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The silencing of psychiatry: is the Goldwater rule doing more harm than good ahead of the US 2020 election?

How a rule intended to curb speculation about political leaders’ mental health has left many psychiatrists questioning their professional body.

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In an electoral contest featuring two septuagenarian candidates and three and a half years into the term of an emotionally volatile president, questions of mental health and acuity loom large. As the election nears its final stretch, these questions are becoming increasingly urgent. But those who could best answer them are forced to sit largely on the sidelines.

The origin of this odd state of affairs dates back 47 years to the implementation of an oft-cited but frequently misinterpreted stricture known as the “Goldwater rule”. Matters were complicated, however, by a sequence of events that began with Donald Trump’s election and culminated in the resignation of several long-time members of psychiatry’s largest professional body. In between was a contentious battle over the role of mental health experts in public discourse. The end result has left the public dangerously ill equipped to understand the mental state of their political leaders.

The Goldwater rule refers to Section 7 of the American Psychiatric Association (APA)’s Principles of Medical Ethics, which says it is unethical for psychiatrists to opine on public figures they have not examined in person. It was created in 1973 in reaction to a fiasco involving the presidential election a decade prior when Fact magazine published the results of an informal poll of psychiatrists which, it claimed, found that over 1200 believed the Republican candidate Barry Goldwater to be psychologically unfit to be president. Goldwater, who lost the election in a landslide, successfully sued the magazine for libel. At the time, the case showed the dangers of reckless speculation about mental health.

Today, there are other questions as to how well the rule has stood the test of time. In the 1960s and 70s there was only so much public material to draw on to make an assessment of a public figure’s mental health; now there are endless reels. An expert can watch hundreds of hours of footage of high-profile people and review hundreds of pages of their written words. Neurologists can observe physical movements and patterns of speech — and track changes over time. A psychiatrist can observe behavioural patterns, actions and words, and take into account what others close to the figure say about how they behave.

The public can observe all these things too, but does so largely without translation or explanation by actual experts. And so what was written as a rule to curb speculation has, in fact, allowed it to run rampant.

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Rather than reform the Goldwater rule, though, in the Trump era, the APA, which has more than 38,000 members, has not only stuck firmly by the policy but, arguably, given it new teeth. In an ethics committee opinion released in March 2017, the APA “reaffirmed the existing policy” and also added further explanations and clarifications that took a highly restrictive slant. According to the new guidance, not only was diagnosing a non-patient unethical, so was commenting on the mental health of a public figure for nearly any reason.

The APA insists it was merely reiterating its existing stance. But many members saw it as a de facto gag rule. One former member who resigned in protest says they “didn't feel [the updated guidance] was legitimate,” but feared that if there were an ethics complaint filed against them then it would be “very painful for me personally and professionally”.

The effect is particularly chilling on early to mid-career professionals, for whom falling afoul of the APA or receiving an ethics complaint could be career-ending. It’s why those who have been most outspoken tend to be late-career, well established, not reliant on federal research funding — or just too outraged to care. “Expert voices have been very deliberately and dangerously silenced,” says Dr Bandy X Lee, a clinical faculty member in psychiatry and law at Yale University. “The detriment to the public’s health is obvious.”

A specialist in violence prevention, Dr Lee saw in Trump glaring red flags — all the signs of a dangerous personality — and felt it important to share her findings, especially after her meeting with more than 50 Congress members brought little result. She has warned that someone with Trump’s psychological profile holding a powerful office was an all-out national emergency. She forecast possible mass deaths, and says the handling of the pandemic has claimed an overwhelming majority of the loss of some 200,000 American lives. She edited The Dangerous Case of Donald Trump, a book of essays from more than two dozen mental health professionals warning that Trump suffers from psychological problems that make him dangerous as a leader. Published in October 2017, the book instantly hit the New York Times bestseller list.

Dr Leonard Glass, an associate clinical professor of psychiatry at Harvard Medical School and a senior attending psychiatrist at McLean Hospital in Massachusetts, is among the contributors to Lee’s book. “We felt we were on very solid professional grounds, making a statement about fitness based on the multitude of public documents available from Donald Trump and the reports of people who had worked closely with him.”

The backlash from peers was swift and furious, however. “We were accused of armchair psychiatry, we were described as being akin to Nazi and Soviet era psychiatrists who collaborated with totalitarian states,” says Dr Glass. But, Glass said, they were not trying to help expand state power; on the contrary, they were critiquing it.

Glass wrote to the APA asking that it rescind its updates to the Goldwater rule. This led to an ultimately fruitless negotiation with the organisation’s ethics committee over his suggestions. When those discussions went nowhere, he resigned his Distinguished Life Fellowship and withdrew from the organisation. “I could [hold off on publishing my views], or leave the organisation and be free to follow my conscience. So that's what I did,” he says. “Are we respect-worthy doctoral-level mental health professionals, or are we unregulated children that you need to control with a gag order?”

