On February 27, 2019, Dr. Bandy Lee and Dr. James Gilligan spoke at The Program in Psychiatry and the Law (the Harvard forensic think tank). The talk was entitled, “Do we surrender our moral compass to technical rule?” They further discuss the question, “Given our professional responsibility to society, if we see dangers to public health and wellbeing, should we refrain from speaking up in professional ways because of a technical rule?” Dr. Lee and Dr. Gilligan are both experts on violence.
Dr. Bandy Lee is an expert on violence on the faculty of Yale School of Medicine’s Law and Psychiatry Division who has served as a consultant to the World Health Organization Violence and Injury Prevention Department as well as other United Nations bodies. Recent calls for her expertise have led to her co-founding and directing the World Mental Health Coalition, which assembles mental health experts to exchange with other disciplines on how we can collaboratively protect societal mental health. This past January, she spoke about how she came to decide to speak out and eventually edited the amazing volume, The Dangerous Case of Donald Trump. I posted a blog which included a video of her talk at the Program in Psychiatry and the Law.
Dr. James Gilligan, M.D., is a Clinical Professor of Psychiatry in the School of Medicine, Adjunct Professor in the School of Law, and Collegiate Professor in the School of Arts and Science at New York University. He is a former president of the International Association for Forensic Psychotherapy. He is the author of Violence: Reflections on a National Epidemic, Preventing Violence: Prospects for Tomorrow, Why Some Politicians Are More Dangerous Than Others and Why Some Politicians Are More Dangerous Than Others. As a faculty member of the Harvard Medical School for many years, he headed the Institute of Law and Psychiatry and directed mental health services for the Massachusetts prisons and prison mental hospital. He served as an expert witness in the litigation that was the subject of the Supreme Court decision in Plata V. Brown.
The transcript of their talk is posted below. Please carefully read it and reflect. Do you agree?
Also, the updated and expanded book The Dangerous Case of Donald Trump will be available on March 19, 2019. This volume features chapters by ten more eminent professionals, including Dr. Jerrold Post.
One of the original contributors is Robert Jay Lifton, who regular readers of this blog know his work on brainwashing, Nazi Doctors, Apocalyptic Cults which all are extremely relevant to this Administration.
In the video on the dangerouscase.org website, Lifton said, “He has no responsibility to what most of us consider to be reality. I call this solipsistic reality, that is, his reality alone, the sense of what his self alone perceives and needs becomes his entire reality. I would focus on his inability to cope calmly with a crisis but rather to respond to any questioning of his views with a kind of attack mode and a potential for violence and that attack mode and potential for violence is under the category of dangerousness.”
Lastly, there will be a conference at the National Press Club Building on Tuesday, March 19, 2019, in Washington D.C. The conference is entitled, “The Dangerous State of the World And the Need for Fit Leadership.” It will also be the official book launch of the new edition of the book, The Dangerous Case of Donald Trump. You can sign up here. And view the flyer here.
Transcript of Their Talk
Bandy: Thank you for having me again. Last time I felt incredibly obliged to speak to such an eminent group of thinkers and scholars, some of whom I have admired from a distance for decades, before meeting you. And you have welcomed me with great indulgence. So I return today with a desire to learn from you, as well as my mentor and colleague Dr. James Gilligan, whom you know almost like a family member. The title of this talk is the main question I have: Do we surrender our moral compass to technical rule? Expounding further, given our professional responsibility to society, if we see dangers to public health and wellbeing, should we refrain from speaking up in professional ways because of a technical rule? I wonder, how many mental health professionals would have spoken up if the American Psychiatric Association had not emphatically instructed that we fall in line with the Goldwater rule, including making public statements about me? I’m no longer even a member. My suspicion is, many more. How much did the public expect to hear from experts about the president, before it was told psychiatrists had no role? I’ve learned over time that they expected as much as official public statements. As citizens, do we not have an obligation to share the special knowledge we have acquired through our privileged place in society?
