If nearly one in five persons in the U.S. experiences mental illness at any given time, as federal data show, then more than 100 members of our federally elected government, including whomever is in the White House, suffer from a clinical mental condition at any given time. Does this affect their ability to lead? And why aren’t the people who are best equipped to help us navigate and explore these questions — namely, psychiatrists — leaving mostly non-mental health professionals to speculate widely in the media on the mental stability of President Donald Trump?
The answer is a misapprehension of psychiatry’s code of ethics, according to a psychiatrist thought to be the last surviving co-author of what is colloquially known to mental health professionals as the “Goldwater rule.”
The Goldwater rule stemmed from a libel suit filed by Republican presidential candidate Barry Goldwater. He sued Fact magazine after it published a 1964 survey in which nearly 1,200 members of the American Psychiatric Association (APA) deemed him not “psychologically fit” to be president. Goldwater, who lost the election, won the lawsuit and in 1973, the APA adopted the so-called Goldwater rule to prevent members from commenting on the mental health of public officials whom they haven’t personally evaluated.
“The first thing to appreciate about the so-called ‘Goldwater rule’ is that it is not a rule, but rather a principle,” Dr. Allen Dyer, a professor of psychiatry at The George Washington University, wrote to The Washington Diplomat in an email. “Much of the current discussion applies rule-based legalistic thinking to a matter of professional judgment based on principle.”
More formally, the rule is known as section 7.3 of the American Medical Association’s Principles of Medical Ethics with Annotations Especially Applicable to Psychiatry, which specifies that “it is unethical for a psychiatrist to offer a professional opinion [of any public figure] unless he or she has conducted an examination and has been granted proper authorization for such a statement.”
Some psychiatrists view this ethical stipulation for APA membership as a gag order. Others see it as an essential tool for protecting the guild. Either way, none of the APA’s roughly 37,000 members has been cited for violating this code during the recent campaign cycle, nor since President Trump took office. Fear of transgression seems to have largely prevented psychiatrists from entering the public debate over whether President Trump, and possibly others, are too mentally ill to lead.
Of course, the definition of mental illness is a broad and subjective one to begin with. Millions of people around the world deal with mental illness but function if not excel in their daily lives. Given the complexities and potential stigma surrounding the issue, some psychiatrists say it is unethical to label someone as mentally ill without a personal evaluation. Others say given the weight of the office that the president holds, it is unethical not to speak out if he or she is a danger to the country.
Trump’s erratic behavior has led a growing number of mental health professionals to openly voice their concerns that the president is mentally unfit to lead.
Many of those professionals — especially non-psychiatrists who aren’t card-carrying APA members and therefore not bound by its rules — have accused Trump of exhibiting a litany of traits that impair his judgment, from narcissism, paranoia and delusions of grandeur, to lying, misogyny and sociopathic tendencies.
Psychologist John Gartner, who taught at the Department of Psychiatry at Johns Hopkins University, helped found the group Duty to Warn, an association of mental health professionals “united by the idea that it is our ethical responsibility to warn the public about the dangers posed by Donald Trump’s mental health.”
In an interview with The Diplomat, Gartner said he believes the president — whom he has never treated — has malignant narcissism, a diagnosis originated by the late German psychoanalyst Erich Fromm, who applied it retrospectively to Adolf Hitler. According to Gartner, the four main parts are: narcissistic personality disorder, paranoia, anti-social personality disorder and sadism.
“His narcissism is evident in his ‘grandiose sense of self-importance … without commensurate achievements.’ From viewing cable news, he knows ‘more about ISIS than the generals’ and believes that among all human beings on the planet, ‘I alone can fix it,’” Gartner wrote in a May 4 op-ed in USA Today, adding that Trump’s repeated lying and lack of remorse “meet the clinical criteria for anti-social personality. His bizarre conspiracy theories, false sense of victimization, and demonization of the press, minorities and anyone who opposes him are textbook paranoia. Like most sadists, Trump has been a bully since childhood, and his thousands of vicious tweets make him perhaps the most prolific cyber bully in history.”
He also noted that, “Trump, like many successful people, shows biological signs of hypomania — a mild and more functional expression of bipolar genes that manifest in energy, confidence, creativity, little need for sleep, as well as arrogance, impulsivity, irritability and diminished judgment.”
