What Mental Health Experts Can Say About The Presidency

Co-authored by Dee Mosbacher, M.D., Ph.D. and Nanette Gartrell, M.D.

“Now that he has won the presidency, why wouldn’t he just ‘pivot’ and become more normal?” “Why would he say things in public that are destructive to him and the nation?”  “Why stir things up unnecessarily?”  “The chaos and incoherence are much worse than expected.”

These are some of the questions and concerns that have been raised about President Trump by persons who are untrained in how mental impairment can manifest. Indeed, the vast array of healthy human behaviors makes it difficult for the ordinary person to detect disability other than in the most obvious cases. Further, the more impaired the individual, the more likely he or she is to deny pathological behavior and insist that it is by choice. In our culture, mental impairment, unlike other medical illnesses, still connotes a moral failure—leading to its denial or use only in epithets. Yet it can afflict anyone, it is nonpartisan, and we can identify it through objective criteria.

The Goldwater rule, which specifies that psychiatrists cannot diagnose a public figure without a face-to-face evaluation, has contributed to the lack of discourse and education about Mr. Trump. An expansion of the rule by the American Psychiatric Association in March 2017 further compromised that possibility. Frequently overlooked is the fact that the Goldwater rule itself occurs under the ethical mandate to contribute to “the betterment of public health,” for which a professional may “share with the public his or her expertise about psychiatric issues in general.” As a result, mental health issues are continually marginalized, and misconceptions persist. It is commonly assumed, for example, that mental impairment will cancel out responsibility, when this occurs only rarely. Also, mental illness does not imply violence: most mentally ill individuals are not violent, and most violent individuals are not mentally ill. What is important, therefore, is not the diagnosis but the combination of particular symptoms and the context — whether observed in a clinical setting or from afar — when assessing dangerousness.

In the case of President Trump, it has been apparent for some time that his inability or unwillingness to distinguish fact from fiction, rageful responses to criticism, lack of impulse control, and wanton disregard for the rule of law indicate emotional impairment rather than deliberate choice. Such signs and symptoms may be tolerable in a variety of settings, but not when this individual has command of the nuclear arsenal. Fitness for duty evaluations are a common practice among forensic psychiatrists and other mental health professionals, who follow a standard assessment procedure while applying it to the duty in question. Although military personnel who are responsible for relaying nuclear orders must undergo rigorous mental health and medical evaluations that assess fitness for duty, no such requirement exists for their commander-in-chief.

At a time of increasing conflict abroad and worsening divisions at home, we believe it is time to remedy this situation. The 25th Amendment to the U.S. Constitution, which addresses presidential disability and succession, has never been invoked to evaluate whether a standing president is fit to serve. However, Congress has the ability to act within its provisions to create an independent, impartial panel of investigators to evaluate Mr. Trump’s fitness to fulfill the duties of the presidency. Congress can pass legislation to ensure that future presidential and vice-presidential candidates are evaluated by this professional panel before the general election, and that the sitting president and vice-president are assessed on an annual basis.

Our specific recommendations are as follows:

1. Under Section 4 of the Twenty-fifth Amendment to the U.S. Constitution, Congress should immediately constitute an independent, nonpartisan panel of mental health and medical experts to evaluate Mr. Trump’s capability to fulfill the responsibilities of the presidency.
2. The panel should consist of three neuropsychiatrists (one clinical, one academic, and one military), one clinical psychologist, one neurologist, and two internists.
3. Panel members should be nominated by the nonpartisan, nongovernmental National Academy of Medicine.
4. The experts should serve six-year terms, with a provision that one member per year will rotate off and be replaced.
5. Congress should enact legislation to authorize this panel to perform comprehensive mental health and medical evaluations of the president and vice-president on an annual basis. This legislation should require the panel to evaluate all future presidential and vice-presidential candidates.  The panel should also be empowered to conduct emergency evaluations should there be an acute change in the mental or physical health of the president or vice-president.
6. The evaluations should be strictly confidential unless the panel determines that the mental health or medical condition of the president or vice-president renders her/him incapable of fulfilling the duties of office.

Congress must act immediately.  Congressional inaction has brought us to a crisis point: the nuclear arsenal rests in the hands of a president who shows symptoms of serious mental instability, with indications that they will likely escalate.  This is an urgent matter of national and international security.  We call on our elected officials to heed the warnings of thousands of mental health professionals who have requested an emergency evaluation of Mr. Trump.  The world as we know it could cease to exist in a momentary, angry outburst.

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 Bandy X. Lee, M.D., M.Div., is a forensic psychiatrist on the faculty of Yale School of Medicine.  In addition to her clinical work in correctional and public-sector settings, she served as Director of Research for the Center for the Study of Violence.  She then co-founded Yale’s Violence and Health Study Group and leads an academic collaborators group for the World Health Organization.  She has consulted with governments to set up violence prevention programs internationally and within the U.S., as well as helped to initiate reforms at New York City’s Rikers Island Correctional Center.  She teaches at Yale Law School and Yale College. She published more than 100 peer-reviewed articles and chapters, edited eleven academic books, and authored a textbook on violence. Her latest publication will be a compendium of mental health expertise in the trade book, The Dangerous Case of Donald Trump .

Dee Mosbacher, M.D., Ph.D., is a psychiatrist and Academy Award-nominated documentary filmmaker who was formerly on the faculty of University of California, San Francisco. As a public-sector psychiatrist, Dr. Mosbacher specialized in the treatment of patients with severe mental illness. She served as San Mateo County’s Medical Director for Mental Health and Senior Psychiatrist at San Francisco’s Progress Foundation. The Diane (Dee) Mosbacher and Woman Vision Papers are archived at the Sophia Smith Collection, Smith College. Dr. Mosbacher’s films are also contained within the Smithsonian National Museum of American History collection.

Nanette Gartrell, MD, is a psychiatrist, researcher, and writer who was formerly on the faculties of Harvard Medical School and University of California, San Francisco. Her 47 years of scientific investigations have focused primarily on sexual minority parent families. In the 1980s and ’90s, Dr. Gartrell was the principal investigator of groundbreaking investigations into sexual misconduct by physicians that led to a clean-up of professional ethics codes and the criminalization of boundary violations. The Nanette K. Gartrell Papers are archived at the Sophia Smith Collection, Smith College.

Drs. Gartrell and Mosbacher are authors of the chapter: “He’s Got the World in His Hands and His Finger on the Trigger: The Twenty- Fifth Amendment Solution,” in The Dangerous Case of Donald Trump.