Trump, psychopathy, and the Goldwater rule

This commentary concerns the debate about whether psychiatrists should express an opinion about President Trump and his probable ‘diagnosis’ of psychopathy (or, if you prefer DSM, ‘personality disorder’); especially in view of his obvious demonstrated destructiveness and dangerousness.

This issue, of whether psychiatrists can properly comment on public figures and their mental status, first came to prominence concerning Senator Barry Goldwater back in the 1960s — when American psychiatrists, in large numbers, made a complete arse of themselves by responding to a questionnaire from some magazine about Goldwater’s mental suitability for the presidency.  Ten years after that — so long after it is difficult not to think of the phrase ‘I used to be indecisive, but now I’m not so sure’ — the American psychiatric Association (APA) finally issued the following statement:

7. 3. 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.

The APA [1] updated and doubled-down this in 2016/7 in a lengthy addendum to rule 7, by asserting that (among other things): ‘Psychiatrists are ethically prohibited* from evaluating individuals without permission or other authorization’.

Note: the APA is a voluntary association which psychiatrists are quite entitled to eschew membership of. 

*And, for those whose first language is not English, or whose English comprehension is not in the first division, the word ‘prohibit’, as defined in the Oxford English dictionary: to forbid something by command, to prevent or hinder by physical means, to make impossible.

There are several reasons for suggesting that is a muddled and inappropriate, even incompetent position for the APA to take:

First, one would be entitled to infer that a degree of weak-kneed deference by the APA to the new Trump administration was involved — which tempts me to use the word pusillanimous.  A former [anonymous] member who feared reprisals said, ‘You wouldn’t want to get on the wrong side of any administration let alone such a vindictive one.’  One might recall the words of Edmund Burke in this context:

The only thing necessary for the triumph of evil is for good men to do nothing.

Second, it is an example of how more or less self-appointed bodies (such as the APA), of which psychiatrists are not required to be members, soon adopt an authoritarian tone ‘prohibiting’ [their words] all psychiatrists (over whom they have no real authority or control) from doing or saying certain things.  They have not ‘cautioned against’, which would be perfectly reasonable, rather they hubristically presume to ‘prohibit’ — it is laughable and bordering on grandiose (cf. OED definition of ‘prohibit’ above).

Third: it is yet another example of how difficult it is for committees to produce sensible statements — or treatment guidelines — and how frequently they devalue their own credibility by making clearly silly pronouncements.

Many eminent doctors have resigned from the APA — Dr Leonard Glass, a professor of psychiatry at Harvard Medical School, resigned and said, ‘Are we respect-worthy doctoral-level mental health professionals, or are we unregulated children that you need to control with a gag order?’ [Rule 7].  A proportion of the psychiatrists I encountered in my training and subsequent career could be described as weak-willed and indecisive, so yes, many do behave like children in front of a school prefect.

There is a relevant paper on the hubris of those in power by Lord Owen and Jonathan Davidson [3] — perhaps it applies to some in the APA, as well as to politicians.

I am also sure their stance will be regarded as hypocritical when the APA is seen by many senior people in the profession as itself being corrupted by big Pharma (which indeed it is).  It is comparable to Trump giving advice on ethical relationship behaviour.

It may also be noted that other professional bodies relating to psychiatry and psychology in the USA, and other English-speaking countries, do not presume pretentious prohibitions.

There is a useful overview of issues involved in a book review written by Alan Stone, a well-known psychiatrist.

Professor Stone is the Touroff-Glueck Professor of Law and Psychiatry in the Faculty of Law and the Faculty of Medicine, Harvard University, Emeritus.

Stone was a member of the APA board of trustees that adopted the Goldwater rule in 1973 and, he states, the only voting member who opposed it at the time — on the grounds that the APA had no right to deprive its members of their freedom of speech — and he says he has never broken the rule, ‘because in my experience it is impossible to accurately evaluate people one has not personally examined’ [my emphasis]. 

