In 1964, Fact magazine published an unscientific survey asking psychiatrists whether they thought the Republican nominee, Barry Goldwater, was psychologically fit to serve as president of the United States. The problem wasn’t that professionals felt the need to share their views of what they considered Goldwater’s dangerous ideas; it was the irresponsible and often bizarre analyses that were in some cases based entirely on rank speculation. “Goldwater is basically a paranoid schizophrenic” who “resembles Mao Tse-tung,” one offered. Another said that he “has the same pathological make-up as Hitler, Castro, Stalin and other known schizophrenic leaders.” A third said that “a megalomaniacal, grandiose omnipotence appears to pervade Mr. Goldwater’s personality.”
Embarrassed, the American Psychiatric Association (APA), in reaction to this debacle, established the “Goldwater Rule,” which barred its members from diagnosing public figures. It concluded that “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.” That’s fair, as far as it goes. But in March 2017, shortly after my uncle, Donald Trump, was inaugurated, the APA didn’t just reaffirm the rule — it expanded it past the point of coherence. Not only were members prohibited from diagnosing public figures, now they could no longer offer a professional opinion of any sort, no matter how well supported or evidence-based, even if they believed that a public figure posed a threat to the country’s citizens or national security.
This is absurd on its face and has potentially serious consequences for the safety of the American people. While psychiatric diagnosis is a technical process, it is entirely within bounds to draw conclusions based on observable behavior. It is one thing to declare definitively that a person has anti-social personality disorder (a specific diagnostic term); it is another to point to behaviors — such as deliberately putting other people in harm’s way for no discernible reason (for example, abandoning our Kurdish allies) beyond one’s own self-interest — and express the general conclusion that it is dangerous to have somebody in the Oval Office who is incapable of empathy. The APA has also stated that “psychiatrists are medical doctors; evaluating mental illness is no less thorough than diagnosing diabetes or heart disease.” That’s true — but what might a cardiologist say if a public figure kept having heart attacks? Would he need to be subjected to a “thorough” diagnostic regimen for a doctor to speculate that there might be an underlying heart condition? If the person who kept having heart attacks was a pilot who refused to seek medical attention, wouldn’t it be malpractice not to speak out? It is not an exaggeration to say that Donald has exhibited pathological behavior that is equally alarming — as evidenced most recently by his callous disregard for his own health and the well-being of those around him when he left Walter Reed hospital while still shedding coronavirus, or when he holds rallies and encourages thousands of people to attend without wearing masks or social distancing in order to prop up his ego.
The American public is inadequately educated about mental health. It would take a serious, sustained explication, backed by the power and reach of a professional association, to help us understand why the emotional and psychological stability of our leaders matters and can have an impact on all of us. Every day legal experts weigh in on Donald’s unconstitutional or norm-breaking behaviors. Since his covid-19 diagnosis, medical experts have speculated about the course of his illness and the potentially dangerous side effects he may be experiencing as a result of the experimental treatments he’s received. Only the mental health experts have been effectively sidelined.
That doesn’t mean opinions haven’t proliferated about Donald’s mental health. It sometimes seems that everyone but psychiatrists has aired their views: Rick Wilson, a co-founder of the Lincoln Project, once described Donald’s behavior as “a combination of waking hallucinations, verbal tics, lies surpassing even his usual fabulist standard, aphasias and lunatic blurtings.”
This is a problem. Not necessarily because characterizations like this lack validity, but because such assessments can inadvertently undermine the seriousness of the case when experts fail to provide an appropriate context in which to understand the psychopathologies. If we look at the past 3? years, Donald has lied publicly in excess of 20,000 times; he has impulsively, and against all reason, gone against the advice of experts who could have helped contain the pandemic and protect the economy; he has put private citizens at risk by attacking them on Twitter because they have criticized him; he has proved himself to be incapable of accepting responsibility, changing course or exhibiting empathy. As Courtney Fingar wrote recently in the New Statesman: “The public can observe all these things too, but does so largely without translation or explanation by actual experts. In the end, what was written as a rule to curb speculation has, in fact, allowed it to run rampant.”
Donald’s rhetoric and behavior do have an enormous impact on and play an outsize role in the day-to-day lives of more than 300?million Americans and more in the larger world. We are, in this respect, in a relationship with him, even if it is inevitably one-sided. While it is impossible to diagnose him in the technical sense — because diagnosis is a stringent process that requires certain steps to be followed and certain data to be collected in a very specific way — shifting our focus from the diagnosis to the impact that erratic, impulsive, psychologically disordered behavior can have on those in a relationship, no matter how one-sided or involuntary, is not just useful but necessary.
I am a trained clinical psychologist and have worked as a clinician. If Donald had walked into my office for an evaluation, I would have gathered less information about him from a normal intake interview than I could gather from the countless hours of video available from his decades in the public eye. Often when self-reports aren’t available — because the patient is either unable or unwilling to offer information — the clinician turns to those close to the patient in order to fill in the blanks. But none of that is necessary because examples of Donald’s disordered, impulsive, self-defeating and destructive behavior, which are unlikely to present themselves in a clinical setting, have been extensively recorded.
Alan Stone, a Harvard professor of psychiatry, wrote that, as citizens, “psychiatrists enjoy freedom of speech — just not in their professional capacity.” Individual psychiatrists have agency and can speak if they want to. But to have a substantive and effective conversation about Donald’s fitness for office, a foundation must be laid by a governing body that can more effectively communicate the overarching concerns.
Adopting a notionally neutral stance in this case doesn’t just create a void where professional expertise should be — it serves to normalize dysfunctional behavior. Paradoxically, the suggestion seems to be that speaking out about mental illness is the problem. But in truth, it is remaining silent about Donald’s obvious psychological impairment that is stigmatizing. By claiming that its silence is neutral, the APA is essentially granting Donald’s campaign an in-kind contribution while the American people remain subject to his often deranged and unpredictable behavior, without the tools necessary to evaluate it or understand how it renders him unfit for the office he holds.