American Democracy is at Best A Semi-Rational Process

 

“Political language … is designed to make lies sound truthful and murder respectable, and to give an appearance of solidity to pure wind.”  George Orwell in Politics and the English Language, 1946.

 

In the closing month of the federal election for President, I think it is useful to consider my previous comments on the Goldwater Rule and Does the Insurrection End The Debate on the Goldwater Rule.  The rule was promulgated by the American Psychiatric Association to prevent casual comments about psychiatric diagnoses of candidates when they had not been examined and given permission for those diagnostic evaluations.

I have always been in favor of this rule largely because it is outside the scope of psychiatric practice and like many forensic settings there can be a prominent conflict of interest based on political affiliations.  It also turns the diagnostic process on its head in that it is no longer used for the benefit of the patient, but the benefit or lack of benefit falls to third parties.  And finally, whenever psychiatric diagnosis is used in the press or other forms of common usage they lose their real meaning. They are no longer useful observations but, in many cases, become ad hominem attacks.

I have not counted the number of comments about narcissistic personality disorder, but it has grown significantly since the 2020 Presidential election and several commentaries that Trump had that disorder.  Antisocial personality disorder and psychopathy (a trait rather than a formal disorder) have also been used to describe him.  Since the terms became more visible, they have been widely applied.  You Tube and TikTok videos suggest how to make the diagnosis yourself or at least recognize it.  They describe typical speech patterns and how you should respond.  Many describe the red flags.  After watching this material none of it seems useful to a psychiatrist who makes the diagnosis and provides treatment. 

There seems to be a significant overlap with people who are difficult to get along with – often in asymmetrical roles like employer-employee.  Do the conflicts that typically happen in these situations rise to the level of a psychiatric diagnosis?  Do conflicts and misunderstanding that occur in other interpersonal relationships rise to that level? Probably not.  But there is a whole lot of videos encouraging people to make that diagnosis.   

The original arguments for making a psychiatric diagnosis on former President Trump were basically threefold.  First, that it was a professional obligation.  Psychiatrists were obliged to warn the American people about the dangers of any diagnosis basically as a public service.  There are several problems with that approach – the most significant being that diagnoses are associated with a wide range of behavior of varying severity and not predictive of anything specific.  It is unlikely that any diagnosis would have predicted the wide variety of significant problems that Trump exhibited following the election. The other problem of course is that it removes the Constitutional threshold for action by the Cabinet and replaces it with a much lower threshold – the psychiatric diagnosis.  It is basically the reason why people do not undergo civil commitment or guardianship proceedings based on a diagnosis.  The law requires obvious behavior that can be observed by any lay person. The 25^th Amendment standard is “ a written declaration that the President is unable to discharge the powers and duties of his office” from either the President himself or a “majority of either the principal officers of the executive department or of such other body as Congress…”  The determination is strictly based on lay observation and not medical or psychiatric evaluations.  Second that it provided additional information for voters that they could use in making their decision.  And finally, the somewhat grandiose assumption that it may be a superior method than the judgment of officials mentioned in the 25^th Amendment. All of those assumptions have failed at multiple levels.

Rather than be concerned about Trump’s diagnosis this may be a question of voter capacity or competence.  In other words, is the voter using available information to make a rational choice?  And can the available information be analyzed rationally?  That requires more than just stating a preference.  It requires a rationale for casting the vote. This is also a difficult measure because there is a value system baked in to some of these decisions.  For example, some votes are based on single issues or traditions like always voting for members of a certain party. Some votes are based on issues like abortion, guns, and censorship even when it is clear the results have been worsening medical care for women, gun extremism, and book banning that includes shutting down some school libraries. The value system can also include extremism like guns, racism and antisemitism.  Even though most reasonable people would agree those values have no place in modern society – they do not disqualify people who value those ideas and vote on that basis.  All of this illustrates why voting is a semi-rational process. On that basis you can also ignore all the negatives that members of the same party or Cabinet say about a candidate’s intellect and character.

The only inconsistency in the law that occurs is that capacity to vote is considered in guardianship and conservatorship decisions by the court.  In my experience I have seen the county forms, but in the hundreds of assessments that I have done – capacity or competency to vote was never a dimension that I commented on.  Associated capacities for entering marriage and contracts were also typically listed but not commented on.  In practice it may be that people who are under guardianship or conservatorship are not offered a trip to the polls or a contract but I cannot say for sure.

The polls themselves handle the issue like everything else in the law and politics as a contentious issue.  For example, these are direct quotes from Minnesota Statutes regarding election procedures:

“Mental capacity is a question of fact for judges of election.” Op. 82, Atty. Gen. Rep. 1942, October 22, 1942.  p. 26

and

“Provision of Minnesota Constitution prohibiting a person under guardianship from voting at any election in the state did not violate the Equal Protection

Clauses of the U.S. and Minnesota Constitutions, since pursuant to Minnesota statute, persons under guardianship were presumed to retain the right to vote, and the constitutional prohibition against voting based on guardianship status applied only when there had been an individualized judicial finding of incapacity to vote. Minnesota Voters Alliance v. Ritchie, 890 F. Supp.2d 1106 (D. Minn. 2012).”  p. 43

The county auditor shall mail a notice indicating the person's name, address, precinct, and polling place to any registered voter whose civil rights have been restored after a felony conviction; who has been removed from under a guardianship of the person under which the person did not retain the right to vote; or who has been restored to capacity by the court after being ineligible to vote. The notice must require that it be returned if not deliverable”.  P. 386

I have never heard of a single situation where an election judge challenged a voter based on their mental capacity and do not understand how that would happen unless they were exhibiting signs of severe mental illness and were disruptive.