Since few diagnoses are ‘accurate’, nor can ever be, that is a superfluous comment.

https://www.lawfareblog.com/psychiatrists-goldwater-rule-trump-era

Another recent overview is from Seon-Cheol Park,

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5900403/

Dissent

Fortunately, at least a few questions have been raised in the literature concerning the ‘validity’ of this Goldwater rule [2].  See also a recent article in the ‘New Statesman’: statesmanhttps://www.newstatesman.com/world/2020/09/silencing-psychiatry-goldwater-rule-doing-more-harm-good-ahead-us-2020-election

Dr Bandy Lee, a distinguished forensic psychiatrist at Yale, edited ‘The Dangerous Case of Donald Trump’, where a couple of dozen health professionals (‘good men’) opined he had dangerous psychological problems — it reached the New York Times bestseller list (see informative interview).  And there is an interview with Dr Lee here in Aug 2020.  Unsurprisingly all that also attracted considerable opprobrium and vituperation — mostly from people with a modest level of education, intellect, and understanding, but expressed with a conviction and certainty that might make you think they must be professors, or even Nobel prize winners.

On a more everyman level, the interview with Rick Riley (the American golf sportswriter and commentator and author of the book with the delightfully punning title of ‘Commander in cheat’) tells you all you need to know about how Trump has always cheated at golf, brazenly, persistently, consistently, and frequently.  It is surprising anyone is prepared to play with him, and those that do are usually revealing something significant about themselves.

As one golfing wit put it: ‘Stormy Daniels is the only person to have played a-round with Trump and come out on top!’ — a triple pun.

I believe Arnold Palmer said he would never do business with someone who cheated at golf — a simple and reliable homily that many people who have encountered Trump may wish they had followed.

Thoughts

I am not intending here to outline a thesis concerning ethics and obligations.  There are the various grounds for stating that the ‘Goldwater rule’ is misconceived, contrived by inappropriate motivations, and by people with illegitimate authority (e.g., see the New Statesman article above).  It has an Alice in Wonderland quality of being unethical in claiming that which it purports to be unethical.  Is that a conceptual catachresis?

Some further observations may be regarded as ‘common sense’ by many people:

First; one does not need a psychiatrist to confirm that Trump’s behaviour is so grossly abnormal that sensible people can see it clearly — nor does one need a physician to diagnose somebody who weighs 200 kg as being morbidly obese, it is obvious to anyone.  Some areas of psychiatry, such as the ‘diagnosis’ of sociopathy and psychopathy, can be regarded as descriptive judgements about people and their behaviour, significantly related to normative behaviour in society.  These are judgements made about other’s personal characteristics and behaviour, which may or may not constitute something regarded as abnormal by one or other groups of people, with or without qualifications, e.g., in psychology or psychiatry.  Concerning these, psychiatrists do not necessarily have special expertise (see below).  Indeed, I know many colleagues, even including some specialist psychiatrists, who are poor at judging other people’s personality and behaviour.  Such judgements go beyond the tick-box checklists, that psychiatrists are now habituated to, for making the diagnosis of illnesses such as depressive disorder.

Second; central hallmarks of psychopathy include self-deception, self-centeredness, self-aggrandisement, and repetitive untruthfulness and risk-taking that is out of proportion to the importance of an issue or its consequences, and a lack of empathy, a callous disregard for, and denigration of, others; especially when they are of no further immediate use.  Thus, relying on an interview with such a person to elicit these features and make a ‘diagnosis’ is manifestly unsound — remember that the Goldwater rule says that a doctor must have interviewed the patient to express an opinion.  That is clearly ridiculous.  I can diagnose Parkinson’s disease in someone as I walk through the shopping mall — there is no attempted prohibition for neurologists to state that the president exhibits Parkinson’s disease.

The diagnosis must rely on externally validated information and the accounts of reliable witnesses.  Concerning these we have a superfluity of evidence to form a reliable conclusion about Trump.  Anyone who wishes to give him the benefit of the doubt and wait for a small Civil War or a mushroom cloud before conceding this, must themselves be regarded as dangerous, dangerously naïve, unable to balance risks, and unfit to form professional judgements.

The best predictor of future behaviour is past behaviour.

Anyone who is unaware of the abundant material in these areas concerning Trump is woefully ill-informed and must have been living in a different reality in the last few years — and yes, I am fully aware that an embarrassing proportion of Americans do live in an alternative reality (wickedly facilitated and fomented by Rupert Murdoch, Facebook-boy, and their ilk).  As stated in the article in New Statesman ‘The point is, why is it tolerated?  It’s right in front of everybody.’

Republicans who support Trump are conniving, colluding, and complicit in his misdeeds.