Gartner warns that any expectations that being president will somehow temper Trump’s behavior is wishful thinking. “When people were saying Trump would pivot and become more presidential, I said, ‘That would be true if he weren’t so mentally ill.’ But people don’t stop being mentally ill when it’s convenient for them or in their best interests to do so. Because this is a genuine illness and not an act, even when it’s in his best interests to start behaving more normally, he can’t do it,” Gartner told us.
Gartner participated in an April conference at Yale University, where event chair Bandy Lee, an assistant clinical professor in the Yale Department of Psychiatry, said that Trump’s mental health “is the elephant in the room. I think the public is really starting to catch on and widely talk about this now.”
While proponents of the Goldwater rule argue that it is unethical to diagnosis a person from afar, Gartner counters that it is unethical to remain silent. “If we see something, we must say something,” he told The Diplomat. “[President Trump] enjoys inflicting pain on people, which is a very dangerous characteristic in a leader.”
J errold Post, director of the political-psychology program at The George Washington University’s Elliott School of International Affairs and founder of the CIA Center for the Analysis of Personality and Political Behavior, agrees with Gartner.
“Serious questions have been raised about the temperament and suitability of He-Who-Must-Not-Be-Named,” Post told reporter Jane Mayer for her May 22 article “Should Psychiatrists Speak Out Against Trump?” in The New Yorker. “It seems unethical to not contribute at this perilous time.”
But not everyone in the field agrees with that assessment. They say throwing out conflicting and highly charged diagnoses, possibly influenced by political prejudices, will tarnish the APA’s reputation — just as the Goldwater lawsuit did.
“It was unethical and irresponsible back in 1964 to offer professional opinions on people who were not properly evaluated and it is unethical and irresponsible today,” APA President Dr. Maria A. Oquendo said in a March statement.
So while pundits have denounced Trump as everything from “not well” (according to “Morning Joe” co-hosts Joe Scarborough and Mika Brzezinski) to just plain “crazy” (Keith Olbermann), the majority of psychiatrists have refrained from joining the chorus of armchair analysts for fear of violating longstanding ethical principles.
Fear of Speaking Out
This fear is misplaced, according to Dyer, who as a member of the APA’s inaugural ethics committee formed in 1973, helped write the original code. The author of several books, including “Ethics and Psychiatry: Toward Professional Definition,” Dyer said in an exclusive interview that “the intention … was not so much to punish members of the APA but to educate members to be sensitive to the ethical norms and principals.”
Dyer recalled that the committee believed section 7.3 was the best way to prevent “another Goldwater fiasco.” Thus, the rule was crafted in part to protect the guild, something Dyer pointed out is rooted in the second paragraph of the Hippocratic Oath that professes a commitment to medical law above all else. “There are two sides to that coin, one of which is that the interests of patients will be served by a principle of beneficence and the profession banding together to articulate principles of ethics that hold the members to common standards,” he said. “The subtler aspect to that is there may be interests in society that are at odds with the interests of the profession.”
The guidance is not meant to silence members, according to Dyer. “Section 7 says, ‘A physician shall recognize a responsibility to participate in activities contributing to the improvement of the community and the betterment of public health.’ That’s an affirmative obligation of the profession,” said Dyer, who is not currently a member of the APA’s ethics committee. He suggested there has been too much focus on the section’s “don’t” and not enough on its “do” that states “a psychiatrist may share with the public his or her expertise about psychiatric issues in general.”
For example, if a psychiatrist who had not examined the president were to say Trump is a narcissist, that would be unethical because it would be what Dyer called “diagnosis from afar.” What would be ethical would be to explain in general terms how the profession understands pathological narcissism. “Then it isn’t the psychiatrist making the judgment the president is a pathological narcissist. It’s an elaboration on the term and the technical meaning of it,” he said.
Clarifying the Rule
In March of this year, the APA’s ethics committee reiterated and even strengthened its stance that members have the right to make public, general statements about psychiatric diagnoses, but that is where the line is drawn. In fact, the group effectively broadened the Goldwater rule to include all observations offered by psychiatrists, not just official diagnoses.
“When a psychiatrist renders an opinion about the affect, behavior, speech, or other presentation of an individual that draws on the skills, training, expertise, and/or knowledge inherent in the practice of psychiatry, the opinion is a professional one.” Thus, even saying that someone does not have a mental illness constitutes a professional opinion and therefore violates the rule.
The APA also noted that when a psychiatrist comments on a person’s mental fitness without their consent, it violates their privacy. Speculating without a firsthand examination compromises the integrity of the profession and has the potential to stigmatize those with mental illness, it said.
