It’s one thing for us to call Trump a narcissist or a sociopath, but it’s another thing entirely when a group of mental-health professionals argue that Trump should not be allowed to debate—or should be impeached—because he’s sick in the head.
Psychiatrists generally refrain from diagnosing people whom they haven’t examined, adhering to what’s called the “Goldwater Rule”. That rule, put into place by the American Psychiatric Association, came into being in 1973 when a group of over 1000 psychiatrists questioned Barry Goldwater’s fitness for office based on their long-distance diagnosis. Other Presidents, including Clinton, have also been diagnosed as mentally ill by the pros.
After the diagnosing of Trump started in 2016, the APA issued a statement in January, 2018 that reaffirmed the Goldwater Rule:
Today, the American Psychiatric Association (APA) reiterates its continued and unwavering commitment to the ethical principle known as “The Goldwater Rule.” We at the APA call for an end to psychiatrists providing professional opinions in the media about public figures whom they have not examined, whether it be on cable news appearances, books, or in social media. Armchair psychiatry or the use of psychiatry as a political tool is the misuse of psychiatry and is unacceptable and unethical.
The ethical principle, in place since 1973, guides physician members of the APA to refrain from publicly issuing professional medical opinions about individuals that they have not personally evaluated in a professional setting or context. Doing otherwise undermines the credibility and integrity of the profession and the physician-patient relationship. Although APA’s ethical guidelines can only be enforced against APA members, we urge all psychiatrists, regardless of membership, to abide by this guidance in respect of our patients and our profession.
A proper psychiatric evaluation requires more than a review of television appearances, tweets, and public comments. Psychiatrists are medical doctors; evaluating mental illness is no less thorough than diagnosing diabetes or heart disease. The standards in our profession require review of medical and psychiatric history and records and a complete examination of mental status. Often collateral information from family members or individuals who know the person well is included, with permission from the patient.
“The Goldwater Rule embodies these concepts and makes it unethical for a psychiatrist to render a professional opinion to the media about a public figure unless the psychiatrist has examined the person and has proper authorization to provide the statement,” said APA CEO and Medical Director Saul Levin, M.D., M.P.A. “APA stands behind this rule.”
I generally agree, for professionals should behave professionally. Doctors don’t diagnose patients without an exam, and psychiatrists are doctors. As an article in the Canadian Medical Association Journal (CMAJ) noted,
. . . One reason for The Goldwater Rule is the likelihood of error in a diagnosis made at a distance. A proper diagnosis requires much more than “a review of television appearances, tweets, and public comments,” the American Psychiatric Association noted in its statement. “The standards in our profession require review of medical and psychiatric history and records and a complete examination of mental status. Often collateral information from family members or individuals who know the person well is included, with permission from the patient.”
You can say we already know enough to agree that Trump is mentally ill, but remember, if you want to assert that in court, the perp has to be examined by mental-heath professionals. Courts won’t accept diagnoses without direct examinations.
Now some mental-health professionals say that there’s a “duty to warn” that overrides the Goldwater Rule, a “duty to warn” about the effect of Trump not just on the well being of America, but on the well being of Americans themselves, making them unstable, liable to suicide, and so on. And so a group of 27 mental-health professionals, including psychiatrists, issued a statement last October warning about Trump. An excerpt from that:
Efforts to bring Duty To Warn into the spotlight have been ongoing since Trump first stepped into the political ring. We are joined by mental health professionals from various field including, but not limited to, psychiatry, psychology, medicine, public health, public policy, and social work; in every field, professionals have been voicing their concern about the president’s instability.
We Are Mandated Reporters
Mental-health professionals are mandated reporters with a duty to warn our patients and the community around us if we feel there is a potential danger. In this case, we collectively feel there is a duty to warn the public of the threat Donald Trump poses both to our nation and the planet.
It is our duty to notice when an individual is a danger to themselves and/or others.
What about the Goldwater Rule?
“The Goldwater Rule is not absolute. We have a ‘Duty to Warn,’ about a leader who is dangerous to the health and security of our patients.” Mental-health professionals are “sufficiently alarmed that they feel the need to speak up about the mental-health status of the president.”
Last October, when a group of 27 mental health professionals, including psychiatrists, published a book arguing that the current US president’s mental state was a danger to the nation, they said they were honouring another medical principle: the duty to warn. The idea behind “duty to warn” is that if you are in a position to know about a danger and have time to alert others, you should do so. Psychiatrists, for instance, are allowed to break doctor–patient confidentiality if they suspect a patient is about to harm a third party.
But part of that duty rests on having done a proper evaluation, according to Dr. David Goldbloom, a psychiatry professor and senior medical adviser for the Centre for Addiction and Mental Health. “You are intervening to abrogate fundamental civil freedoms,” he said. “You can’t do that from having read an article or watched television.”
