“One of the basic concepts I had was that if there are some benefits to having some depression manic symptoms; the corollary is that there are some limitations to being normal and mentally healthy.”
To get started, can you give a little bit of the backstory of how you came to conceive of and write the book? It is clear that some of your experiences with your patients were very important, and that is reflected clearly throughout the book. So, what was the relationship between your own clinical experience and the theory you came to develop about mental illness and political leadership?
I have probably treated over a 1,000 people with bipolar illness over two decades. I have a lot of experience with the individual experiences people have with this condition. A lot of my patients were people who had been very successful in careers of business, academia, and science, and I knew from talking to them about their lives that this illness was a benefit to them in various ways.
Once I started thinking about that, it was a simple step to see if anyone else had already written about [this possible relationship]. When I looked at some of the scientific studies, I saw some evidence about the benefits of manic and depressive symptoms. Then I put it all together, and it all made sense. Bipolar illness and depression can have some benefits for people in their lives.
You talk about Ted Turner in the book, but the majority of people you focus on are in the military, political, or public service space. What was the process you used to decide to focus specifically on these political figures, rather than say business leaders or sports figures?
The reason was there had already been books written about writers and artists. In particular, Kay Jamison had written a lot about that. It was accepted that people who were writers or artists may be manic depressive and had benefited from it. The implication, however, was that it was just them and that they were written off as being different from the rest of us. Certainly more different than a president or a general, and I wanted to make the point that it is not limited to writers and artists; these benefits occur in any line of work. In particular, the effects on political and military leaders are relevant to everyone since these figures affect the whole society.
How did you construct your mental profiles of the historical figures and the ailments they might have had. Obviously, one thing I noticed in the book is the emphasis on genetics or the mental health family members, such as Churchill’s daughter. Besides genetic factors, what are some of the sources by which you build these profiles?
The basic idea I had, which is the same thing we do in psychiatric practice when we make a diagnosis, is to not rely just on symptoms, which most people naturally do. In psychiatry, we don’t do that because it is obvious that symptoms can occur in many different illnesses with overlap. So that is a simple issue, and the way you get around it with scientific research is by bringing in other independent validating lines of evidence.
Three other ones have been specifically accepted by the mainstream. Genetics, and if you have a genetic condition. Bipolar condition is highly genetic, so it is relevant there. The course of the illness, and this is the most important. The symptoms may happen at certain times of life in different illnesses, and they may last a different amount of time which is very relevant. The last one is treatment effects, and actually getting treated. A symptom might reflect an illness if the symptom is bad enough that it actually was treated by a doctor.
So, for example, bipolar disorder is episodic and comes and goes in different times of one’s life?
Exactly. So the typical age of onset is 19 for the first manic episode. Usually, the first depression is around the same time. A typical episode for mania lasts around a few months, and the depression lasts 3-6 months. Then they go away for a year, sometimes more, and they come back. There is variation around that but that is the average. One way you know that some depression may be part of a bipolar illness is that is starts when a patient is sixteen and lasts a few months and then comes back every two or three years. That is very different then if someone is depressed for a month when he or she is 55 years old and that is the only time.
In terms of the profiles, it seems that a majority of them are living in the past around 100-150 years. Would it have been significantly more difficult to try to build these profiles around ancient political figures or politicians from very far back? Thomas Jefferson, I understand, would suffer from bouts of depression, for instance.
Yes, it is very difficult to go ancient. It is also difficult to go very recent. The reason for the ancient is obvious; we just do not have the kinds of surviving documentation about the personal details you often need to know to make a psychiatric diagnosis. How they slept, what there sleeping patterns were, and if they made suicidal threats are all the type of information we don’t know.
So basically I came to the 50-year rule. We know the most about a leader about 50 years after they died. That is the time when all his friends and family pass away, and all these people who have concerns about writing things about them that may hurt someone’s feelings decline. Often times there are personal archives that are locked for 50 years or so for those reasons. So for Churchill, nobody knew that he had this severe depression or suicidal thoughts during his lifetime. It was kept quiet by him, his family, and his doctors based on confidentiality. Ten years after he died, his doctor released his public memoirs and gave us this information.
That is also the reason why we do not know about recent figures. People who are currently living try to hide their personal details. It takes about 50 years for us to find out.
So it is all about finding that happy medium of those who are long gone and still present?
That is right.
I want to ask you about this idea that mental illness gives rise to some sort of humility in certain figures. Contrasted from folks like George McClellan and Neville Chamberlain, who were mentally healthy and perhaps over-confident, there is perhaps some quality of humility that can arise from a manic depressive disorder?
