IN 2017 FORENSIC psychiatrist Bandy Lee, along with a group of concerned mental health experts, took the national stage to call out what they saw as the dangerousness of newly inaugurated US president Donald Trump. Lee put together a conference at Yale claiming they had a duty to warn the public about Trump's capacity to cause harm. The public took notice: The conference led to a New York Times–bestselling book, as Lee and colleagues consulted with members of Congress on the topic.
But the discussion was bogged down by an obscure professional guideline known as the Goldwater Rule. Introduced by the American Psychiatry Association in 1973 after Barry Goldwater sued Fact magazine for publishing psychiatrists' armchair opinions about him, the Goldwater Rule restricts what clinicians can say about individuals, including public figures, who are not their patients. In a tense week between an assassination attempt on Donald Trump and Joe Biden deciding to step down from the 2024 presidential race, TAP managing editor Lucas McGranahan sat down with Lee to discuss Trump's “symbiotic” relationship with his supporters, the nature of violence, and the ethics of speaking up.
LUCAS MCGRANAHAN: You've written and spoken at length about how Donald Trump is a danger to America and the world. What evidence did you feel you had for your concerns in 2016, and how, if at all, have your thoughts changed since then?
BANDY LEE: The best predictor of future violence is past violence. He had already exhibited verbal aggression. He had boasted about sexual assaults. He had incited violence at his rallies. He had expressed an attraction to powerful weapons, including nuclear weapons, and he was drawn to brutal dictators who have practiced vast human rights violations. So we were concerned about his dangerousness and his unfitness, which is different from diagnosis.
“As psychiatrists, we have a responsibility to patients, as well as to society.”
LM: What does the assassination attempt on Trump tell us about our current moment?
BL: I think the assassination attempt is a natural consequence of his violent rhetoric, his incitement to violence, his instigation of a violent insurrection, and his introduction of violence as a political tool. Violence tends to be very contagious. I haven't been following too much how he has responded, but I heard that he started out with messages of unity at his acceptance speech at the convention. All that is going to be superficial compared to his actual demonstrations of violence.
After the Manhattan District Court's conviction of Donald Trump, some of the most esteemed psychiatrists in the country, who are also authors of The Dangerous Case of Donald Trump: 27 Psychiatrists and Mental Health Experts Assess a President [expanded from 27 to 37 in its second edition in 2019], formed a panel to perform a dangerousness risk assessment, as forensic psychiatrists often do to advise with sentencing. The panel assessed that Trump is highly dangerous. The assessment was submitted to [New York State Supreme Court] Judge Juan Merchan and the commissioner of probation. Being highly dangerous with very little tethering to reality, Trump can create any message and any image with persuasiveness. But his violence-proneness has not changed, and I would not say any of my assessment has changed since we first came out with warnings of his dangers.
LM: How did these First Warnings about Trump come about?
BL: In early 2017 when I realized that many of my colleagues were fearful of speaking up, I held a conference to bring us together at Yale School of Medicine. It was an ethics
conference on the whether we had a societal professional responsibility to educate and inform. And at that conference we decided we did. Proceeding from it was The Dangerous Case of Donald Trump, which we were told was an unprecedent New York Times bestseller of its kind. We donated all revenues to the public good to remove any conflict of interest. I was invited to all the major news programs, network and cable, and was on the front page of The New York Times. Since the book, many others joined us to form the World Mental Health Coalition, which at one point had 5,000 members, all mental health professionals. We're the largest and only mental health association concerned with dangerous leadership.
LM: Your new book is about “Trump contagion.” Could you explain that phrase?
BL: It's called The Psychology of Trump Contagion: An Existential Threat to American Democracy and All Humankind. It's now out on Kindle. My purpose in publishing it was to emphasize the fact that the dangerousness in Donald Trump, as I said since 2017, is not an individual problem but a public health problem. I had warned that having someone with such severe symptoms in a position of power and influence, with great exposure to the public, would eventually cause his symptoms to spread. We normally don't think of mental symptoms as spreading, but I would argue that they are even more contagious than physical symptoms, because you don't require physical exposure for the symptoms to spread. It's been shown through social media studies how quickly negative emotions, and even more so mental symptoms, could spread.
LM: You use the concept narcissistic symbiosis. That seems like a psychoanalytic or psychodynamic idea.