All these considerations point to the fact that voting and politics in the United States and elsewhere is a semi-rational process.  It was designed that way by the founders.  There are minimal qualifications to run for office - basically age, citizenship, and in some cases residency requirements. It is interesting that you cannot vote in many states if you are convicted of a felony but that does not disqualify you from running for President.  The top issues for most voters are not rational decisions.  I wrote a recent post on the fact that the President has little to do with the economy and an academic analysis showing Democrats were much better for the economy could not be explained rationally. That type of analysis can be applied to any of the top issues that voters are considering. There is one candidate who has been severely criticized for intellectual and character defects that include ignoring an attempt to overthrow the US government, lying for 4 years about an election outcome, lying more recently about disaster relief, and being convicted of multiple felonies. A significant number of voters and politicians in his own party elect to ignore these facts.  On the other hand members of his own party have endorsed the opposition candidate and actively campaigned for her. Forty of 44 cabinet and staff members of his own administration have said he should never be in the White House again.

This election exposes all the ugliness of American democracy that was previously not discussed.  All it took was a candidate who was more focused on himself and a few people at the highest income levels, disingenuous antiestablishment rhetoric, a lot of name calling, and some active obstructionism to real solutions.

My guess is the Founders of the Republic – did not see that coming.   

 

George Dawson, MD, DFAPA

 

References:

1:  2024 MINNESOTA ELECTION LAWS Office of the Minnesota Secretary of State, Elections Division. Annotations provided by Minnesota Attorney General.  Accessed on October 11, 2024.  https://www.sos.state.mn.us/media/5067/minnesota-election-laws-statutes-and-rules.pdf

 

Graphics Credit:

1:  Trump Photo:  Gage Skidmore from Surprise, AZ, United States of America, CC BY-SA 2.0 <https://creativecommons.org/licenses/by-sa/2.0>, via Wikimedia Commons" https://commons.wikimedia.org/wiki/File:Donald_Trump_(52250930172)_(cropped).jpg

2:  Harris Photo:  Lawrence Jackson, Kamala Harris Vice Presidential Portrait.  Public domain, via Wikimedia Commons" https://commons.wikimedia.org/wiki/File:Kamala_Harris_Vice_Presidential_Portrait.jpg

 

Does the Insurrection End the Debate on the Goldwater Rule?

 

I think it does and both sides lose.

As a refresher take a look at my earlier comments on the Goldwater Rule at this link.  More briefly, the Goldwater Rule was implemented by the American Psychiatric Association (APA) as ethical guidance to its members following an incident where a 1964 magazine survey of psychiatrists concluded that the Republican candidate Barry Goldwater was “psychologically unfit” to be President of the United States.  As you can see from the ad in this previous post, there was a strong implication by the Lyndon Johnson campaign that a Goldwater presidency would put the country on a path to nuclear war.  Goldwater subsequently sued the magazine and was awarded damages – three years after he lost the election.

In the meantime, the APA included the following section in the Principles of Medical Ethics with Annotations Especially Applicable to Psychiatry.

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.

Since I wrote the original post, I have queried many colleagues who are also APA members and as far as I know no member has ever been sanctioned by the APA or any of its district branches for violating the Goldwater Rule.  There has been a lot of intense debate about it and that debate has never been as intense as during the recent Trump administration.  Beyond the debate there are unequivocal examples of psychiatrists ignoring the Goldwater Rule and, in some cases, criticizing the APA about it. The rhetoric extends to the point that the APA invented the rule because it was embarrassed about the original Goldwater incident and it was suppressing the free speech rights of its members who felt an ethical duty to use their skills to either warn or protect the United States from President Trump.  While some have found that rhetoric to be admirable, I do not. First, APA membership is completely voluntary and the obvious way to escape its long reach into First Amendment rights is to not be a member.  The predictable response to that suggestion is that all of the benefits of membership will be not be available and that might put non-members at a disadvantage.  Having been an APA member for over 30 years, I can attest to the fact that there are minimal advantages to being a member primarily as discounts to publications by the organization.  Even then, the American Medical Association (AMA) membership fee is much lower and includes free access to many more publications.

A second consideration is the context of what is happening.  In my previous post, I pointed out that psychiatrists are trained to assess problems in a particular context.  During years of training that comes down to a face-to-face discussion with the patient about problems that were either identified by the patient or someone else.  Collateral information is considered and that can be exhaustive. A diagnosis and problem formulation follows. Until the profiling of political leaders, criminals, and historical figures came into the scene in the past few decades there was no suggestion that psychiatrists could assess people at distance with any degree of accuracy. In fact, criminal profiling is generally done these days by trained law enforcement personnel suggesting that no psychiatric qualifications are necessary at all.  It all seems predicated on a folk psychology model that personality features and patterns of behavior are constant over time and dependent on past behavior. Some of the commentators on this issue have identified themselves as forensic psychiatrists. Forensic psychiatrists are paid to do even more exhaustive interviews and review of collateral information than clinical psychiatrists. They may take 15-20 hours to do an assessment compared with a clinical psychiatrist who probably has 60-90 minutes at the most. The idea that forensic psychiatrists endorse assessments at a distance seems even more incongruous to me.

