Wednesday, May 31, 2017

The psychiatric debate over diagnosing Trump, explained : A Clear and Present Danger: Narcissism in the Era of President Trump Paperback – February 2, 2017 by Steven Buser (Editor), Len Cruz (Editor), Jean Shinoda Bolen (Contributor) (Chiron Press)

Psychiatry’s “Goldwater Rule” has never met a test like Donald Trump

Photo by Chip Somodevilla/Getty Images

Ever since the primaries, it’s been something of a parlor game to weigh in on Donald Trump’s psychological state. We’re awash in armchair analyses from mental health professionals and journalists: in Atlantic cover stories, in Vanity Fair, on Twitter, and even here at Vox. The latest entry: Stat News has a report that strongly suggests Trump’s odd and deteriorating speech patterns are the result of cognitive decline, or perhaps early-stage Alzheimer’s.

And yet many of the country’s top experts on mental disorders have stayed largely silent in all these takes. Psychiatrists are not talking for a reason. The American Psychiatric Association, the leading professional organization for shrinks, has a longstanding ban on its members commenting on the mental health of public figures, called the Goldwater Rule. The rule not only forbids psychiatrists from diagnosing a public figure’s behavior without obtaining their consent or personally evaluating them but also forbids any public opining on them at all. Even if to say, “Trump doesn’t have a mental illness.”

The psychiatrist who wrote the guide to personality disorders says diagnosing Trump is "bullshit"

Some psychiatrists are saying it’s time to rethink this core ethical guideline. The rule, they say, is acting like a gag order, preventing qualified psychiatrists from giving the public important perspective on the mental health of a president whose behavior is out of step with any other president in history.

“The public has a right to medical and psychiatric knowledge about its leaders — at least in a democracy,” Nassir Ghaemi, a Tufts University psychiatrist, recently argued at an APA conference. “Why can’t we have a reasoned scientific discussion on this matter? Why do we just have complete censorship?”

The controversy is sure to rage on, as many psychiatrists stand by the professional precedent. The rule itself has even been expanded recently. But just the existence of the debate is an incredible moment not only in the field of psychiatry but in American politics. It’s not just armchair psychiatrists who are concerned about Trump’s mental health — some of the real ones are even willing to rethink their professional ethics because of it.

The Goldwater Rule has really never met a situation quite like Donald Trump.
What is the Goldwater Rule?

In 1964, Fact magazine sent a survey questionnaire to all 12,356 members of the American Psychiatric Association, asking: “Do you believe Barry Goldwater is psychologically fit to serve as president of the United States?” Only 2,400 responded, and about half said that either Goldwater — the Republican candidate for president, who was rumored to have suffered through nervous breakdowns — was fit for the office or they didn’t know enough to make a call.

The other half? Hoo boy.

“It is ... abundantly clear to me that he has never forgiven his father for being a Jew,” one respondent wrote. “The core of [his] paranoid personality is ... his anality and latent homosexuality,” wrote another. “I believe Goldwater has the same pathological make-up as Hitler, Castro, Stalin and other known schizophrenic leaders,” wrote yet another. (Comparisons to Hitler came up a lot.)

Fact magazine called this “the most intensive character analysis ever made of a living human being.” What it was: a complete embarrassment to the field of psychiatry and the beginning of the end for Fact. After his election loss, Goldwater successfully sued the magazine for libel; the $75,000 settlement put the small publication out of business.

And the episode compelled the APA’s ethics committee to ban its members from making future diagnoses about public figures in the press.

It only applies to card-carrying APA psychiatrists. It doesn’t apply to psychologists, social workers, or New York Times columnist David Brooks. In February, a psychologist told me with deadly seriousness, “This is the worst case I have seen in my career,” regarding Trump and a diagnosis of narcissistic personality disorder.

So while claims about the president’s mental health have been made by just about every other group of person on earth, psychiatrists are discouraged from jumping in, even to correct the record.
The Goldwater Rule recently got broader

The temptation to break the Goldwater rule exists every election cycle, but it was exceptionally high in 2016. And in August, the APA issued a warning to its members, reminding them that “breaking the Goldwater Rule is irresponsible, potentially stigmatizing, and definitely unethical.” But after Trump assumed the presidency, the APA went further. This past March, the APA ethics committee reevaluated the rule — in part in response to the media interest in Trump’s mental health, and in part because APA members requested it.

The review didn’t just reaffirm the rule. The board actually published an opinion that broadens the scope of it to include all “professional opinions” about a person’s psychological state.

For instance, if a psychiatrist were to say, “Trump looks disheveled,” that could be construed as a professional opinion. “What they [the APA] essentially did was say anything that could be casual observation is now off limits to psychiatrists to comment on when it comes to public figures. ... That’s absolutely everything,” Claire Pouncey, a Philadelphia-area psychiatrist, tells me.

