Diagnostic Manual
Is it irresponsible to hold firm on the “Goldwater Rule,” which restricts psychiatrists and psychologists from commenting on the mental health of the President?
After almost every tweet and action by President Donald Trump there is an outpouring of alarm about his mental health.
Political commentator George Will in a Washington Post article on May 3, 2017, wrote that President Trump has a dangerous disability. In a subsequent MSNBC interview he called it a mental disorder. Other pundits, news anchors, columnists, and ordinary citizens have similarly questioned the mental health of President Trump.
Is this a liberal conspiracy, as some Republicans have claimed?
Hardly. The fact is that leading Republicans and conservatives have also questioned Donald Trump’s mental stability. During the presidential debates Kentucky Senator Rand Paul called Donald Trump “a delusional narcissist and an orange-faced windbag,” adding that “a speck of dirt is way more qualified to be president.” Texas Senator Ted Cruz said Trump was a “pathological liar… doesn’t know the difference between truth and lies. He lies practically every word that comes out of his mouth. The man is utterly amoral. You know, morality does not exist for him.” And Louisiana Governor Bobby Jindal declared: “Donald Trump is a madman who must be stopped.” Others as well have questioned Trump’s mental state: Michael Bloomberg (“Let’s elect a sane competent person”), Stephen Hayes (“Yes, Donald Trump is crazy,”), and David Brooks (“Trump…appears haunted by multiple personality disorders”).
And currently, according to journalist Carl Bernstein, senior Republicans are privately discussing the President’s mental stability.
James Comey himself, referring to Trump’s accusation that former President Obama wiretapped him in Trump Tower, called Trump’s claim “outside the realm of normal” and “crazy.”
This rising cacophony of voices questioning the president’s mental health is unprecedented and alarming. Exacerbating this alarm, and validating the gravity of this situation, are the assessments of Donald Trump’s mental status by eminent mental health experts, such as psychiatrists Robert Jay Lifton and Judith Herman. They questioned his ability to act rationally in a crisis—a frightening prospect for the man who controls the nuclear code.
Earlier this year thirty-five psychiatrists, psychologists, and social workers issued a warning about Donald Trump’s mental health. And on April 20, 2017, another thirty psychiatrists at a Yale University symposium warned of Donald Trump’s “dangerous mental illness.”
In rendering their views these professionals have exposed themselves to sanctions by their professional associations. These organizations prohibit a psychiatrist or psychologist from diagnosing someone they have not personally examined—commonly interpreted as an office visit examination. The Goldwater Rule of the American Psychiatric Association and a similar ethical rule of the American Psychological Association do not consider valid or acceptable diagnoses drawn from even extensive observations of behavior in a wide variety of real-life settings and interactions. They specify a sharp distinction between such diagnosing “at a distance” and diagnosing based on a “personal” examination, as in an office visit.
Can this dichotomy stand up to close scrutiny? Or does it fly in the face of widely endorsed principles for assessing behavior and mental status? Shouldn’t the crucial litmus test be the amount and quality of data relevant to a diagnosis? An office visit can sometimes provide little, while direct observation of behavior in real life can yield more extensive material for a valid evaluation.
When I was a school psychologist, we often observed children in their classrooms and play situations for the purpose of assessing behavioral disturbances and making recommendations. The insights from these in-vivo on-site observations of real behavior in everyday settings were considered superior to data from office evaluations. The office visit is an artificial setting that can inhibit, restrict, and mask behavior, compared to natural settings—especially with uncooperative or manipulative patients.
How many psychiatrists and psychologists would relish the opportunity to observe their patients at work, out on a date, or at the family dinner table--a fantasy feast that’s rarely feasible. But with Donald Trump, they have it all—a power-packed smorgasbord of behaviors delivered on a huge golden platter.
Would anyone seriously argue that Donald Trump’s behavior during the campaign--and currently--is insufficient for evaluating who he is? Would a visit by Trump to a psychotherapist reveal something that the whole world hasn’t observed on TV, Twitter, and in the press?
Thanks to social media and 24-hour cable news coverage, showman Donald Trump has delivered a banquet of disturbing behaviors in real time. You can even TiVo his speeches, actions, and tweets and savor them over and over at your convenience—or view the thousands of videos posted on YouTube. It’s a diagnostician’s dream windfall.
With this in mind, the examination of the smorgasbord of real behaviors, often in real time, are personal examinations —not based on news reports, other third party communications, or hearsay. Thus the American Psychiatric Association and American Psychological Association need a better argument for dismissing assessments based on these personal evaluations than tagging them as “diagnosing from a distance,” while sanctifying the office visit.
These revealing real-time displays of Donald Trump’s antics have apparently persuaded mental health experts to violate their professional associations’ codes of ethics and render diagnoses.
Should they be censured for this?
That begs the question, Is the Goldwater Rule obsolete? The rule was invoked more than half a century ago in 1964, when 1,189 psychiatrists who responded to a questionnaire said presidential candidate Barry Goldwater was mentally unfit for the presidency. The American Psychiatric Association was right to invoke the Goldwater Rule. At that time opportunities to observe politicians’ behavior were scant. Television coverage of political campaigns was limited, and personal subjects were off limits—or addressed only lightly. The ethics of journalism steered reportage away from the personal lives of candidates. We often didn’t learn about their peccadilloes and missteps until years later--or after they were dead. Today’s news world is vastly different--everything is fair game and subject to scrutiny with technologies that often erase the line between public and private..
What if a President is mentally unfit?
Because the U.S. Constitution was vague about the rules for succession if the President were to die, resign, be removed, or became disabled, the 25th Amendment was added to the Constitution. Section 4 of the amendment states that the President can be removed if he is “unable to discharge the powers and duties of his office.”
But absent from this amendment is how to determine “unable” under a variety of circumstances. If the charge were mental illness wouldn’t we want the most qualified professionals to participate in that determination? The Goldwater Rule would shackle those experts.
Yes, reevaluation of the Goldwater Rule poses challenges. We certainly don’t want to open the floodgates for wholesale diagnosing of people in public life. Parameters, limits, and special situations will have to be designated. Not an easy chore—but one that is essential for enabling the most authoritative voices to weigh in on potentially catastrophic situations like we may now be facing. To hide behind a flawed ethical principle rather than meeting the challenge of today’s complex world is unacceptable.
Should there be a national or global disaster due to the president’s mental instability—the very instability about which psychiatrists and psychologists have warned--history will not be kind to the American Psychiatric and Psychological Associations for silencing their members’ assessments.
We may be witnessing one such disaster. In what many Republican and Democratic members of Congress called “terrifying, reckless and deeply disturbing,” President Trump released classified intelligence from a foreign ally to the Russians. His rationalization for this possible breach of national security is “I wanted to share with Russia.” Is this a sign of the man-child in the White House that David Brooks portrayed in The New York Times on May 16, 2017? Is it an expression of the developmental level of a five year old in kindergarten: “I wanted to share my crayons with Billy who hit me yesterday. Maybe now he will like me.”
American Psychiatric and Psychological Associations: What are you waiting for?
To shift gears, why not jointly sponsor a national forum consisting of mental health experts and leaders in other relevant disciplines to debate, explore, and set appropriate procedures and actions that can address unusual circumstances.
Bernard Starr, PhD, is a former president of the Brooklyn Psychological Association and the Association for Spirituality and Psychotherapy. He is also Professor Emeritus at CUNY (Brooklyn College), and a member of the American Psychological Association for over thirty years.