Focusing only on the conclusory article (1) post insurrection it is clear why psychiatric opinion adds nothing to the political mix.  In the first paragraph, the authors conclude that Trump is “clearly mentally unbalanced and unable to grapple with a reality that threatens his inflated and fragile ego.”  They suggest that only reason that people would not believe their statement is that they ascribe his behavior to “puckish idiosyncrasy or creative disruption”.  That gives their statement way too much explanatory power. How about the obvious political considerations and Trump’s previous behavior as a businessman?  He is clearly a guy who is used to steamrolling over people and often uses the legal system to do it.  He demonstrated that in the primary and the debates.  He demonstrates it on a weekly basis toward anyone who he thinks is being disloyal – irrespective of their track record. He threw his Vice President under the bus for adhering to the Constitution that he was sworn to uphold. Who would describe that behavior as puckish?  Any objective observer would see that President Trump is a negative force and somebody that you do not want to deal with and hopefully would never be employed by. In political terms, he is an autocrat that deals in propaganda and he knows the power of propaganda. By definition, that is dangerous to any democratic republic but once again – it has nothing to do with psychiatry or the special training of psychiatrists.

The preamble in that conclusion: “clearly mentally unbalanced” is also rhetorical.  He has tens of millions of followers who all believe the propaganda. The authors themselves acknowledge that if Trump was a private citizen they would not be concerned and that their concern is only based on the fact that he was the President. This would be the first case of mental illness based on the condition of Presidency. The additional evidence in this article that Trump was “delusional”, “impulsive”, vengeance seeking, or “deranged” is non-existent and it can easily be argued that deficiency occurs as a direct result of not having personally examined him to ask him for direct explanations.   All of the examples cited are consistent with the behavior of a highly self-interested politician or businessman who will do anything to win. In the event that the authors have not noticed there are tens of thousands of these people walking around in American society. Possibly hundreds of thousands and none of them are being treated by psychiatrists.

The authors previous argument that they have an ethical responsibility to warn the public about Trump’s dangerousness based on a presumptive personality disorder falls apart under that scrutiny.  If there is no clear evidence of a diagnosis there seems to be no basis for the authors to base their actions on. Further Trump’s recent statement on the day of the insurrection and even since are no more radical than many of his colleagues or followers. Why are psychiatrists needed when there is nothing to base a professional opinion upon?

Early in the course of the Trump presidency, the issues arising with the Goldwater Rule were analyzed by Kroll and Pouncey (2).  After considering all of the variations their conclusion was that the Goldwater Rule was based on the need of the APA to prevent embarrassment to the profession by making statements similar to the statements made by psychiatrists during the original Goldwater controversy. That assumes that the APA as a guild is successful in preserving and promoting the interests of psychiatrists in the USA.  The track record there is very sketchy.  The APA and medicine in general has been completely unsuccessful in preserving a practice environment conducive to quality care.  At many levels it has facilitated that transition most notably by a near complete lack of opposition to managed care tactics and legislation and more recently collaborative care initiatives.  The APA has not been successful in advocating for patients with the most severe forms of mental illness. There has also not been any success in advocating for reasonable infrastructure to help the severely mentally ill avoid homelessness and incarceration. That string of failures is potentially more embarrassing than whether or not a few psychiatrists look foolish on the evening news.  I think there is an ethical basis for the Goldwater Rule that extends far beyond embarrassing the many by the few.

One of the key dimensions that I have not seen anyone comment one is that most psychiatrists are liberal Democrats. Psychiatry is the only medical specialty where that is true.  That is a clear bias when assessing a President from the opposite political party.

The insurrection itself clearly illustrates that psychiatric intervention in a Constitutional crisis is not possible or advisable.  I am basing that on the fact that for 25 years I participated in thousands of civil commitments, guardianships, and conservatorships.  I know all the legal requirements for these proceedings in both Minnesota and Wisconsin.  There is no court in any county in either state that would accept a legal proceeding against the President based on his current public behavior.  A typical argument against my position would say it is a utilitarian argument and therefore limited on those philosophical grounds. I don’t think it is at all.  If you are arguing that psychiatrists need to be involved, the question needs to be asked: “What for?”  The psychiatrists who have been the most vocal that President Trump is dangerous or irrational and, in some cases, claim that they are being stifled by the APA and the Goldwater Rule need to have an endpoint.  Every day psychiatric practice dictates that if you are seeing a dangerous individual you have to enact a plan to protect the patient and others. I don’t think that level of evidence exists – it certainly does not rise to the level of court intervention. The next step would be approaching members of Congress and asking for Impeachment or invoking the 25^th Amendment. They don’t need psychiatrists for that.  So what mysterious psychiatric intervention do the Goldwater Rule deniers want to see happen?  Should psychiatrists sitting in arm chairs call someone in the White House and tell them to remove the President based on his most recent outrageous statements?  That clearly would not work.  The concern that he has access to the nuclear briefcase also does not work. The evidence at this point is very clear, his cabinet had the opportunity to enact the 25^th Amendment and they declined.  Vice President Pence declined even after he was publicly berated by the President. Limits were set by the Department of Justice, the Joint Chiefs of Staff, social media companies, the National Guard and law enforcement on the ground.  President Trump had an unorthodox exit from the White House but he did leave.  Several days later the public was informed that he left a letter for President Biden.