Let’s pause on that for a second. The ethics of my profession allow me to publicly conclude that Trump’s behavior has been “erratic at times.” But Pouncey — who has spent her professional career deeply and systematically analyzing human behavior — cannot.

Furthermore, the APA even clarified that a psychiatrist saying “a person does not have an illness” is also a “professional opinion” and in violation of the rule.

The penalty for breaking the Goldwater Rule (potentially being kicked out of the APA) also isn’t drastic as it seems. The APA is a professional organization that publishes scientific journals, puts on conferences, and provides opportunities for continuing education. It’s not a medical licensing board. You can be kicked out of the APA and still practice psychiatry. On the other hand: If you’re a doctor, being kicked out of the APA for an ethics violation would not be great publicity.

While the APA is standing by its rule and its reevaluation (APA president Maria Oquendo confirmed this to me in an email), it did set up a forum to debate it at its annual meeting in San Diego this past weekend, in which Pouncey took part. I didn’t attend, but I obtained a recording of the session.
The case for the Goldwater Rule

The primary case for keeping the Goldwater Rule is pretty simple: It protects “the integrity of our profession from members who are willing to draw judgments on the basis on information that’s incomplete,” Paul Appelbaum, a Columbia University psychiatrist and former APA president, said at the San Diego debate last weekend. There might be a few bad apples who make spurious claims about candidates, but the APA can disavow them taking cover under the rule.

But there are also a few other considerations. In its March opinion, the APA ethics board outlined three main reasons to keep the rule.
A psychiatrist should ideally conduct evaluations with the consent of person being evaluated (there are exceptions for emergencies and people in the custody of police).
Psychiatrists ought to conduct in-person evaluations before reaching their conclusions.
There’s the threat of further stigmatizing mental illness. (There are plenty of people with mental health problems who rise to powerful positions and are productive members of society. Historians like to point out that Lincoln suffered through depressive episodes.)

“We can do a great deal of public education without putting a label on people,” Appelbaum argues. “The rule ... encourages us to speak in general terms about mental disorders while underscoring our own lack of knowledge about this particular individual.”
The case against the Goldwater Rule

Pouncey, who also has a degree in philosophy and has written on the ethics of the rule, actually agrees with much of the Goldwater Rule. Personally, she doesn’t feel it is appropriate for her to comment on the mental health of the president. But she worries: If there were a case that she felt compelled to speak out on, she’d like to reserve the right to do it.

“I don’t want to use diagnoses as epithets, but if I have real concern about a possible public risk, and I really feel compelled to speak out about it, I’m going to do that,” she says.

The rule — and the revised interpretation of it — goes too far in restraining a doctor’s speech, Pouncey says. (She also points out there’s no empirical evidence to show the public discussion of a celebrity’s mental health further stigmatizes mental illness.)

Pouncey argues there are other forces to restrain doctors from making inappropriate public diagnoses that negate the need for the Goldwater Rule. One is legal. If you’re a psychiatrist who makes a suspect diagnosis that damages the reputation of an individual, well, that sounds a lot like libel. (And remember: Goldwater successfully sued for libel, with the Supreme Court making the final call) There’s also the court of public opinion. If a psychiatrist steps out of line in 2017, you can be sure there will be tweetstorms condemning him.

Overall, Pouncey wishes the APA had trust in its members to make the right determination of whether to go public with an opinion.

She’s not alone.

“The Goldwater rule is really a masterpiece in contradictions,” Jerrold Post, a psychiatrist at George Washington University who spent much of his career crafting psychological profiles of world leaders for the CIA, said at the APA meeting. The APA code of ethics encourages psychiatrists to engage with the public — but not on the one topic psychiatrists are expertly informed on.

Post laments that during the 1993 siege of the Branch Davidian cult compound in Waco, Texas, he missed an opportunity to go on the news and offer an analysis of David Koresh, the cult’s leader.

“I had been studying him for years, and saw him as a narcissistic borderline who under pressure ... could be led to seek martyrdom,” he said.

Meanwhile, the federal government was doing nothing but amping up the pressure — staging a weeks-long raid and standoff. Rather than surrender, Koresh lit the whole compound on fire, killing 76 inside. “When I believed I had something useful to say, I did not,” Post said. “That still bothers me.”

Tuft’s Ghaemi argues public discussion of politicians’ mental health doesn’t need to be stigmatizing. History has shown that some psychiatric diagnoses — like depression — imbue a leader with advantageous qualities, like increased empathy. If there’s a stigma around mental illness, he argues, it might be partly psychiatry’s fault for not highlighting this nuance.

