Many believe that the falling poll numbers for Donald Trump are a measure of his mishandling the coronavirus pandemic to the point of calamity or his divisiveness in the face of a racial crisis. While these things may be partially true, there is a far more important, overriding factor: his inability to hold ongoing rallies.
His loss of continual exposure to the public has meant his supporters would separate enough to see reality for themselves. This is a phenomenon mental health experts have spoken about in The Dangerous Case of Donald Trump: how his continual exposure through the presidency would make him uncontainable, and we issued a “Prescription for Survival” in March 2020, to highlight how his removal or, if not, at least removal of influence was necessary for our collective health.
There are many medically unjustifiable misconceptions we have about mental disease, but none is perhaps as consequential as the denial that it can be contagious. Indeed, its contagion could be more efficient than other forms of infection since it does not require physical exposure but only emotional bonds. We noted at the onset of the coronavirus pandemic that the more important pandemic to gain control over was “the mental health pandemic.”
Weakened hosts, an environment that facilitates transmission, and our lack of consideration even of the possibility—even among some psychiatrists wedded to an atomistic view of people—has made Americans more vulnerable. In addition, poor mental health contributes to denial, and therefore those who are the most affected are the least likely to admit that anything is wrong. Bioterrorism is frightening, but psychological warfare even more so, for it hijacks the very mind that is capable of protecting itself.
My focus as a preventive psychiatrist has been the ecology surrounding individuals. Contagion of mental symptoms is common in public hospital and prison settings, where there are high concentrations of untreated, severe mental disturbances. Severe symptoms can spread among family members, criminal co-conspirators, gangs, and other tight-knit groups. A colleague and collaborator at the World Health Organization, Dr. Gary Slutkin, has long advocated that we consider violence and other behavior an infectious disease whose spread we can interrupt. International terrorism and suicide are known to be contagious, for example. Effective prevention, therefore, requires population-level interventions and application of psychiatric principles to systems, institutions, and cultures. The last course I designed for students at Yale Law School was one of translating law into social policies that prevent violence and further societal health.
Three conditions are necessary for the spread of mental symptoms:
1. Severe pathology in an influential figure
The transmission of mental symptoms has been given different names: induced delusional disorder, shared psychosis, folie à deux, trois, quatre,…, or millions—depending on the number affected—or mass hysteria when affecting a whole population. All describe the same phenomenon, but none are satisfactory. The latest, induced delusional disorder, focuses on the most commonly transmitted symptom, delusions, but does not cover other possible symptoms, such as mood. Shared psychosis captures the syndrome-like severity, but is a misnomer because it often does not involve actual psychosis. Folie à deux, or “madness in two,” is perhaps the most preferred but a foreign phrase. Finally, “mass hysteria” describes well the frenzied quality that arises from the sharing of symptoms among crowds, but often does not actually involve symptoms of “hysteria”, or histrionics. The important feature is that mental symptoms are not confined to the person; they take hold and spread across interpersonal boundaries, just as they initially take over one portion, and then eventually the whole of the mind of an individual.
Severe psychopathology in an influential figure, therefore, transmits to others or a group, until the exposed persons or groups come to feel, think, and behave as if they had the same disorder as the primary person. Unlike normal social dynamics, where enthusiasm, common purpose, or even outrage can be “infectious” but individuals retain their uniqueness, the spread of pathology is especially efficient and deleterious, taking over the personalities of those involved.
Transmission happens more readily in vulnerable persons, but those who succumb are not necessarily of unsound mind to start. Delusions of persecution or general paranoia are the most common to transmit, but even bizarre beliefs, such as the primary person being of divine origin, are not rare. Exposure to actual delusions is unlike exposure to strategic lies or simple misinformation; they are more infectious because the primary person is genuinely convinced of them and the emotional pressures for others also to believe them is stronger. For example, when an influential figure holds the paranoid belief that a serious viral pandemic is a “hoax”, orchestrated by one’s enemies to bring down one’s presidency, it can be more emotionally persuasive than any reality and is difficult to correct.
2. Group members with high emotional investment
Another condition for the spread of mental disease is emotional investment. Folie à deux describes shared madness within a pair, but here we will focus on folie à groupe, or the spread of mental symptoms in a group. The group can be a household (folie à famille), a prison dormitory or cell-block, a religious or other highly emotionally-bonded group, a community, or a nation. Members may have high emotional investment in the primary person because of family relations, gang affiliation, cultic programming, or similar symptoms to start. Pathology in the primary individual facilitates transmission: a compulsive drive to “tweet”, a desire to deny reality coupled with propaganda, intolerance of uncertainty leading to pressures of conformity, and an insatiable need for adulation driving addiction-inducing, hypnotic rallies. These symptoms create the ideal conditions for additional transmission of symptoms.
As symptoms spread, cognitive distortions, delusions, and other manifestations take on an emotional power that are difficult to match with normal responses. Induced delusions function like primary delusions, wherein resistance is too great for evidence or truth to gain traction. Those who try to maintain their grounding in reality experience stress, anxiety, ostracism and exhaustion and may eventually submit. When it originates in disease, it is different from culture but is more aptly called a “cultural disorder.”
3. An environment that fosters contagion
Conditions of isolation, either physically or through filtered information, especially when they “immunize” against alternative viewpoints through phrases such as “fake news” or “the enemy of the people,” combined with constant, high levels of exposure to the symptomatic primary individual, is the formula for shared delusions. The environment, therefore, is very important.
Many have remarked on the cult-like quality of the leader-follower arrangement we see with the president and his supporters. The dynamic alarmed my colleagues in the mental health profession enough to write entire volumes. Existing arrangements of “viral” social media, profit-driven news programs that rely on ratings, and rallies that reinforce herd mentality and conformity, all contribute to the spread of symptoms.
How is the recognition of shared psychosis, or folie à groupe, helpful? We know from the scientific literature that, when contact with the inducing individual is removed, the shared symptoms usually subside just as dramatically as they have appeared. If removal is not possible, we know that reducing exposure can be helpful. We can prevent epidemics from occurring in the first place by screening for mental impairment before individuals take positions of influence. Further, we can take steps to protect ourselves in the future by promoting public mental health and education about mental disease, as well as reducing environmental “toxins” that include propaganda, brainwashing, and filtered information. Knowing that mental compromise can contribute to physical demise, and recognizing the distinct, characteristic patterns of disease, we can better avoid mistaking it for a normal choice or just another ideology that excites people.