The Republic survived without psychiatric intervention and none was indicated. The Goldwater Rule did not prevent some psychiatrists from making rhetorical statements from both the right and the left.  Nobody was sanctioned because from a practical standpoint it is ethical guidance – and I think it is good ethical guidance.

Is there a role for psychiatrists in these situations apart from making a speculative guess about the mental status of the Commander-in-Chief?  I think there is and that is in an advisory capacity about some of the group dynamics and containment of violence that occurred. It is absolutely critical to notice when propaganda is being used to incite violence or in this case an insurrection. Propaganda is not a “shared delusion” it is emotionally charged speech that can lead to fixed irrational positions.  It has to be recognized and countered in order to prevent the mass level of dysfunction associated with the denial of systemic racism, pandemic denial, mask denial, climate change denial, and the denial that the Presidential election was free and fair.  All of those levels of denial associated with the Trump administration occur in the context of longstanding denial that there is a serious problem with firearms in this country.  If psychiatrists want to be politically involved – those are the hard problems that need to be addressed.

There is much to be said for psychiatrists’ experience with containing violence and aggression.  When I witnessed what happened on January 6, I had many concerns about Inauguration Day.  My primary concerns were whether there would be adequate force to stop a similar attack and minimize the risk of injury to the police or demonstrators.  As I saw the barriers erected my concern was whether they was a plan in place to keep large groups away from the fences and avoid a violent confrontation.  Was there intelligence about the possibility of foreign actors taking advantage of the situation? And most of all – did the police and National Guard have clear rules of engagement to contain escalating violence and aggression and avoid serious injuries.  It turns out that everything except the rules of engagement were handled well. 

My advice about the Goldwater Rule either way is straightforward.  Forget about debating the President’s mental status in public.  The standard for Presidential capacity is a lay standard and not specified by any statute.  Psychiatric opinion is and will be remain unnecessary.  And if an APA member decides they want to bring an ethics complaint based on a violation of the Goldwater Rule – that is a waste of time as well. Stay focused on your own medical professionalism and remember that being a psychiatrist does not necessarily make you immune to emotional reasoning, political rhetoric, or propaganda. There are probably many more friends, neighbors, and relatives that need to get back on track to carry on the more mundane work of democracy.  

 

George Dawson, MD, DFAPA

 

References:

1:  Leonard L. Glass,  Edwin B. Fisher, Bandy X. Lee.  Trump’s Danger is now Undeniable.  He is clearly mentally unbalanced and unable to grapple with a reality that threatens his inflated and fragile ego.  Boston Globe January 7, 2021.

2:  Kroll J, Pouncey C. The Ethics of APA's Goldwater Rule. J Am Acad Psychiatry Law. 2016 Jun;44(2):226-35. PMID: 27236179.

Graphics Credit:

1:  Donald J Trump official portrait By Shealah Craighead - White House, Public Domain, https://commons.wikimedia.org/w/index.php?curid=63769676  Downloaded from Wikimedia Commons on 1/29/2021

2:  Barry Goldwater 1960 portrait By United States Senate - https://www.senate.gov/artandhistory/history/common/generic/Featured_Bio_GoldwaterBarry.htm  Public Domain, https://commons.wikimedia.org/w/index.php?curid=79152516

Downloaded from Wikimedia Commons on 1/29/2021

 

Disclosure 1:

Jerome Kroll, MD was one of my professors when I was a resident at the University of Minnesota.  He is a brilliant psychiatrist and wrote one of the best books ever The Challenge of the Borderline Patient.  He was also one of many professors who taught me that you can argue with colleagues and nobody has to take it personally - a good lesson in politics as well. 

Disclosure 2:

In my previous post I pointed out that for the past several decades I have been a small "i" independent.  That has changed with recent events.  I would find it very difficult to vote for a Republican based on their collective behavior and inability to respond to President Trump for the good of the American people.  But I still  do not think that psychiatrists have anything to offer in that area.

Supplementary:

I decided to attach the next several paragraphs based on what I have encountered over the Goldwater Rule into arguments I have heard from deniers and supporters of the rule. The last section are my personal observations (from above) - admittedly not independent of the others

Goldwater Rule Deniers:

1: Psychiatric or mental health experience is necessary in the case where a President may be incapacitated and unable to perform their duties.

2: Psychiatrists are ethically bound to publicly speak out if the President is incapacitated and a potential danger to the country.

3: The only reason the Goldwater Rule exists is to prevent embarrassment of the psychiatric profession.

4:  There may be an element of financial conflict of interest if the Goldwater Rule was recently modified over concerns that the APA may receive less money/tax benefit because of criticism of the President.

4: The APA suppresses the free speech rights of psychiatrists who speak out on the basis of their public assessment of the President.

5.  At least some deniers of the Rule believe that there should be a lower standard for capacity or mental illness if it is applied to the President. In other words, psychiatric opinion is conditional on whether or not the person being observed is the elected President at the time.

