
He has problems with aggression and violence and is now
responsible for a mass homicide of hundreds of thousands who, but for his
lies, deceptions, and suppression of the Centers for Disease Control and
Prevention (CDC) and medical experts, would otherwise be alive. His
history of violence stretches back into his childhood, when he attacked a
neighboring toddler with rocks, but his more recent violent acts have, since
his candidacy for presidency alone, included the following: verbal attacks;
boasts of sexual assaults; repeated threats and incitement of violence;
traumatization of children by the thousands; the dispatch of federal forces
against peaceful protesters; displays of belligerence against enemy and
allied nations alike, including the assassination of a high-ranking Iranian
general on an official visit in Iraq and the massacre of Kurdish allies; and
the stimulation of a renewed nuclear arms race. There are many more but
cannot all be listed here. He has no known history of substance abuse,
although stimulant misuse cannot be ruled out in light of evidence from
multiple witnesses and reports. His medical history includes a history of
obesity, heart problems, and elevated cholesterol.
Of all his signs and symptoms, the most concerning is a ballooning
of his pathological narcissism that has led to ever greater, delusional levels
of grandeur, feelings of omnipotence, and total belief in the impunity of the
presidential office: “Article II means I can do whatever I want” (Speaker’s
Press Office, 2020). This has escalated to the point where he cannot
imagine that he could lose a second term unless the election is “rigged”
(Liptak, 2020), believes that he deserves “a redo of four years” (Wade,
2020), and declares himself, “the law of the land” (Baker et al., 2020). Rage
attacks are common in such a needy personality, for expectations always
outpace reality, and eventually everyone falls short. However, when there is
an all-encompassing loss, such as the loss of an election, it can trigger a
rampage of destruction and reign of terror in revenge against an entire
nation that has failed him. It is far easier for someone of his fragile, inflated
self-image to consider destroying himself and the world, including its
“laughing eyes,” than to delegate himself to the status of “loser” and
“sucker” (Goldberg, 2020b)—which will feel like psychic death.
On top of his fragile sense of self is a need for power, a lack of
empathy, and cruelty, which all make him dangerous. He has felt no
remorse or sorrow for the almost 200,000 Americans lost to Covid-19 but
rather his inaction and cavalier attitude have facilitated a most insidious,
enduring, and most lethal form of genocide, whether intention is conscious
or subconscious. Rather, partly out of envy of other human beings for
having the human characteristics that he lacks, he shows signs that he
derives pleasure from others’ suffering and death (Lee, 2020c). Moreover,
he delights in putting people in danger, as when he forces his followers into
crowded indoor rallies without masks, as he demands that they prove their
loyalty to him with their lives. All of these characteristics are associated
with a poor prognosis, and their management should begin with
containment and limitation of access to both weapons and power.
Formulation of Trump followers

Mr. Donald Trump’s followers are of a wide range of population

demographics. Despite that, are of a highly varied demographic.
Nevertheless, they are more old (53 percent of age 65 and older) than
young, more married (55 percent) than unmarried, more white (54 percent)
than colored, more men (52 percent) than women, less educated (50 percent
of non-college graduates) than more, and lower income (61 percent of less
than 30,000-dollar annual income) than higher (Pew Research Center, 2018;
Cole, 2019). If considered individually, most of these followers would
likely not be diagnosed with mental health problems; in fact, the probability
is high that they would be categorized as being of normal health. As a
group, however, Trump followers display a mass psychology of irrationality
and impairment, much as has been described in works such as that of
French medicine-trained crowd psychologist Gustave Le Bon (1896).
Moreover, when an individual in possession of serious impairments is in
power, many supporters will themselves start to exhibit the same behaviors
and symptoms as in the leader, because of their emotional bonds. A likely
common manifestation of that phenomena is decreased ability, on the part
of the followers, to imagine that there could be anything wrong with them,
as well as a violence-proneness against anyone who would suggest this of
them or their leader. Hence, any attempt to normalize these maladaptive
characteristics would be as erroneous as seeking to normalize the leader’s
psychopathology, but caution is warranted. Other particularly “contagious”
symptoms are delusions and paranoia. The present remarkable situation is
that Trump supporters are steadfast in their approval of him, despite the fact
that he is, as we have established, not mentally well or fit for duty
according to any metric or standardized technique that mental health
professionals employ. There is seemingly no degree of demonstrable
incompetence, egregious behavior, or destruction of the nation’s democratic
norms and welfare that can diminish the resolve of Trump supporters to
stand by their leader.
That wide display, across society, of characteristics similar to those
that Donald Trump himself presents leads to their coalescence into a
number of group characteristics that social psychologists have identified.
These group characteristics are: (a) authoritarianism, or an outgrowth of
largely narcissistic wounds that cause “regression” to an earlier stage of
emotional development that agrees with deference to authority, aggression
toward outgroups, and a rigidly hierarchical view of the world; (b) social-
dominance orientation, or a related trait that emphasizes being dominant,
driven, tough-minded, disagreeable, and relatively uncaring in a “might
makes right” world that corresponds to an earlier stage of moral
development; (c) outgroup prejudices, which can arise from having
relatively little experience of the intergroup contact that is necessary to
induce empathy and to reduce fear; and (d) relative deprivation, which has
resulted from the massive job losses that came with automation and rising
inequality (Pettigrew, 2017). Consideration of these group characteristics
can go some way toward explaining the collective psychology of Trump
supporters. The president’s loyalists are more readily found in areas of low
mobility, in which largely Republican state legislations have sharply
reduced the funding for institutions of higher learning upon which people
depend for education and future opportunity. Such legislation helps to
create precisely those conditions of stress under which both individuals and
groups of people are more likely to “regress” and to yearn for an authority
figure. More specifically, they tend to seek authority figures who they
believe are capable of easing their pain and solving their problems like a
parent, and hence displaying strong, dominant qualities. Much of that pain,
and many of the psychological problems center around grievance and envy,
with people feeling as though they are being deprived, in relation to both
what they expected to have at a certain point in their lives as well as to what
groups they erroneously perceive to be “less deserving” seem to possess.
These feelings are rooted in socioeconomic realities, especially relative
poverty, but once they translate into psychological injury and take
maladaptive form, they become ripe for exploitation.
That exploitation is perhaps most strikingly manifest in the Trump
era with staged rallies that have been called, “identity festivals,” around
their focal slogan, “make America great again,” which represents a
reactionary call to return to an earlier time in the nation’s history when
America’s position in the world was dominant, its presidents and Supreme
Court judges were all white males, its immigration policy was more
restrictive, and its society was more racially segregated. Deep within the
unconscious, however, it is a metaphorical desire to return to the safety of
the womb, where one is protected from the world through impenetrable
walls—and is one of the reasons why a concrete wall at the U.S.-Mexico
border, no matter how ineffective in keeping out real danger, is irresistible.
A demagogue who understands and exploits this fantasy is able to stir those
who have felt inept, inferior, and abjectly insignificant into reimagining
themselves as a powerful, entitled people of destiny. Through the
vilification of outgroups such as immigrants, Democrats, the so-called
“elite”, and the media that was critical of Donald Trump, his supporters and
attendees of his rallies can evacuate their feelings of self-loathing,
weakness, and humiliation. In purging themselves of those feelings they
transfer them onto others; by casting others as the epitome of evil they are
then able to refigure themselves as being superior and chosen. Accordingly,
Donald Trump, the man who delivers them this intoxicant, is exalted for the
brash social dominance he displays, the prejudices he affirms, and for
protecting them from the world, which they experience as a very dangerous
and threatening place (Allport, 1954).
That exaltation and sense of identification are behind the inseparable
bond that leader and followers have come to share, like parent and child.
Once the followers identify with their leader, any criticism of scandal
concerning his fraudulence, his inanities, or his criminality is experienced
as simultaneously posing an existential threat to themselves; their leader is
not just protector but country, constitution, and government itself. Criticism
therefore activates defensive denial, disavowal, and a willingness to fight to
one’s death to protect their “protector”. As this is essentially an inviolable
bond, if a situation were to arise wherein unfavorable facts, science, and
incriminating evidence were to mount, the more they will rather unmoor
themselves from reality. In doing so, they find and cling ever more closely
to the few sources of information that will corroborate their beliefs and
adopt unquestioningly their leader’s fixed, false beliefs. Their ability to
return successfully to previous levels of functioning depends on the
swiftness of any intervention, the completeness of the separation from the
leader and sources of propaganda, and the support they receive in the
aftermath of the trauma.
Formulation of the nation