Lee had already resigned from the APA some years before, over her concerns the organisation was too beholden to pharmaceutical interests. But even if the rule did not impact her, the shaping of perceptions by the APA’s public campaigns hampered her and thousands of her colleagues' ability to get their message out, even if they were not APA members.

“Our concerns over the president’s mental health were the number one topic of national conversation two and a half years ago. And then the APA stepped in. And within weeks, all the news inquiries stopped, and it has stayed that way since,” she says.

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Critics of the APA see its reluctance to take a position on the president’s fitness to rule rooted more in self-interest than any ethical stance. Many livelihoods are at stake in an organisation with a sizeable budget which includes $20,132,328 in salaries paid to 225 employees (38 per cent of the APA’s overall operating expenses), according to its 2018 tax returns. And further scrutiny of executive salaries shows that from 2011 to 2018, officers, directors, trustees and key employees within the organisation saw their collective salaries almost double in that period from $1,574,404 to $3,041,520.

Though federal funding remains low in relation to overall revenue ($1,183,112 in government grants for an organisation with a revenue of $59,957,467 for the 2018 tax year), many of the board of trustees, prominent in their various psychiatric specialisms, rely on government funding for their research projects within large public institutions. Any rupture with the federal government may threaten this revenue stream. “You wouldn’t want to get on the wrong side of any administration let alone such a vindictive one,” says the former member who wished to remain anonymous for fear of reprisals.

When approached, the APA was reluctant to provide any further clarification on whether the Goldwater rule is still fit for purpose in today’s media environment, instead just reiterating that the 2017 guidance was simply a reaffirmation of a consistent ethical approach which has stood within the organisation for decades. Furthermore, when asked about a psychiatrist’s public duty to warn, the organisation says this ethical guideline has been misunderstood and only applies to a patient under a doctor’s care who is in imminent danger and never to someone observed at a distance.

Lee counters: "The purpose of the Goldwater rule was to protect public health. It was never supposed to protect a public figure at the expense of public health.”

Nor is Lee alone in believing that the Goldwater rule is being misused. In a 2016 paper entitled, "The Ethics of APA’s Goldwater Rule" which was published by the Journal of the American Academy of Psychiatry and the Law, authors Dr. Claire Pouncey and Dr Jerome Kroll assert that the Goldwater rule was an excessive response by the APA to what was clearly an inflammatory and embarrassing moment for American psychiatry, concluding that embarrassing the profession simply violates etiquette rather than ethics.

The authors go further in claiming that by privileging the professional reputation of psychiatry above all other considerations, the Goldwater rule itself becomes unethical when it leads to suppression of public discourse around potentially dangerous public figures. They also find little empirical evidence to support the APA’s restrictive claim that only personal examination can lead to a valid diagnosis and point out that “the Goldwater rule cannot distinguish between thoughtful and well-researched psychiatric commentary on public figures and flippant sound bites about celebrities and politicians”.

Dr. John Martin-Joy, a psychiatrist in private practice in Cambridge, Massachusetts, and author of the book Diagnosing From a Distance, a study of the ethics of the Goldwater rule published this year, objects to the APA’s one-size-fits-all guidance. He sees the organisation’s refusal to allow individual psychiatrists' discretion about commenting on public figures as “coercive paternalism”. At its worst, the Goldwater rule becomes dangerous when viewed through this paternalistic lens because of its tendency to oversimplify a complicated ethical dilemma, thus painting thoughtful members as ethical violators, and at best is open to misinterpretation, he says. “The actual text of the Goldwater rule hasn’t changed since 1975 but the way it was written was extremely confusing.”

Martin-Joy views the 2017 APA ethics committee review of the edict not so much as a doubling-down but rather an effort to clarify what many had viewed as unclear opinions and a progressive loosening of the rules by the APA ethics committee interpretations in 2008 and 2015. The current rule still leaves room for interpretation with certain exceptions which require permission by a court or the US government in the broad areas of forensic psychiatry, national security and diagnosis in insurance company decisions for example  so why then would an exception not be made, asks Martin-Joy in his book, for individuals psychiatrists concerned about the impact of a president’s mental health on national safety?

Instead, Martin-Joy favours an alternative approach that the American Psychoanalytic Association — a separate association — developed in the 1960s. While acknowledging the risks associated with diagnosing a public figure, often in the midst of a highly charged political media environment, Martin-Joy — who is a member of both the American Psychiatric Association and the American Psychoanalytic Association — says: “An individual [psychoanalyst] can take account of those issues but may decide to go ahead anyway if circumstances warrant it.”

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Even amongst the dissenters of the psychiatric association’s approach, however, there is a broad spectrum of opinion. When it comes to sounding the alarm about Trump in particular there is disagreement on where the line should be drawn, what the focus should be and what language should be used. To some degree this is based on each person’s particular field of expertise.

