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Trump’s fragile mental health must be handled with as much care as the coronavirus outbreak ǀ View

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The Chinese government’s handling of coronavirus should be a cautionary tale for any epidemic. Denial and secrecy early in the outbreak did not make the disease go away but helped the virus to gain a tenacious hold.

Now, the infection is spreading across Europe and the Middle East, having (so far) killed nearly 3,000 people and generated over 83,000 confirmed cases of infection. Short-sighted interests have damaged China’s economy and international standing, and now threaten world stability.

Whether we know it or not—or, all the more so if we refuse to consider it—we may be facing a similar situation in the United States with mental health. While we make many false distinctions between physical and mental illness, none is perhaps as consequential as the denial that mental symptoms can spread.

As a psychiatrist working in public hospitals and prisons, I have seen this phenomenon a great deal. When severe mental illness goes untreated, its potential to spread among the previously healthy within households or gangs increases dramatically. Emotional bonds, more than physical contact, serve as the vehicle. My violence prevention work with US state governments and international organisations has centred around preventing outbreaks using public health approaches.

We had cautioned that delaying impeachment could be a risk because a delay in containment would cause the ballooning of a sense of unlimited power and impunity. Rapid progression after such a delay maximised the potential for paranoia and narcissistic rage, while the combination of impeachment and acquittal created conditions for a heightened desire for revenge.
Bandy X. Lee
Forensic psychiatrist

One of the early whistleblowers of this strain of coronavirus, Dr Li Wenliang, who tried to warn his medical colleagues as early as December 2019, was reprimanded and compelled to denounce his warning as unfounded, illegal behaviour. A little more than a month later, he died of the disease, sparking nationwide controversy.

We are currently experiencing a similar process in the United States with the mental health of the incumbent president. Mental health professionals have come forth with concerns in ways that are unprecedented for any president of any party in US history. In response, the federally-funded American Psychiatric Association (APA) has also intervened, not to address the crisis but to tighten restrictions on speaking about this particular public figure. The new, formerly unseen rule without exceptions that many call a “gag rule” has been misleadingly dubbed a “reaffirmation” of an old guideline, and those who would speak up have been targeted through public campaigns. As a consequence, while the public continued to ask, ‘where are the mental health professionals?’ the chilling effect on the entire profession has not allowed proper information to get to the public in time for its protection.

The contagion of bodily infections is dependent on three conditions: an offending agent (a “germ”), a weakened constitution (poor immunity, for example), and a facilitating environment (cramped conditions and poor hygiene, among others). The spread of mental pathology in a body politic requires three analogous conditions: severe pathology in an influential figure (the offending agent), followers who are emotionally-bonded or invested in that figure (poor population health), and systems that fail to stop the transmission (corruption and weak institutions).

We had cautioned that delaying impeachment could be a risk because a delay in containment would cause the ballooning of a sense of unlimited power and impunity. Rapid progression after such a delay maximised the potential for paranoia and narcissistic rage, while the combination of impeachment and acquittal created conditions for a heightened desire for revenge. Now, the president is replacing those who offer information he does not wish to hear and controlling information where lives may be lost. There is a dangerous coronavirus outbreak looming - made worse because of a possibly more dangerous pandemic. With each failure to contain the president psychologically, there is a worsening of symptoms, accompanied by “loss of insight” about what is wrong and a push for the reality that is inside one’s head.

Persons with non-psychotic disorders can develop delusions under pressure, as the overwhelming need to believe in an alternative reality makes fantasy real for them. They then become more likely to spread their symptoms, as a delusional person who truly believes in one’s delusions can be very convincing. People speak of puzzling features emerging even from formerly respectable attorneys and lawmakers surrounding the president, and ask what is inducing them to aid and abet him. While there may be many reasons for this, when the level reaches the point of irrationality, we must consider contagion. Shared psychosis, or mass hysteria, is what we expect to happen from allowing a severely impaired, influential person, who has gone untreated, wide and constant, unmitigated exposure to supporters and the public.

Many say that Donald Trump is not a departure from the values of the Republican Party but its culmination. Our own study showed differences in political party contribution to violent death rates, even when controlling for policy, suggesting differences in levels of health and not simply ideology. These seal the third condition for widespread shared psychosis: it provides the fertile ground, or an environment that facilitates the spread of cognitive distortions, delusions, and other mental symptoms. A refusal to have even a serious discussion about the issue contributes to allowing what others have called a “cult” or “fascism” to take hold in the first place. Psychological conditioning through media manipulations, containment within social media bubbles and orchestration of alternative belief systems through the president’s incessant tweets, hypnotic rallies, and group conformity, only make it worse.

Why is awareness of the transmission of mental symptoms important? An open conversation about a natural phenomenon can enhance understanding and allow correct identification of the problem. Furthermore, the spread of mental symptoms may not only contribute to physical disease but acceptance of something much worse. As the US president grows more symptomatic, our window of being able to intervene is also rapidly closing. People keep asking, "what is it going to take for the public to realise that he is unwell?" The problem is, the sicker he becomes, those under his influence will see it less as a problem - and this has been the trend. The coronavirus epidemic will become more deadly because of poor mental health and capacity rather than because of the organism itself.

In cases of shared psychosis, the required intervention is to remove contact with the symptom-inducing individual. The symptoms in the induced individuals then usually subside as dramatically as they have appeared. Even if a full intervention was not possible, we can strengthen resistance in society (as we would support the immune system in a body. Honesty, transparency, and education about what we are dealing with can lessen the induction of false beliefs and help us to contain both kinds of pandemics before it is too late.

  • Bandy X. Lee is a forensic psychiatrist at Yale School of Medicine and a project leader for the World Health Organization Violence Prevention Alliance. She represents the views of only the World Mental Health Coalition, as its president

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