Earlier this month, the American Psychoanalytic Association sent an email to its 3,500 members reiterating a policy position it had made in 2012: It does not require that its members refrain from speculating publicly about the mental health of public figures, a standard known as the Goldwater Rule.
Because Donald Trump is president, this email clarification became a national news story on Tuesday. Stat was the first outlet to report on the decision with a story titled “Psychiatry Group Tells Members They Can Defy ‘Goldwater rule’ and Comment on Trump’s Mental Health,” but several outlets followed with similar coverage noting the same thing. No matter that the American Psychoanalytic Association is a much smaller group than either the 115,700-member American Psychological Association or the 37,000-member American Psychiatric Association. Was the ethical firewall that had previously prevented medical professionals from speculating on the president’s mind cracking?
Well, no—for one thing, the existence of the Goldwater Rule has not prevented medical professionals from speculating on what might be happening in the mind of our president. But for another, the organization says this characterization misrepresents what the organization was trying to do when it sent that email. In a statement quickly posted to its website, the APsaA clarified that it had not been intending to encourage members to defy the Goldwater Rule at all:
The American Psychoanalytic Association (APsaA) seeks to clarify statements made in a recent article in STAT. … In an email to association members, our leadership did not encourage members to defy the “Goldwater Rule” which is a part of the ethics code of a different mental health organization, the American Psychiatric Association (APA). Rather, it articulated a distinct ethics position that represents the viewpoint of psychoanalysts.
That ethics position, which is also posted on the organization’s website, was written in 2012 and provides guidance on how psychoanalysts ought to think about diagnosing in public. It is a conservative document: While it notes that psychoanalysts “should offer relevant psychoanalytic insights to aid the public in understanding a wide range of phenomena in politics, the arts, popular culture, history, economics, and other aspects of human affairs,” it ultimately suggests that these insights are best given without specific commentary or assessment on individuals, asserting that “injudicious and unsupported use of psychoanalytic inference is harmful to the profession and to the public.”
In providing an example of what its members should avoid, the same 2012 document eerily names the reason why we are all here:
Avoid thinly veiled, disingenuous diagnostic interpretations of public figures, such as “I can’t say anything about Senator Smith because I haven’t interviewed him, but people who behave like him generally have a narcissistic personality disorder.” Obviously, you are offering a diagnosis of Senator Smith.
Narcissistic personality disorder is widely accepted as the most common way of pathologizing what might be wrong with the president of the United States, Donald Trump. It’s the answer to the collective “This guy seems crazy, is he crazy? Could someone please tell us if he is actually crazy?” going around. Even senators are doing it—consider this exchange between Rhode Island Sen. Jack Reed and Maine Sen. Susan Collins caught on a hot mic that they thought was off. Reed starts:
“I think — I think he’s crazy,” apparently referring to the president [the Post’s note and also the most reasonable guess]. “I mean, I don’t say that lightly and as a kind of a goofy guy.”
“I’m worried,” Collins replies.
This was an off-the-cuff comment, but it actually nicely sums up many of the problems surrounding the Goldwater Rule, the 25th Amendment, Donald Trump, and mental illness: As a society, we have realized that a mental illness diagnosis is not something to be thoughtlessly bandied about. It’s not a good way to explain something you don’t like or to categorize someone you don’t trust. Mental illness is serious business, we have learned, which means that when we talk about it, we should be serious.
It is certainly positive that we have become more measured and restrained in our deployment of unwarranted diagnosis, of calling someone “crazy.” Doing so is stigmatizing and problematic. But this restraint has manifested into a sort of different problem—as we make our way on the journey of accepting people with mental illness as regular, worthy human beings who happen to have medical problems, we have reached a bizarre inflection point, one where we recognize the gravity of diagnoses but still do not seem to know how to actually talk about mental fitness without reinforcing stigma. Whether or not the president has a mental illness does not qualify or disqualify him from serving in office. But a clearer understanding of what we should attribute to his mental deficiencies and what we can blame on him, Republicans, and society in general could be useful.
That’s why it’s so unfortunate that psychiatrists are “barred” from offering their expertise on this matter. It’s also why every time we try to discuss these arguably complex and thorny problems, we end up distracted by whether we ought to be saying anything about them at all. And the irony is that the Goldwater Rule itself exists in part to avoid stigmatization. As a refresher, the rule came into being after now-defunct Fact magazine asked 12,000 psychiatrists in 1964 for their clinical assessments of Barry Goldwater, then the Republican presidential candidate. A couple thousand responded, and of those, half asserted that he was psychologically unfit to be president. Fact published these responses and Goldwater lost the presidency—but won a $75,000 libel case against the magazine. So, in 1973, the American Psychiatric Association crafted the Goldwater Rule, which states:
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.