According to Dr John Talmadge, a Texas-based psychiatrist in private practice and retired professor of psychiatry, “Books and articles about Trump’s childhood, his personality, etc, that’s beside the point. You have a president with brain damage.”

Yet others prefer to avoid diagnostic labels altogether, focusing instead on what Trump says and does rather than what he might be thinking or what state his brain might be in. Observing and highlighting dangerous behaviour does not amount to medically diagnosing someone, such experts point out. For Glass, the aim is to speak in terms of fitness to serve. “I avoid talking about mental health because it’s a broad brush and carries the implication that people with mental disorders can’t serve admirably and that’s simply not something that I believe and don’t want my message confused,” he says.

Dr Prudence L. Gourguechon, a psychiatrist and past dean of the Chicago Psychoanalytic Institute, and among those who left the APA due to its recent Goldwater stance, comes at it from a similar perspective. “Behaviour and sequences of events I feel comfortable talking about. I can observe it. What I try to avoid as much as I can, is any excessive speculation about his internal mental life. I think all that stuff about malignant narcissism or more recently dementia is really distracting,” she says, arguing that such labels allow Trump supporters to dismiss both the charges and their own observations about the president’s behaviour.

She treads a careful line on mental acuity. “Cognitive decline is an overarching phrase and implies we know what his previous level was,” she says. “But if you see evidence of impaired judgement, if you see inability to understand or disregard for consequences of actions or social norms, you can talk about those.”

The term “diagnose” is central to the debate, but is often misused. A medical diagnosis relates to a patient under a doctor’s care and forms the basis for a treatment plan. It is based on an examination, often on laboratory tests and interviews with the patient and potentially close family members. Pointing out that something disturbing might be going on with the president psychologically or neurologically is not per se a diagnosis. “I know the public often thinks of whatever a doctor does is a diagnosis but we diagnose only a fraction of the time,” says Lee. “Assessments of danger, on the other hand, are central to current mental health practice."

Glass says it’s important to distinguish between making a judgment call on fitness for the role of president and making anything that sounds like a diagnosis. The former is appropriate in his view, the latter is not. “It might seem like a splitting of hairs to talk about fitness as opposed to diagnosis. But there's a good professional reason for distinguishing between the two,” he says.

“I am drawing a bright distinction between my relationship to Donald Trump if he were my patient, which he isn't, versus my relationship to Donald Trump as my president,” says Glass. “He is not my patient. I don't have to get his authorization to speak about him.”

Dr James Merikangas, a neurologist and clinical professor of psychiatry and behavioral sciences at George Washington University, says it is possible to do what is known as a differential diagnosis on a public figure. “There is a clinical method for it,” he says.

This involves listing the different possible causes of an issue, usually in a priority of most common to least common, most likely to least likely, or most dangerous to least dangerous. He believes it is possible to do this type of assessment through observation. A neurologist, he says, would look at how a person walks, gets up, and balances. And doing so in Trump’s case “shows that his neurological condition should be investigated”.

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For all the parsing of medical semantics and ethics — important though they may be — there is also a philosophical question at stake regarding tolerance for egregious behaviour, whatever its cause may be. If something has broken and changed, perhaps it is in the public psyche and its tolerance for presidential behaviour that only a few short years ago would have been considered completely beyond the pale.

It’s unclear whether mental health professionals being unleashed would even move the needle much in the current polarised political climate. George Shipley, a veteran Democratic strategist, believes the issue is a non-starter on the campaign trail. “Americans have no contact, unless it’s in the family, with mental illness,” he says. “The country is so polarised now. It won’t really move any votes.”

Former White House communications director Anthony Scaramucci believes talk of Trump’s mental health is a needless distraction and urges a focus on policy and character instead. “I have never been in the dementia camp,” he tells New Statesman, with regards to discussion around Trump. “I want to argue policy and lack of presidential style, lack of empathy, divisiveness. I want to provide an objective set of criteria, I want to evaluate him as a political executive who arguably has one of the most important if not the most important roles in our civilisation, and I want to go down the list of qualifications and say ‘I’m sorry, he’s not fit to serve in that role’.”

Gourguechon also argues that the Goldwater rule is of secondary concern, the primary being the public’s acceptance of Trump’s words and actions in the first place. “We can all shout and say ‘oh my god, Trump’s got a narcissistic personality disorder!’ But so do most politicians to one degree or another. The question is, why is deviant behaviour or inadequate decision making tolerated? Why are so many people comfortable with dangerous limitations in executive functioning? If people want to see it, it’s there,” she says.

“This whole idea that therapists and psychiatrists are quiet or not quiet is really not the point. The point is, why is it tolerated? It's right in front of everybody.”

Additional reporting by Lara Williams

Courtney Fingar is editor-in-chief of Investment Monitor, a New Statesman Media Group publication.