Should mental health professionals be allowed to comment on the psychological state of public figures? An analysis of APA's Goldwater Rule

When, if ever, should mental health experts be allowed to offer their professional opinions regarding the psychological state of a public figure without having examined them personally? (Lilienfeld O.S., Miller J. D. &Lynam D.R. 2018) This question was a source of controversy during the 1964 U.S. Presidential elections when Fact Magazine founded by Ginzburg and Boronson published a special article titled ‘Goldwater, the Man and the Menace’ and dedicated 38 pages of psychiatric comments about the mental health of Barry Goldwater, a Republican Presidential Nominee at that time. The cover of the magazine proclaimed, ‘1189 Psychiatrists affiliated with the American Psychological Association say Goldwater is Psychologically Unfit to be President’. It is only after this defamation case that the APA took a formal stance on this question by adopting the Goldwater Rule under section 7 of APA’s Principles of Medical Ethics. This rule prohibits psychiatrists from making statements regarding the psychological state of public figures in a professional capacity, with the larger objective of regulating the kind of information being advocated by the psychiatric community and to prevent psycho-babble from infesting psychological discourse (APA Ethics Code, 2003). In this essay, I seek to establish the importance of this rule by describing the necessity of a direct personal examination of the patient by the professional, its importance in safeguarding the repute of the profession, and lack of validity for ‘diagnoses at a distance’ which is based on psycho-history (using retrospective analyses). Before that, however, I will establish the relevance of this topic in the current global context. 

In the wake of the 2016 U.S. Presidential elections, media houses claimed that Donald Trump was afflicted by Narcissistic Personality Disorder and therefore, unfit for assuming office. Three psychiatrists- Judith Herman, Natalie Gatrell (Harvard University) and Dee Mosbacher (University of California, San Francisco) wrote a letter to President Obama requesting a formal psychiatric examination of the President elect (Lilienfeld O.S., Miller J. D. &Lynam D.R. 2018). John Gartner, a psychologist at Johns Hopkins University, told U.S. Newsthat Trump suffered from ‘malignant narcissism’ and that he was mentally ill and temperamentally unstable to become president. Such statements are problematic at several levels. Not only do they trivialize mental illness, but they also conflate unacceptable behaviour with mental illness reinforcing stigma which prevents inclusion of the mentally ill (Frances, 2017). The intent of these statements is not discernible and they could be motivated by political malice rather than the desire to keep the masses informed (Applebaum, 2017). Personally, I believe that mental health professionals should not diagnose public figures with psychiatric disorders, to restrict the creation of unhealthy narratives which politicize mental health such as in the examples given above. This personal belief stems from the reasons described below. 

Firstly, in-person interviews are considered the gold standard for psychiatric diagnoses and treatment (Pierre, 2016). In his op-ed in the New York Times, Robert Klitzman, a professor and psychiatrist at Columbia University supports this view by clearly stating that assessing patients face to face is essential. He believes that establishing a rapport with patients is key in understanding the roots of their illness and making an accurate diagnosis (2016). Friedman (2008) also believes that an accurate diagnosis is not possible without a face to face examination. In an interview with National Public Radio, Applebaum, a leading American psychiatrist argues that without prolonged interaction with the individual, it is impossible to tap into the deep recesses of their mind or figure out patterns in their thoughts and behaviors which are both preconditions to understanding their illness (2017). Observing an individual’s behaviour in public is not sufficient for psychiatric diagnosis. It could be that the individual is simply using techniques of impression management to project themselves in a certain way, without being dysfunctional in any capacity (Applebaum, 2017). 

Thus, there are many problems associated with ‘diagnoses at a distance’. Diagnoses at a distance is based on psycho history (interpretation of historical or political events and figures using psychological theory). Psycho-historical accounts are generated using retrospective analysis, which has been criticized because of susceptibility of the analyst to hindsight bias (which is the tendency to have predicted an outcome after analyses). Psycho-historical analyses has acquired an ‘un-scientific’ connotation and is often compared to Freudian theory (Lilienfeld O.S., Miller J. D. &Lynam D.R. 2018). Claims made using this method are low on validity. Hence, when relying on psychohistory, individuals must make no attempt at formally diagnosing the patient. The terms ‘psycho-history’ and ‘psychiatric diagnosis’ must not be used interchangeably as that misguides the audience. An example of misguidance occurred when Jerrold Post, violated the rule by constructing a psychiatric profile of Sadam Hussein. He was condemned by several of his contemporaries for this. It is only after he received criticism did he clarify that his aim was to make a “political personality profile” on Sadam Hussein, for the benefit of the US Congress, not to make a formal diagnosis (Post J. 1990). 

Flippant statements made by mental health professionals tarnish the reputation of the entire field. In response to statements regarding metal health of President Trump and Hilary Clinton, Maria Oquendo (President of the APA, 2016-2017) wrote that offering such opinions compromises the integrity of the mental health profession as a whole (Lilienfeld O.S., Miller J. D. &Lynam D.R. 2018). In an online article, she mentioned that laypersons already view psychiatry and psychology with skepticism. Therefore, using mental illness terminology loosely would exacerbate their skepticism (Ferguson, 2015). Allen Frances, chair of DSM-IV (APA, 1994) also denounced psychiatric name calling. Many prominent individuals are in support of this rule, as it curtails the use of careless remarks. But, it has also been condemned for a number of reasons. Critics claim that this reduces public education about mental illness. However, education about mental illness need not be related to a particular public figure but about the illness itself. Another criticism is that if mental health professionals do not comment on the mental health status of popular figures, un-informed individuals will do so. In that respect, perhaps an independent consensus panel can be set-up to debunk such uniformed claims. There is scope for further analysis of the rule to make it more useful in combatting unhealthy narratives which associate undesirable behaviour and mental illness and to ensure ethical psychological practices. 

References 

Ethical Principles of Psychologists and Code of Conduct (2003). Retrieved from https://www.apa.org/ethics/code

Applebaum, P.S. (2017). Reflections on the Goldwater Rule. J Am Acad Psychiatry Law, 45 (2), 228-232. Retrieved from https://pdfs.semanticscholar.org/256d/21cca8b3a350801e45d6497ac6e7c927bc9b.pdf

Friedman, R. A. (2008) Role of Physicians and Mental Health Professionals in Discussions of Public Figures. Journal of the American Medical Association. 

doi: https://scholar.google.co.in/scholar?hl=en&as_sdt=0,5&q=Friedman,R.A.

Lilienfeld, S. O., Miller, J.D., & Lynman D. R. (2017). The Goldwater Rule: Perspectives From, and Implications for, Psychological Science. SAGE Journals. Retrieved on 19 March 2019 from https://journals.sagepub.com/doi/abs/10.1177/1745691617727864

Pierre, J. (2016). Goldwater 2016: Are psychiatrists’ opinions of Trump rigged? [Web Blog Post]

Post, J. M. (2015). Ethical Considerations in psychiatric profiling of political figures. Psychiatric Clinics, 25 (3). https://www.psych.theclinics.com/article/S0193-953X(02)00011-4/abstract