On the 2016 Election, the Goldwater Rule, and “Diagnoses from Afar”
Dear Friends [and Readers],
It’s time for us to have a conversation about the Goldwater Rule and the appropriateness of assigning speculative psychiatric diagnoses to public and political figures (or anyone else, for that matter).
Some of you may know that I’ve often posted media articles that touch on this and other related issues in the past, but I continue to see disagreements on the basic issues at-stake, even within my hyper-liberal, generally well-informed social media circles. Furthermore, speculation as to whether Donald Trump has this or that mental illness continues to be a consistent narrative in the popular press — I would link to some of the articles, but I’d rather not give them the signal-boost. So what I’m going to do is take yet another stab at breaking down a few of the reasons that no one should ever be diagnosing anyone with a mental illness in the absence of a thorough diagnostic evaluation by a trained clinician (and maybe not always even then).
First, a brief history lesson. In the midst of the 1964 presidential election, Fact magazine conducted and subsequently published an article based on a survey that they had conducted that basically asked professional psychiatrists to speculate on the mental fitness of Republican candidate Barry Goldwater. To their credit, many psychiatrists declined to participate, but some did. After Goldwater lost that election, his campaign filed a libel suit in response to the article — which they won. This led to the promulgation of the so-called “Goldwater Rule” by the American Psychiatric Association in 1973, which forbade psychiatrists from offering professional opinions about public figures under most circumstances. For those of you who are curious, here’s the full-text of that 1973 rule:
On occasion psychiatrists are asked for an opinion about an individual who is in the light of public attention or who has disclosed information about himself/herself through 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 been granted proper authorization for such a statement.
To be absolutely clear, the Goldwater Rule itself is an institutional ethical mandate that was self-imposed by and only specifically applies to psychiatrists. In part, it was adopted to limit further controversial political entanglements, to protect the public reputation of the profession, and to avoid future legal liability. But it was also adopted because diagnosing an individual from afar — someone we may never have met in person, much less spoken to, much less conducted the appropriate diagnostic assessments — with a mental illness is unethical as fuck. That goes for clinicians, physicians, journalists, and everyone else in the entire world.
Here are just a few of the (overlapping) reasons that you really shouldn’t be casually throwing around psychiatric diagnoses in basically any context ever:
1. Mental illness is not some kind of convenient rhetorical or explanatory device for understanding why some people are assholes. Let me say this again because apparently this isn’t clear to everyone: being an asshole is not a diagnosable medical condition, psychiatric or otherwise. Ditto being otherwise unlikable or irritating or weird or eccentric or what have you. And honestly, within the specific context of the current presidential election, in what way does it enrich our discourse to speculate or joke about the possibility that Trump has an undiagnosed mental illness?: surely his behavior speaks for itself in so far as the political debate is concerned. What’s more, when we attribute Trump’s bigotry to mental illness, I suspect that by placing so much emphasis on Trump the (aberrant) individual, we run the risk of willfully blinding ourselves to other explanatory variables that may be far more important to attend to for the purposes of the public discourse (e.g., structures of racism, sexism, class, and privilege). Personally, I’d rather devote my time and energy to engaging in constructive dialogues about how to dismantle those systems than pointless speculation about undiagnosed mental illnesses that might actually interfere with any kind of real progress.
2. Labels are powerful, and the way that we apply labels matters. Labels have the power to normalize, empower, and de-stigmatize; equally, they can become powerful anchors of other-ness. This is true of all of the ways in which we represent and contribute to representations of mental illness —in my experience, the overwhelming majority of fictional depictions and media accounts of mental illness are godawful, for the record. When we make overhasty attributions that negative or socially non-conforming behaviors are consequences of mental illness we contribute to negative stereotypes, prejudice, stigma, and misinformation. Hardly a day goes by that I don’t overhear someone saying things that are straight-up factually untrue about mental illness.
3. Stigma casts a shadow: when we label someone with an undiagnosed mental illness simply by dint of behavior that we find repulsive, we cast an undeserved pall on every other individual to whom that label may be (justly or unjustly) applied. Indeed, this penumbra of stigma often extends beyond those individuals diagnosed with the illness to encompass and affect close others, including family members and even individuals who are employed in the mental healthcare field. Attitudes toward mental health in the United States — really, globally — are frankly appalling. In turn, that stigma and those attitudes contribute to such outcomes as devastatingly high suicide rates among individuals with mental illnesses and extraordinarily high barriers to treatment-seeking and treatment receipt.
