During the 1964 Presidential campaign Senator Barry Goldwater (R. Ariz.), issued a number of statements concerning his willingness to actually use tactical nuclear weapons in limited conflicts. Goldwater’s nuclear musings led to broad concerns about his embrace of “extremism,” magnified by pro-Johnson ads depicting a young girl picking petals off of daisy with a nuclear mushroom in the background. Factmagazine joined the fray by publishing an article entitled “The Unconscience of a Conservative: A Special Issue on the Mind of Barry Goldwater,” wherein the magazine reported the results of a poll of over a thousand psychiatrists, 1,189 of whom opined that Goldwater was psychologically unfit to be President of the United States.[1]Goldwater sued Fact’s editor, Ralph Ginzburg, for libel and collected $75,000 in damages, back when that amount was something.
Thereafter, in 1973, the American Psychiatric Association, in apparent embarassment over psychiatrists issuing overreaching professional, diagnostic opinions about the mental status of public figures, without having interviewed the person or having obtained an appropriate release, issued a foreclosing ethical rule, Rule 7.3, which states:
On occasion psychiatrists are asked for an opinion about an individual who is in the light of public attention or has disclosed information about himself/herself through the 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 granted proper authorization for such a statement.
This rule has been enshrined by the A.P.A. as the “Goldwater Rule.”
The unprecedented, daily demonstration of behavioral deviance by the current occupant of the White House has led a number of mental health professionals to strain against the A.P.A. leash of Rule 7.3, asserting professional and moral obligations to warn, educate and protect the public. See Lee, Brandy, M.D. (Ed.) The Dangerous Case of Donald J. Trump: 27 Psychiatrists and Mental Health Experts Assess a President, (St. Martin’s Press, N.Y. 2017). Some professionals suggest that Rule 7.3 conflicts with an afirmative duty of mental health professionals to warn non-patients of known dangers to them from the mentally unbalanced as articulated by the California Supreme Court in Tarasoff v. Regents of the University of California, 17 Cal. 3d 425 (1976). There, Dr. Lawrence Moore, a psychologist employed by the University of California failed to warn Tatiana Tarasoff, that his patient, Prasenjit Poddar, a Bengalese foreign student, related his intent to kill Tatiana. Dr. Moore, having diagnosed Poddar as suffering from acute and severe paranoid schizophrenia, request the campus police to detain Poddar. The police released him, perceiving him to be normal, and Moore’s supervisor at the University ordered that Poddar not be further detained, leading to a suit by the Tarasoff family when Poddar carried out his threat.
The California Supreme Court identified a duty by mental health providers to warn individuals threatened explicitly by their patients or when they perceive that their patient represents a dangerous threat to others. While many states have adopted the Tarasoffobligation to warn by statute or case law, most states require an explicit, credible threat, rather than a general diagnosis of dangerousness, which many consider to be an inherently unreliable conclusion. More importantly, there is nothing in the Tarasoff opinion that obligates a mental health professional to warn the general public against the dangerousness of a person, who is not the professional’s patient.
In March of 2017, the A.P.A. Ethics Panel, without consultation with its general membership, doubled down on the issue by providing an additional admonition adding the prohibition of
“any opinion on the affect, behavior, speech, or presentation of an individual that draws upon the skills, training, and/or knowledge inherent in the practice of psychiatry.” [2]
While it may be inappropriate and unprofessional for a mental health professional to give or disseminate a formal professional opinion as to the mental stability of a public figure, based on public pronouncements and behavior alone, it does seem reasonable and appropriate and ethical to raise concerns that demonstrated abberant behavior by a public figure raises and issue or concern about the potental of dangerous future deviant behavior by persons in positions to inflict great public harm. Rule 7.3 has as a practical matter not been widely enforced because of due process and First Amendment concerns, but some professionals note that the A.P.A. ethical rules are adopted by some state regulatory bodies as standards of conduct and a violation might lead to the filing of embarassing complaints and publicity.