The group did tell members that they are not precluded from profiling historical figures “aimed at enhancing public and governmental understanding of these individuals.”
So far, however, public discussion by APA members has focused less on historical analysis and more on whether the rule-that-isn’t-a-rule should be scrapped, modified or adhered to impeccably.
In May, during the association’s annual meeting, a standing room-only gathering of psychiatrists from across the nation listened as an expert panel debated the Goldwater rule. Their collective arguments, as detailed in an account written by one of the symposium’s organizers, Dr. Nassir Ghaemi, a professor of psychiatry at Tufts University Medical Center in Boston, reveal that concerns over the rule extend beyond protecting patients and the profession, but also touch on the long-standing struggle in psychiatry to overcome suspicions that it is not a real science.
Rep. Tim Murphy (R.-Penn.), himself a clinical psychologist, often cited a pervasive “anti-psychiatry” bias in federal policy that drove him to push for more government support of mental health services and evidence-based treatments. He also called for the creation of the nation’s first-ever Cabinet position of a clinically trained professional to oversee mental health care delivery.
His efforts were based in part on a 2014 House report that he said showed that “those most in need of treatment — patients with serious mental illnesses such as persistent schizophrenia, bipolar disorder, and major depression — are the least likely to get the acute medical help they desperately need.”
Many of Murphy’s recommendations — including an assistant secretary position for mental health and substance abuse — were incorporated into the bipartisan 21st Century Cures Act of 2016, which increased resources for mental health patients and enacted a raft of reforms.
But a furor erupted when President Trump chose psychiatrist Dr. Elinore McCance-Katz as the new mental health czar, bypassing Murphy’s own pick, widely reported to be Dr. Michael Welner, a forensic psychiatrist.
Murphy expressed his outrage in a statement accusing McCance-Katz (who has yet to be confirmed by the Senate) of having a history of defending what he called pseudo-scientific “anti-medical” approaches to care. The APA endorsed Welner, as it did endorse McCance-Katz once she was announced as the White House pick, citing her training as an addictions specialist as welcome during a time when the opioid crisis rages across the U.S.
The acrimony points to how historically, the way psychiatrists define, diagnose and treat mental illness has, at times, led some in medicine to hold psychiatry at arm’s length. In 2013, just prior to the release of the APA’s fifth edition of its Diagnostic and Statistical Manual of Mental Diagnosis (DSM-5), Dr. Thomas Insel, a psychiatrist who directed the National Institute of Mental Health, wrote a scathing rebuke of the field manual, often considered the Bible of psychiatry. He called it simply a “dictionary” and derided its over-reliance on unproven symptom clusters that have no basis in biology.
Other critics of the field often touch on psychiatry’s extensive relationship with the pharmaceutical industry, which some believe has led to overmedicating the human condition to swell the ranks of those who take pills. Gary Greenberg, a Connecticut-based psychotherapist and prominent author of “The Book of Woe: The DSM and the Unmaking of Psychiatry,” criticizes the APA for claiming “the naming rights to psychological pain” for the sake of profit.
At the heart of the debate lie the subjective, contentious and ever-changing definitions of mental illnesses ranging from depression to bipolar disorder. Psychiatrists themselves have come under fire for their personal biases. During the debate at APA’s annual meeting, Dr. Paul Appelbaum, a psychiatry professor at Columbia University, reportedly said that after 40 years in the field, he’d consistently observed that a psychiatrist’s views of a presidential candidate “without exception” mirror that psychiatrist’s political leanings.
Ghaemi of Tufts University Medical Center countered that, “If we accept the perspective that we should say nothing in public because psychiatrists have different views (e.g., bipolar vs. attention deficit disorder vs. sociopathy vs. narcissism), all of which could be wrong, in this case we must admit that psychiatrists just don’t know what they’re talking about and thus should say nothing.” Doing so, he wrote, would mean “accepting the basic critique of anti-psychiatry groups — namely, that there is no truth to psychiatric diagnoses.”
Rejecting this as “nihilistic,” Ghaemi argued in his report that this approach was antithetical to science, which relies on the free exchange of ideas until the truth, which he called “corrected error,” emerges. “Science involves refutation of false hypotheses, not censorship of them,” he concluded.