Bandy: Is expertise to be used to enlighten and empower, or to exclude and then oppress, as I believe the APA is helping this administration to do? As for the First Amendment, is it not specifically intended to prevent tyranny? What is more conducive to tyranny than the control of awareness by imposing silence and, in the process, depriving the people of critically relevant information? Do we not have faith in the usefulness of psychiatric knowledge and the benefits of our clinical experience? The first half of the Goldwater rule that encourages education of the public, tends to be ignored. Even where we are to refrain from diagnosing public figures, the rule is subordinate to the overarching principle that we contribute to the betterment of public health. How do we reconcile a clear, legally-binding duty to protect our patients, but no duty to protect society, and only an obligation to protect the privacy of a public figure who is not even a patient? How seriously should we take our responsibility to society as outlined in the Code of Medical Ethics, which says that our primary duty is to patients as well as to society and as outlined in the Declaration of Geneva, which gives us a humanitarian mandate? And do we take moral agency out of ethical considerations, as the new interpretation of the Goldwater rule attempts to do? These are my questions. I now turn over to Jim.
Tom: Before that, I want to just make a mention, both Jim and Bandy have avoided being sandbagged with the Goldwater rule, carefully steering away from mental illness and diagnosis. They emphasize the dangerousness of human behavior, which as citizens are certainly allowed to comment on. Jim’s chapter gives a very sequentially, carefully reasoned analysis of why behavior should be an issue, rather than a diagnosis.
Speaker 4: Tom, just as a technical term, Bandy has no risk from the Goldwater rule, because she’s not a member of the APA. People who voice positions, which are viewed as unethical by the APA in the Conflict Forum, are subject to being criticized by the APA. But Bandy has zero risk from the Goldwater rule, which I believe she alluded to a few minutes ago. It’s not an operative thing for her.
Bandy: Yet, I do respect the American Psychiatric Association as a purveyor of professional ethical guidelines. I do look to it for some level of ethical authority.
James Gilligan: Well, let me jump in right on these issues. I thought I’d begin by emphasizing what I do mention in the chapter I wrote for the book that Bandy edited, The Dangerous Case of Donald Trump. One thing I’m going to start by emphasizing, as Tom also said, that I’m not interested in labeling Trump with any particular psychiatric diagnosis, for many reasons and quite independent of the Goldwater rule. One reason is because mental illness alone doesn’t necessarily make him, or any other political leader, either dangerous or unfit for office. Both Abraham Lincoln and Winston Churchill have been widely documented as suffering from severe depression. Churchill was, of course, a well-known chronic alcoholic. Another reason is that mental illness and dangerousness are only slightly correlated. Most mentally ill people never commit a serious act of violence. And most violent people are not diagnosed as having a major mental illness. For example, I’ve read that only about 1% of people who have committed murders are found to be not guilty by reason of insanity. It’s really the exception, a rare exception to the rule.
James Gilligan: So there’s only a slight correlation between mental illness and dangerousness. The second thing I’ve got to say is that most psychiatrists really focus on clinical psychiatry and mental illness. Their job is to treat individuals, diagnose them, treat them for their individual case. That’s called clinical psychiatry. But it seems to me that psychiatry also is a branch of public health and preventive medicine or preventive psychiatry. To the extent that we also I think are in that role, we have a duty not just to individual patients, we have a duty to society. The same way that a public health professional would have a duty to diagnose a flu epidemic, and do what we could to have it stop, regardless of what particular individual has it. A third thing I’ve mentioned is, in assessing dangerousness, that’s quite different from diagnosing mental illness. I’ve spent my career really studying violence, the causes, and prevention of violence. I tried to learn everything I could about it. Regardless of whether or not the person committing it is mentally ill or not. Notice, I ran the mental health programs for the Massachusetts prison system for many years.