6.  The personal interview is not reliable and all of the information necessary to make a diagnosis is already out there in the public domain.

7.  The President's personality or alleged mental illness is the primary problem in what appear to be poorly thought out decisions.

 

Goldwater Rule Supporters:

1:  The Rule is the rule and direct examination of the patient is required to get the assessment out of a purely speculative mode where observations potentially have multiple possible meanings.

2:  The politicization of psychiatry is inevitable with experts for either party.

3:  The politicization of psychiatry potentially impacts patients’ willingness to see psychiatrists for help.

4:  Competency versus capacity – competency requires legal definition, capacity may be informal but that is unlikely in a contested procedure.

5:  Scientific accuracy of predictions of dangerous behavior are not good (Estelle v. Barefoot and APA amicus brief)

6:  Psychiatrists are not immune to rhetoric, propaganda or emotionally charged speech. The original treatment of Goldwater is a good example.

7:  If the issue is dangerousness and we are talking about President Trump there were many more dangerous presidents based on total war casualties that occurred during their terms – including Lyndon Johnson who was elected in part on the alleged dangerousness of his opponent Barry Goldwater.

8:  The President's personality or alleged mental illness is difficult to separate from purely political tactics like intentional misinformation or propaganda that are designed to disrupt and manipulate the electorate. 

 

GD:

1:  The Rule is ethical guidance that has never been enforced.

2:   The Rule is obviously ignored – nobody has ever been sanctioned by the APA or a District Branch in the 50 years it has been in effect

3:   The Rule only applies to APA members so people outside of the APA should not be concerned about it.  If you are really concerned about it don’t be an APA member and comment as much as you like.

4:   Presidential capacity is a lay standard that is not specified in any legal statute. In other words, there are no judicial descriptions of a standard for Presidential incapacity, no standard of proof.

5:  There is no mechanism to remove the President from office based on psychiatric opinion.  There are however political and legal mechanisms (25^th Amendment, Impeachment) to remove the President based on the opinion of his cabinet and in the case of repeated impeachments disqualify from further election eligibility.  A non-psychiatric standard is defined in the 25^th Amendment.

6:  In retrospect, some of the original campaign against Goldwater was propaganda (see ad on nuclear war) and that was reflected in some of the psychiatric opinion at the time.

7:  Psychiatrists potentially have a more significant role at the level of the group dynamics of violence, aggression, misinformation, propaganda, and the containment of violence and aggression.

8:  Several polls have characterized psychiatry as the most liberal medical specialty and the only one where a majority of members are Democrats.  That conflict of interest should be disclosed when commenting on opposition party politicians.

 

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



References:

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.



Disclosure:

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

Psychiatry and Torture

For me - torture has never passed some basic thought experiments.  The first is whether or not there is any information that critical that could be memorized by individuals that would be worth the effort to either conduct torture to get it or resist torture to prevent its disclosure.  Reading Alan Turing's effort  to crack German cryptography  in World War II comes to mind.  Those messages had to do with the deployment of German submarines.  In that case there was a elaborate code that could only be decrypted by a team of geniuses and a computer they invented.  That was 70 years ago.  Is it likely that information in the computer age would be easier and more efficient to hide outside of human memory?  It certainly seems like it to me.  In the case of relationships, wouldn't surveillance be a much more reliable source of information?   The second is the mindset of the person being tortured.  If I knew the information was redundant, carried by multiple sources,  or subject to fail safe why would I not tell any captor what they want to know?  Third, if my captors either did not believe me or decided to proceed for other reasons, why would I not tell them exactly what they want to know or make up any story they wanted to hear to get them to stop?  The cinematic stereotype of resisting any disclosure at all costs while undergoing various forms of torture seems totally irrational to me.  All of these considerations taken to their conclusion would produce information that was accurate but possibly rejected because it was easily obtained or information that was inaccurate but accepted because it was made up under duress.  Either way it seems like a very poor source of information.

The Senate Report on the CIA interrogation and detention methods came out a few days ago and there is the expected media enhanced political furor.  The entire document is 499 pages long.  It is also redacted to remove details that could not be declassified.  I decided to take a look at it because I saw one of Atul Gawande's tweets decrying the involvement of the medical profession that he described as "doctors, psychologists, and others sworn to aid human beings......".  That struck a chord with me because I was aware of this issue and how the American Psychiatric Association reacted to it in 2005.  Then president Steven Sharfstein, MD took the initiative in making it explicit that it is unethical for psychiatrists to participate at any level in torture, enhanced interrogation or even deceptive interview practice.  There was some lag in a similar response from organized psychology but eventually both organizations came out with a joint statement on the issue.

Psychiatry and the CIA have crossed paths on occasion most notably on the notion of being able to profile political leaders.  The original ethical conflict with CIA psychiatrists was the Goldwater Rule (see reference 3). That rule states that it is not ethical to diagnose a person (usually a public figure) without actually interviewing that person and disclosing the information with their consent.  It came about as a result of the 1964 Presidential election.  The candidates were Barry Goldwater and Lyndon Johnson.  One of the more infamous attack ads in political history suggested that Senator Goldwater would put the US at higher risk for involvement in a nuclear war.  A survey of psychiatrists suggest that he was unfit for the office.   That same article points out that even today despite the rule, there appear to be no shortage of psychiatrists willing to offer their opinions about people they have never personally examined.    