4. The purpose of psychiatric diagnoses is not to label or categorize behavior at all. This one is a bit trickier to grasp, I think, but the essential purpose of diagnosis is actually to identify and treat underlying (biologically-mediated) syndromes that interact with people’s environments in such a way so as to give rise to clinically significant distress and disability (sometimes referred to as “functional impairment”). Inattentiveness is not the same thing as ADHD, and not all people who are frequently inattentive have the medical syndrome that we refer to as ADHD, nor would everyone who is inattentive benefit from Ritalin pharmacotherapy. Equally, narcissism is not the same thing as Narcissistic Personality Disorder. (For the record, I have very little doubt that Donald Trump would score in, say, the upper quintile on an questionnaire designed to measure narcissism as a personality trait if he answered the questions honestly, and if you want to use narcissism as a colloquial, descriptive term referring to concrete behaviors that he exhibits, go right ahead. But to be clear: that shouldn’t be confused with saying that he has Narcissistic Personality Disorder.) If you’re talking about psychiatric diagnoses, and you’re not thinking about reducing suffering and stigma, improving treatment, distress and disability, and recovery, then there’s a good chance that you’re doing it wrong.
5. The very existence of many of the existing psychiatric diagnoses is extremely controversial even — especially — among trained mental health professionals and researchers. The same thing is true of the particular sets of criteria on which those diagnoses are based. There are very real concerns about both the validity (essentially, the realness) and the clinical utility of many such categories/labels. Indeed, the subset of mental illnesses that are collectively referred to as “personality disorders,” including both Narcissistic Personality Disorder and Antisocial Personality Disorder (both of which have been suggested as potential diagnoses for Trump in the popular press) are among the most controversial, and many experts in the field (including the Personality and Personality Disorders Working Group for the most recent edition of the DSM, DSM-5) have advocated drastic overhauls to the criteria based on which such disorders are diagnosed and/or eliminating many of the current personality disorder diagnoses from the DSM altogether. Furthermore, even the best available methods for diagnosing mental illnesses (structured clinical interviews administered by training clinicians) are deeply, deeply flawed, and rates of misdiagnosis (both underdiagnosis and overdiagnosis) in standard community clinical settings are staggeringly high, which ought to both dramatically decrease our confidence in any of the speculative diagnoses that are being thrown around and — separately — concern us deeply.
In the end, pretty much the only thing that the practice of “diagnosing an individual from afar” actually accomplishes is to undermine attempts to alleviate suffering associated with medical conditions that are simultaneously all-too-common and tremendously stigmatized and misunderstood. To the contrary, doing so almost invariably contributes to that suffering. In the case of (mental) health professionals, this practice of diagnosing from afar detracts from the credibility of the profession and the real science of clinical psychology. In the case of the political media, publishing accounts that violate the spirit of the Goldwater Rule distracts from real issues: favoring gossip and speculation over policy and substance. Maybe it helps some of us to sleep better at night to think that Trump’s behavior is aberrant (it’s really not) and to explain it away as a sign or consequence of mental illness, but let’s be real: no one who’s genuinely struggling with mental illness ever deserves to be casually lumped together with Donald J. Trump.
At their best, psychiatric diagnoses are basically clinical and research heuristics that help us to identify and understand common mechanisms and patterns across people in support of treatment; in contrast, diagnoses are at their worst when they’re being used to obfuscate and over-pathologize the origins of human behavior — everything from being gay (homosexuality was classified as a mental disorder in the DSM until 1973) to just plain being a hate-mongering demagogue — and when they’re contributing to the systematic stigmatization of individuals with mental illnesses. Really, the only times that we should ever be using psychiatric diagnoses in any capacity are when they’re being used in support of the central aim of alleviating suffering — whether in research, clinical practice, community-building and anti-stigma efforts, or, in some cases, helping individuals make sense of their own lived experiences and struggles. Outside of that fairly narrow context, the deployment of psychiatric diagnoses is almost always essentially meaningless, and often actively harmful.
Thank you for time and consideration. Sincerely,
Benjamin Swerdlow
Doctoral Student, Clinical Science
University of California, Berkeley
P.S. The same thing goes for blithely labeling others’ objectionable or non-typical behaviors with phrases such as, “They’re crazy” or “They’re nuts.” In case it somehow wasn’t already clear, we’re talking about real medical disability here, folks. Don’t contribute to it. The language that you use matters; representations matter.
P.P.S. If you read this and think “Well I said that once but I was joking or being glib and all my friends knew that”, well, that’s a substantial part of the problem right there.