James Gilligan: Then Bandy and I together did a violence prevention experiment in the San Francisco jails. All of these were quite independent of whether somebody was mentally ill or not. We were preventing suicide, homicide, riots, hostage-taking incidents, mass rapes, arson, all the kinds of violence that may or may not be a subject to mental illness. So I’m approaching this question about Trump not primarily from the standpoint of conventional mainstream psychiatry, is he mentally ill or not, and if so, what’s the diagnosis? But, is he dangerous? In terms of mental illness, I think if you took many of the public statements that Trump has made at face value, and you line them up with the criteria for different mental disorders in DSM5, you can say that he … if we were creating a differential diagnosis of the potential diagnosis we want to rule out if we were to examine him publicly, I could come up with eight or 10 differential diagnoses. But that’s very different from giving him a diagnosis. That’s what you would do if you actually examined him in your office, and had all kinds of studies. But that’s not what I’m interested in doing, I don’t think it’s relevant.
James Gilligan: I’ve really studied dangerousness, the liability of a person to increase the rate of violence in a society, from looking at it from a public health standpoint. Now, we know that most politicians who, we can easily say, are dangerous or have been dangerous, didn’t necessarily kill anybody themselves. I’m not sure that Hitler ever killed anybody or Stalin. They may have, a few individuals, but we think of them as some of the most dangerous people in history because they were responsible for the murder of tens of millions of people. But not done by them, but done by their followers. I’m not saying Trump is Hitler or Stalin, obviously, he’s not. But what I am saying, the general point about a politician, as I speak of Trump of being dangerous, I’m not saying he himself is likely to do what he mentioned he could do, which is walk out on 5th Ave and murder somebody. Which, as he said, he could do without losing a single vote. I’m not saying that is what he’s likely to do. At least I have no reason to say it.
James Gilligan: But that has little or nothing to do with whether he’s dangerous. My point is that he, like many politicians, incites his followers to be dangerous. He actually boasts about, what I think would be hard to say were not violations of the law, if they were prosecuted by the law when he talked about grabbing women by their genitals, whether or not they agreed to that. But we do know that he has incited his followers to violence. I give multiple examples in the chapter I wrote in the book. I’m not going to take the time to run through all of them. But if you followed him, it’s hard not to know things that Trump did. It’s all over the newspapers. My point is that, from the standpoint of preventing violence and dangerousness, it is much more important for us to take the point of view of public health and preventive medicine, than to get hung up on the issue of clinical psychiatry, is Trump himself mentally ill, or which diagnosis does he have? One thing I could mention is that we know that he tells untruths by the thousands. We know that, not just because of fact-checkers in the media … who Trump dismisses as fake news.
James Gilligan: But also just from what Trump himself says. Because he has repeatedly, time after time, actually contradicted himself. I mean, he said one thing one day, and the opposite the next. I did this, I did not do it, and so forth. So clearly, just from Trump’s own mouth, I think we can conclude that he’s been telling untruths, just as I said. Not by the score, but by the thousands. That gives us two possibilities, as it seems to me. Either he believes the untruths that he’s saying, in which case I think we have to say he’s out of touch with reality, by definition. Which would be consistent with delusions or psychosis. Or that he knows that what he’s saying is untrue, which would be a symptom of someone who’s called being a psychopathic liar. That is somebody who just constantly tells an untruth, in order to manipulate people for his own advantage. I think you could say there’s an implicit assumption that he’s either delusional or a psychopathic liar. My own guess is, the likelihood is more probably the latter than the former. I think he’s more likely a manipulative psychopath than delusional. On the other hand, it doesn’t even matter.
James Gilligan: What I’m saying is that the question isn’t so much whether Donald Trump as a person is dangerous, it’s whether what he says and does is dangerous. He says things to his followers, beat up people who protest against me, so badly they’ll have to be taken out on a stretcher. I promise I’ll pay your legal bills. When they did that … actually, some of his followers then were tried for assault and battery, because they had beaten up people so badly. Trump’s only complaint was that they weren’t violent enough yet. He said, in the past, they would have done more, and so on. Of course, when I wrote my chapter it was before this Charlottesville, Virginia incident, where neo-Nazis and other Trump supporters drove a … one of them drove a truck through an audience of pedestrians, as you all know, killing one woman and seriously injuring one or two dozen other people. Trump … again, I’m sure you’re all familiar with this, response to that was, there were good people and bad people on both sides. Kind of creating a moral equivalency between this murderer and the protesters, who were quite non-violent. Certainly, not even approaching in comparison. I outlined my whole position more closely in the chapter in this book. I just want to mention, these are some of the things that I’m involved with.