The United States of America is a 244-year-old democracy with a mixed

history of colonialism and slavery that was experiencing increasing
vulnerabilities through political corruption, economic inequality, and
increasing public alienation for decades, until all of these factors converged
to elect and support the presidency of Donald Trump and have now
culminated in the tragic national mismanagement of a global pandemic, in
the midst of other national crises. The current episode of systemic
deterioration can probably be identified as taking root in the mid-1990’s. At
that time, with Newt Gingrich as speaker of the House, U.S. politics started
to turn into a partisan “blood sport,” replete with name-calling, conspiracy
theories, and strategic obstructionism—foreshadowing the current
presidency. Some may date it back to the 1980 Ronald Reagan victory when
his campaign struck a deal with Tehran to delay the release of the hostages
until after the presidential election, a possibly treasonous act for his own
gain of power. Gingrich’s “Republican Revolution” was interested not so
much in legislating as it was in using the U.S. Congress as an arena to
create conflict and drama; in doing so, it broke bipartisan coalitions in order
to “win”, and plunged Washington into permanent dysfunction (Coppins,
2018). It was that point in the last decade of the twentieth century that
marks, perhaps, the juncture at which normal politics ceased and
identifiable characteristics of dysfunctional pathology began to appear.
From that point on, U.S. politics became increasingly defined by failure to
conform to social norms, deceitfulness, failure to plan ahead,
aggressiveness, reckless disregard for safety, irresponsibility, and lack of
remorse about that behavior. These proclivities resulted in a stolen
presidential election that saw the appointment of George W. Bush, similar
to the 2016 election in the electoral college arrogating the people’s choice,
and also a carelessness toward the September 11 terrorist attacks of 2001
that came to foreshadow the carelessness with which Covid-19 would in
turn be handled.
The new pathology within U.S. politics interpreted previous global
leadership following the fall of Communism as being insufficiently self-
interested, and it worked to abuse its powers for greater hegemony, as well
as to exploit the grief and confusion of the nation following September 11,
2001, in order to advance its prior policies and objectives of expansion. One
particular think tank, Project for the New American Century, planned and
focused on the invasion and control of Iraq since the 1990’s, for example. In
keeping with the renewal of opportunistic policies, other pathological
characteristics also appeared: a grandiose sense of self-importance; a
preoccupation with global dominance; a sense of entitlement; the
exploitation and dehumanization of others; and the assumption of arrogant
and haughty behaviors or attitudes. As all this was taking place, the
environment continued to be mismanaged, ignoring the signs of global
warming that grew more evident, a new worldwide nuclear arms race
began, and many progressions toward democracy started to reverse trends.
In that manner, disordered behavior manifested not just in individuals but in
nations: through unnecessary wars, American attitudes led not only to the
destruction of others but also to self-destruction. Bitterness toward partisan
politics and the terrible policies it produced began to build in the
population, while other liberal democracies marveled at the its lack of
representation.
The financial crash of 2008 only deepened the bitterness. A result of
the practices and excesses of the banking system, the financial crisis was
also largely self-generated. If the crash itself was devastating, doubly
infuriating was the fact that the subsequent bailout bill rewarded the same
system that had caused the crisis, even as ordinary people continued to
suffer from its repercussions. Leading bankers often went entirely without
prosecution, most keeping their fortunes and some their jobs, and before
long the banks were back in business. Meanwhile, Americans on the middle
and lower economic rungs of society had to take on new debt and often lost
their jobs, homes, and retirement savings. Unlike the banks, many average
Americans never recovered from the crash, and young people who came of
age during the Great Recession were the first generation in a long time to
find themselves poorer than their parents.
Following the financial crash, and through the long period of
recession, inequality in the U.S. worsened, as did social fragmentation,
another marker of declining psychological health. Chasms opened between
all different social and political groupings: upper and lower classes,
Republicans and Democrats, metropolitan and rural people, native-born and
immigrants, ordinary Americans and their leaders. The bonds that hold
society together began to tear apart, and the reforms of the Obama years, in
health care, financial regulation, and green energy, while aspiring to heal
those wounds, proved only to be palliative. The long recovery that occurred
over the course of the last decade mainly served to enrich corporations and
investors, to lull professionals, and to leave the working class even further
behind. Moreover, the long-term effects of the economic slump increased
polarization and discredited authority, especially that of the government.
The result of that, however, was a response that is typical of dysfunctional
societies; an abused nation chose to place its trust in another abuser who
would only accelerate those problems: Donald Trump.
Continuing what he began in his election campaign, he has,
throughout his entire presidency, pitted citizens against one another along
lines of race, sex, religion, citizenship, education, region, and political
allegiance. As a result of those actions, a third of the country has locked
itself in a hall of mirrors that it believes to be reality; a third has driven
itself mad with the effort of trying to hold onto the idea of knowable truth;
and a third has given up even trying to do anything at all. Having acquired a
federal government crippled by years of right-wing ideological assault and
steady defunding, Donald Trump has effectively set about finishing the job
by destroying the professional civil service, filling it with loyalists who will
work only to further his own interests, and forcing them to function as his
private operations. The major legislative accomplishment of his
administration, one of the largest tax cuts in history, was of equally little
benefit to the majority of Americans: it sent hundreds of billions to the
wealthy who then subsequently rushed to contribute to Trump’s re-election
fund.
By early 2020, when the coronavirus pandemic reached the U.S., the
nation had already received over three years of Donald Trump’s wreckage
along these lines. It was for these reasons that, when confronting the
challenges of Covid-19, the response of the U.S. was shockingly
inadequate. Despite months of advance warning of the virus’ arrival, and
despite a vast amount of resources at its disposal, the U.S. squandered every
opportunity and depleted every means until the nation’s economy and world
stature have all but collapsed. It acted not like an economically-advanced
nation but as one with an ineffective infrastructure and a government either
too corrupt or too inept to act as required. The consequences have been
stark. The “American carnage” he vowed to stop in his inaugural address
was his actual world view, with which he would make reality match, and
the U.S. was its unfortunate recipient. The pandemic has not united
Americans against a common threat; nor has it acted as a great leveler.
Instead, the pandemic and its handling have become a source of
indignation: Black, brown, and poor people are suffering and dying in
disproportionate numbers; the rich are profiteering during the crisis even as
tens of millions of people are laid off and left without employment (Packer,
2020). A report in early August 2020 revealed, 643 Forbes-certified
billionaires grew their collective wealth by an estimated 685 billion dollars
(Helenowski, 2020), just as the nation itself plummets into a new Great
Depression.
Meanwhile, the U.S. now resides in a newly unstable world:
unconstrained North Korea, coupled with a more assertive China, could
further destabilize Northeast Asia; an Iran that no longer feels bound by the
non-proliferation treaty membership is an ever more destabilizing actor in
the Middle East; and, in an election year, Russia, China, Saudi Arabia, and
Israel all have a stake in swaying the results. We have a president who
believes he is manipulating everyone else in his infinite wisdom, but of
course the opposite is true. Without stable leadership, and with most major
authorities and institutions corroded, the nation is more vulnerable than
ever. Even if the cataclysm does not happen, we will no longer be living in
the same world, and the damage he has done to our institutions, our identity,
and our sense of reality is already a gift to our enemies.This formulation of
the nation makes two things strikingly clear. First, we can see that it is
possible for societies to become sick, just as individuals do. Second, it is
evident that the response to societal sickness must be the same as that given
to a sick individual: triage and treat, and keep treating until the nation
returns to normal levels of functioning. Given the current situation that our
society finds itself in, the provision of care needs to occur with great
urgency if the sickness is to be treated with success.

A plan

We see from the above formulations that societal sickness and individual
disorder intertwine, especially where an influential public figure is
concerned. The distinction should not be between society and individual, or
between political office and civilian status, but whether there are patterns
and characteristics consistent with pathology, and how best to treat it. A
hallmark of mental compromise is that one loses insight, or the ability to
recognize that something is wrong. We observe this in clinical settings: the
sicker the patients, the more they insist they are well and avoid evaluation
and treatment at all cost. Healthy individuals and societies, on the other
hand, are quick to examine themselves, and to seek attention or guidance
for anything that bothers them, so that they can correct and improve
problems before they get out of hand. As they are anxious to resolve any
issues so that they can advance, they also do not hesitate to solicit advice
from experts. This healthy impulse to monitor and to seek help for oneself
diminishes, however, as an individual or society falls into sickness. It is
therefore imperative that we take action before insight, or self-awareness,
dissipates and is entirely lost. Once that point has been reached and passed,
the course of disease accelerates, and the hope for the individual or the
society to save itself is nearly gone.
At the societal level, mental health experts are supposed to perform
the vital task of facilitating that insight, in addition to also helping to put
into context what the general public is seeing in the case of an impaired
leader. When a two-party political system obscures the difference between
what is partisan and what is pathological, for example, expertise can help
identify the distinction through standardized, neutral methods. Without that
differentiation having been made, pathology can infiltrate almost any
human institution to exploit its fault lines, to bulldoze rational systems, and
to take over. A lay population is more likely to conflate pathology with the
wide spectrum of normalcy, since human health accommodates great
variation, and without knowing how deeply disturbances can run, it is
natural to see things in the frame of the familiar. Mental health experts, on
the other hand, have the research-based knowledge and clinical training
required to recognize the stereotypical and well-established patterns of
pathology. Such experts can then alert the general population as to the
existence of these pathologies, and also educate them about their
characteristics. This societal role is especially crucial for the most
dangerous pathologies, since we mostly assume that others are like us even
when they merely take on a “mask of sanity,” to borrow the phrase from
psychiatrist Dr. Hervey Cleckley’s (1941) classic book. In other words,
experts can highlight pathology’s distinguishing features to help the public
to be able to have self-awareness and to protect itself. The aim is not for
mental health professionals to overtake the people’s decision-making
process, but by sharing professional insights and knowledge, to help them
make informed and self-benefiting decisions.
Having access to facts and expertise, or the best available
knowledge, is critical to a people’s ability to govern itself. As such, making
themselves available to society is a vital service that independent experts
can offer in ways that institutions dependent on government funding, or
White House-employed physicians, cannot. The provision of this service
should be voluntary but also proactive. We, unlike many other civilized
nations, do not have an official, independent advisory system of experts.
Instead, experts are called in for limited topics that usually serve
politicians’ purposes or are “hired” by wealthy and powerful interests that
can afford their services. The end result is that expert voices are sometimes
misused or stifled precisely in the moment of need. We know from the
Trump era that leaders abusing power stifled attempts to remedy the
situation, and the American Psychiatric Association, against most of its own
membership and against independent professionals, stopped even the truth
from getting out.
The public therefore depends on independent experts’ sense of
conscience and responsibility to society to speak up in times of need.
Experts should therefore not feel restricted to waiting until the powers-that-
be call them, for this delimits their function merely to being “hired guns.”
The necessity of such an approach is particularly evident where mental
health is concerned, as, because of the nature of mental compromise, the
likelihood of experts being called is inversely proportional to need.
Moreover, if mental health experts were to present only when authorities
request them, then a situation would emerge wherein those without voice or
power—increasingly the public—would most likely be left behind.
Responsibility to society is one of mental health professionals’ primary
responsibilities, alongside their responsibility to patients. At times, they
may need to provide education about when to consult with experts, or under
what circumstances one might expect experts to act on the initiative to warn
and to protect the public, and to hold them accountable, just as society does
with the rest of professional ethics: patient confidentiality is held to be
sacrosanct, but health professionals are also required to break it when
necessary to preserve human life. In the case of public figures, further, there
is no patient confidentiality but rather the protection of speech under the
First Amendment, even before we get to professional societal responsibility.
 At this point, we are now in a position to understand how Donald
Trump may act in response to the growing pressures of the upcoming
election and behave through to the end of his presidency. In that regard,
important elements in the equation are the reaction of his followers as well
as any action that the nation may choose to take. It is in the hope that those
actions, over which we have control, might alter the outcome that is driving
this writing. Instead of being pummeled into passive acceptance of the
course that unmitigated pathology has dictated so far, we have a choice. In
this light, we can review here the likely possibilities for the future in the
absence of intervention:

1. Donald Trump may attempt to destroy the nation and himself. This
possibility sits at the top of our list, not only because it is a devastating
prospect that we wish to do everything to avoid but also because of the
ease with which he could make it a reality. Donald Trump’s profound
awareness of his incapacity would cause him to do anything to cover
up his illegitimacy and to remain in power so that he can prove, above
all to himself, that he is not a “loser”. This is already being
demonstrated by his relentless insistence on reopening the economy,
holding “super spreader” rallies, and his continued promulgation of
misinformation about the pandemic being almost over, even as it
strikes and kills more people than in any other nation. Now, with an
election looming, he is on his way to refusing to concede the results, to
calling the election a fraud, and to insisting on remaining in office. If
all do not work, as the nation reels from disease and destitution and
discontent mounts, using his presidential powers to make a dramatic
display of military might, to stoke social unrest, or to stage a terrorist
attack will be very tempting, and could set in motion any level of
further destruction. We must come to the recognition that he is truly
someone who would do anything, no matter how terrible, no matter
how destructive, to stay in power.
2. Donald Trump may isolate himself and hide away. It may seem
counterintuitive, but the flip side of extreme violence is cowardice.
Donald Trump has shown himself easily frightened, and indeed he
once hid in his basement “bunker” when a large crowd of protesters
approached the White House. His constant taunting of former vice
president and presidential candidate, Joe Biden, that he is hiding, when
 he is not, may indicate projection and wishful thinking. Hiding away
may also include fleeing to another country, should his election defeat
and criminal prosecution become more certain. What is important for
the public to keep in mind is that this type of cowardice can also easily
give way to more impulsive and dangerous acts of retaliation for his
perceived humiliation (such as when he attacked peaceful protesters to
clear the way for a photo-op, when he was convinced the world was
laughing at him for hiding the previous night). He can equally become
a danger to the country by leaving it and by giving away the nation’s
secrets.
3. Donald Trump may die of natural causes. This is not a small
possibility given his age, poor diet and obesity, heart condition, and
apparent neurological condition, in the midst of a pandemic that he has
worsened and prolonged while taking particularly poor precautions for
himself, his staff, and his followers. From the information that we
have, it seems the most likely cause of such an eventuality would be
either coronavirus infection, a heart attack, a stroke, or any
combination of those.
4. Donald Trump may be assassinated. Although his own suspicion and
cowardice keep him protected, if someone had the intent to assassinate
him, it would not be difficult because of the ease with which he is
manipulated and his own carelessness with communications. An
assassination would more likely be from a foreign source than a
domestic one, and the assassin would most likely be someone willingly
invited rather than an intruder. While his susceptibility to influence
currently makes him more valuable alive, and thus affords him a
degree of protection, this may change at any time if, for any reason, he
were to become a liability rather than an asset.
5. Donald Trump may descend into “insanity” and/or suicide. His mental
fragility is evident by his loose grip on reality, his propensity to grasp
at conspiracy theories when under stress, and his inability to deviate
from his poor coping mechanisms. Under great strains, further collapse
into psychosis and increasing detachment from reality is not, therefore,
a distant possibility. Indeed, as the election nears and his poll numbers
drop, it seems already to be happening. If it continues, and he loses
touch with reality completely, the dangers may lessen. We could reach
a stage where it is difficult for even his most ardent supporters to
 defend the state of his mental health and, as such, he might finally
receive the treatment that he needs. Nevertheless, it is the period
leading up to such a psychotic spiral, when he retains enough
wherewithal to unleash his fear and paranoia on the world, that will be
most dangerous. In this period, we may also include the possibility of
suicide. It is hard to imagine a person who has done such great damage
to the nation for his personal benefit would be prone to suicide, but a
person who hurts others is more, not less, likely to hurt himself. The
frightening aspect is that he would probably try to bring down as many
people as possible with himself.
6. Donald Trump may fall under prosecution. This possibility depends
less on standard processes and more on the tenacity of individual
prosecutors and the demands on the part of the general public. Donald
Trump has used his powers to subvert the law many times, such as
when he fired a U.S. attorney in New York who was investigating his
inner circle. If the public refused to accept his destruction of norms,
illegality, and chaos, and continued pressing, then the tide may turn in
a manner that allows for his prosecution and sentencing.
7. Donald Trump may be persuaded to resign. This would be the most
ideal solution and yet not the most difficult one to achieve. In fact,
because of his irrationality and psychological fragility, he could even
be the easiest president to persuade to resign, without any
preconditions even being necessary. This tendency can be seen in the
ease with which he yielded northern Syria to Turkey, with no tangible
gain for the U.S., or his facile signing of a nonbinding agreement with
the North Korean leader, just for show. Further increasing the
likelihood of this possibility is the fact that he has also, on a number of
occasions, displayed considerable impulsivity, often appearing to
concur simply with the last person he spoke to, regardless of any
promises or commitments he might have made previously. To persuade
him to resign from office would, however, require both psychological
prowess as well as direct access, and there does not, at the present,
appear to be a person with the required skills and inclination in his
vicinity (although the hope that this will become a possibility is behind
this profile).
Note that a “peaceful transition of power” after losing an election is missing
from the above list of possible outcomes. Such a transition could only occur
if the last possibility were realized, namely that someone persuaded him to
concede. In the absence of successful persuasion, he might instead resort to
attempting to stay in power by any number of methods: through challenging
the results, instituting martial law or the equivalent in the case of civil
demonstrations against his refusal to leave, or invoking any of the vast
emergency powers that are vested in the presidency. An alternative to
successful persuasion would be swift intervention immediately following
election results, but preferably before, along the lines of removing the
dangers or removing his influence through the Twenty-Fifth Amendment,
urgent impeachment, court-ordered involuntary mental health evaluation, or
removal from decision-making and exposure to the public. The more time is
allowed to pass with his growing expectations and increasing external
pressures and fears, the greater the dangers will grow, which makes the
“lame duck” period, were there to be one, the most dangerous of all.
Being now in possession of both this sober synopsis of possible
future outcomes as well as our earlier formulations, we are able at this point
to devise a plan of action. This plan is grounded in the awareness of the fact
that, like almost all mental health problems, a nation’s problem is
ecological: all of the elements involved are interdependent. What this
means, in other words, is that what Donald Trump does is dependent on
how his followers respond and also on what the nation chooses to do with
him. Similarly, what Trump followers do is dependent on how he directs
them and also how the nation engages with them. That network of relations
applies to all parties. While this ecological understanding of the situation
should be “common sense,” clinicians, especially psychiatrists, too often
look at individuals as atoms without context. Bio-psycho-social models and
ecological frameworks are therefore designed to enable clinicians to break
this habit of thinking and approach problems from a different perspective.
Not only clinicians need encouragement to see not only the
individual but also the context. The public, likewise, may have the
preconceptions that the work of mental health professionals is limited to
individual patients only, whereas one of our chief responsibilities is in fact
public health. The American Psychiatric Association has actively
encouraged this in the Trump era, confusing clinical psychiatry with
preventive psychiatry, which is in the domain of public health, but a public
figure posing a danger to society is a public health issue, not one of clinical
psychiatry. Since I have taught at a law school for fifteen years, I can make
an analogy: in the legal profession, there are instances where lawyers
personally represent clients, but there are also instances where they might
share knowledge to inform the public about general legal matters that affect
the nation. Indeed, day after day they come on broadcast programs
frequently to comment on current affairs and the importance of a legal
viewpoint. Mental health is similar: there are instances where mental health
professionals see individual patients, but there are also instances where
those of us who consult and advise on policy or intervene at the population
level through public health engage in public education. Never do we
confuse our role as personal provider with our public health role.
The dimension of prevention through public health is, moreover,
becoming ever more important in light of increasing knowledge about all
the ways in which social determinants contribute to individual wellbeing.
As we now know, more clearly than ever before, that caring for the health
of the population in general can help prevent a vast majority of diseases
before they even occur, there is no excuse to treating only individuals one at
a time and after they have fallen ill. Therefore, while the ecological model
might at first seem to make the picture more complex, it affords greater
simplicity and new possibilities: since factors contributing to the problem
exist on multiple levels simultaneously, we are presented with a variety of
different points at which we can intervene to bring about positive change. A
consequence of that is that we all have a vital role to play in almost any
situation, no matter how small our influence may seem at first.
The effects of reaching an understanding that the nation’s problem is
ecological can extend further still. If more independent mental health
professionals spoke up, and spoke openly, then concepts about which there
currently is disagreement can be clarified for the public, and institutional
corruption and abuses of power can be exposed, and an ethical consensus
can emerge through the engagement of moral agency and autonomy. As a
reminder, a public health approach to the current situation does not mean
engaging in diagnosing the president and treating him as a private patient.
Instead, society is the patient, and professionals have direct responsibility to
preserve its safety, health, and wellbeing as well as to serve it through
meaningful contributions of their mental health knowledge. What this
means is that, if efforts to alert authorities to the dangers faced have not
brought about society’s protection, they can call on the ultimate authority:
the people themselves. What follows here are some specific steps that can
be taken in three key phases: intervention at the level of individual,
intervention at the level of followers, and intervention at the level of
society.

