President Trump’s unprecedented behavior — his tweets disparaging the man he appointed as attorney general and his bizarre speech to the National Scout Jamboree, to name a couple of recent examples — has fueled ongoing speculation about his mental health. It has also renewed discussion of the Goldwater rule, an ethical standard adopted by the American Psychiatric Association that essentially tells psychiatrists not to speculate on a public figure’s mental health unless you’ve examined him or her.
Recent news headlines implied that psychiatrists are ditching the rule in response to Trump, but that’s not quite true.
The Goldwater rule takes its name from Barry Goldwater, the GOP nominee in the 1964 presidential election whom opponents labeled as a right-wing extremist and demagogue and was roundly defeated by Lyndon B. Johnson. The rule arose from a 1964 cover story in Fact magazine that had the headline, “FACT: 1,189 Psychiatrists Say Goldwater is Psychologically Unfit to Be President!” Although the headline was technically correct, it was also misleading, as the story was based on a survey sent to more than 12,000 psychiatrists, 80 percent of whom did not reply.1 In response to the story, Goldwater sued Fact for libel (and won), and the American Psychiatric Association created the Goldwater rule.2
Last month, Stat News reported that the American Psychoanalytic Association had sent an email to its members telling them that they should not feel bound by the rule restricting them from commenting publicly on a public figure’s mental health.
But the email didn’t mean a change to the Goldwater Rule.
First, the email reported on by Stat didn’t come from the organization behind the Goldwater rule — the American Psychiatric Association — but from a very similar sounding, yet distinctly different (and 10 times smaller)3 group, the American Psychoanalytic Association. (And if that’s not confusing enough, there’s also the American Psychological Association. Last year, its then-president wrote that “psychologists should not offer a diagnosis in the media of a living public figure they have not examined.”4)
Second, the American Psychoanalytic Association’s policies have not changed, according to Wylie Tene, director of public affairs for the group, who told me in an email that the Stat article was misleading. The message sent to members was meant to clarify that the Goldwater rule applies only to members of the American Psychiatric Association, Tene said, noting that her group has its own set of ethics codes and policies. “Our members are still cautioned about diagnosing public figures,” Tene said.
So we have the psychiatrist and psychologist groups saying don’t comment on a public figure’s mental health and the psychoanalytic group saying be very careful if you comment. But those are official policies, and individual opinions differ widely. Some mental health professionals have defended the Goldwater rule, including Allen Frances, who helped write one edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, a book so influential that it’s sometimes referred to as the Bible of mental health disorders. “Bad behavior is rarely a sign of mental illness, and the mentally ill behave badly only rarely,” Frances wrote in The New York Times. “Psychiatric name-calling is a misguided way of countering Mr. Trump’s attack on democracy.”
Other mental health professionals have spoken out on what Yale psychiatrist Bandy X. Lee has called psychiatrists’ “Duty to Warn” when a leader is dangerous to the health and security of their patients. (The term comes from laws that allow or in some cases compel psychiatrists to break confidentiality rules to alert police or potential victims when a patient poses an imminent danger to someone.)5 Leonard L. Glass, an associate professor of psychiatry at Harvard Medical School resigned from the American Psychiatric Association in protest of the Goldwater rule, writing in The Boston Globe that it was “inappropriate for the APA to assert that I would be in violation of my profession’s ethics code if I continued to speak out in what I consider a thoughtful, data-driven, and responsible fashion regarding Trump or any other public figure.”
Here at FiveThirtyEight, we’ve written about the ethics of speculating about a candidate’s mental health, and last September, we discussed the Goldwater rule, its genesis and what it means in the age of Trump in an episode of Sparks, our science podcast. Our science team has deliberately shied away from speculating on President Trump’s mental health for reasons similar to those given in support of the Goldwater rule — armchair diagnoses are often wrong, throwing labels around can increase stigma around mental illness and discourage people with these conditions from seeking treatment, and speculating on public figures’ mental health is beyond the scope of our profession.
As we noted in our podcast discussion, attitudes and ideas about mental health have changed a lot over the past decades. Fact magazine’s 1964 article about Goldwater made sinister insinuations that his father was gay, and at that time, homosexuality was listed as a diagnosable disorder in the American Psychiatric Association’s Diagnostic and Statistical Manual. (The diagnosis of “homosexuality” was not removed from the DSM until 1973.) Narcissistic personality disorder, which some mental health professionals have speculated that Trump has, is listed in the current DSM. But some researchers have criticized the DSM description of it, and the consensus on this disorder may evolve over time.
When discussing a public figure’s mental health, we need to ask whether we’re really engaging in scientific discourse or using medical terms to bolster a political argument. For those offering an armchair diagnosis of Trump, what purpose does a diagnosis serve?
Let’s imagine for a moment that these label-throwers are right and that Trump truly has a mental illness. Were he to publicly say, “My doctor has diagnosed me with narcissistic personality disorder, and I’m working on a treatment plan — bear with me,” that probably wouldn’t automatically disqualify him from office. The protocol for removing a president who is unfit for office is laid out (vaguely) in the 25th Amendment, but if the goal is to unseat the president, impeachment is probably an easier route, in part because no one really knows how the 25th Amendment would be implemented. The patterns of behavior that people point to as evidence that Trump is unfit to serve aren’t all that different from the ones that Trump exhibited during the campaign, after all, which makes it difficult to argue that his fitness for the job has changed since his hiring.
The things that raise alarm bells about Trump are his words, deeds and tweets, and there’s no need to make any kind of psychological diagnosis to assess or criticize those. “A diagnosis of a public figure is really not important,” psychiatrist Prudence Gourguechon, a past president of the American Psychoanalytic Association wrote in a blog post. Gourguechon supports the Goldwater rule and said, “What is important is to look at their words, behavior and stated values and see how these intentionally and unintentionally affect the electorate, public discourse and American culture.”
It doesn’t take a psychoanalyst to understand Trump, Frances told Evan Osnos at The New Yorker: “He’s the most transparent human being who ever lived. Giving it a name doesn’t explain it or change it.”
Moreover, projecting psychiatric labels on people with opposing political views toes a dangerous line. Both Russia and China have used punitive psychiatry to silence political dissidents in recent history. People accusing Trump of insanity might well feel different about the practice if it was turned on one of their favored candidates.
Slapping diagnoses on public figures like Trump is “essentially name-calling and it’s not constructive,” Susan Molchan, a psychiatrist who spent much of her career at the National Institutes of Health told me. “It’s making an assumption and trying to attach a stigma, and it’s not fair to people who are clearly mentally ill and aren’t bad,” she said.
Psychiatric diagnoses have a range, and a diagnosis isn’t a good predictor of how someone will behave or how functional they are in their job or in society, Gourguechon said in an interview. “A diagnosis is good for treatment and for insurance reimbursement — without a diagnosis you can’t get your psychological or psychiatric visits covered — but it’s not very good for understanding people in their depth and complexity.”