James Gilligan: I don’t feel that I’m really … what can I say, either violating the Goldwater Rule or constrained by it. I think that I’m really talking not about, is Trump mentally ill? I’m talking about, is he dangerous? Is he dangerous indirectly through his effects on his followers in the words he uses? I’m not trying to understand his words from the sentiment of, what is going on in his mind when he utters them? That’s never really the question from a public health standpoint. The question is, what effect does that have on people who listen to those words? We’ve seen what the effect is, sometimes it’s murder. There are some things that Trump has said that … I mean, you don’t have to be a psychiatrist to understand what he’s saying. Everybody knows that he reminded his followers that they could always assassinate Hillary Clinton if they want to do it. He said, “If she came into power, I don’t know what the judges can do. Maybe the Second Amendment, folks. I don’t know.“ It may be an analogy here to the way Henry II got his knights to kill Thomas Becket.
James Gilligan: Trump is doing the same thing, not saying directly, “Go out and kill this person.” But saying, “Why are people allowing this person to still be alive?” I think Trump in his indirect way was playing Henry II. To me, that’s a sign of dangerousness. I don’t think I’m misusing psychiatric terminology because, after all, dangerousness is not a mental disorder. It’s a description of behavior. All I’m trying to do is say, I spent 50 years closely observing the most dangerous people our society produces. I hear that same language in Trump. Many people have pointed out that he uses the language of the Mafia. Somebody who testifies against him is a rat, and ratting him out. I heard that in the prisons. You would get killed in a prison if you ratted on one of your fellow inmates, or on somebody in the community. Trump is using the language of the Mafia. He’s using the language of dictators. It’s clear that the political leaders whom he is holding up as his ideal or role models, are multiple murderers. Putin, Kim Jong-un, the crown prince of Saudi Arabia. I can go through the list. Let’s say, one last thing. I know there’s a great risk, which is important not to fall into. It’s almost impossible to talk about without some disapproval from the politically left, at some point, somebody again, raising the question of Hitler.
James Gilligan: That’s too easy because nobody is really comparable. But I do want to at least acknowledge some analogies that I think are going on in our society now. I’ve put it in my chapter. The great German sociologist, Max Weber, wrote a wonderful piece about politics as a vocation. One thing he said was, he thought that he and other professors really should not make any direct comments about a political party or leader. They could talk about politics in general, in the abstract, but I think he was afraid they would be persuading their students who to vote for. But I’ve always been bothered by his saying that. It seemed to me that it may have discouraged many of the leading intellectuals of Germany during the Weimar Republic from speaking out publicly against Hitler when he was clearly giving all kinds of evidence of being dangerous. What I’m saying is, I don’t think the German Psychiatric Association in the 1930’s deserves any credit for having remained silent as Hitler came to power. You don’t have to be Hitler though to be dangerous.
James Gilligan: You don’t have to be Hitler for the same principles to apply. I’m just saying, Hitler is an example. Because it’s so extreme, and Trump certainly has not done anything comparable to that yet, all I’m saying is I think it’s important to intervene so we don’t wind up wondering what happened. Hitler, after the burning of the Reichstag, declared martial law. Trump has just declared a national emergency. Well, we have a stronger democracy than the Weimar Republic did, but the parallels are so manifest. I think it’s important for us to try to remind people of this. I’ll say one more thing, then I’m going to shut up so people can talk. I do sympathize with the Goldwater rule because I do remember one of the psychiatrists, who was quoted in a magazine at the time, said that Barry Goldwater was schizophrenic. Well, this was I thought really inappropriate and uncalled for. It was a huge mistake. We shouldn’t be going around, flinging around terms like schizophrenia. Goldwater was dangerous in many ways, but I think there’s no evidence that he was schizophrenic. Look at the rest of his life.
