Richard A. Friedman, MD

Psychiatrists and other mental health professionals are frequently called on by the media to give their expert opinion about public figures whose behavior raises a question about their mental health or fitness. Often, this involves colorful, eccentric, or flagrant misbehavior in the sexual or financial realm.

Consider, for example, former Congressman Anthony Weiner who resigned his seat June 16, 2011, amid revelations of his repeated lewd online behavior: Mr Weiner 

 In the summer of 2013, while running as a mayoral candidate in the Democratic primary in New York City, it was revealed that he had continued to post lewd images of himself online, and he was pressured (unsuccessfully) to quit the race.

Understandably, the media sought commentary from mental health experts. How, they asked, was the public to understand such apparently self-destructive behavior?

Some mental health professionals suggested Mr Weiner’s indiscretions might be an addiction. Others theorized that he might be driven by sexual needs that were unmet in his marriage and by feelings of inadequacy about his masculinity. Still others raised the possibility of a mood disorder.

As psychiatrists, we have expert knowledge about human behavior and mental illness. Thus, we have a potentially unique-and powerful-influence in the discussion of public figures. But what professional and ethical obligations should we follow in this role? Are we to relate to the public as expert clinicians, commentators, or educators-or some mix of these roles?

To answer the question, a bit of historical perspective is instructive. Just before the 1964 presidential election, a muckraking and now defunct magazine called 

 decided to survey members of the American Psychiatric Association (APA) for their professional assessment of Senator Barry Goldwater of Arizona, the Republican nominee running against President Lyndon B. Johnson.

 Ralph Ginzburg, the magazine’s notoriously provocative publisher, had heavily advertised the issue in advance, saying it would call into question Mr Goldwater’s character.

APA members were asked whether they thought Mr Goldwater was fit to be president and what their psychiatric impressions of him were. It was not American psychiatry’s finest hour. The survey, highly unscientific even by the standards of the time, was sent to 12,356 psychiatrists, of whom 2417 responded. The results were published as a special issue: “The Unconscious of a Conservative: A Special Issue on the Mind of Barry Goldwater.”

The psychiatrists’ assessment was very harsh. Half of the respondents judged Mr Goldwater psychologically unfit to be president. They used terms like “megalomaniac,” “paranoid,” and “grossly psychotic.” Some offered specific diagnoses, including schizophrenia and narcissistic personality disorder. Only 27% of the respondents said Mr Goldwater was mentally fit, and 23% said they did not know enough about him to make a judgment.

There were several attempts at a psychodynamic formulation of Mr Goldwater’s character. One unsigned comment called the candidate “inwardly a frightened person who sees himself as weak and threatened by strong virile power around him,” and added that “his call for aggressiveness and the need for individual strength and prerogatives is an attempt to defend himself against and to deny his feelings of weakness.”

Whatever their motivation, these physicians had given very specific and damaging psychiatric opinions, using the language and art of their profession, about a man whom they had not examined and who surely would never have consented to such damaging statements. The remarks were immediately condemned by both the American Medical Association and the APA, and Mr Goldwater brought a $2 million libel suit against Fact and Mr Ginzburg. The Supreme Court awarded the senator $1 in compensatory damages and $75,000 in punitive damages-and, more importantly, set a legal precedent that helped change medical ethics.

The APA had the Goldwater debacle in mind when, in 1973, it first drafted its 

Principles of Medical Ethics With Annotations Especially Applicable to Psychiatry

 These Principles, in particular sections 5 and 7, delineate a set of ethical requirements for communicating with the media. Section 7.3 has come to be known as the Goldwater Rule:

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.

Likewise, the American Psychological Association’s code of ethics stipulates that psychologists provide expert opinion only for individuals they have directly examined.

In short, since 1973 the ethical standard has been very clear: psychiatrists and psychologists can comment on mental health issues in general, but it is unethical for them to offer a professional opinion about an individual without directly examining that person and getting his or her permission to comment.