I decided to take a course on profiling political figures by one of the original psychiatrists who worked on these methods -  Jerrold Post, MD.  The course was offered at the Door County Summer Institute in August 2003.  He provided a disclaimer at the outset that "psychological interpretation" based on childhood experiences was a scientific fact that could be applied to the analysis of the personality of political leaders.  Over the next 4 days he reviewed personality and its development in political leaders, how personality is a factor in political decisions and decision making in hundreds of different compromised and uncompromised political leaders.   The final day was devoted to a look at terrorism.  He made the argument that terrorists were psychological normal meaning that they had no major psychiatric diagnoses.  He suggested that that there were predominant personality types attracted to terrorism including aggressive sociopaths and angry paranoids and that a common externalizing defense could be observed in both groups.  He discussed theories about personality types that might comprise terrorist groups.  The issue of the Goldwater Rule seemed irrelevant.  Dr. Post presented profiles that were based on actual historical data about the lives of political leaders rather than the self report that typically forms the basis of most psychiatric evaluations.  It was after all his job and he and his cohort of colleagues specializing in the psychology of political leaders developed methods for this work.  It culminated in a text of how this analysis proceeds (see references).  The text provided a fuller appreciation of the limits of this kind of analysis than the PowerPoints:  

"Understanding and predicting the behavior of smart, highly functioning individuals, who are acutely aware of their circumstances and what might be needed to surmount them,  make it a very tricky undertaking.  It is possible that, in spite of their own psychological inclinations, such persons, if not alone, then certainly with the help of many advisers, whose only occupational purpose is to help leaders pursue their own personal and political self-interest."  (p.  300).

Translation: the psychological profiling done by psychiatrists and psychologists with decades of experience is less of a sure thing than the television profilers that you can see on a nightly basis.   At that point I decided that the analysis of the psychology of political figures by the CIA was really not the same as somebody on the local news speculating about the next mass shooter.  In many ways this analysis has much more relevant data than any typical psychiatric evaluation.

The ethics of the psychological profiling of politicians seemed resolved.  What about interrogations and coercion.  It turned out that there was a course the next year  called "A Law Enforcement Approach To Behavior Analysis" taught by Dale Mueller, a 30 year veteran with the FBI.  The course covered crime scene analysis, terrorist personality types and interview strategies, hostage and crisis negotiations,  interviews for deceptive verbal behavior, and interrogation techniques that answer the question: "What does law enforcement do to get a confession?"  That course was an eye opener in terms of the differences between interrogation and a clinical interview.  He described interrogation techniques and the reliability of various observations that suggested a person my be lying.  He described the optimal environments and mindset of the professional conducting the interrogation.  He emphasized good preparation and a non-threatening manner.  Interrogations are not without stress for the person being interrogated because at some point the strategy may become a direct confrontation like:  "Because of A, B, and C you are lying."  The interrogator may stand directly over the the person being interrogated for additional effect.  Some famous interrogations were reviewed and a tape of an interview was shown.  It was a product tampering case.  The suspect had social and possibly psychiatric problems.  The main focus of the interview was to convince her to admit to the crime and she did.  Specific interrogation techniques were discussed for different terrorist personality types.  Interrogation is an alien interaction with people for a clinical psychiatrist like me.  Psychiatrists are clearly not trained in these techniques and generally do not have much interest in who is guilty of crimes or not.  During the actual interrogation of a person who appeared vulnerable, I would probably have veered off to discuss  those problems and solutions rather than focusing on a conviction.  Interrogation seems to be the sole purview of law enforcement and nothing that a psychiatrist would do.

The issue with psychiatrist employees in the CIA or any other organization - even at the contract level is the ever present conflict-of-interest between professional standards and the interest of the organization signing the pay check.  In many cases that is a changing point of reference and it is not always clear.  I have consulted with expert witnesses for example who felt that at some point they were massaged into a position that they really did not want to testify to by the attorney who hired them.  Physicians can clearly be manipulated into doing whatever other entities want them to do and that is why it is imperative that professional organizations take a stand that is unequivocal, based on professional standards and faster than any other response.  In this case, organized psychiatry - specifically former APA President Sharfstein was at the forefront.  I applauded his position then and I applaud it now.  There is always some criticism that this just involved jumping on the bandwagon with everyone else but the public opinion result at the time was far from certain.  After the opinion was public, there was hardly any acknowledgement that anybody cared.  That opinion came out 8 years before the current Senate document.

Searching the document reveals exactly 1 reference to psychiatry/psychiatrist, 56 references to psychologist/psychology, 58 references to medical officer, and 5 references to physician/physician assistant.  The most specific references include this section in the summary about contract psychologists who "devised" the enhanced interrogation techniques.

The political rhetoric is always interesting:

1.  Does torture produce results?  After reviewing the evidence I don't think there is any evidence that it does.  In fact, it is daunting to think about the millions or billions of people who have been tortured at one point or another in human history with this goal in mind.  In retrospect much of the contested information was trivial and meaningless in the course of human history.  I don't recall any major battle or war where the outcome was determined on information produced by torture.  I think there is a stronger argument that terrorism or what used to be called guerilla warfare produces more results than torture.  And let's not forget that a contractor with the National Security Agency probably released more secret data that all of the people tortured since the dawn of time.  And all of that data was accurate.

