Should Psychiatrists Have Mental Health Oversight in Politics?
By Anonymous
A recent article by Dr. Nassir Ghaemi lays out the dilemma facing Psychiatry and its role in politics: adhere steadfastly to the Goldwater Rule and skirt a constitutional mandate under the 25th amendment, or engage in the protection of society from psychiatrically compromised leadership and risk the politicization of psychiatric assessment. Additionally, in an admirable and Tolkien-esque position, Dr. Ghaemi argues that psychiatric illness can be (and likely has been) an asset to national leadership throughout history.
A brief review of the attitudes of APA leadership and other senior psychiatrists that led to the codification of Section 7.3 in the Principles of Medical Ethics with Annotations Especially Applicable to Psychiatry suggests that the core concern of the Goldwater Rule was the protection of an individual’s right to privacy. The APA did not want our field to play fast-and-loose with protected health information. Recklessness of that kind would certainly backfire.
The imperative to protect the privacy of everyone, no matter how public or powerful a figure, ought to bring a dead halt to all conversations about dropping Goldwater. A violation of privacy is an automatic violation of Primum non nocere. Hence, if we are going to be available to participate in a 25th amendment competency process the question becomes, “How do we provide assessments to politicians — behind closed doors?”
The impaired practitioner model
Interestingly, fields such as medicine, aviation, and law already have programs that could serve as templates for confidential mental health oversight for politicians. Impaired practitioner programs in medicine acknowledge that employment in the field cannot be withheld on the basis of the mere presence of a psychiatric condition, while paying respect to the potential risks that those conditions pose to the public. Impaired practitioner programs are supported by state medical boards because they improve public trust presumably by reducing the number of mental health-related events, while providing some assistance to the afflicted practitioner. The adaptation to politics is fairly straightforward: a mandatory, confidential assessment upon election to public office, and mandatory compliance with treatment should any issue be identified.
In practice, presidents, for example, who tend to have narcissistic traits and who might be vulnerable to alcoholism, would likely be required to attend weekly psychotherapy, and to be tested quarterly for excessive alcohol intake. One might ask why this isn’t already written into our national laws as a universal precaution.
Criticisms of impaired practitioner programs are abundant however, and well-founded. These programs are often led by physicians who have had their own substance use issues, and who therefore tend to be heavily valenced toward over-diagnosis and over-management; they gain ego-integrity by painting program participants to be just as “defective” as they were, and by handling them as such. Random drug screening (a nearly universal measure in impaired practitioner programs, regardless of the participant’s diagnoses) is stressful and disruptive in the context of a physician’s schedule. Some participants may rightly feel that the programs do more harm than good, detracting from their ability to place patient care first. Additionally, these programs can be financially brutal for younger physicians, and conflicts of interest (e.g. assessments performed by physicians with a stake in a rehabilitation program) are rampant. Physicians entering these programs are effectively blackmailed into compliance in order to continue on paths they have spent their entire lives sacrificing for.
Another large problem facing impaired practitioner programs is the method of referrals. The Florida program has a “rat clause” that effectively stipulates that any participant is obligated to refer a non-participant with a suspected mental health problem. Meanwhile, other physicians with deadly problems stay below threshold through years and years of suffering and damage in the absence of mandatory, universal screening.
Finer consideration of the subtleties would be necessary were these programs to be adapted into impaired politician programs.
Characterological assessment model
The following proposal is as concerned with the essence of the 25th amendment (that leaders must be competent) as it is with the true spirit of anti-Goldwaterian sentiments currently rising within the field (despair that our leaders often display signs of problematic psychopathology). It is suspected that vocal anti-Goldwater advocates are not reeling exclusively in response to their detection of pathological narcissism or dementia in prominent public figures. It is likely that they are using those stated observations as stand-ins for traits that they know intuitively to be even more problematic: poor insight, corruption, and anti-sociality. These traits pop out of the screen to practiced psychiatrists and Michael Moore alike, but they are potentially more unfair to talk about publicly. They are, however, valid and ostensibly more salient disqualifications to public office in the eyes of the American people — there have been no popular songs celebrating America’s role as the world’s sociopath.
If people prefer virtue, can a politician’s potential for corruption be reasonably guessed at prior to taking office? Such a characterological assessment is indeed possible with interview and observation aimed at clarifying a few character dimensions.