The guidelines are clear enough, but what, exactly, is the ethical reasoning behind them? Other than to avoid another professional embarrassment such as the critique of Barry Goldwater, why must psychiatrists and psychologists avoid offering their medical opinions of public figures?

For a mental health professional-or any physician-to publicly offer a diagnosis of a nonpatient at a distance not only invites public distrust of these professionals, but also is intellectually dishonest and is damaging to the profession. After all, a professional opinion should reflect a thorough and rigorous examination of a patient, the clinical history, and all relevant clinical data under the protection of strict confidentiality, none of which is possible by casual observation of a public figure. To do otherwise is unethical because it violates this fundamental principle and thereby misleads the public about what constitutes accepted medical and nonmedical professional practice.

This does not mean, however, that mental health professionals must remain silent. For example, the APA’s Principles clearly enjoin psychiatrists to share their knowledge and expertise with the public

A physician shall continue to study, apply, and advance scientific knowledge, maintain a commitment to medical education, make relevant information available to patients, colleagues, and the public, obtain consultation, and use the talents of other health professionals when indicated (section 5).

Psychiatrists may interpret and share with the public their expertise in the various psychosocial issues that may affect mental health and illness (section 7.2).

Thus, mental health professionals have a potentially important role in educating the public about mental health issues-and a great opportunity to dispel the stigma of mental illness by doing so. The critical distinction is between offering general information about a condition as it pertains to a public figure and rendering a professional opinion about an individual, involving a specific diagnosis, prognosis, or both.

So a psychiatrist who commented on Mr Weiner’s actions would be well within ethical bounds to speak generally about psychological principles that help the public understand his behavior. Consider what Dr Richard C. Friedman (no relation), a clinical professor of psychiatry at Weill Cornell Medical College in New York, said about Mr Weiner in an interview with the 

 “It’s almost as if a little child were playing at being a politician and trying to hide something. . . .The level of denial is so great, and it’s so incompatible with major responsibility, that the psychological puzzle is not only to find out why he’s doing the particular behavior, but why somebody would be functioning at such an uneven level.”

Regarding Mr Weiner’s habit of texting women pictures of his penis, Dr Friedman said that this suggested someone with a deep insecurity about his body image and his masculinity. “There’s a different type of narcissism that’s based on self-esteem problems, in which the person then defensively covers up by saying: ‘Aren’t I wonderful? Look at my wonderful organ. Isn’t it beautiful?’”

Dr Friedman used general psychological terms (eg, denial, body image, self-esteem, narcissism) to speculate about Mr Weiner’s psychology, which served to educate the public about the symptoms and psychology of narcissism in general. The public is then free to decide whether this information applies to Mr Weiner. This commentary was clearly within the ethical bounds of the Goldwater Rule. If, on the other hand, Dr Friedman had said that Mr Weiner had narcissistic personality disorder, he would have moved beyond educating the public to rendering a diagnosis from afar and, as such, he would have clearly violated this ethical principle.

One can expect that some public figures, including politicians, will be psychiatrically or cognitively impaired, given the high prevalence of psychiatric and substance abuse disorders. An estimated 46% of American adults will experience a mental or substance abuse disorder in their lifetime, according to the National Comorbidity Survey Replication.

Should a question arise about the cognitive functioning of a politician, it would be perfectly within ethical guidelines for a psychiatrist to suggest neurocognitive testing, as long as the suggestion was free of diagnostic speculation. After President Reagan left office, he revealed that he had Alzheimer disease.

 Given his well-known reputation for absentmindedness, it was speculated that he might have been cognitively impaired while in office. We do not know if he had neurocognitive testing as president, but it would have been reasonable and ethically permissible for a mental health professional to suggest neurocognitive assessment of a sitting president whose cognitive functioning was in question.

Are there instances in which the Goldwater Rule can be violated? In 1991, Dr Jerrold M. Post, a psychiatrist, provided a psychological profile of Saddam Hussein during a public Congressional testimony.

 On the basis of several biographies and interviews with persons who knew Hussein, Dr Post diagnosed him with malignant narcissism, a severe personality disorder marked by grandiosity, cruelty, and paranoid behavior.