James Gilligan: I do think the American Psychiatric Association did have good reason to say, look, be careful, folks. Don’t just throw these psychiatric diagnoses around. If you disagree with someone politically, say that. But you’re not speaking as a psychiatrist if you do that. What I’m saying is, I’m trying to be very careful about not throwing psychiatric diagnoses around loosely. But I really have made deep studies of dangerousness and violence. I really think I can back up anything I’m saying about Trump as somebody who is dangerous, regardless of what’s going on in his private mind. We have enough data, just from seeing what he has said and done publicly. That’s my point of view. I realize, people can have other opinions, reasonably.
Male speaker: Two fast points. One is that Dante pointed out that the hottest places in hell were reserved for those who remain neutral in a time of crisis.
James Gilligan: Excellent.
Male speaker: So you had a historical precedent. Second point … well, two related points. One is, it apparently has been reported as the view of Trump followers, that they have simply discounted what he says. He’s not going to do that, he’s just trying to piss off the Democrats, or trying to provoke the liberals, and so forth. There’s a double-think down the end. I guess it’s 1984. Right. But the point being, they have a way of managing this situation, where other people are saying, how is he going on? They’re saying, he’s just trying to make waves. Finally, I can’t remember where I saw this recently, but apparently, and this is a very political statement to be making. I apologize for it in advance, that hate crimes go up in Republican administrations. It did so in the Bush administration, it’s doing now to an unprecedented degree. It’s the old notion that we’ve had discussions about here, of the moral atmosphere being established from the top. That license to be bigoted can trickle down in much more than an economic sense.
James Gilligan: That’s right.
Male speaker: Jim, I’m making a couple of comments, if I might. I also want to say, I think I’m the only person in the room who’s ever adjudicated in the enforcement of the Goldwater rule. The APA would not object to your saying that toxic speech or unconscionable speech, can have effects, though it’s hardly part of the psychiatric armamentarium. When we say, this individual is delusional … not Trump, I make this up, a schizophrenic who is actively delusional, and who is drinking. It is a part of settled science to say, that person’s risk has been dramatically increased. It’s been increased over what the alcohol would do alone, and over what the schizophrenia would do alone. That would be unarguable. Bandy and others in her group have made the case that this president is unfit for duty, that he’s incapable of serving. Though I personally have enormously strong negative feelings about this individual, I have critical opinions about making that assertion. Because I do a lot of fitness for duty evaluations, and you don’t do them from a distance. You do them after an examination, and no examination has been performed. I think it is reckless to assert somebody is or is not fit, absent having done that rigorous examination. I also think, referring to this as a technical rule is disingenuous. The Goldwater rule is an ethical rule. It’s been alive and well since it was approved around 1970. It has not been restated because of the election of Donald Trump. The wording of the rule has remained exactly the same and has referred to making a professional opinion. So in a public setting where you two say, this guy is either delusional or psychopathic, the APA would reasonably challenge that assertion as being unethical. They would say, in nicer words, how the hell would you know? Where you two assert that he is doing things, which have bad effects on his followers, is a horse with a different color, and they would say, go to it. There is no desire to stifle anybody. I’m going to stop here.
Bandy: Please allow me to clarify that I have never said that Mr. Trump is unfit for office. I have been recommending that in such situations, where one has shown evidence of dangerousness, that normally we would do an examination, that an examination would be recommended. I have also stated that dangerousness usually disqualifies someone from office because most fitness or duty exams also examine one’s threat to oneself or others. So I have mentioned that it’s a component of the fitness for duty exam. I strongly believe that fitness for duty is ultimately a political decision, just as disability, competence, and unfitness in most situations are legal decisions. So we simply add our medical assessment and recommendations.
Male speaker: So numerous people in this book have said that he is not fit for duty. Lance Dodes went on record in the paper and in his chapter. You may say that you have not, and why don’t we bypass that? But it is clear that multiple people in that book have said, in the absence of actual knowledge, that he is not fit for duty. I think that’s damaging to the mental health professions.