Intervention at the level of individual

Before going into people’s interventions, I will do here an intervention of

my own, which is to describe two proclivities that are particularly important
to look out for in a leader, which are sociopathy and pathological
narcissism. We have refrained from diagnoses both here and in The
Dangerous Case of Donald Trump (Lee, 2019b), because diagnoses
virtually say nothing about matters of public health concern; that is,
dangerousness, unfitness, or even criminal responsibility. In other words, no
diagnosis in the Diagnostic and Statistical Manual of Mental Disorders
(APA, 2013a) ensures any of these outcomes. Nevertheless, the two
mentioned major categories predispose to, although do not guarantee,
dangerousness, and ethical guidelines encourage professionals to educate
the public in general terms. Hence, this information is to answer the
public’s frequent questions, since the public still thinks in terms of
diagnoses and expects diagnoses from mental health professionals (which
the American Psychiatric Association has not helped), and education is the
intended intervention. Yet, these are still not diagnoses but tendencies,
within which exist specific diagnoses (such as antisocial personality
disorder or narcissistic personality disorder). Also, diagnosis is an intricate
process that happens mostly by exclusion after the review of all medical
records, and, until then, a differential diagnosis is important to consider for
the following reasons:
When a person repetitively cons others, lies, cheats, and manipulates
to get what he wants, does not care whom he hurts as long as he gratifies
himself, the indifference to the feelings of others for personal gain may be
the sign of a severe disturbance called sociopathy. In humans, the ability to
sense the feelings of one another, to care about one another, and to avoid
harming others sometimes even at the expense of one’s own safety or
advantage is called empathy. This basic human characteristic is missing in
sociopaths, which leads to an absence of guilt, easy manipulation, and
controlling or even hurting others for power or pleasure. Far from being
“clever like a fox,” they lack an essential part of being human, which is
why sociopathy is among the most severe mental disturbances (Dodes,
2017). This disturbance in emotional development can cause failure to
conform to social norms; deceitfulness and repeated lying; impulsivity or
failure to plan ahead; irritability and aggressiveness; reckless disregard for
safety of self or others; consistent irresponsibility; and lack of remorse.
Sociopaths make cold-blooded murderers and ruthless rulers, and while
they may lack empathy, they can sense the vulnerabilities of others the way
predators understand their prey.
Pathological narcissism is present when people have a strong need,
in every area of their life, to be treated as if they are special. Other people
are simply mirrors, useful only insofar as they reflect back the special view
of themselves they so desperately crave. The heart of pathological
narcissism may be seen as: entitlement, or acting as if the world and other
people owe them and should bend to their will; exploitation, or using the
people around them to make themselves feel special, no matter what the
emotional or even physical cost to others; and empathy-impairment, or
neglecting and ignoring the needs and feelings of others, even of those
closest to them, because of their own, all-encompassing and urgent need to
feel special (Malkin, 2017). The usual course of unconstrained pathological
narcissism is to seek positions of ever greater power and celebrity; to settle
for fear is admiration is unavailable, and to seek infamy if celebrity cannot
be achieved. Overall, pathological narcissists are predisposed to being
dangerous because of the brittleness of their sense of worth. Unable to take
responsibility for any errors, mistakes, or failings, they overcompensate by
creating a grandiose image of themselves. Any slight or criticism is
experienced as a threat to this fragile self-image, and to cope with the
resultant hollow and empty feelings, they react with narcissistic rage,
which can be brutal and destructive for the perceived source of humiliation
(Zinner and Lee, 2020).
These do not determine, but contribute to, concerns based on
tendencies (quality measurements) and on dangerousness and unfitness
(quantity measurements). Concerns have been great, even before Donald
Trump crossed a number of recent alarming thresholds: scaremongering and
fomenting violence from the White House (Cassidy, 2020), attacking the
electoral process (Rupar, 2020), escalating global instability (Friedman,
2020), and allowing a deadly pandemic to grow exponentially (Lee, 2020c).
Given the relatively limited capacity he has, we can expect only a small
range of possibilities and, consequently, behavior characterized by
considerable predictability. With provocation of or incitement to violence
being one of his main maladaptive coping strategies, this means that we are
entering a period in which there will be an elevated risk of all forms of war:
civil, international, or nuclear. Nothing is off the table, and no stone will be
left unturned in his campaign to hold onto power at all cost. The greater our
readiness, both psychologically and physically, the more likely we are to
emerge unscathed.
The medical standard of care that an individual such as Donald
Trump requires is simple. As he is a danger to self and to others, he needs to
be contained, to have his access to weapons removed, and to be
psychologically evaluated regardless of whether or not he gives consent.
The professional evaluation would determine the least restrictive course of
management that would ensue, but full containment would not be lifted
until he could demonstrate that he is no longer a danger. Such measures are
drastic but are sometimes necessary to protect both the patient and the
public (and, since patients very commonly express appreciation for the
protection once they are better, these measures are fully instituted in the
law). It is notable that, before the mid-1960’s, all mental health care was
involuntary and considered to be necessarily so because of the nature of
mental impairment. Currently, we allow for much more leeway in all but
the most severe cases where a person is a danger to oneself or others and is
refusing treatment. Crucially, there is nothing in mental health law that
states that a president is exempt from its prescriptions; in fact, a president is
supposed to receive precisely the medical standard of care. In other words,
there is no “Office of Legal Counsel memo” equivalent that prevents mental
health intervention the way the memo recommends non-prosecution of a
sitting president for national security reasons. We might say, however, that
“the Goldwater rule” has been similarly abused, in that a guideline has been
promoted as an absolute rule so as to facilitate a sitting president being
above the law, even at the expense of national security and public safety.
While mental health law dictates that the president is accorded no
special privileges, and is denied no needed care, the reality at the current
moment is different. For various reasons, including obstruction by the
medical community itself, specifically a succession of White House doctors
and the American Psychiatric Association, Donald Trump is in a position in
which he is least likely to receive the care he needs. Despite that, thousands
of mental health professionals have nonetheless come forward and provided
broad medical consensus, in a manner without historical precedent, and,
responding to relentless public demand, they performed a formalized
assessment with the information that made it possible in April 2019. That
assessment showed that there was a serious and imminent risk posed to
public health and safety because of a lack of mental capacity, and this led to
our making the following recommendations:

1. The President must be removed from access to the nuclear codes. The
fate of human civilization should not be dependent on an unstable
individual without rational decision-making capacity.
2. The President’s war-making powers should be curtailed. The
temptation to draw the nation into a devastating war for reasons other
than the good of the nation will be too great for a president who lacks
the capacity to lead (Lee et al., 2019).

These still hold as the most significant and necessary interventions. In their
absence, we require alternative recommendations based on “softer”
treatment principles.

Alternative interventions at the individual level

In the absence of concrete limitations, we must not lose courage but turn to
the things we can manage, which are considerable. They include:

1. Behavioral containment
2. Psychological limit-setting
3. Care of the self
4. Grounding in truth
5. Demand for justice

The underlying principle is this: to set boundaries and to care for ourselves.
Now, going through them briefly in turn, behavioral containment refers to
removing the individual from a position in which they have access to
significant power and the ability to do harm. In our March 2020
“Prescription for Survival,” we stated: “we have a Presidency that is
incapable of protecting lives but is making a global pandemic deadlier—not
just through incompetence and ignorance, but through a dangerous
detachment from reality, an inability to care for its citizens, a need to
convey false information, and other symptoms.” We recommended removal
of danger by any means, including any of the following or their
combination:

1. Invocation of the 25th Amendment on the president

2. A new urgent impeachment of the president, with televised hearings
3. Immediate voluntary resignation of the president
4. Emergency court-ordered involuntary mental health evaluation of the
president
5. Complete removal of decision making about this public health
emergency from the president and suspension of White House press
conferences about the coronavirus (World Mental Health Coalition,
2020).