BL: These are psychosocial dynamics observed in times of societal stress, which have indeed been described in psychodynamic terms. At such times, there can be regression, or widespread developmental wounds, which is what pathological narcissism is about. And when you have a large proportion of the population exhibiting those signs, they may be drawn to a similarly developmentally wounded leader who projects himself in an ideal image, in defense against his feeling powerless and inadequate, to appear not only adequate but omnipotent and omniscient. His followers, in turn, vicariously fulfill their need to be powerful through this leader image. It's the same developmental wound, but one projects oneself as an all-powerful leader, and the others fall in line as followers who believe that they can experience power by aligning themselves with such a leader. There's a kind of magnetic attraction that happens subconsciously, irrationally, and almost chemically, so that no amount of persuasion could help lead them out of this kind of symbiosis.
LM: You are an expert on violence. Your 2019 book on the topic takes an interdisciplinary, holistic approach.
BL: Yes, the reason for publishing my textbook was to bring together the disparate fields of violence studies, which have been traditionally siloed, with psychiatrists studying only suicides, the criminal justice system dealing only with homicides, historians and political scientists dominating collective violence, and anthropologists cornering unique, culturally bound forms of violence. There was a need to bring these different categories together, because my hypothesis was that violence was a measurable tendency in itself. I often say that violence is a societal disorder. It's very hard to predict violent actions by an individual—as a forensic psychiatrist, I'm often called to predict or to project future violence in an individual, but it is barely better than random at the individual level.
At the societal level, on the other hand, violence turns out to be very predictable. In fact, Dr. James Gilligan, Dr. Bruce Wexler, and I did a study of violent death rates in the country over 110 years. We found that suicides and homicides rose and fell together, and, in fact, when studied together, they're much more strongly explanatory. That helped me to conceptualize violence as a societal problem as well as a general tendency that may manifest as suicide, homicide, or warfare depending on context and culture, and sometimes individual personality.
What ultimately determines a society's general tendency for violence is structural violence, or inequality. This is what is behind what I have been calling our “collective suicidality.” We are currently in a death spiral because of extreme inequality, which has driven self-destructive politics, organized crime, rampant behavioral violence, and existential dangers.
LM: This research on violence seems to dovetail with your work on prison reform.
BL: My interest in violence prevention began from my background of growing up in New York City when it was very violent, and then working with violent offenders in prisons and jail settings beginning in my residency, and then consulting with the World Health Organization since its launch of a landmark document called “World Report on Violence and Health,” which brought together all the different areas of scholarship—actually, it did exactly what I envisioned for my textbook. It truly revolutionized our way of thinking about violence. We went from seeing violence as a security or criminal justice matter that we merely respond to, to viewing it as a public health problem that we can bring our multidisciplinary knowledge, including psychiatric knowledge, to try to prevent.
“It's the same developmental wound, but one projects oneself as an all-powerful leader, and the others fall in line as followers who believe that they can experience power by aligning themselves with such a leader.”
Based on scholarship and science, we made recommendations for countries to implement nationwide in terms of change of laws, police reform, prison reform, and programs for victim support. One hundred thirty-three countries documented that, after 12 years, interpersonal violence was reduced by 16 percent globally. That's a significant reduction that was shown could be achieved through scientific knowledge and political will.
LM: What is a reform that illustrates your approach?
BL: I've recently been invited to look at the New York State Prison system, especially how to reduce solitary confinement. There are two competing philosophies in the United States prison system, which is the leading carceral state of the world. The first is to react to violence through more violence, either by imprisonment within the prison, which is solitary confinement, or through threats and intimidation. The second is de-escalation, addressing mental health issues, and programming involving prosocial engagements.
A program that I helped evaluate won what is called the “Oscar of government programs,” the Ash Institute Award. It's the Resolve to Stop the Violence Project, or RSVP, which happened with the San Francisco County Jails. They implemented a radical program already in 1997 by gathering violent individuals all into one open dormitory and engaging them in intensive programming, 12 hours a day, six days a week, where they would engage with one another, learn social skills, and mentor one another. People were predicting riots, mayhem, and murder in the beginning, and it turned out to be the safest dormitory in the entire jail system. A comparable dormitory would have one felony-level violent incident per week. This dormitory had one, and then none for 13 months.
The rest of our country, after going in the opposite direction of proliferating incarceration, solitary confinement, and supermax prisons, has now realized that that method has not worked. And now many programs similar to RSVP have replicated around the country. The philosophy of restoration rather than retribution has been highly successful, and programming in general has been shown to be far more effective in reducing violence than traditional, punitive methods. And this is what we're trying to introduce to the New York State system.