Of course, we know that Trump is a danger to the country simply because of his statements and actions, and that seems to me independent of whether he has an official DMC diagnosis by professionals.
But Yale psychiatrist Bandy Xenobia Lee, in an interview with Salon (of course), says that it’s her duty to warn people about Trump’s instability.
Lee has a history of trying to publicize her views that Trump is mentally ill; see the section on this in Wikipedia, which also describes her lobbying Congress. That section says this:
in 2017 [Lee] was editor of The Dangerous Case of Donald Trump, a book of essays alleging that Trump suffers from psychological problems that make him dangerous.
. . . In an interview she also said, “whenever the Goldwater rule is mentioned, we should also refer to the Declaration of Geneva, established by the World Medical Association 25 years earlier, which mandates physicians to speak up if there are humanitarian reasons to do so. This Declaration was created in response to the experience of Nazism.”
And it’s possible that some of this has to do with, yes, inequalities in American society:
Lee then stated in an interview with Salon in May 2017 that Trump suffers from mental health issues that amount to a “state of emergency” and that “our survival as a species may be at stake.” She also discussed her political views, linking what she sees as increasing inequality in the United States to a deterioration in collective mental health.
She continues her efforts in the Salon interview (click to read):
First, she argues that Trump shouldn’t be allowed to debate:
Trump spent most of the debate heckling and interrupting, mixed with some blatant lying. How would you assess his debate performance?
The huge error was in allowing the debate to happen in the first place. “How was his debate performance?” is the wrong question to start. A debate presupposes mental health. We cannot pretend to have one when management of psychological impairment is what is warranted. The majority of the country may be horrified at what he is doing, but we continue to help the disorder in every way possible by treating his behavior as normal. It applies first to the politicians, then to the media and then to pundits who do not come out and honestly say: “This is beyond anything I have seen and beyond what I can understand — can we consult with experts?” And experts, for a psychological matter, would be mental health experts. Perhaps even specialists of personality disorders or sociopathy would be necessary, given the severity.
I’m not sure people treated his behavior as normal; the media was full of people saying that he seemed unhinged. Having someone like Lee weigh in that he’s mentally ill and shouldn’t have been allowed to debate adds little to that; in fact, I thought the debate was salutary in one sense: Americans got to see how unhinged Trump is. If they want to elect him after that, well, they’ll get what they deserve.
One gets the feeling, throughout this interview and in Lee’s other writings, that part of the reason for her crusade goes beyond her view that an unleashed Trump will harm America; it may well also involve her blatant dislike of his politics. In that respect she goes over the top in emphasizing the psychological toll of Trump on America, a toll that presumably should have mandated his impeachment:
The reinterpretation of the “Goldwater rule,” as happened at the onset of this presidency, has been exceedingly harmful, in my view, for silence in the face of grave dangers facilitates conditions for atrocities. Last month, we created a blow-by-blow account of how we exactly foretold the president’s mismanagement of the coronavirus pandemic, based on his psychological makeup. We could not effectively convey this in advance, because the public was led to believe that the “Goldwater rule,” which is a guild rule applying only to 6% of practicing mental health professionals, was universal, or worse yet, some kind of law. But in truth, to change a guideline whose purpose is to protect public health to protect a public figure at the expense of public health violates all core tenets of medical ethics.
Yet Lee has been broaching the Goldwater Rule for a long time (I don’t know how she gets away with this if she’s a member of the APA), and yet nothing has happened to Trump despite her books and her many interviews, all making the same point.
And she may well be right that Trump meets the ever-shifting psychiatric criteria for mental illness. I’m no professional, but Trump’s behavior seems way, way out of line—the tails of the human behavioral distribution. Still, I’m not comfortable with professionals giving a professional opinion by observing Trump the same way we do: scrutinizing his tweets, his press conferences, his debate performance. The man is out of control. But don’t psychiatrists need to talk to a patient before they tell the world he’s nuts? The effect of Trump on people is obvious, and you don’t need to be a mental health professional to see that his Presidency is risky to America. Having Dr. Lee tell us that, in our professional opinion, he’s nuts, adds nothing to our fear of the man.
In fact, if people tried to remove Trump from office, or prevent him from debating, based on Lee’s opinion that Trump is mentally ill, it wouldn’t work. People would just laugh at the attempt, and impeachment on the grounds of mental incapacitation wouldn’t do, either, at least not with a Republican Senate.
I can see where Lee is coming from: she’s a forensic psychiatrist and presumably sees nuances in Trump’s behavior that we don’t see. But we don’t need nuances—we know all we need to know, and if a liberal psychiatrist says Trump is certifiably a bull-goose loony, that will have no effect in swaying his supporters. We already have the means to stop Trump, and we can exercise it in the next four weeks by casting our ballots against him.