Although Dr Post was criticized for breaking the Goldwater Rule, he invoked a Tarasoff-like principle stating that he had a duty to warn because this psychiatric knowledge could be instrumental in shaping policy decisions that could save many lives, just as a psychiatrist has a duty, under the Tarasoff ruling, to break confidentiality if a patient is an imminent threat to a third party and to warn that person of the risk.

 While the predictive validity of psychiatric analysis of an individual at a distance is debatable, if it is deemed vital to public safety or national security, one could reasonably defend it even if it violates the profession’s code of ethics and is personally damaging to that individual.

What about biographies and other scholarly works in which public figures are subjected to psychiatric scrutiny? For example, consider the psychobiography of President George W. Bush by Dr Justin A. Frank, a psychiatrist, who characterized the president as a “paranoid megalomaniac” and an “untreated alcoholic.”

 These are clearly diagnostic assessments that seem to violate the Goldwater Rule, but Dr Frank’s view is that his book is a scholarly psychobiography, not expert opinion, and is thus outside the purview of the APA ethics guideline.

Perhaps, but the line between a scholarly psychiatric profile and a casual off-the-cuff diagnosis of a public figure is not so clear. Even if the intent of the mental health professional in both scenarios is very different-understanding the psychology of the person (psychobiography) or attacking the character of a reviled political candidate (the Goldwater case)-both share a similar ethical problem: unauthorized psychiatric assessment of a person who is not examined by the professional.

Psychiatrists have unique knowledge and expertise and can play an important role in the discussion about the mental health of public figures. Our comments should be geared toward general information about the nature and course of psychiatric illnesses and their treatments. We should always remember that our role is not to provide unsolicited or unauthorized professional opinions, but rather to educate the public.

Dr Friedman is Professor of Clinical Psychiatry and Director of the Psychopharmacology Clinic at Weill Cornell Medical College in NY. He reports no conflicts of interest concerning the subject matter of this article.

 Hernandez R. Weiner resigns in chaotic final scene. 

http://www.nytimes.com/2011/06/17/nyregion/anthony-d-weiner-tells-friends-he-will-resign.html

?pagewanted=all. Accessed January 30, 2014.

 Hernandez JC. Weiner admits to more lewd exchanges but denies an addiction. 

. July 25, 2013. http://www.nytimes.com/2013/07/26/nyregion/weiner-admits-more-online-exchanges-with-women-after-quitting-house.html. Accessed January 30, 2014.

 Taylor K, Hernandez JC. Weiner’s behavior prompts a question: why did he do it? 

. July 29, 2013. http://www.nytimes.com/2013/07/30/nyregion/weiners-behavior-prompts-a-question-why-did-he-do-it.html. Accessed January 30, 2014.

 Ginzburg R, ed. 1189 Psychiatrists say Goldwater is psychologically unfit to be president! 

, 414 F2d 324, 337 (2d Cir 1969), cert denied, 396 US 1049, 90 SCt 701, 24 LEd2d 695.

The Principles of Medical Ethics With Annotations Especially Applicable to Psychiatry

. Arlington, VA: American Psychiatric Press Inc; 2008.

 American Psychological Association. Ethical principles of psychologists and code of conduct. 

 Kessler RC, Berglund P, Jin R, et al. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. 

 Altman LK. While known for being forgetful, Reagan was mentally sound in office, doctors say. 

. October 5, 1997. http://www.nytimes.com/1997/10/05/us/while-known-for-being-forgetful-reagan-was-mentally-sound-in-office-doctors-say.html. Accessed January 30, 2014.

 Post JM. Ethical considerations in psychiatric profiling of political figures. 

 Goleman D. Experts differ on dissecting leaders’ psyches from afar. 

. January 29, 1991. http://www.nytimes.com/1991/01/29/science/experts-differ-on-dissecting-leaders-psyches-from-afar.html?pagewanted=all&src=pm. Accessed January 30, 2014.

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