One of the basic concepts I had was that if there are some benefits to having some depression manic symptoms; the corollary is that there are some limitations to being normal and mentally healthy. One of these limitations to be fully normal and healthy is what is called mild positive illusion. It’s normal for people to be a little more optimistic about things than reality warrants The benefit of this is that we are likely to make more efforts to make the things we want to happen actually happen.
In everyday life, this doesn’t cause much trouble because the rest of the world reigns you in when you may seem too arrogant for instance. However, when you reach power, you often have a bubble of yes-men around you, and that normal illusion can become a hubris syndrome as Lord David Owen calls it. The leader then can become very arrogant and not listen to other people or other ideas.
On the other hand, if you have depression, you tend to have lower your self-esteem. Those kinds of people when they reach power don’t have a positive illusion to begin with, so it doesn’t expand into a hubris syndrome; they remain pretty level-headed. People like Lincoln don’t overestimate themselves, even though they have a great deal of power.
I think there is something President Lincoln said that if you want to see how a man is give him power and see what he does, or something along those lines.
He said, “If you want to know a man’s character, give him power.”
Are there some mental illnesses that just don’t help at all in leadership or political roles?
Yes. In general, the conditions besides manic depression illness are not very helpful. Schizophrenia, for instance, is a chronic delusional condition where you are out of touch with reality to an extreme extent, and that will not help as a leader in any way. A lot of people in the past have claimed there are benefits to schizophrenia, but that is probably because in psychiatry a lot of people with manic depression illness were misdiagnosed with it for a century. We really overestimated the whole concept of schizophrenia. If you describe it the way we know it now, there really are no benefits to it.
How about something such as a run of the mill anxiety disorder?
Some people claim that if you have some obsessions there are benefits to it, but if you read about those people they are usually rather high energy. They are not low energy depressive sets of people, and the high energy type of people tend to be manic. That’s what mania is: a higher state of energy and activity. When you are manic you can be very active on the same thing over and over again, and people may misdiagnose that as an obsessive-compulsive illness when it really isn’t.
Other anxiety states are not helpful. If you have a lot of panic attacks, there is not much benefit to that. Some people also claim ADD is beneficial but again a lot of times people with ADD in fact just have a lot of energy and are compulsive, which is related to manic traits and temperaments. People who have mania are distractible, which is an ADD symptom, so they can get misdiagnosed.
Also, people think sociopathy or antisocial personality is beneficial, and in some ways, if its mild it can be. Again, however, people who are manic may seem sociopathic in the sense they have a high self-esteem, are called narcissistic and they seem very self-involved because they seem arrogant. Which they are to some extent, but they also have high energy levels and are very creative and those features are not associated with sociopathy or antisocial symptoms.
What are some of the political leaders you were considering for the book but just didn’t make the cut? Were there some people you wanted to include but had to leave out?
There were a number of people I wanted to get into more. There’s actually a little over a dozen people over the book and originally I only started with a few, so that was an extension of the plan. I think more than that may have made in unwieldy in terms of a practical manner.
However, in terms of other people, I would have wanted to write about George Washington, who probably had relatively severe depression based on descriptions Jefferson and others made of him. I didn’t do the research because I knew I wouldn’t include them but there were signs in Thomas Jefferson that he had some manic-like symptoms in him. With all his creativity and his traveling energy, and his high libido for instance.
Other people I considered that may have been interesting include Stalin. Some people have written about him having paranoid illusions. Lyndon Johnson people have brought up potentially had bipolar illness. Mostly given space limitations I didn’t end up investigating them to confirm with myself if they fit those definitions or not.
The last question I want to ask you harkens back to an interview I watched with you in January with Michael Smerconish on CNN which may be particularly relevant today because it is election day. What is your take on the so-called “Goldwater Rule” in whether doctors ought to make comments about the mental health of leaders?
I think the Goldwater rule is 50 years old, and it’s time for it to retire. It has produced a silence in American psychiatry in a time of relative crisis. Dr. King once said the worst part of the Civil Rights era was not the actions of the bad people, but the appalling silence of the good people. To be silent, even on reasonable grounds, when there are important social issues that we professionals could contribute to the discussion is unacceptable. The rationale was that you shouldn’t make a diagnosis of public figures because you don’t have sufficient information, and secondly that it is a harmful thing to do.
I would argue that both of those rationales are wrong. We do have sufficient information about some of these people. Trump, for instance, we know he doesn’t sleep much; he is distractible and high energy, and his libido is off the walls. Those are all manic type symptoms that are worth talking about. It is not necessarily a harmful thing to do, and that is a view that comes from stigma and viewing mental illnesses as all being bad. My perspective is that it’s a positive thing to say someone may have manic-depressive symptoms. In some ways it may be negative, but to view it as fully negative is quite stigmatizing and something our profession should not be doing.