How The Mental Health Community Has Missed The Point About Diagnosis and Political Capacity
Lloyd I. Sederer, MD
Psychiatric diagnoses about the President of the United States recently have abounded. As if they made a difference. They do not.
Step back and consider three examples.
First, if a person has diabetes does that mean they cannot conduct themselves ably? Depends on their functioning with the illness. For most and most of the time their mental functioning is fine. But it is not if they fall acutely ill and enter a diabetic coma.
Second, a person may have heart disease and still be clearly contributing to family and community. But not if they enter a state of acute heart failure where their brain is poorly oxygenated.
Third, a person with a depression diagnosis can function fine, unless the illness becomes grave and the dark mood colors sound judgement or if cognitive capacities are diminished because of the illness.
In other words, diagnosis is not a good measure of capacity, or mental functioning. It is not at all a reliable measure of disability. It is the state of a person’s illness, their capacity to think and behave responsibly, that matters. That’s why all the fuss about whether President Trump has a psychiatric diagnosis is not worthy of consideration. Diagnosis is a static condition with generally no clear relationship to moment to moment capacity to think, feel or behave, which is more fluid. Functioning, which can be observed and monitored, is what counts.
The American Psychiatric Association (APA), a professional organization where I have been a member for decades and which has some 37,000 members, issued an ethical guideline in 1973 indicating that its members should not offer a diagnosis unless they personally consulted upon or treated a person – and thereby developed a professional, diagnostic opinion. This was called The Goldwater Rule and was created in the wake of a legal suit. During Senator Barry Goldwater’s run for the presidency of the USA, Fact Magazine surveyed 12,356 psychiatrists asking if they thought the Senator was fit for office.
2417 doctors responded; 657 said they thought he was fit but 1189 indicated they thought not. The latter group offered a diverse medley of diagnoses and disparaging comments about Mr. Goldwater and his state of mind.
After Goldwater lost the election, he sued Fact Magazine for this calumny, and won. Then the APA concluded, not a good thing, not an ethical thing, to opine on the mind of a person you do not treat, whether that be a President, candidate, celebrity, etc. That “rule” continues to today, though its teeth are clearly not very sharp.
Psychiatrists are trained to observe and report on human behavior. Some are very good at it, as are journalists, fiction and non-fiction writers, and many others. Psychiatrists, I think, can thoughtfully comment on behaviors observed in person or through media channels. A vocal public debate on what we see and hear is a great privilege we enjoy in this country. But that is not the same as offering a diagnosis. Not only is there little (or anything) to be gained from offering a diagnosis, it can undermine the credibility of the author who is looking from a distance, and, once again, it generally is not a reliable predictor of capacity and functioning.
A book is about to come out in which 27 authors, many quite notable, are compiled in a title called: The Dangerous Case of Donald Trump: 27 Psychiatrists and Mental Health Experts Assess a President. While I have not seen the book prepublication I fear that it will, for some contributors, violate the Goldwater Rule, such as it is. But of more concern is that once again psychiatrists and other mental health professionals will dare to go where no one should, to diagnose without a doctor-patient relationship, and thereby diminish the trust the public will have with them.
Dr. Lloyd Sederer is a psychiatrist and public health doctor. The opinions offered here are entirely his own.
His next book, The Addiction Solution: Fixing America’s Drug Crisis, will be published by Scribner (Simon & Schuster) on May 1, 2018.