All’s Not Quiet on the Western Front? The Stigma against Mental Health Treatment for World Leaders ()
Some of the most anxiety-inducing positions in our world involve political leadership. As a society, we are very cognizant of the physical toll such work can take and pay close attention to our leader’s bill of health. We want to know that our governor, monarch, or commander is healthy and we are quite sensitive to fractures in that ironclad depiction. However, physical health is not the lone concern, and there is a second side to the constant stress coin. Imagine a King or Queen, a Prime Minister, or a President who started experiencing not physical, but emotional distress or erratic behavior because of the professional rigors and schedule demands. Now imagine if that individual reached out for help and saw a psychiatrist or therapist. If other high-ranking officials or the public knew of this human vulnerability, would the reaction be supportive? Or would there be immediate doubt cast on that person’s ability to serve in their office and perform to the expected standard? Is society progressing toward a reality that would be more open to world leaders benefitting from psychological care? Or have we regressed? In this paper we discuss three historical examples, separated by 50 years, with markedly different outcomes.
By the end of World War I (WWI), General Erich Ludendorff (Figure 1. PICRYL, 1900 ) was the most powerful person in Germany. He came from a lesser noble family and rapidly rose within the German military. As a member of the Prussian General Staff, he helped develop the infamous Schlieffen Plan, which shifted the vast majority of Germany’s military might to the west to deal a swift blow to France, knocking them out of the war. The plan was predicated on a slow mobilization of Russia, leaving Germany time to shift its forces from the defeated France to the east before Russia was able to attack Germany (Tuchman, 2014) . Ironically, his meteoric rise to fame (or infamy) came through an effort to correct an error in the plan. Russia was able to mobilize quickly and was threatening Eastern Prussia. Ludendorff was sent with Paul von Hindenburg, a German military legend from the Franco-Prussian War, to stave off collapse in the east. They inflicted a series of crushing defeats upon Russia, helping to ensure the war became a brutal conflict of attrition. In 1916, Hindenburg was appointed to be the Supreme Commander of the German Army, and Ludendorff served as the First Quartermaster-general, Hindenburg’s right-hand man (Tschuppik, 1932) .
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Figure 1. Erich Ludendorff, first quartermaster-general of the German Army, 1916-1918.
By that description, it may not sound like Ludendorff qualifies as a world leader. However, Hindenburg served as more of a figurehead, occasionally moderating Ludendorff’s decisions but largely staying out of the day-to-day operations. Ludendorff gradually became the director of a de facto military dictatorship, controlling not only military decisions but virtually every aspect of the economy, with the power to alter state policy at a whim. As Hindenburg himself put it, Ludendorff’s capabilities as a strategist and military mind meant that “Even the Kaiser took orders from [him].” (Brownell et al., 2017)
Ludendorff is not a sympathetic figure; he ruled a regressive state that suppressed any sign of dissent. He continued to press for further conflict well past the point that a German victory was possible. After the war, Ludendorff contributed greatly to the “stab in the back” myth that doomed Germany. Rather than acknowledge that the German military had been defeated on the battlefield, military leaders and right-wing groups (including the Nazis) spread the idea that defeat was caused by citizens on the Homefront (specifically Jews and socialists). Among many other challenges, this myth contributed to the downfall of the nascent Weimar republic and allowed the Nazis to rise to power. Some characterize Ludendorff as the “first Nazi,” and he played a large role in the Nazi’s first attempt to grab power in the Beer Halle Putsche. (Brownell et al., 2017)
As First Quartermaster-general, Ludendorff had an intense and regimented work ethic, rising early and working late. He was also known as an intense micromanager, calling subordinates many rungs down the chain of command to obtain information about operations. As the year of 1918 wore on, and the German High Command’s plans for a series of repetitive assaults on the British and French lines failed, increasingly reinforced by American troops arriving day by day, Ludendorff began to show signs of distress. Always prone to aggressive emotional displays, this tendency increased, and as he pushed himself even further, his already minimal sleep decreased. In his book, Hundred Days, Nick Lloyd describes the final months of World War I. Ludendorff’s subordinates were concerned and feared that the leader of the German Empire and military machine was unhinged.
It was evident in the days after Amiens that Ludendorff’s nerves had suffered. From this point—mid to late August—he seems to have become weaker. Tiredness, bordering on exhaustion, marked his features as he alternated between piteous depression and ridiculous optimism. More and more staff officers now began to notice the decline in their chief, at one point even arranging for the eminent psychiatrist and Chief Staff Physician, Dr. Hochheimer, to pay a visit to [Ludendorff]. When Hochheimer met Ludendorff and began to assess his condition, he found a man bordering on a nervous breakdown, who was overworked, exhausted and unable to function effectively. (Lloyd, 2013)
General Ludendorff accepted Dr. Hochheimer’s conclusion and engaged in care. Though this predates most anxiolytics and all antidepressants, the psychological treatment for intense occupational distress was perhaps not all that dissimilar from today. Dr. Hochheimer provided a safe space for Ludendorff to express vulnerability, offered supportive reflection, and made recommendations as to how he could improve his habits that were leading to intense burn out: setting restrictions on his working time, improving his attention to sleep and exercise, and making modifications to his diet. Sources at the time indicate that these efforts were at least temporarily helpful. (Lloyd, 2013)
By mid-September Dr. Hochheimer seemed to have worked a minor miracle… Hindenburg personally thanked him for the “transformation” in Ludendorff’s demeanor, which had been improved by less work in the afternoon and more sleep, which the doctor carefully observed. “My patient is doing better each day… The calming effect of my work and my words has made me quite happy.”