Many people — including some doctors, and the people who put Trump into this position of power — struggle to understand psychopathy; but they should be able to see his behaviour and his record, and act accordingly, without the need to formally conceptualise it as psychopathy.  They cannot be excused from their culpable complicity in enabling this disastrous situation, and now, even worse, from failing to stop it, as they appear to be doing as I write this (Jan 11^th).

An aside

I am, perhaps, the only psychiatrists to stop a murder trial on the basis that the chief prosecution witness was legally insane.

The relevance of the following story has clear and simple parallels to the considerations regarding Trump.

The man was a severe psychopath, like Trump.  I instructed the Queens Council running the case that the way to establish this was to illustrate to the court that the various statements and behaviours that he exhibited, as described, and accepted as evidence in court, were quite clearly of such an extreme degree that any ordinary person would say the man was clearly ‘evil/abnormal/mad’.  With much coaching this QC eventually succeeded, and the judge called a halt to the proceedings.  He summoned the legal teams into his rooms and asked what the report that I had prepared was going to say.  I had of course educated the QC to the extent that he was able to reply that the features of psychopathy were X,Y,Z of such an extreme degree they were clearly perceived as abnormal by any ordinary person — it was hard work, this psychopath had run rings around this QC for a whole day under cross-examination.  To this the judge immediately replied, ‘well that’s obviously the case’.  The fact I was saying that constituted ‘psychopathy’ was a superfluous rubber-stamping of their conclusion — just the cherry on top of the cake.

The prosecution had no other substantive evidence, so the judge dismissed the case against the accused.  I was told this constituted the first occasion in English jurisprudence where a murder trial had been dismissed on the basis that the chief prosecution witness was insane.  I was chuffed about that.

Summary

These considerations indicate that the ‘Goldwater rule’ — insofar as anyone considers it has authority, logic, or validity — is trumped by such considerations as the duty to ‘inform, warn, and protect’. 

The balance of considerations must clearly take account of the likelihood and consequential severity of the risk, which is very great when the psychopath in a siege is heavily armed, or with hostages and wired up to a bomb, or when his hand is constantly within reach of the nuclear trigger.  One can certainly understand people being alarmed by this — indeed, anyone who is not alarmed by it has a deficiency in their ability to comprehend risk.

Thus, many of the educated and informed regard the ‘Goldwater rule’ as having little or no established authority or status, little rationale, and no formal legal standing either — indeed it is regularly transgressed, e.g., in forensic psychiatry, as it was when I gave my opinion as above.  It concerns me that psychiatrists follow such injunctions by ‘quasi-authorities’ (cf. Guidelines) as if they had a child-parent relationship with such bodies, rather than acting as autonomous adult professionals, with, as Churchill might have put it, ‘intestinal fortitude’.

Psychopathy is only reliably established by other independent substantiated evidence, and the account of multiple reliable informants about the subject’s actions and behaviour (over a long time), and much less by an interview of the subject on a particular occasion.  Again; ‘The best predictor of future behaviour (dangerousness) is past behaviour (dangerousness)’.

As with my judge in the above trial, it is perfectly reasonable and possible for psychiatrists, or any other intelligent well-informed person, to summarise the features of psychopathy, as they are agreed by many experts, and illustrate how Trump’s extreme behaviour fits them closely, so closely as to leave no reasonable doubt about the conclusion.  The fact that these have been observed by many people, and exhibited consistently and persistently over time, clinches the description — and it is a description rather than a ‘diagnosis’.  One does not need a psychiatrist to confirm that any more than one needs a physician to diagnose somebody who weighs 200 kg as being morbidly obese, it is obvious.

Metaphorically then, Trump’s character, or personality, obviously weighs in at around 200 kg.  It is an inescapable conclusion that he fits the description and definition of a severe and dangerous psychopath.

If I met a colleague who disagreed with that, I would infer that he was a poor clinician, or that he was so cowed by the threat of retribution if he expressed his opinion honestly that he would have to be considered as pusillanimous.  That is, it seems, what a lot of my colleagues can be classified as being.

A not infrequent result of the chaotic and traumatic situations such psychopathic characters create around themselves results not only in the denigration, injury, and death of other people, but also in the suicide of the psychopath.

Ego requiem meam doleat.   (Cicero; Attrib)