Psychiatrists Debate Speaking Out On Donald Trump’s Mental Health

The Goldwater Rule has received considerable attention this year with the election of Donald Trump. The rule was put into place to dissuade psychiatrists from talking about the mental health of politicians without actually doing an exam after some had speculated about Barry Goldwater’s mental health.  As I noted in July, the American Psychoanalytic Association has released an emailed statement freeing its members to give opinions on the mental state of Donald Trump. The controversy has continued with the publication of a book entitled The Dangerous Case of Donald Trump: 27 Psychiatrists and Mental Health Experts Assess a President.

The New England Journal of Medicine has an article by a psychiatrist, Claire Pouncey, resonding to criticism of the book and making an argument for psychiatrists to be able to comment on the mental health of Donald Trump. Here is a portion:

…in October, psychiatrist Bandy Lee published a collection of essays written largely by mental health professionals who believe that their training and expertise compel them to warn the public of the dangers they see in Trump’s psychology. The Dangerous Case of Donald Trump: 27 Psychiatrists and Mental Health Experts Assess a President rejects the position of the American Psychiatric Association (APA) that psychiatrists should never offer diagnostic opinions about persons they have not personally examined.Past APA president Jeffrey Lieberman has written in Psychiatric News that the book is “not a serious, scholarly, civic-minded work, but simply tawdry, indulgent, fatuous tabloid psychiatry.” I believe it shouldn’t be dismissed so quickly…

The relevance of the Goldwater rule has spiked in the past 2 years in the setting of Trump’s candidacy and now presidency. There are good reasons to respect the intention of Section 7.3. Most psychiatrists want to teach the public about the myriad presentations of mental illness and character pathology and not to oversimplify, stigmatize, promote stereotypes, or disparage the persons whose mental health we work to improve. We believe that people with mental illness can flourish and contribute to our communities, and on the flip side, we do not assume that everyone who behaves erratically or earns public disapprobation is mentally ill. Most psychiatrists do not think we have superpowers that let us know the inner thoughts and psychological workings of strangers. Section 7.3 reminds us to remain humble about the claims we can reasonably make and to present ourselves responsibly for the sake of our patients and our profession.

Increasingly, however, some psychiatrists are expressing professional concern about Trump’s public remarks and behaviors and what they mean for public safety. Lee and her coauthors clearly take themselves to be fulfilling the moral obligation of Section 7 by using their specific expertise as mental health professionals.

The Goldwater rule, like the other APA annotations, is meant to clarify a principle of medical ethics, not contradict it. Yet in March 2017, shortly after Trump’s presidential inauguration, the APA broadened the rule to apply to “any opinion on the affect, behavior, speech, or other presentation of an individual that draws on the skills, training, expertise, and/or knowledge inherent in the practice of psychiatry”5 — an expansion that would silence psychiatrists who want to honor the moral obligation of Section 7 by educating the public about the dangers they see in Trump’s psychology. The problem is that psychiatric diagnostic terminology has been colloquialized, so the public and the press use it to describe Trump, but when a psychiatrist does so, use of the same words is considered to be a formal diagnosis (at least in the eyes of the APA). As a result, psychiatrists are the only members of the citizenry who may not express concern about the mental health of the president using psychiatric diagnostic terminology.

The Dangerous Case of Donald Trump challenges the APA position that a psychiatrist cannot know enough about a person she has not interviewed to formulate a diagnostic impression. Contrary to the APA, a physician who has not formally evaluated a patient is not making a diagnosis in the medical sense, but rather using diagnostic speculation and terminology informally, with the benefit of education. That characterization applies to the orthopedist or physical medicine specialist speculating on the knee injury of the football player limping off the field and the dermatologist wincing at a stranger’s melanoma in the grocery line as well as to the psychiatrist interpreting Trump’s public statements. Physicians don’t stop knowing what we know when we leave the clinic. Psychiatric terminology has become part of the common parlance, and the authors in Dangerous Case describe and define that terminology much better than, say, Ralph Northam. The question is whether psychiatrists are the ones we should hear it from.

I expect that the APA will denounce and dismiss this book and its authors, but I encourage others not to do so. Dangerous Case is unapologetically provocative and political, and the authors clearly take themselves to be contributing to the improvement of the community and the betterment of public health, as the AMA (and APA) principles of medical ethics direct. Dangerous Case will have supporters and detractors for good reasons — some political, some social, some psychiatric — that have much more to do with views of Trump’s mental health than with the Goldwater rule. I believe that the APA, in the interest of promoting public health and safety, should encourage rather than silence the debate the book generates. And it should take caution not to enforce an annotation that undermines the overriding public health and safety mandate that applies to all physicians. Standards of professional ethics and professionalism change with time and circumstance, and psychiatry’s reaction to one misstep in 1964 should not entail another in 2017.

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1 Comment

  1. 1
    . Slavoljub Djurdjic,MD,PhD says:

    Psychiatrists can not do the psychological profile of anybody without the Psychiatric and Psychological evaluation, proper. Anything else is just the abuse of the profession  and the people,so called,evaluated. Psychoanlists have been known for the erroneous evaluations and interpretations. And,for the sterile therapy. I would not pay attention on their conclusions.

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