Breaking the rule does not come with any actual consequences, and the larger American Psychological Association does not require its members to abide by a Goldwater Rule. But the American Psychiatric Association has stood steadfastly by it. Its president at the time reasserted the organization’s commitment to the rule in an August 2016 blog post, and then again in March when the association’s ethics committee issued a three-page statement reiterating support for the rule. The ethics committee’s March statement reminded its members that adjudicating a stranger’s mental health—whether or not you offer a diagnosis—breaks the Goldwater Rule and ought to be avoided. It also nods to the idea that diagnosing from afar “has the potential to stigmatize those with mental illness.” (Of course, rejecting the idea that it is ever possible to responsibly discuss the effects of mental illness also stigmatizes mental illness.)
Adjudicating the Goldwater Rule has become as much of a cottage industry as diagnosing the president. In Slate, prior to the election, Sally Satel argued that while it is possible and defensible to assess Trump’s mental health from afar, it is simply not necessary to do so. As she put it:
I don’t think a diagnosis would actually provide any new insight into the choice we have to make about who we should elect president. It does not matter whether Trump might have NPD. …That’s because diagnoses do not allow us to predict future actions with great certainty. Past behavior and enduring character traits, on the other hand, do—and we have seen more than enough to understand what Trump’s (and Clinton’s) are.
Trump actually being president vaguely shifts this goal post, but only slightly. In New York, Jesse Singal cogently argues that it is time to abandon the rule, because it’s presumably preventing the most responsible psychiatrists from offering up their expertise in this monumentally important case. Singal writes:
Surely some psychiatric problems should be disqualifying for certain positions that entail responsibility for other people’s well-being. Were it the case that Trump has untreated narcissistic personality disorder (as some experts believe he does), that would suggest he is a bad fit for a position like president of the United States.
Singal is right about revoking the rule, but he’s wrong about why. Whether or not psychiatrists agree that Trump is a bad fit for the position of president of the United States is totally irrelevant to whether Trump gets to be president. The question around whether a diagnosis means anything now centers not on whether it will sway voters but on whether it could be used to implement the 25th Amendment, which asserts that the president can be removed from his position if he is deemed “unable to discharge the powers and duties of his office.” Goldwater Rule or no, it is extremely unlikely that the 25th Amendment will be invoked, with or without a “real” diagnosis, because it is not whether Trump has NPD that matters—it is whether those in power will stand up to him, and the answer to this is a resounding no. Besides, if you run the numbers, you’ll see that impeachment is a lower bar anyway. So, Donald Trump’s possible NPD is irrelevant from a pragmatic perspective (if you were hoping that might get us out of this mess).
So why nix the Goldwater Rule? Because it could help us to finally turn the corner when it comes to discussions of mental health. Right now, mental illness is regarded as so taboo and damaging that psychiatrists themselves are barred from making any kind of comment on it whatsoever. This approach suggests that the mere possibility of mental illness would be reason not to vote for a candidate, or to shun a celebrity, etc. In 2017, candid discussions of mental illness should not be embarrassing and stigmatizing. They should be accepted as part of living in the world among humans. It’s true that we have a ways to go before we get there, but barring the most qualified people from these discussions certainly won’t help.
It is perfectly possible that a future presidential candidate could be both mentally ill and the best person for the office. In April 2017, psychiatrist Leonard Glass resigned in protest from the APA after 41 years of membership, citing his disagreement with the board’s decision to maintain the Goldwater Rule. In an op-ed in the Psychiatric Times on the matter, Glass asserts that both Abraham Lincoln and Winston Churchill suffered from diagnosable mental illness but still managed to be excellent leaders. And as many psychiatrists have in fact already argued, Trump’s true deficiencies center not around his possible mental impairments but around his potential and capacity for evil. To blame that on a mental disorder lets Trump off easy and does a disservice to those actually struggling with mental illness.
Revoking the Goldwater Rule won’t solve our Trump problem. It might, however, allow us to stop focusing on this ridiculous question of whether mental illness is disqualifying just by existing and find better ways to contextualize and explain why such assumptions are wrongheaded. It’s hard to blame the Goldwater Rule for our current societal predicament, in which we are collectively unsure of just how, exactly, we can talk about mental illness without being stigmatizing (tricky) and just when, precisely, it is OK to call anyone “crazy” (still never).
But I can’t help thinking that allowing experts to more fully participate in these kinds of conversations could help us move toward a deeper and better understanding of mental health.