The first of these character dimensions might be hunger for “secondary gains” emerging from the act of taking office. Secondary gain usually refers to the benefits accrued by a patient when they adopt a sick role. We mean to extend the meaning here to include any unstated benefit that an individual obtains through any action, such as obtaining public office.
Almost no one is a saint, and some secondary gain is just flat out unavoidable. For example, we know that almost no one goes to medical school for entirely altruistic reasons. But hunger for and facility with secondary gains detract from the integrity of the office. These character traits are readily guessed at up front, difficult to hide, and may be disqualifying.
Another dimension of character that could be assessed up front is the aspirant’s authenticity. In such an assessment, an “ideologically matched” psychiatrist could, for example, evaluate whether a person’s life history is consistent with their stated policy objectives. Partly because all preoccupation and belief have their roots in past experience, counterfeit goods are easily detected. Candidates who exceed a certain threshold of misrepresentation for the purpose of obtaining office might be disqualified for a period of time through this method, until they can achieve authenticity.
Measures such as these would radically change the meaning and effectiveness of government, by changing the composition of the people in government. They could alter our national identity in a way that is almost too impressive to imagine.
Experts in Human Engineering
None of the ideas expressed above are novel proposals, really; a 1948 statement from President Harry Truman to the American Psychiatric Association is frequently quoted by historians of our field:
Never have we had a more pressing need for experts in human engineering. The greatest prerequisite for peace, which is uppermost in the minds and hearts of all of us, must be sanity… We must continue to look to the experts in the field of psychiatry and other mental sciences for guidance in the evaluation of our mental health resources.
70 years later, no one ends up being quite so practiced and so lonely in their considerations about secondary gain and character as psychiatrists and psychologists. Meanwhile, many politicians appear to rely on the fantasy that secondary gain does not exist, and to have higher than average levels of anti-social traits; as a result, government appears histrionic and ineffective. As national attention to corruption in Washington mounts, it would be good for the country if mental health and government agreed to team up to address these basic human realities, honoring the spirit of both the 25th amendment and Goldwater.
Particularly at the apex of psychoanalysis’ popularity in America, in the time after Freud and before the rise of the DSM and biological psychiatry, there was an idealistic aspiration among analysts (an elite subgroup of psychiatrists trained in that distinct form of psychotherapy) to lay a hand on government. There was a somewhat naive belief that psychoanalysis could serve to relieve kings, senators, justices, CEOs, and presidents alike of their problematic unconscious conflicts. With analysis, world leaders would be enlightened, peaceful and prosperous alliances between societies would be forged, and the most dangerous threats to life in the nuclear era might be contained.
It’s entirely appropriate that psychiatry has since tempered its stated aspirations. Our field is infamous for its abuses of public trust (e.g. nearly systemic sexual misconduct in the Viennese and early American circles, lobotomies, insulin coma therapy, misogynistic theoretical roots). Jeffrey Lieberman has convincingly portrayed academic growth in psychiatry as plagued by knowing self-deception.
Like all good narcissists, we were simply not ready for the responsibilities and status we wanted. We may still not be. Even today the field is rightly considered several decades behind other medical disciplines in terms of the sophistication, specificity, and efficacy of available treatments. Our standard nosology, the diagnostic and statistical manual, is considered by some physicians in other fields to be anti-physiological and hence irreconcilable with designation as medicine.
Given the mistakes we’ve made, the ideal psychiatrist of the last 50 years may have been the one who worked quietly and effectively to heal as many individual patients as possible, avoiding public recognition (and envy), in order to generate firm root-level support for the field.
We need that earned public trust, and that earned self-respect. To echo a sentiment of Dr. Ghaemi, our societies are likely on the verge of asking much more of mental health as a repository of knowledge and skills that are profoundly organizing and salutary in the chaos of colliding cultural forces. The study of Psychiatry makes so many philosophical problems obsolete. The educational background required to enter this field takes a tour through fertile grounds on the four corners of the humanities, sciences, and medicine for good, conciliatory solutions to the divisive preoccupations that define our era. And the skillset — the ability to assess character in a reliable, reproducible fashion — wed to an empathic understanding of how characterological elements originate and perform— has virtually unlimited applications for any society that is quite sincere in its desire to persist. Everyday this field becomes more relevant and better equipped.
I don’t think we need to shy away from making a contribution, so much as to examine carefully what it would need to look like.