Female speaker: It seems like we can avoid this discussion, based on what you said about the inciting people to be dangerous. If people could interview some of those people in a professional manner and find out what inspired them to be violent, then you are actually dealing with a person, and you can provide documented evidence that takes the pressure off you, in terms of whether you should comment or not, and provides illustrations of how it’s impacting. If somebody does a major study of these people and says, this kind of language, which we can then link to the president, is causing people in this country to commit hate crimes and other sorts of things against people. It would seem one way out of this.
Bandy: Jim and I have always approached dangerousness and violence from a public health perspective. I have made clear that the personal mental health of the president is not of concern to us. But rather whether there is a general atmosphere that encourages violence and increases rates of violence by virtue of the situation, which is, Mr. Trump in the office of the presidency, not Mr. Trump himself. The reason why I call the Goldwater rule a technical rule refers to its interpretation, that it’s taken out the context. We eliminate consideration of the principle that it falls under, which is to participate in activities that improve the community and public health. By simply interpreting the rule, the literal wording of the rule, and then stipulating that there are no exceptions to it, it does become a technical rule, rather than an ethical and moral guideline. That’s what I was referring to.
Male speaker: The real interesting cases of ethics are when there are two rules, and there seems to be a contradiction. You raised the idea that clearly there are professional social responsibilities. Then there’s this other rule that one should not opine about an individual, absent an examination and a release. Interpreting that conflict doesn’t reduce the rule to being a technical one. It’s what happens when you apply both rules to a specific situation. For instance, Jerrold Post decided that his information was so important about Saddam Hussein, that he would testify his personal and professional opinion that he had formulated for the CIA in Congress. He would talk about malignant narcissism, which he distinguished from the narcissism we see in the DSM-5. So it’s not an established diagnosis, but he wanted to make clear that he thought this guy was really dangerous. Both his employer and the APA thought that he should have kept quiet. That there were employment rules and ethical rules that should have caused him restraint. That’s a matter that reasonable people can debate.
Male speaker: We’re doing a panel about causation at AAPL. It hasn’t been accepted yet, but we’re hoping. I was a little hung up on the notion of: he’s causing violence. It seems to be inclusive to the idea of an enabler. The person who enables an addiction isn’t causing the addiction. They make it appear. So you have people with already existing racist stuff, who have now become licensed to act based on an enabling concept.
Terry: If you listen to the testimony that’s going on this morning, he’s making exactly that same point. He said, what he did was, he enabled and required indirectly the action that Michael was taking. It was interesting to listen to, because we all know that’s what’s happening. That he’s able to remove himself from any kind of violence, at the same time that he’s expecting it from someone else.
Male speaker: Because if you plead peace, he fires you.
Male speaker: Yes. I’ve got three things. One is, in what I’ve read I don’t see, just sticking with the assessment’s dangerousness, for me the science precedes the ethics. If there are problems with the science, then I think it’s hard to talk about the ethics. I didn’t notice anything that was persuasive for me, and I do agree with the idea of narcissism. There was nothing in what I have read so far that has predictive validity. That’s one concern. Number two is the real absence of historical context. I mean this in a longitudinal sense. Given the fact that you’re talking about personality, and personality is very much context-driven, how do we make all of our decisions on forced choice kinds of things? You’re either for this, or you’re against this, the rhetoric on one side or the other, constitutes some sort of description of causation. This gets to language. I mean, the whole border thing is about immigrants and violence and criminal behavior, going back to Taft and Nicaragua, or even beyond that, to Cuba and the United States.
Male speaker: We’ve never had an easy way to sort that out. It’s being in Walpole when you work. How do you begin to sort out who is just coming over, who is going to be a coyote, who’s trafficking drugs? Who’s an immigrant, who isn’t? This is such a morass that the split, the forced choice around which a lot of this debate takes place, fits a democracy, but it doesn’t fit the domination of violence.
James Gilligan: Let me say another thing. In public health, and when it comes to making predictions about epidemiological outcomes, that is changes in the rates of say homicide or suicide in a population, people often refer to the contrast between risk factors and protective factors. I would agree, rather than speaking in terms of causation, I would speak in terms of risk factors and protective factors. I wrote a book called, Why Some Politicians are More Dangerous than Others, in which I’