2.  Does torture inflame the enemy and lead to more adverse consequences for the torturers?  I heard an interesting discussion of this issue on Fareed Zacaria's Sunday morning show on CNN.  The discussant was an Arab from the Middle East and it was clear that his sympathies did not align with the US.  When asked about the impact of this document on public opinion, he said that he did not think it would have much of an impact because of a baseline issue.  Most people had such a low opinion of the United States that they would expect something like this to happen.  There was after all the Abu Ghraib prison incident in 2003.

3.  Are there qualitative differences in torture?  Certainly these techniques were bad but they pale in comparison to the atrocities described in the middle east and the atrocities inflicted by some of these combatants on their own countrymen.  As one of the consulting psychologists pointed out about 48 hours after the report was leaked there is also the question of what is worse a slap in the face during an interrogation or "sending in a Hellfire missile that kills grandma and the kids."  (ABC news Thursday AM show)

4.  How is the release of this document relevant to the concept of American democracy and American life?  Interestingly one of the critics on the Sunday morning show gave the opinion that self disclosures like this report does seem to distinguish American democracy from other political systems and raises the general awareness  that this is true.

5.  How can I make the most of this story?  Certainly media outlets and bloggers are motivated to whip this story up to attract viewers to their sites.  I saw a very funny comedy sketch by a stand up comedian who ranted against "Cheeto eating bloggers.." who were destroying his comedy act by posting politically incorrect experimental pieces that he was trying out in his routine as though he was serious.  The blogosphere likes to see itself as more innovative and more pious than the press but conflicts of interest remain.  It has gone from a corporate conflict of interest to conflict of interest at an individual level.  At many levels bloggers are more strident, argumentative, and hyperbolic.  It is not too surprising that they attract a like-minded following.  That being said, there have been few psychiatric bloggers that seem to have picked up on the torture issue.  It was an active area of discussion on the APA Listserv with several psychiatrists taking the role of human rights advocates.

Professionals often find it difficult to resist government interventions.  I have criticized the lack of an adequate response from organized psychiatry and organized medicine to any number of government interventions.  In other cases, they have come through with an exceptional response.  On the torture issue, Dr. Sharfstein took an unequivocal position on torture.  I was involved in a discussion of the issue at the time and there was speculation that there would be political pressure from "CIA psychiatrists".   There is always the question of whether a small special interest group within an organization can affect its policy.  In this case, the clinical focus of the membership, the maxim to do not harm and the modern conceptualization of the physician-patient relationship.  In the end there was no commentary that I am aware of from CIA psychiatrists.  I am not sure that there are any CIA psychiatrists.  I applied to be a CIA psychiatrist at about 15 years ago and the focus of the position was on interviewing potential employees rather than terrorists.

I think it is important to clarify any role that psychiatrists were involved in these activities.  They are not trained in interrogation techniques and I think that most psychiatrists would balk at the techniques.  On the other hand, it is clear that programs can be developed within government agencies that have little to do with clinical training and may clash with patient centered ethics.  It is also true that psychiatrists or physicians can abandon their usual clinical roles and use their knowledge for other purposes.  I am very skeptical of the science behind any of these techniques.   That sounds like an absurd statement on the face of it, but keep in mind the references to the program being based on a "learned helplessness model".  That is a scientific model that has been used to study depression.  Any review of that model would show that using it to develop an interrogation program is quite a stretch.  Actual human research would not pass the scrutiny of any Human Subjects Review Committee that I am aware of and it certainly is not associated with any standard of care.  The acceptance of these ideas indicates that there is really nobody in the CIA capable of scientifically reviewing a program like this or they just did not care.  As to the ultimate question of psychiatric involvement, I have a more definitive source on order (reference 5) and will report any differences here.  There is also an online database (reference 6) but it does not have much granularity but some of the linked reports contain a some details that I have not seen anywhere else (reference 7).


George Dawson, MD, DFAPA



References:

1.  Senate Select Committee on Intelligence.  Committee Study of the Central Intelligence Agency's Detention and Interrogation Program.  Foreword by Senate Select Committee on Intelligence Chairman Dianne Feinstein.  Findings and Conclusions.  Executive Summary.  Approved December 13,2012.  Updated For Release April 3, 2014.  Declassification Revisions December 3, 2014.

2.  APA Official Actions.  Position Statement on Psychiatric Participation in Interrogation* of Detainees.  Approved by the Board of Trustees, May 2006.  Approved by the Assembly, May 2006

"The American Psychiatric Association reiterates its position that psychiatrists should not participate in, or otherwise assist or facilitate, the commission of torture of any person. Psychiatrists who become aware that torture has occurred, is occurring, or has been planned must report it promptly to a person or persons in a position to take corrective action........"

3. American Psychiatric Association: Principles of Medical Ethics With Annotations Especially Applicable to Psychiatry. Arlington, VA: American Psychiatric Association, 2013 (p.9):

"...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."

4.  The Psychological Assessment of Political Leaders: With Profiles of Saddam Hussein And Bill Clinton.  Jerrold Post, MD (ed). The University of Michigan Press, Ann Arbor 2003, 462 pp.