It does not appear that this treatment was widely known by the German military forces and certainly not the German public, but his staff was aware of Ludendorff’s treatment. Ludendorff resigned at the request of Kaiser Wilhelm in October of 1918, just a few days prior to Germany signing the armistice that ended combat on the western front. Notably, his psychiatric treatment was not a factor in his being removed from German Military leadership, rather, it was due to his rejection of the Allies armistice terms and insistence that the military continue a futile fight. (Lloyd, 2013)
One might imagine an arc of progress continuing from this point, bending towards routine psychiatric care for those in high stress political positions. After all, the German Empire in 1918 was an authoritarian society with little tolerance for weakness, and yet their leader engaged in psychiatric treatment. His treatment was not widely known to be sure, but a large group of Ludendorff’s staff was aware, and it was recorded in history. Surely, then, a modern society nearly 50 years in the future would have progressed even further.
Unfortunately, that is not the case. In 1965, Lyndon Baynes Johnson (Figure 2. PICRYL, 1967 ) was serving as the 36th President of the United States. He had taken over after the assassination of John F. Kennedy in 1963. He had plans to radically change American society and improve the plight of the economically disadvantaged, his so called “Great Society.” But increasing tensions in Vietnam, and the policy position at the time to intervene to prevent further expansion of communism in southeast Asia, led to a decision point to increase America’s troop presence in the area and escalate the conflict. Perhaps Johnson was increasingly aware that he was pushed onto a path without an exit strategy, one that would cost American lives and threaten the progressive policies that he hoped to implement. Over the course of 1965, those close to him noticed increasing signs of psychological distress, as his press secretary Bill Moyers described in an interview summarized in a biography of Johnson:
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Figure 2. Lady Bird Johnson and President Lyndon B. Johnson at their ranch.
Bill Moyers described Johnson to me as not only paranoid but deeply depressed. Even in the best of times Moyers remembers Johnson as given to paranoid outbursts and depressive reactions. But it was “never more pronounced than in 1965 when he was leading up to the decision about the buildup in Vietnam.” Moyers attributes it to “the realization about which he was clearer than anyone that this was a road from which there was no turning back.” “Johnson saw the decision to send in troops as marking the potential demise or ‘end of his presidency’… It was a pronounced, prolonged depression,” Moyer adds. “He would just go within himself, just disappear--morose, self-pitying, angry… He was a tormented man,” who described himself to Moyers as in a Louisiana swamp “that’s pulling me down.” When he said it, Moyers remembers he was lying in bed with the covers almost pulled above his head. (Dallek, 1998)
Johnson’s speech writer Richard Goodwin shared similar concerns. Independently of one another, the President’s two close confidants sought out three psychiatrists to discuss the President’s conduct. They learned they had reason to be concerned but were unwilling to bring their concerns directly to the President. Per a politico article on this topic, “No documentation has been released to suggest that Kennedy’s successor got treatment for mental illness.” (Thompson, 2015)
He may have feared public reaction to the knowledge that the Commander in Chief was seeking psychiatric care. Perhaps such a relegation would have led for calls for him to resign. Did he have reason to be concerned? Unfortunately, yes. In the summer of 1972, George McGovern was the insurgent candidate for the Democratic nomination. His selection was not assured by the time of the quickly approaching convention, and he had not yet selected a running-mate. McGovern preferred Ted Kennedy, who turned him down more than once, and began making his way down a list of alternate candidates for Vice President (VP). He selected Thomas Eagleton, the Missouri Senator, based on his ability to help win over Catholics to his ticket. In 1972, it was not standard practice to do intensive digging into the prospective VP’s background. Within days of making the announcement, the campaign learned of Eagleton’s history of depression, with three prior hospitalizations and electroconvulsive therapy. Eagleton addressed these questions head on, speaking openly about his history of mental illness, specifically his tendency to push himself too far and work too hard. (Staff, 2012)
To no avail, as both sides of the aisle immediately called for him to leave the ticket. McGovern initially attempted to stick with Eagleton, but as he began to drop in the polls, he quickly reversed stance. Only 18 days after being selected to be the Democratic nominee for Vice President did Thomas Eagleton withdraw his candidacy.
This historical context leaves us with a lingering question: have we made any progress towards destigmatizing mental health treatment for world leaders in the last 50 years? No President since has reported engaging in any type of psychological treatment. While the pressures of the job for world leaders continue to mount, it is hard to imagine that increasing communication, scale of economies, and military threats have lessened the burdens associated with running a nation. The stigma of mental health care has seemingly improved overall, and a greater portion of the public than ever is engaged in some form of mental healthcare. (Olfson et al., 2014) Why, then, are we still reluctant to accept the notion that our world leaders, who have arguably the hardest jobs on the planet, should have access to care? With our improved understanding of the mind-body continuum and the endless potential psychosocial risk factors associated with political leadership, why should we only focus on physical health? These concepts are worth exploring, as the psychological health of leaders seems to be of equal importance. Perhaps we should continue to study history, even brutal societies and leaders of the past, like Ludendorff, and translate meaningful lessons learned to our present and future.