LM: You have a master of divinity degree. Is your work on violence or in other fields in some way spiritually grounded?
BL: Yes. I did a course of divinity studies alongside medical school because at the time I felt that I needed to humanize my medical education, but it has turned out to be one of the most valuable backgrounds I could have, dealing with seriously ill psychiatric patients or prisoners in crisis, for whom religion has played a large role. And so I could bring my own religious background, and I've studied other faiths as well. There's a lot of commonality—Christianity, Judaism, Buddhism, Islam. I believe it fulfills a critical need. Psychiatry can go only so far. It treats the body, brain, and mind. A spiritual practice quenches the soul, which is a critical, if not central human need. It's useful not just in terms of scholarly pursuit of violence prevention or clinical practice, but even in our own grounding and sanity, during times of violent upheaval and societal turmoil.
Bandy Lee is not a member of the American Psychoanalytic Association (APsA), and the views expressed in this interview are her own. APsA issued its own guidance for clinicians speaking about public figures in 2012. This interview has been edited and condensed.
First published online August 2024.
LM: Another key psychosocial idea is shared psychosis.
BL: Shared psychosis is the end result of Trump contagion. The contagion spreads from a powerful public figure with severe symptoms, first among vulnerable individuals, but eventually even among the normal population. It is called shared psychosis because each individual person may not be psychotic, but the entire group acts as if they were—that is, detached from reality. I've seen a great deal of shared psychosis in the public-sector settings where I have worked, in prisons and state hospitals, where patients with severe symptoms can go untreated for long periods of time. They can affect those around them, especially when they're isolated in a family setting or in a street gang or a cell block. It's a phenomenon that's been examined for the past century and a half, where the primary individual induces symptoms in secondary individuals, who look almost identical to primary individual. The treatment is to remove exposure, usually hospitalize or incarcerate the primary individual, and the secondary individuals return to their previous state.
LM: The so-called Goldwater Rule has been invoked to criticize you and your colleagues for speaking out about Trump. How do you understand that rule?
BL: First of all, I modified my Yale School Medicine conference to be focused on the ethics of speaking up, because I was very alarmed at the American Psychiatric Association's modification of the Goldwater Rule less than two months into the Trump presidency. The original rule was understood as a guideline to refrain from diagnosis of public figures without examination and without consent, which makes total sense. We were not speaking of Donald Trump like a patient we needed to diagnose. We were speaking of him as a public health threat and as professionals who had a responsibility to protect society. As psychiatrists, we have a responsibility to patients, as well as to society. So when they modified it to say, “Do not make any comment whatsoever under any circumstance, including in a national emergency,” that was absolutely alarming. In my view, it went against all the core tenets of medical ethics, as well as the Geneva Declaration, which was instituted by the World Medical Association in response to the experience of Nazism after the Nuremberg trials, because too many physicians cooperated and collaborated with a dangerous government. The declaration makes clear, whether it's active cooperation or silence in the face of a destructive regime, that that is contrary to the humanitarian goals of medicine.
And so for me, that was a blatant misinterpretation or reframing of the Goldwater Rule. Actually, the original Goldwater rule in itself was unnecessary to be stated. We simply don't diagnose anybody without a personal examination, and we don't publicize their diagnosis without consent. But it was inserted specifically for public figures, as a political compromise,
after Barry Goldwater's campaign where he attributed his landslide loss to a magazine that sensationalized psychiatrists' opinions. The APA magnified this formerly noncontroversial, insignificant guideline, which was adopted by no other mental health association, to silence mental health experts. A guideline that was politically generated was bound to be politically abused, and that is what we saw during the Trump era, which was catastrophic in my view. I believe that without [the APA's] intervention, there could have been an intervention before the first term of Donald Trump's presidency was over. We would not have had the catastrophic mismanagement of the COVID-19 pandemic that eventually led to 1.2 million American deaths, we would not have had the crisis of democracy of January 6, and we certainly would not have had a second Donald Trump candidacy.
LM: In a CNN interview, you seemed less concerned about Joe Biden's mental fitness than other commentators.
BL: Your readers will know a psychological phenomenon called projection. In order to deny unwanted qualities in oneself, one attributes them to others, especially one's opponents. And that is a powerful way to deny that you actually have those problems. And since the defining feature of Donald Trump's presidency and candidacy has been his mental unfitness and his mental health issues, he honed in on Joe Biden's much more benign signs, if they are signs at all.