Those recommendations still apply, even and especially as we approach an

election: while it is imperative that the people vote in overwhelming
numbers and mobilize others to vote, we must recognize that voting alone is
insufficient. Even the process of simply beginning to take steps toward
containment, especially if they are televised, will help temper the swollen
grandiosity that, fostered by four years of flattery from underlings and
chants from crowds, has now morphed into grotesque delusions of grandeur
capable of great danger. Delusions of impunity that have amplified, as the
president discovered that he could violate the norms of civil society and
even commit crimes without consequences, may diminish as grounding in
reality is reestablished (Herman and Lee, 2017). In any case, the constraints
must come from without from other relevant areas for both the president
and his enablers also to respect the election process and results. Conversely,
if we were to give up prematurely on implementing these procedures, and
made it evident that we have surrendered to the course of events, then those
same parties would feel further emboldened in their attempt to subvert the
elections.
That point then leads to the next treatment principle: psychological
limit-setting. Many individuals with Donald Trump’s characteristics do not
have the ability to set limits for themselves and in fact crave to have limits
imposed on their behavior from without, even as they fight against those
constraints. This behavior is akin to that of a toddler who may complain and
throw temper tantrums when limits are imposed, but who simultaneously
gains a sense of comfort and order from those same restrictions. In such a
situation, the toddler is testing to see if constraints will come from the
authorities, which translate into reassurance that one is receiving care, being
held, and even held to account so as to prevent one’s going astray or falling
apart. For an individual who is no longer a toddler and is disordered in this
way, the nation, its people, and its authorities bear some responsibility when
behavior gets out of hand. The slower and more tentative the limits, the
more out of control the individual will become. “Tiptoeing around” an
abusive personality is therefore unproductive, even if it is the first
instinctive “survival” response. It is the influence of that response that
results in situations wherein the worst abuser is the last to be called out, the
pathological liar the last to be called a liar, and the most pernicious white
supremacist not even called a racist. Ultimately, this only enables
maladaptive behavior.
The issue of limits and their importance is observed in the
president’s preoccupation with “law and order.” Underlying it is his sheer
desire to mobilize the forces of the police and federal agents purely in order
to satiate his need for violence and power, certainly. However, a more
fundamental factor behind that preoccupation is the conviction that the
world can only be safe if a strong external force imposes severe limits, as he
perceives others’ internal life to be as lawless and disorderly as his own.
This is one of the key reasons why granting power to developmentally-
wounded individuals is very dangerous and often leads to wanton abuses of
the power they are given, which ultimately destroys the society or nation
within their charge. Accordingly, rather than unbounded indulgence, what is
needed instead is to set proper limits early, forcefully, and consistently. This
means calling out lies immediately instead of later in private settings or in
news articles, strictly adhering to and enforcing norms and standards of
behavior—including the law—no matter what the abuser says, and perhaps
even to require fitness-for-duty evaluations to candidates before the position
is offered, just as all other important jobs that handle life-or-death matters
do. Strict limit-setting at an early stage is crucial, as allowing delusions of
grandeur, impunity, and omnipotence to balloon for a protracted period
before suddenly setting limits without guardrails can be dangerous. The
problem of trying to impose limits only at a late stage was demonstrated
with the long-delayed but later fast-tracked impeachment in the fall of
2019: extreme retaliation in the form of a massacre and an assassination
resulted, just as we predicted (Feinberg, 2019; Porter, 2019), followed by
mass firings and exonerations of war criminals. In the absence of concrete
boundaries, expert consultations are critical for properly timing and
measuring response.
Citizen mobilization is both an important and a highly effective
means of limit-setting. It is a monumental task that should place priority on
citizens’ care for the self, the third treatment principle we listed above. One
way this citizen mobilization can occur is through protest marches, which
are important, vital, and highly effective (Chenoweth and Stephan, 2011),
but does not end there. We may recall that Donald Trump once said, and
indeed said only once, “Certainly, if I don’t win, I don’t win” and that if that
were the case then he would “do other things” (Oprysko, 2020). He made
that statement within the context of historic Black Lives Matter protests,
which demonstrated an astonishing outpouring of civilian dissatisfaction
that undoubtedly shocked him. While few at the time made the connection
between the protests and his comment, it was a powerful example of how a
population can set psychological limits on a president by expressing
discontent en masse. The Women’s March of 2017 is also not to be
underestimated; although prevention and therefore events that have not
happened are difficult to see, worldwide protests that engaged over 3 to 5
million in the U.S. alone measurably played a psychological role in
tempering his excesses for at least a year.
It is therefore important not to underestimate people’s power;
indeed, it is the most powerful there is in a society, regardless of form of
government. Realizing and cultivating this power, in turn, is the most
effective intervention. This entails more than simply mobilizing numbers of
people. Effectiveness requires spiritual resolve, resilience, and
resourcefulness. These qualities are vital because, as we have seen in the
examples of Portland, Chicago, and other cities, the more powerful the
movement, the more likely it will be met with force before it succeeds, as it
will arouse great fear in unpopular rulers. It is important to interpret the
violence that ensues as a sign of weakness, and not to freeze or to surrender
but to draw upon the flexibility, creativity, and generativity that come with
spiritual grounding. Mohandas Gandhi (1993) likened the rigorous
preparation for, and ongoing practice of, nonviolent discipline to the
training of a soldier. The advice I regularly give to medical or law students
as they go into “battle” with disease or in defense of their clients is: “In an
emergency, first check your own pulse.” It follows the dicta: “Physician,
heal thyself,” and “Know thyself.” These same imperatives apply to citizens
in advance of their mobilization. In other words, in order to achieve greater
outward power, the people should, seemingly paradoxically, first tune into
themselves and meet their own needs. This involves making sure one is
getting enough sleep, eating healthy meals, connecting with friends and
family, and limiting news consumption. Balance, personal time, and
distance are powerful tools for retaining perspective, knowing when to act
and when not to act. Recognizing and attending to one’s own state,
therefore, is an essential part of everyday responsible practice. Therefore:
“Take a break—this is your number one responsibility!”
The importance of this foundation assumes particular significance
during the time leading up to the election, when anxiety levels are high.
Many are also feeling exhausted in their prolonged efforts, and therefore it
is important to remind ourselves that anxiety and exhaustion are normal,
shared, and a signal to ourselves to take time for renewal. Pausing to honor
the pain we feel for the world, widening our vision, and taking one step at a
time, seem counter to the trend of the dramatic, obtrusive, and apparent
violence before our eyes, but it is the source of true strength. Hence, it is
crucial to set boundaries for spiritual centering: an hour a day, an afternoon
a week, and a spontaneous “getaway” once in a while to devote to pure
enjoyment while letting nothing intrude. Taking the time to connect back
with the universal, through the arts, meditation, or simply time spent with
loved ones is essential. Universal human values, such as equality, justice,
truth, compassion, and reverence and appreciation for life, mobilize vital
strength in times of difficulty. Therefore, these practices, far from being
irrelevant, remote, or even selfish, are the crux of our being effective in the
world. Having a mentally-impaired leader by nature is demoralizing and
draining, for he emits the opposite energy: spiritual dearth, rigidity, fear,
paranoia, and violence. Since emotional, psychological, and spiritual
pressures are more burdensome than purely physical ones, particularly over
prolonged periods of time, it is essential to build up reserves and to keep
replenishing them even in the midst of intense battle.
We may “know” this, but it is important to remind one another. It is
essential to complement contemplative time with fellowship, community,
and like minds gathering to help foster the fourth treatment principle:
grounding in truth. Pathology’s onslaught of corruption, aggression, and
oppression, alongside its constant attempts to subvert reality with unreality,
health with sickness, and truth with delusion, can be exhausting. Moreover,
to be grounded in truth is particularly important, as a ruler’s inability to face
reality translates for the population into a deprivation of information, rights,
and eventually life. Truth causes the greatest consternation in dangerously
impaired leaders. This is because it is a formidable antidote to their power;
you reveal that “lying does not make it so.” Speaking the truth can be
therapeutic in at least two ways: first, it helps you to ground yourself in
reality when forces are relentlessly trying to uproot and to topple you; and
second, you become part of a life-affirming impulse that coalesces into a
powerful collective when everyone does it. Readers may have heard of
psychological defense mechanisms such as denial, projection, and reaction
formation being used by this presidency, and these can be understood as
unconscious actions to divert away from the truth, which is the most
intolerable to a disordered leader trying to escape reality. Those three
defenses describe a particular sequence of behaviors: the worst perpetrators
will be the least willing to admit their wrongdoing (denial), they will
solidify that denial by accusing opponents of their own misdeeds
(projection), and they will assert themselves to be the opposite of what they
truly are (reaction formation): “I am the least racist person in the world!”
“There’s nobody that has more respect for women than I do!” and so on.
Understanding the nature of these dynamics and their progression is a key
to scattering their stronghold.
When assaults on reality have induced a “malignant normality,”
pathology has taken the reins, and things that were unthinkable four years
ago have now come to constitute the new normal. And when everyone is
lying to you all the time, even if you do not believe the lies, you no longer
know what to believe, and your balance is toppled. This hampers you from
being able to form opinions, to make judgements, and to take effective
action. Donald Trump may condemn opponents of his own guilt; he may
never forget those who spoke up against him; and everything he touches, he
may destroy—as he has the environment, our alliances, international trade,
the judiciary, and even our common sense of decorum. When normality
itself becomes extreme, those who speak the truth, or stay with professional
standards, come to sound extreme. A moment of decision may come: will
one remain with the truth or with mere appearances? The truth may be hard
at first and bring on accusations from colleagues or peers, but this is where
a stable center can activate a moral compass or the force of conscience that
allows one to stand one’s ground. This offers courage to those who see the
same but are afraid, opens the potential to grow in number, and soon we can
mobilize massive strength. This calls for leadership in all and not just
followership. The other path leads to a rabbit hole, whereby we must add
more and more distortions to justify one’s position, to distort reality, and to
help the pressures that suppress and oppress.
The American Psychiatric Association is a primary example of an
institution that chose a guise of ethics over responsibility, and a pretense of
professionalism to ignore a crucial fact: that denial does not make a
problem go away. It did great disservice to lead the nation on a course of
denial, for it is always easier to prevent than to try to limit losses after a
problem has become barely containable. These approaches, while initially
self-serving, are maladaptive and, especially in the context of abuse of
power, facilitate injustice and harm. In a setting of such rampant corruption,
collusion, and concession on the part of powerful institutions, personal
grounding helps to maintain the emotional balance that is necessary for
moving the needle, especially when no other organized body would.
Professions, meanwhile, can create forms of ethical conversation that are
impossible between a lonely individual and a distant government (Snyder,
2017). Experts of all fields can aid people in their attempts to ground
themselves by functioning as “witnessing professionals” who facilitate
reality testing (Lifton, 2017).
At the current moment, people should also feel themselves free to
consult with experts, such as mental health professionals who can provide
counseling and relief from symptoms such as anxiety or depression.
“Trump anxiety disorder” as a syndrome of anxiety and multiple concerns,
helplessness and paralysis, and difficulty sleeping deriving directly in
relation to the uncertain sociopolitical climate and its events is a condition
that nearly every therapist in the country has been dealing with since the
start of this presidency (Panning, 2017). Early consultation with mental
health professionals can help resolve problems quickly and is itself a sign of
strength and resilience, not of weakness.
It is, finally, impossible to understate the importance of being aware
of one’s own status and potential. Self-knowledge, or autognosis, involves
having both the clear and solid insight that true power lies in the people,
and that self-knowledge allows for knowledge of the enemy. That is, in
proportion that the knowledge of our strength grows, so does the knowledge
of the power structure’s weakness. Knowledge itself is also power. When
there is much gaslighting by an impaired leader who desperately needs to
be right in order to bolster his own sense of self and to hold onto a sense of
absolute power, then that means much of the population will be put in the
wrong. Rather than fix any problems, the leader will make people even to
doubt their perception that there is a problem. This is why knowledge and
self-knowledge are important, as well as checking that knowledge through
access to sound journalism and to evidence-based expertise. One of the
ways in which illegitimate power can retain advantage is by blocking or
confusing the flow of valid information and sound knowledge. Access to
facts and expert insight is precisely the armament for demanding justice,
the last treatment principle, and to call out all leaders who are serving
themselves rather than those that they supposedly govern. Regardless of the
grand showcasing and the parading of authority, illegitimate power is
ultimately a weak paper tiger that depends on its façade, and tyrants but
buffoons on a soap box if no one obeyed them. Draw the curtain on the
Wizard of Oz, and you will find a tiny, weak man; the ability to reality-
check, with the support of journalists and experts, allows you to do just that.

