Is Psychoanalyzing Our Politicians Fair Game?

Nassir Ghaemi, MD, MPH


August 15, 2016

In This Article

Necessary, but Draconian

Let me state my view clearly at the outset, and then I'll try to explain the reasons for my perspective: I think the Goldwater rule is necessary, but draconian. I do not think it is simply wrong, nor do I advocate for no restriction at all, as is the case with the American Psychological Association. But I think the Goldwater rule should be revised and much more limited in scope.

I'm a Distinguished Fellow of the APA and have been a member all my career (for over two decades), and was a member of the APA Task Force to Revise the Ethics Guidelines, founded in 2002. In retrospect, I think we made a grave error in leaving the language of the Goldwater rule unchanged a decade ago.

This issue has been raised recently in relation to the questions some have raised about the mental or temperamental "fitness" of Donald Trump to be president of the United States. The standard view is that psychiatrists can and should say nothing. (This restriction does not bind psychologists—who do not have medical degrees, unlike psychiatrists—because the American Psychological Association does not have an ethical restriction to comment on the mental health of public figures.) The alternate view some have raised is whether we have duties as citizens that outweigh professional restrictions.

There is one central flaw to this rule: "Personal examination" of a patient is not the main basis for psychiatric diagnosis at all. It is neither necessary nor sufficient to make a psychiatric diagnosis, irrespective of whether the patient is a public figure or a nameless unknown. It would be a very bad psychiatric clinician who would base his diagnosis solely, or even primarily, on "personal examination" of the patient.

How many millions of times do patients enter psychiatric emergency departments and claim they did not use any drugs? The emergency department psychiatrist ignores the patient's denial and notes that the blood cocaine level is positive. Or she ignores the patient's denial when multiple policemen, emergency medical services (EMS) workers, friends, and family report that they saw the patient shooting up cocaine just before he passed out. The patient's denial, based on the "personal examination," is not the first or last word in psychiatric diagnosis.

We see the same issue in more nuanced ways in routine clinical practice. The patient presents with depression; she denies any past manic symptoms. The patient's father, mother, sister, and husband, all present in the room, report many manic symptoms that they all corroborate. Either the patient is wrong, or the rest of the world is wrong. Usually, the rest of the world is right, and the patient is in denial. This problem of "lack of insight" is very well established in the psychiatric literature and is common with bipolar illness for manic symptoms in particular.

Lack of insight appears to be part of some psychiatric conditions, especially delusions and mania, and thus the patient's report of symptoms is not accurate or valid much of the time. Furthermore, patients are also influenced by cultural stigma and discrimination to be less willing to accept certain, or any, psychiatric diagnoses as valid. Thus, the patient's ability to say, "Yes, I have diagnosis X" is not the main basis for making psychiatric diagnoses. Stated another way, "personal examination" of the patient does not necessarily provide the diagnosis, and in fact is usually trumped by evidence from other sources that are more valid (eg, medical records, police or EMS reports, family report, work records, and legal documents).

All this is to say that accurate psychiatric diagnosis is not about "personal examination." It's about having sufficient documentation—from whatever source, whether it be directly from the patient or not—to support the diagnosis. Thus, I think it is a common misuse and abuse of the Goldwater rule to insist on personal examination. We should insist instead on adequate documentation.


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