The APA justifies the Goldwater rule by arguing doctors need to have obtained consent and have conducted in-person exams to offer a professional opinion. But Ghaemi points out doctors make exceptions to these rules all the time. One: It’s often the case that psychiatrists can’t trust their patients to be honest about their symptoms (so they have to find corroborating reports of behavior). And two: they don’t always have to obtain consent when it comes to dangerous situations (like in an emergency room.)
With so much of Trump and other public figures’ behavior logged online, the Goldwater Rule may be harder and harder to justify

It’s not 1964. And Trump isn’t Barry Goldwater.

Never before has a president come with such a massive trail of behavior to analyze, in the form of 34,000-plus tweets, hundreds of hours of TV appearances, and a huge trove of journalism documenting his actions, decisions, and lies. He also continues to behave in ways that defy historical precedent for a president — for instance, intervening over and over in an investigation into his campaign’s ties to Russia.

Donald Trump’s digital trail makes him one of the most analyzable public figures in history.

And it’s still an open question in psychiatry the extent to which our digital footprints can be used for diagnosis.

“We now have more information than ever about many politicians,” says Joshua Miller, a psychologist who directs the University of Georgia’s clinical training program. And this information, “paired with the reality that clinical interviews are not some magical source of information with regard to psychiatric disorders, suggest that diagnoses made from afar in these cases may not be inferior to diagnoses made following an in-person interview.”
Trump’s behavior could have more to do with personality than a mental health disorder

In February, I reported on a petition that’s now signed by more than 55,00 people. It’s headlined “Mental Health Professionals Declare Trump Is Mentally Ill And Must Be Removed.”

The petition struck a chord. It declared Trump has a “serious mental illness.” The petition was started by John Gartner, a clinical psychologist and former Johns Hopkins professor. He’s convinced Trump has an array of personality disorders, including narcissistic personality disorder, that make him unfit for office and a danger to the world. “I would bet my life of my children on it [the diagnosis],” Gartner told me. “That’s how confident I am.”

Gartner is not a psychiatrist, and therefore not subject to the Goldwater Rule. But was he right to diagnose Trump, considering that he had not personally evaluated him? And further, what use is it to label Trump’s behavior as pathological?

I knew Gartner could make the diagnosis. And indeed, if you go down the list of diagnosing criteria for narcissistic personality disorder — which include things like “has a grandiose sense of self-importance” and “requires excessive admiration” — it does sound a lot like Trump.

But the diagnosis was missing one hugely critical factor: suffering.

“Everyone has a personality,” Allen Frances, a psychiatrist who took part in writing the DSM, told me. “It’s not wrong to have a personality; it’s not mentally ill to have a personality. It’s only a disorder when it causes extreme distress, suffering, and impairment.” (Frances colorfully told me diagnosing Trump “is bullshit.” And to be clear, mental health researchers are deeply split on the question of whether one needs to personally suffer to be mentally ill.)

Complicating matters further: These days, most mental illnesses exist on a spectrum. “Even disorders we thought ... you either had it or not — categorical things like schizophrenia — we now know are much more like spectrum disorders,” UGA’s Miller says. “You can have some schizophrenic traits, but not all.” And that’s especially true of personality disorders, which he says are all just extreme manifestations of otherwise “normal” personality traits. The question What is a mental disorder? he says is “probably one of the most intractable debates that exists. And it’s playing out with Trump now.”

Which is to say: To an extent, a diagnosis of Trump will always fall on a matter of opinion.

If Trump’s behavior is purely the result of his personality — and not a disease --- that’s still consequential. Psychologists generally feel personality is a stable trait. And that means our past behavior predicts our future behavior. What’s more, research finds ascending the ladder of power only magnifies your personality traits, and makes you more likely to act in accordance with them. You don’t need a diagnosis to say Trump has a troubling pattern of behavior or to conclude that pattern is bound to continually repeat.

Trump has narcissistic tendencies, avoids acquiring expertise, is impatient, impetuous, and obsessed with winning, often lies, turns around on campaign promises, is running an extremely disorganized White House, and so on.

This is a clear pattern of behavior. And it’s likely to continue.
If psychiatrists could diagnose Trump, what would it accomplish?

Those who want to diagnose Trump — I believe — are doing it out of genuine concern. They don’t want someone with a disordered manner of thinking in charge of the nuclear codes.

But we also have to consider this deeply pessimistic question. And finally, there’s this thought to consider. If psychiatrists were to speak up against Trump, would it even matter?

After all, voters were well aware of his behavior, thinking style, and history before the polls opened in November. Due to partisanship, new information about a candidate tends to not actually change your behavior.

“We have a problem with narcissism, but the narcissism isn’t outside of our profession; the narcissism is within our profession,” Appelbaum said at the APA meeting. “There are very few unemployed steelworkers in Michigan whose votes would have been changed hearing me as a psychiatrist at an Ivy League university in New York opining on why I thought the candidate they were going to vote for was unbalanced.”

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