Intervention at the level of followers

A wounded psychology is drawn to wounded leaders and attracted to ideas

that will make the wounds worse. This is because pathology is drawn to
pathology, and the deeper the pathology, the more maladaptive and
destructive its choices and course. Because pathology is indistinguishable
from normalcy to many in the public sphere, it would do us well to require
some kind of screening mechanism for keeping pathology out of politics.
This is another method of prevention, since once pathology takes hold of
power, it is very difficult to get it out. Empowering followers through true
authority and strength is therefore better than listening to what they say in
their compromised state; enabling their unhealthy attractions is good for
neither them nor anyone else. With true authority—which is the result of
some knowledge, skill, or vision—a follower grows in personhood, mutual
respect deepens over time, and one gains in independence and power as one
absorbs the authority’s knowledge, skill, or vision. With false authority—
arising from a leader’s emotional need for followers—one loses
personhood, becomes conformist, and adheres on the basis of fear,
growning increasingly dependent and disempowered over time. A
population may be predisposed to looking for a parental figure to take care
of them in times of distress—or in cases of relative poverty, as in the U.S.,
which is more psychologically injurious than absolute poverty. One can
either exploit the situation or empower this population with education,
health care, and employment, to elevate them into making healthy choices.
The tyrant exploits this vulnerability in a society that is already
weakened by disorder, blind to it, and unable or unwilling to take corrective
measures which would prevent a tyrannical takeover. Once he does, he and
his sycophants deepen and widen the disorder, dismantling and changing
the society’s norms, institutions, and laws to reflect fully their own
pathology. By distorting reality and truth, perverting moral values, fortified
by magical thinking and contempt for reason, these distortions lead to a
kind of absurdist unreality where up is down and black is white, and what
one knows to be true may have nothing to do with the officially sanctioned
version of the truth. In this manner, the criteria of mental normalcy and
pathology are redefined as well, and psychology and psychiatry, like other
branches of social science, are coopted to serve the regime. Pathology
becomes “normalized”, both in the statistical sense and in the standards of
mental health, while actual mental health, defined as the capacity for
multilevel and multidimensional development, is denigrated and
“pathologized”. The inherent and violent irrationality, bereft of internal
brakes that stem from a conscience, and unchecked by external forces, the
tyrant’s reign eventually collapses (Mika, 2017). The followers, being both
the reason for the power that the tyrant wields, as well as being the tyrant’s
own creation, become first instruments and then casualties along the way. In
order to intervene positively for the followers, it is important to keep in
mind that: (a) they are not acting in fully-informed, rational ways, no matter
their exceptionally strong insistence; and (b) they are highly dependent
followers, not individuated leaders (Donald Trump included!), and therefore
guidance and support are necessary. Easily escaping from individual
autonomy to group behavior, a positive aspect of this predisposition is that
they respond to good leadership.
I am often asked how to engage these followers, which is a chief
question for many people. Mental health professionals are indeed frequently
confronted with the question: “How do we reason with a Trump supporter?”
The quick answer to that query is: “You don’t.” That Donald Trump’s
supporters must be convinced and won over, in order from him to be
removed from power, is a common misconception that people have. The
reality is that the opposite holds true: removing him from power will reduce
the followership. In the meantime, people should follow certain general
guidelines when engaging with Trump supporters. First, they should not be
confronted with facts, for it will only rouse resistance (subconsciously, they
already know what is true, which is why they project onto others their own
characteristics very accurately; for example, their radically irrational
support of the leader can be described as symptomatic of the “Trump
Derangement Syndrome” they often accuse of others, or call peaceful
protesters “the violent left,” even when the FBI reports that the tiny
percentage of violence that did occur is from the right-wing Boogaloo
Boys). Second, persuasion should not be the goal, for that will only lead to
exhaustion: the problem is in their granting an impaired individual power,
not in their cognitive system or, most of the time, even their mental health.
Third, people should continue to state facts, evidence, and science-based
approaches elsewhere, repeatedly and without apology, intimidation, or
shame, so that a delusional narrative does not “bulldoze over” the truth
through its sheer emotional force, upon which pathology depends.
Rather than facts and arguments, other management principles
should be followed with Trump supporters, as follows:

6. Reduction of exposure to “the leader”

7. Reduction of cultic programming
8. Change of circumstances
9. Emotional support
We begin here with one of the key principles of our professional practice: in
all matters of health, we triage before we treat, and the removal of the
primary offending agent comes first; it is for this reason that our first
principle focuses heavily on Donald Trump. His removal from office and
the accompanying reduction of exposure that his supporters have to him
will automatically release many from his influence. The reduction of
exposure will diminish the natural induction of highly contagious symptoms
among the population that comes with having a severely mentally-impaired
person in an influential position: violence, paranoia, fixed false beliefs, and
loss of connection with reality.
Following that first intervention, the next treatment principle should
be employed in order to effect a reduction of cultic programming,
programming which can by itself reform thoughts and inculcate fixed false
beliefs. Fox News, One America News Network, and other sites that
promote right-wing conspiracy theories, as well as social media that filter
information to create functional “bubbles”, are all forms of programming
that work to serve that function. First, promoters of thought reform through
disinformation should not be allowed to be called “news”; fabrications and
deceptions are by definition not news. Secondly, we must investigate who is
benefiting and gaining power or support for illegitimate policies through the
hijacking of minds of the population, instead of through honest, legitimate
means. Thirdly, mental health experts must investigate the harm that this
manipulation of minds induces in the mental and physical wellbeing of the
public, which should well be predictable and therefore preventable, rather
than treating individuals only after they have been damaged and their
relationships destroyed. If the level of such programming is also reduced in
conjunction with a change of circumstances, as the next principle outlines.
By removing people from the circumstances that rendered them vulnerable
to predators in the first place, they can be protected from being exploited
again. Steps for bringing about such a change might include: reducing
relative poverty and enhancing access to education, health care, and social
mobility. More of this is covered under “Intervention at the level of
society.”
Finally, for future healing, especially of the trauma that will
inevitably ensue with the realization that the person they believed to be
their “savior” was actually their mental and material abuser, Trump
followers will need emotional support from friends, family, and others. As
great as the hurt may be within relationships, or rather precisely because of
the hurt, it helps to know that thoughts and behavior have biological,
psychological, and social causes, and in this instance the cause has been
largely social and not of the individual’s fault other than having been
vulnerable to influence. Genuine human connection and acceptance will
provide them with the strength to abandon cherished beliefs and to help
hasten their recovery. One must also be prepared for the instance where
some or many cases may take a lifetime to recover, or not at all. The
difficulty depends on level of emotional investment, length of time of
attachment, and degree of trauma one is likely to experience upon
separation. Of note, not included here in this assessment are the president’s
billionaire followers, who are unlikely to reform but instead to look for
another “Donald Trump” and to continue to contrive ways to enlist
emotionally deprived and vulnerable people in order promote an agenda of
ever increasing power and profits. The intervention for this is proper
prosecution of white-collar crime and the reduction of inequality or extreme
imbalances of power.