Long-Shot Legal Efforts
That’s why some psychologists like Gartner have publicly and persistently beaten the drum about Trump’s mental state. Gartner started a petition, which now has nearly 60,000 supporters, to remove Trump from office by invoking the 25th Amendment because he “manifests a serious mental illness that renders him psychologically incapable of competently discharging the duties of President of the United States.”
Adopted in 1967 after President John F. Kennedy was assassinated, the 25th Amendment clarifies that if the president is incapable of carrying out the duties of the office, then the vice president legally can. The amendment does not spell out what constitutes incapacitation, but mental illness is conceivably a reason. It is a high bar to clear, however. Forcibly removing a president from office would require the support of a majority of executive departments, such as Cabinet secretaries or another group designated by Congress, as well as the vice president. If the president refuses to step down, a two-thirds majority bicameral vote in Congress would then be needed to oust the president.
Gartner, who divides his practice between Baltimore, Md. and New York, said his petition is based on a widely accepted code of ethics, namely the “duty to warn” — generally viewed as the obligation of all mental health professionals to notify law enforcement if a patient is thought to be in danger of self-harm or poses an imminent threat to others.
But Dyer emphasized that the closest psychiatry comes to this norm is a California Supreme Court ruling specifically calling for therapists to sound the alarm about patients who pose a threat, not a member of the public. “There is no duty to warn in the actual code of ethics. It is a subjective sense that many people feel in view of the alarm of Trumpism,” Dyer wrote in an email.
Despite the long odds any legal attempts to remove Trump from office face, there already is a Democratic-sponsored bill in the House calling for a commission to oversee a medical examination of the president if the 25th Amendment is triggered. In that case, Gartner believes his petition helps give Congress professional cover. “If we can say 56,000 mental health professionals are warning you that [the president] is dangerously mentally ill, and you are thinking of removing him, we offer the professional observation for what you are seeing with your own eyes,” he said.
Yet that argument assumes agreement over which diagnostic criteria to use. Malignant narcissism does not appear in the DSM, for example, and so technically it is not a clinical psychiatric diagnosis. Narcissist personality disorder does appear in the DSM, but does not accurately describe the president, according to Dr. Allen Frances, the psychiatrist who defined the criteria for the diagnosis. In a letter to The New York Times, Frances wrote: “He may be a world-class narcissist, but this doesn’t make him mentally ill, because he does not suffer from the distress and impairment required to diagnose mental disorder.”
Rather than experience distress, the president inflicts it, typically to his benefit, wrote Frances. “Bad behavior is rarely a sign of mental illness, and the mentally ill behave badly only rarely,” he wrote.
Dyer said he agreed “generally” with Frances and suggested that whether or not the president has a mental illness is beside the point, wondering if “the real objections are moral and political.”
Many psychiatrists also have pointed out that personality traits such as impatience or impulsiveness should not be confused with personality disorders. And even if Trump — like millions of people around the world — were formally diagnosed with a mental illness, he likely wouldn’t be the first leader to suffer from one. In fact, psychiatrists have long speculated about the link between a higher IQ and mental disorders such as depression and schizophrenia, which have plagued countless artists, writers, intellectuals and, yes, heads of state.
In his book, “A First Rate Madness: Uncovering the Links Between Leadership and Mental Illness,” Ghaemi uses examples such as Napoleon, Abraham Lincoln and Winston Churchill to prove his theory that, “The best crisis leaders are either mentally ill or mentally abnormal; the worst crisis leaders are mentally healthy.”
Can psychiatrists help the nation navigate the murky terrain of a president’s mind? Dyer thinks they can and should. “Psychiatrists have to act responsibly. That doesn’t mean you can’t answer questions and address concerns … that can become part of the debate, even as the media focuses on the legal considerations [of] obstruction of justice and corrupt financial dealings,” he said. “Psychiatrists are … looking for ways that their contribution can be constructive rather than further burden the divide.”
In the end, the ongoing debate may be a largely academic one. After all, Trump made no secret of his behavior and thinking prior to the election, but voters still elected him into office. Those voters may not care about the opinions of a group of psychiatrists, regardless whether they adhere to the Goldwater rule or break it.
Dyer suggested that rather than focus on the mental status of our elected leaders, we should turn inward to reflect on who we are as a common people. “I think as a country the task we need to address ourselves is [asking] what are the values we hold in common in this country? How are they applied in a particular situation, and [what happens] if one politician and a group of politicians are flouting those values? I think that is the debate we need to have.”
About the Author
Whitney McKnight (www.whitneymcknight.com) is a freelance writer in Washington, D.C.