Saturday, March 12, 2016

The Goldwater Rule and Political Commentary

The New York Times recently ran an opinion piece by Robert Klitzman, MD on "Should Therapists Analyze Presidential Candidates?"  He provided a good review of the Goldwater Rule, that was put in place after an embarrassing poll of psychiatrists decided that Barry Goldwater was not fit to be president of the United States.  I did not hear much about psychiatrists during the 1964 Presidential election because I was in the eighth grade at the time.  Our civics class was engaged in a detailed version of Risk that allowed us to rule different countries and act like world leaders.  It was the height of the Cold War.  There were a couple of buildings in town that were designated fallout shelters.  In those days there were announcements about nuclear tests and when the radiation cloud would be passing over town.   As a kid, I can remember thinking that nuclear war was imminent and the government was trying to send us the message that it was survivable.  I did not realize that was propaganda until at least a decade later.  The Johnson campaign was able to capitalize on that zeitgeist with the famous attack ad at the top of this post.  It was an interesting ad because Senator Goldwater was never mentioned.  But the implications were very clear - elect Goldwater and there would be nuclear war.  Some political analysts believe that this was the first significant attack ad in American elections.  The reality of Barry Goldwater stood in contrast to the media portrayal.  He was in the Senate for 5 terms ending in 1987.

That was the context for the poll of psychiatrists by Fact magazine that concluded Goldwater was "psychologically unfit" to be president.  Dr. Klitzman lists a number of quotes from some of these psychiatrists and writes a very informative article on both the Goldwater Rule and subsequent modifications for the profiling of political leaders.  He cites the profiling of Saddam Hussein by Jerrold Post, MD, the first psychiatrist to develop expertise in this area.  He goes on to list a number of profiles of historical figures as well as non-psychiatrists in the news who do not hesitate to offer diagnoses of political figures or criminals who they have never personally examined.  Senator Goldwater sued Fact magazine and was awarded damages but that happened 3 years after the election was over.  The American Psychiatric Association rewrote a section of the ethics manual that became known as the Goldwater Rule in response to the Fact magazine poll.

The Goldwater Rule is technically a section in The Principles of Medical Ethics With Annotations Especially Applicable to Psychiatry.  Here is the section copied directly from that manual:

Section 7.3
On occasion psychiatrists are asked for an opinion about an individual who is in the light of public attention or who has disclosed information about himself/herself through public media. In such circumstances, a psychiatrist may share with the public his or her expertise about psychiatric issues in general. However, it is unethical for a psychiatrist to offer a professional opinion unless he or she has conducted an examination and has been granted proper authorization for such a statement.

There have been a lot of debates about how the rule should be reworked so that psychiatrists can share their expertise with the public.  The rule as it is written seems to depend on the lack of an examination or a release ruling out the public presentation by a psychiatrist.  I would not have a problem with the section being written to say that psychiatrists should never offer an opinion in the media about a person of interest and it all comes down to conflict of interest considerations.  Commenting on national television is a case in point.  There seems to be no shortage of therapists who seem quite willing to present their analysis of body language or speculation about diagnoses in the absence of any examination of the patient.  Psychiatrists should not engage in this activity, because it is basically speculation and not based on any scientific or clinincal method.  Assuming the psychiatrist has conducted an examination, the issue of authorization looms large in the rule.  Should a psychiatrist ask a patient for a release just to present their diagnosis or formulation to the public?  I don't think so.  The only leeway I am willing to grant is for research purposes as authorized by an Institutional Review Board using deidentified data.  An interested public or media representatives does not come close to the threshold for maintaining confidentiality.  Any psychiatrist knows that reporters do not want general statements about mental illness or psychiatric disorders, even if they present their proposal like that in the first place.  Once the interview starts, they want speculation about the person of interest and that should be unacceptable for psychiatrists.

There is the potential case of a person who may really want this information out in the media and I would question that intent if there was an active legal case.  Would the psychiatrist be getting the authorization as part of a larger legal strategy to get favorable public opinion?  I do think that commenting on stories that are already out in the press, and making a point about those stories is perfectly acceptable.  I have done that here on this blog, pointing out that I have no personal knowledge of the person involved or their psychiatric diagnosis, but that the issue has broad implications for the field and therefore merits discussion.  The commentary here has been about Greyhound therapy and the way that violence and aggression are approached in community and state hospitals.

The context is important.  Psychiatrists are trained to operate in a very specific environment.  They are supposed to determine who has significant mental illness and then treat those people in hospital and clinic settings.  Those methods are not generally applicable to people who don't have mental disorders.  This is a limitation of psychiatry that most people don't understand.  In the absence of clear biological markers, psychiatric disorders are defined as conditions that cause impairment in academic, family or personal life.  Many of the politicians in this case (including Senator Goldwater) had no such impairment.  The comments presented about him were essentially another version of an attack ad.  There was no reason to suggest he had any diagnosable condition and the other technical terms used are even more vague in the absence of a clearly defined disorder or problem.

The technical jargon used by psychiatrists is generally meaningless to the public.   Terms that I hear quite a lot of these days include narcissism, psychopathy, and even antisocial personality disorder.  I can imagine that the next step of interested viewers is to look up the "criteria" for these traits or diagnoses online.  When looking them up, the same mistake is duplicated - the viewer is reading words on a page describing an experience they have never experienced.  A significant number of viewers will conclude that they may have the same problem or at least they know a lot of family members and coworkers who do.  Making all of this jargon readily available has been a greater disservice than a service to the public.  

And finally, at least in the case of Goldwater - the fact that most psychiatrists are Democrats cannot be ignored.  The last time I heard any analysis of this point psychiatrists were described as the only medical speciality that was predominantly Democrats.  From listening to the political commentary of some of my colleagues,  psychiatrists are no more immune to standard political biases or rhetoric than the average person.  It is a major problem to have a conservative Republican analyzed by the political opposition.  That should be an obvious point but I don't see any of the pundits these days disclosing their political affiliations.      

Psychiatry is a medical speciality that is meant to be practiced like all other branches of medicine - behind closed doors.  Medicine is supposed to be practiced for the benefit of the patient and not the physician.

We should never lose sight of that.

George Dawson, MD, DLFAPA


1:  Robert Klitzman.  Should Therapists Analyze Presidential Candidates?  New York Times.  March 7, 2016.

2:  R. Ginzburg (ed).  1,189 Psychiatrists Say Goldwater Is Psychologically Unfit To Be President.  Fact Special Issue; September-October 1964; pp 24-64.


Not a Democrat or Republican.  I will leave it at that.

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