Intervention at the level of society

The U.S. is unusual among civilized nations in that it does not have a strong
“Fifth Estate” of independent experts, to serve as a check on the three
branches of government, to supplement the Fourth Estate of the press and
the news media. Instead, when decision makers do not find their desired
answers through existing channels of evidence, science, and scholarship,
they seek other contractors or partisan think tanks to get the perspective
they desire. This truncates a chief means of deliberation: one that is based
on sound scholarship, with the composure, detachment, and research
integrity that come with independence from political considerations.
Scholarly disciplines have developed to the point where it is possible to
determine the answer to almost any policy question, in almost any area,
based on research results alone. This does not mean that scholarship
replaces human decision making—indeed, most roles around the world take
the form of advisory boards—but it would allow for an important use of the
vital resources that are available in a civilized society while serving as
neutral ground on which to resolve hyperpartisan issues. Professional and
academic standards, as well as the strict monitoring of conflicts of interest,
as occurs in scientific research, are designed to help preserve neutrality. The
distance and the time for academic rigor that one is afforded, furthermore,
would serve as the societal equivalent of “checking one’s pulse” before
acting in an emergency.
Among matters that have reached emergency proportions because of
a lack of expert scholarly input, just like the presidency, is mass inequality.
Like the climate crisis and the pandemic, the marginalizing of science and
scholarship has allowed society to ignore and to miss alarming warning
signs. Now, these matters have reached existential proportions. The level of
inequality that existed before the coronavirus pandemic was already
crippling, but acting in synergy with other crises, such corruption and
incapacity, the scale and severity of inequality has escalated exponentially
since the arrival of the virus in the U.S. The price of stocks may have
plunged in March 2020, but since then they have been rising in value at
record rates, as central banks pledged trillions of dollars in an
unprecedented intervention aimed at propping up markets and the economy.
That intervention does not, however, help the average worker. In 2016, the
wealthiest 10 percent of U.S. households owned 84 percent of all stocks; in
the six-month period following March 2020, U.S. billionaire wealth
increased by 637 billion dollars, that is, by more than 21percent. While the
rich are enjoying remarkable success with that boom, tens of millions of
workers remain unemployed during the worst downturn since the Great
Depression (Horowitz, 2020).
While the removal of the primary offending agent, Donald Trump,
as the emergent and imminent problemin our current “triage”, it is only the
beginning. Addressing the issue of social inequality is a project that should,
indeed, start simultaneously or at least follow closely behind. Inequality is
an enormous problem that virtually affects all other areas of our lives.
Psychologically, it not only creates social distrust and inept governance, but
produces a large population of vulnerable people unable to protect
themselves against public health threats, including both a viral and a mental
health pandemic. As such, the secondary consequence of rampant inequality
is that when crises hit, such as the coronavirus pandemic, the gap between
those at each end of the spectrum widens alarmingly further. The same
thing that we can currently observe to be taking place will also happen
when the nation is met with any of the other growing array of global crises,
including those of climate change and of the threat of nuclear war.
 What do we mean by mass inequality? In its most global sense, the
term can be understood to describe the present situation in which vital areas
such as health care, education, and communications are rapidly advancing
while the majority of humankind is being increasingly left behind. As that
occurs, disparities between people in terms of health, gender, race,
economic, and educational status increase, bringing about a cascade of
effects that include a diminution of a society’s psychological health. In
many respects, the consequences of such inequality amount to no less than
the difference of life and death, or a “collective suicidal tendency” for
humankind, which is the only way we can describe our policies on climate,
war, or nuclear weapons, if we only took the time to look. This level of
inequality is also called structural violence, and it is the most lethal form of
violence (Lee, 2019). The excess deaths alone that result from this type of
violence exceed all the deaths resulting from suicides, homicides, and
collective violence combined, year after year. As long this deep inequality
persists, and structural violence is allowed to continue and persist, we will
see high levels of all other forms of violence, since structural violence is
also the most potent stimulant of behavioral violence.
The inequality that we can perceive in society is, to an extent, the
result of an economic arrangement that has become a squandering
mentality. Such a mentality leaves populations impoverished while
paradoxically leading them to believe it will in fact make them richer.
“Making America where you can get rich again” was a Reagan era claim
that accompanied policies that effectively destroyed that ability for the
overwhelming majority of people. In a greater extreme, Donald Trump has
been mentally defective enough to usurp his followers’ reasoning and to
offer grand claims to “make American great again,” just as he destroyed it.
Beyond economic considerations in their own right, higher levels of income
inequality within a country correlate strongly with lower levels of good
health, among the rich as well as among the poor. In short, greater income
inequality can be clearly associated a significant number of negative side-
effects, including, among other things, higher levels of mental illness, drug
abuse, murder and assault, obesity and obesity‐related death, teenage
pregnancy, racism, and incarceration. The Trump phenomenon is an
entrenchment in these socioeconomic pathologies: mountains of debt,
plutocracy leading to corporate takeover of politics, domination by the
military-industrial complex, prejudice, persecution, and loss of direction as
a nation. Collectively, they consist of societal pathologies erode America’s
position of leadership on the world stage. A squandering mentality means
that one can only exploit and expend but not grow; leaders of this mentality
naturally use their positions to take and to amass ever more power to take.
Hence, also numbered among the consequences of significant societal
inequality comes to be a higher-than-average death rate—even one of the
worst rates in the world—from a pandemic (Worldometer, 2020).
The U.S. currently leads the world in Covid-19 cases and deaths,
which was predictable from the universal phenomenon we know: that
violence, disease, and death increase in unequal societies. If we look around
the world, countries with high inequality also have greater sociopolitical
instability in the form of assassinations, coups, and riots. Such countries
also generally suffer from inferior institutions, in terms of less efficient
governments, as well as a weaker rule of law and a greater prevalence of
corruption. Despite its global status, the U.S. has the highest levels of
inequality among the advanced economies: it is closer to Mexico, and even
to Brazil—one of the most unequal economies—than it is to Denmark or
the Netherlands (World Bank, 2020). The situation that prevails in countries
with such high levels of inequality is one in which the wealthy are uniquely
advantaged and privileged. They have a strong motivation to keep
institutions weak in order to minimize redistribution of wealth, while at the
same time they also have significant power to influence those same
institutions, given their relatively high share of the available resources. The
end result of that is a dysfunctional society, such as the one that currently
exists in the U.S., in which a mentally-impaired leader becomes almost a
necessary ingredient to preserving such an extreme system.
In spite of all that has been said, human beings are, essentially,
astonishingly free. Even individuals with severe mental illnesses, who tend
to be more rigid, retain remarkable levels of free will. It is for that reason
that the presence of “insanity”, to use a legal term, seldom leads to an
insanity defense, and rightly so. As such, anyone worried about Donald
Trump not being properly criminally charged on account of these mental
health considerations need not be—he is far from that possibility! Now
back to human freedom: this freedom applies equally to the people, who
have agency, as the healthy mind is resilient, resourceful, and creative under
almost all circumstances. This does not, however, mean that we should
neglect this unique asset—on the contrary, we should seek always to
maximize and to protect it. We contrast this to the rigidity of a calcified
system of predatory capitalism: it cannot adapt to climate change, to a
pandemic, and to changes in the population, but rather binds people to it
with ever-growing insecurity and instilled fears of losing their livelihoods.
Human versatility, on the other hand, is almost infinite and can adjust to an
infinite number of situations. The reduction of inequality by itself is not
difficult; it does not require large money or effort, and a small amount can
bring about massively positive results that ripple into widespread
improvement of societal emotional health. It is only the political will that is
lacking, or rather freedom from the massive political barriers that “dark
money” and relentless special interests have put in place, against the
principles and the will of the republic. This is why the reduction of
inequality, or structural violence, must be an urgent consideration after the
removal of Donald Trump, for the preservation of democracy itself.
Meanwhile, we can counteract—not cure—some of these effects through
smaller measures:

10. Strengthening unity in diversity

11. Investing in health, including emotional health
12. Investing in education, access to facts, and sharing of expertise
13. Investing in emotional growth, cultural activities, and creativity