5.  Steven H. Miles.  Oath Betrayed: America's Torture Doctors.  University of California Press, 2009, 312 pp.

6.  Doctors Who Torture Accountability Project.  Link.

7.  Physicians for Human Rights.  Doing Harm: Health Professionals’ Central Role in the CIA Torture Program.

This document is interesting because it has the qualifier "physicians (including psychiatrists)" four times in the report even though it is based on the original Senate Report.

Supplementary Info:

Supplementary 1:  Photo credit as suggested on WikiMedia:  Derived from File:911 - FEMA - Areas debris impact (graphic).png by Therese McAllister, Jonathan Barnett, John Gross, Ronald Hamburger, Jon Magnuson of the Federal Emergency Management Agency (FEMA) of the United States Department of Homeland Security. As a work of the United States government, it was released to the public domain.

Supplementary 2:  I sent Physicians for Human Rights an e-mail on December 21, 2014 to clarify the qualifier they use in their analysis of the Senate document  "physicians (including psychiatrists)".  I will post their response here as soon as I get it.

Footnotes About Commenting On Mental Health Tragedies In the News

Recent events have led me to think about the issue of commenting about tragedies that affect celebrities and their families.  American culture and even the law suggests that anyone who leads a public life should expect public commentary even during a time when it would be considered poor form if applied to anyone else.   It is an interesting twist for people who are protectors of confidentiality their entire careers and who know some of the real reasons why that is important.  One of the most critical is the issue of self aggrandizement as in "I am a special person because I have access to information that nobody else has access to."  Introspection and self analysis are generally useful tools to examine this aspect of personal information and whether or not it can be handled neutrally.  As an added corollary whether that information comes from a celebrity can create an additional burden on the person who has received it.  Can the information be handled neutrally when the source is a celebrity who has millions of fans?  A few observations about the recent events:

1.  The event is a projective test - there are clearly individuals and groups who have specific points or observations that they would like to make about the person or event.  Those points may have very little to do with the reality of that person's life and more to do with the agenda of the observers.  In the worse case scenario there may be public remarks that are controversial or in some cases very negative about the person or the event they were involved in.  Nobody ever seems to bring up the obvious conflict of interest issues when these remarks are made, not the least of which is selling more media stories.

2.  In the case of a loss there is public but appropriate grieving.  Reminiscences about shared common events and critical events in the persons public life are good examples.  In this case, a psychiatrist generally has no more to offer specifically about that person than anyone else.  In the event that the psychiatrist was actually treating that person, ethical guidelines prohibit any disclosure about that treatment even after death.  That should include the identification of a person as a patient.

3.  Stereotyping can occur and I am thinking of the general sequence of events that "this person belonged to this subgroup and what happened to him/her happens to a lot of people in this particular subgroup."  Things are rarely that simple.

4.  Medical professionals are no different from anyone else and may make remarks that have more to do with their own interests than the deceased or the aggrieved family.  In some cases the medical professionals are paid to give their opinion in the media either as a regular commentator or as an interviewed guest.  I have heard some argue that their credentials allow them to make special interpretations of events to the public, but I have never really seen that play out.

5.  Commenting on these tragedies does very little to change the inertia in the system.  The problems with the care for addictions and mental illnesses are well documented on this blog.  The main problem is that our federal and state governments are oriented more toward enriching health care companies rather than providing practical and affordable health care insurance to the average person.  They do this by a number of state sanctioned rationing schemes and that rationing falls heaviest on the care for mental illnesses and addictions.  It is one thing to lament the tragedy of another fallen star, but the commentary is never followed up with any action to prevent further tragedies.

6.  A condensed life is one worth living.  A lot of media have canned obituaries that people have been working on for some time.  In the event of an untimely death, it seems that there is a lot of cutting and pasting going on.  It gives the appearance of a detailed analysis of the person's life.  The appearance of thoughtfulness.  People rarely think about why editors include some paragraphs rather than others.  The press generally gets far too much credit for objectivity and there is not enough focus on the ever present conflict of interest.  Articles are written after all to generate advertising dollars and in today's world that means clicks.  Controversy generates clicks and detailed objective analysis does not.

If it was up to me (and it clearly is not) - the whole process of the way celebrity tragedies are covered and reported would be revisited.  There is no evidence that I am aware of that the wisdom of professionals or public health officials regarding mental illness or addiction treatment is conveyed any better in this context than others.  The more specific problems of drug addiction and suicide are after all tough problems that generally do not respond well to basic education.  Attaching celebrity to those problems does nothing to heighten awareness or advance the public health message.  These tragedies are also common.  It is difficult to find a family that has not been personally impacted by similar events affecting the people that they personally know.  I take a very negative view of trying to "analyze" a persons problems based on media reports and other sketchy information and yet it is common to see experts in the media drawing all sorts of conclusions.  What I have personally found useful in the grieving process is a review of the person's positive accomplishments.  It is amazing what an "average" person can accomplish over the course of their lifetime.  Celebrity in all likelihood extends and intensifies that list.  It is also a prerequisite that people who actually know the person - that is people who have been in real relationships with that person - compile the list.

With that approach experts are left with offering their condolences to the survivors - like everybody else.


George Dawson, MD, DFAPA