Any reasonably educated and perceptive layman can read the diagnostic criteria for Narcissistic Personality Disorder in the Diagnostic and Statistical Manual of Mental Disorders (5thEd.) and see for themselves the behavior that could logically lead to a diagnostic conclusion for the malady, that would fit the behavior and statements of Donald Trump like one of Paul Manafort’s expensive and well-made suits (i.e. grandiosity, fixation on fantasies of power and success, sensation of entitlement to special treatment and obediance from others, exploitation of others for personal gain, demonstration of a pompous and arrogant demeanor consistent demonstration of impulsive and bullying behavior, lack of empathy for others, etc.). Yet, according to Dr. Allen Francis, Professor Emeritus at Duke University and the person who drafted the criteria, Trump, who might clearly be a world class narcissist, is not thereby mentally ill because there is also a requirement that a personality disorder lead to “clinically significant distress or impairment.” In other words, he doesn’t receive stress, he causes it.”[3]
In the spring and summer of 2017, the New Yorkermagazine ran articles raising the issue of whether or not Trump would lead to the abandonment of the Goldwater Rule.[4]Presumably because of growing public concern about his mental status, President Trump requested Admiral Ronny Jackson, then the White House physician to assess his mental status during his annual physical in January, 2018. Jackson gave the President a laughingly inadequate Montreal Cognitive Assessment test that is sometimes used to diagnose Alzheimers dementia. The test consists of 30 questions, easeily answered by normal people. The questions include the requirement of drawing ten past eleven on a clock face, distinguishing a camel from a lion or a rhino, counting to five and subtracting 7 from 100. Trump passed with flying colors as any third grader would.
The test is only relevant to cognitive disorders and has nothing to do with personality disorders.
The real problem is that in the absence of a complete breakdown by the subject of the concern, there is no real place to go with it other than to alert those around the President to the potential necessity of invoking the 25thAmendmentto the U.S. Constitutionwhich contemplates action in the event a President is disabled. There are those who recommend the establishment of a standing commission to review the mental health of the President under the banner of the 25thAmendment, yet that probably raises more concerns that it resolves regarding privacy rights and political intrigue and bias. We cannot effectively guard against all negative impacts of mental or emotional deficiencies (i.e you cannot for example legislate against an absence of judgment). Not all mental or emotional trevail disqualifies a person from leading a nation (i.e. Lincoln’s depression and Churchill’s bipolar disorder). The issue arrives with alarming regularity (viz. Nixon’s narcissim and paranoia and Reagan’s Altheimer’s disease in his second term. Yet to silence, reasonable and legitimate concerns by mental health professionals about abnormal behavior by the most powerful person in the universe, seems to be a misguided intradiction.
The First Amendmentprovides lawyers with the the right to speak out when the President tramples upon the Constitution.Mental health professionals should enjoy the same right to publicly express their concerns, as long as they don’t assert their concerns as established fact of mental illness. In the absence of a severe, disabling melt down, we must rely upon the ballot box and the courts to free us from disruptive, incompetent or corrupt public officials.
[1]Goldwater was a former U.S. Air Force pilot and Air Force reserve general, whose views were not radically different from General Curtis LeMay, the World War II Hero and Air Force general of whom JFK commented during the Cuban Missle Crisis, that in the event of war you want LeMay in the first plane, but you never want him deciding whether to go to war.
[2]It should be noted that the American Psychological Association and other mental health professional organizations generally follow the A.P.A.’s lead, but that is not universal. The American Psychoanalytic Association has no such prohibition and doesn’t consider it to be an ethical issue, but many professionals belong to both organizations.
[3]Fox, Maggie “Donald Trump Isn’t Mentally Ill, He is Just Unpleasant, Psychiatrist Says.”, NBCNews, February 16, 2017.
[4]Mayer, Jane “Should Psychiatrists Speak Out Against Trump,” New Yorker, May 15, 2017 and Gersen, Jeanne Suk, “Will Trump Be the Death of the Goldwater Rule?” New Yorker, August 23, 2017.