The specific ways in which each of these can be implemented are endless,
and every gesture adds to the general ecology. A step in the right conceptual
direction will be to break out of our compartmentalized, dichotomous
thinking: just as both mental impairment and criminality can coexist in
Donald Trump, our problems can be both the president and preexisting
societal conditions. Indeed, considering them in their complex whole allows
us to understand how they interact—for example, far from substituting one
for another, mental impairment and criminality make one more dangerous
than either alone. An impaired president and societal disrepair work
synergistically to bring about more rapid destruction than just one or the
other. We can then consider our own actions both as individuals and as
members of a greater whole, and practicing both simultaneously will be
more productive than either by itself. Finally, mental health would serve a
population better if its insights from clinical experience were applied to
public mental health and not only be confined to individual treatment;
individuals themselves are not isolated but in constant interaction with an
ecology.
As we gain perspective and grope toward a unity that integrates
greater diversity, we become flexible, resourceful, and effective and better
able to find life-affirming solutions for almost any situation. We can break
out of rigid rules as we improve in our understanding of principles.
Cohesion then becomes easier, as we counteract the conformity that forces
fragmentation and division, or the chief manifestations of disease. The more
we connect the dots and gain a better grasp of underlying patterns, the more
we can also foresee what is coming and prevent problems before they
become overwhelming—and we find that even tiny acts matter, if applied in
the right places, for an ounce of prevention is indeed worth a pound of cure.
This brings us to the purpose of this profile: prevention. The deterioration
of this presidency was predictable, and therefore preventable, and
prevention is possible where there is knowledge and understanding. Sharing
a unified purpose as we recruit and exchange resources across different
disciplines and diverse sectors is one of the powerful methods of public
health and, as it turns out, an effective way of solving most of society’s
problems.
 Afterword

One of the greatest travesties with regard to the mental health emergency
that descended upon our nation has been the silencing of mental health
experts. If anything, our era has shown how critical mental health is, in a
leader, in a populace, and in systems, and how we must not take it for
granted but understand the socioeconomic conditions that support or harm
it. One would have thought that the American Psychiatric Association
(APA) would lead the way rather than throw a country back to the Dark
Ages, when mental health was a topic that could never be discussed, and
those who know most about it must hide themselves away. This is what
happened when, just as a historic movement of mental health professionals
had attained the attention of the people to the extent that it had become the
number one topic of national conversation, the APA stepped in with an
aggressive campaign to shut down all relevant experts—and succeeded for
all the subsequent years. Perhaps it should not have been surprising: my
own, singular reason for stepping up to speak out in the first place was my
alarm at the APA’s alteration of “the Goldwater rule,” at the start of the
Trump presidency, so that those who kept with the new version of the “rule”
would be forced to violate the core tenets of medical ethics. The core tenets
I am referring to are that we keep our responsibility to society, which is the
second highest, if not commensurate, to our responsibility to patients. They
are also to hold human life and our care of that life as paramount: in other
words, no other interest should take precedence before human health,
safety, and survival. Critically, they include our keeping with the
Declaration of Geneva—a universal pledge that all health professionals
around the world make, which includes that we speak up in contexts of
injustice, and especially not to collude with destructive governments.
Finally, there is the principle under which “the Goldwater rule” itself falls:
that we participate in activities that improve public health—not harm it in
order to protect a nonpatient political figure. Giving priority to a public
figure, who is not even a patient, was for me the red flag that presaged
tyranny—and, indeed, it was only the first institution to fall in line, later to
find company even in the Department of Justice. Some have called this “the
original sin” of our era: a gag order that compromised the public’s ability to
protect itself against all subsequent dangers.
 The bottom line, in my view, is that the public has a right to the
truth. It has a right to know what is happening, with the greatest clarity
possible. The verdict seems simple: the real purpose of “the Goldwater
rule” was to keep the truth from coming out, whatever the reason. But we
now see the consequences of trying to cover up a mental health issue: entire
segments of the population have signed onto delusional beliefs, the media
have successfully participated in gaslighting, and the otherwise healthy
experience skyrocketing stress, all the while critical matters of the nation go
unaddressed. The role of mental health professionals is to support the
education and understanding that are needed for health and safety. Whereas
the APA had made its extraordinary choice to leave the public to fend for
itself, it had no right to silence independent professionals acting on their
own conscience and honest attempt to keep with professional ethics. Even
before its blockage of the major media, by creating a fiat, it was requiring
that professionals cede their autonomy and become mere technicians, which
is a formula for tyrannical abuse. All arguments for depriving the public of
the truth having thus failed me, I have decided to lay it out in this profile, in
the best way I know how without holding back anything that I deem
critical, for this is what the people expect of us. Society has invested in our
knowledge and training, and it is only a matter of course that the people
expect mental health experts, who are the guardians of mental health
knowledge, to explain mental health phenomena that are overarchingly
affecting them. And hence what I do here is all that my medical education
has prepared me to do and what I understand is the goal of ethics: not to do
harm. If this is not my duty as physician and psychiatrist, I do not know
what is.
From the start, I stated that the choice to collude with a destructive
regime rather than to uphold ethical principles would likely cause even
more damage than an earlier decision by the APA’s psychological
counterpart, the American Psychological Association, to modify its own
ethics guidelines to facilitate and design government programs for torture.
This is because any stifling of the dissemination of vital information, in the
context of such widespread danger to society, was bound to cause far more
devastating harm than 1,000 torture victims, as bad as that was. Now, with
400,000 deaths projected by the end of this year, all because of mental
health reasons and not because of the nature of the pandemic itself, I
believe that that assessment will be hard to reject. There is a reason why
thousands of mental health professionals joined us at the World Mental
Health Coalition (WMHC) and chose to step up where the APA has failed
in societal leadership. To the present day, we at the WMHC are still calling
on the APA to retract its “gag order” and to apologize for misleading the
American people and the media.
Before the APA’s intervention, the more than fifty Congress
members who invited us to meet with them told us that their ability to act
depended on our educating the public. The people are empowered for self-
government only when they have access to facts and the best available
knowledge, including mental health knowledge. Experts, in turn, have a
duty to society that far exceeds a mere technical role, which has rather
facilitated the relentless psychological manipulation and misinformation
that have become the chief means of control and harm. This is a natural
consequence of our answering calls only of those with wealth and power,
and not acting on our societal obligations. The real duty that experts have is
to render their services to the betterment and benefit of humankind.
Certainly, that is the minimum that all health professionals have pledged to
do since 1948, after another experience of tyranny: Nazism.
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 About the Author

Bandy X. Lee, M.D., M.Div., is a medical doctor, a forensic psychiatrist,

and a world expert on violence. She became known to the public by leading
a group of mental health professional colleagues in breaking the silence
about the current U.S. president’s dangerous mental impairments. She is
currently president of the World Mental Health Coalition, which is
dedicated to promoting public health and safety.
During medical school, she also obtained a divinity degree to
expand her understanding of the human condition. Trained at Yale and
Harvard Universities, she was chief resident at Massachusetts General
Hospital and a research fellow at the National Institute of Mental Health. As
a faculty member of the Law and Psychiatry Division at Yale School of
Medicine for seventeen years, she taught at Yale Law School for fifteen of
those years, covering the mental health aspects of asylum law, criminal
justice, and veterans’ legal services. Her clinical work consists of
psychiatric services at maximum-security prisons and in state hospitals, in
addition to working as an expert witness for the state and federal courts.
She served as Director of Research for the Center for the Study of
Violence (Harvard, U. Penn., N.Y.U., and Yale), co-founded Yale’s
Violence and Health Study Group at the MacMillan Center for International
Studies, and has led an academic collaborators project for the World Health
Organization’s Violence Prevention Alliance, helping to translate
scholarship into implementation and to support research in low- and
middle-income countries. She has consulted with governments on prison
reform and community violence prevention, such as for France, Ireland,
Alabama, California, Connecticut, Massachusetts, and New York. She has
also played a key role in initiating reforms at Rikers Island, a correctional
facility in New York City known for extreme levels of violence.
She created a popular Global Health Studies course at Yale College,
“Violence: Causes and Cures,” which led to the most comprehensive
textbook on the subject to date, Violence: An Interdisciplinary Approach to
Causes, Consequences, and Cures (Wiley-Blackwell, 2019). She published
over one hundred peer-reviewed articles and chapters, fifteen edited
scholarly books and journal special issues, over two hundred op-eds in
outlets such as the Guardian, the New York Times, the Boston Globe, the
Independent, and Politico, and the New York Times bestseller, The
Dangerous Case of Donald Trump: 37 Psychiatrists and Mental Health
Experts Assess a President (Macmillan, 2017 and 2019). The last proceeded
from an ethics conference at Yale School of Medicine, which led her to
consulting with over fifty members of the U.S. Congress.
The World Mental Health Coalition (worldmhc.org) is a professional
organization that assembles mental health experts to collaborate with other
disciplines for the betterment of public mental health. It also attempts to
step in where the American Psychiatric Association has failed in societal
leadership. Her current goals center around educating the public on mental
health matters that have national and international consequence, so that it
can be empowered to protect itself.
She owes great debt to her maternal grandfather, Dr. Geun-Young
Lee, a renowned physician who helped inspire many in reconstructing
South Korean society after the war, and to her mother, who continued to
practice his philosophy in her beloved United States. Everything that the
author has done, especially since this presidency, emanates from and is
dedicated to her beloved late mother, Dr. Inmyung Lee, healer, writer, and
musician.
 Table of Contents
Preface
Introduction
A Profile of Donald Trump
A Profile of Trump Supporters
A Profile of the Supporting Environment
Recovering America’s Soul
Afterword
References
About the Author