Gilding the Goldwater Lily

Psychiatry and politics do not have a history of mixing well. Is this why we need the Goldwater Rule?

Psychiatry and politics do not have a history of mixing well. In 1972, democratic presidential nominee George McGovern briefly considered US Senator Thomas Eagleton as his vice-presidential nominee. Despite Eagleton’s impressive record of being the youngest Missouri attorney general in the state’s history at age 31, McGovern requested that Eagleton withdraw as his nominee. Why? For the simple reason that Eagleton was known to have voluntarily sought effective treatment for depression. Yet the damage was done, as McGovern’s opponents used the opportunity to question the soundness of his judgment in selecting Eagleton. One wonders how such a scenario might play out today. Would society be more enlightened or would we repeat this pattern of weaponizing mental health?

My esteemed colleagues assert that the Goldwater Rule (GWR) is “fine,” but in need of refinement.1 Having addressed the GWR before,2 I will be mercifully brief—particularly because I would like to introduce a new set of unofficial “rules” that I hope will bring clarity to a debate that has been ongoing for some 50 years. My colleagues do well in quoting a favorite Bob Dylan song about the changing times. Yet the weight of change is often counterbalanced with the time-worn aphorism plus ça change, plus c’est la même chose. Even in this era of social media and information overload, human nature remains the same. Students of human nature will recognize how little has changed since American Psychiatric Association President Daniel Blain, MD, denounced such “professional opinions” many years ago, calling them a “low blow to all who would work to advance the treatment and care of the mentally ill of America.”3

Since the inception of the GWR, the pushback and boundary-blurring around it has neither resulted in any appreciable “helpful knowledge” nor served to “improve the community and better the public health.” By now, it is painfully apparent that most advocates of liberalizing or abolishing the GWR are motivated by political partisanship. The temptation is evidently too great for us to avoid using the mantle of our profession to stigmatize a political figure with pejorative labels.

The examples given by my colleagues seem generally unrealistic insofar as easily observable symptoms are very likely to be attended to by those who will see them long before the public would. Any “refinements” notwithstanding, it still seems implausible that a psychiatrist who 1) has not examined a sitting US president and 2) has no access to that president’s private health care information is in a position to make psychiatric diagnoses or conduct risk assessments on that president.

At the end of the day, we are left with mere speculation based on symptoms observed in a nonclinical, time-limited setting. The speculation typically amounts to a tallying of perceived character flaws—not public education about serious mental illness. My psychodynamic training, now quite out of fashion, compels me to dwell a moment on my colleagues’ repeated use of negatives (eg, “I do not want to speculate…”). I commend them for acknowledging this, as some may be so bold as to claim they are not speculating at all. They have “seen the movie,” so to speak—they have confirmed their findings via multiple news media clips and have been able to amass a checklist of findings to prove their point. However, enumerating symptoms and criteria of a particular diagnosis, without explicitly stating that diagnosis, seems questionable. It allows one to speculate right up to the line and point to the diagnosis from inches away without touching it or speaking its name.

All this begs the question: Why do psychiatrists continue to wrestle with the GWR as though it is either obsolete or in need of change? Is it because our brave new world demands a retrofitting of a longstanding APA ethics rule? Has ubiquitous video monitoring abrogated the need for a personal exam and record review? Or perhaps, having vanquished all mental suffering, we have become restless and wish to set our sights higher. A noble goal indeed. Yet in practice, it seems GWR violators are primarily focused on spotting character flaws they believe voters are too unenlightened to perceive.

Having said my piece about the GWR, for what I hope is the last time, I am now prepared to roll out what I should like to call the Knoll-Water Rules:

1. GWR violations damage the credibility of psychiatry.4 Psychiatry is not in need of further credibility damage.

2. GWR violations have not appreciably improved public trust of psychiatry (see rule 1).

3. When psychiatric terms, diagnoses, or medical authority are used to express opinions in public media about political figures without examining them, look for a political agenda.

4. Psychiatrists are poorly able to depoliticize their opinions in public media about political figures. This rule is immutable regardless of how the GWR might be revised.

5. GWR violations involving a US president have resulted in neither a cornucopia of public health benefits nor increased public appreciation of the importance of mental health. Other approaches to achieving these goals are highly recommended.

6. Duty-to-protect and Tarasoff-type laws apply to patients being treated by psychiatrists—not to US presidents with whom one has no doctor-patient relationship. Should a US president require civil commitment, an appropriate state hospital psychiatrist will surely be provided.

7. Accomplished individuals have been known to have character flaws. This applies to both US presidents and psychiatrists.

8. The GWR does not prevent psychiatrists from engaging in political activism—as US citizens.

In sum, it seems to me that the GWR is fine. Period. No refinements needed. Passionate advocacy may be best redirected to improving mental health care in the United States. As excellent as one’s diagnostic skills from afar may be, one might remember the 25th Amendment and take some comfort in the fact that the president’s cabinet, the vice president, congress, the chief White House physician, and the entire White House medical unit are likely to be in a slightly better position to observe concerning signs and, if necessary, recommend an emergent course of cognitive therapy and mindfulness training.

Dr Knoll is a professor of psychiatry and director of forensic psychiatry at SUNY Upstate Medical University in Syracuse, New York, and clinical director of Central New York Psychiatric Center in Marcy, New York. He is Emeritus Editor in Chief of Psychiatric TimesTM and president-elect of the American Academy of Psychiatry and the Law (2022-2023).

References

1. Blotcky AD, Pies RW, Moffic HS. The Goldwater Rule is fine, if refined: here’s how to do it. Psychiatric Times. January 6, 2022. Accessed January 10, 2022. https://www.psychiatrictimes.com/view/the-goldwater-rule-is-fine-if-refined-here-s-how-to-do-it-

2. Knoll JL IV, Pies RW. Psychiatry, “dangerousness,” and the president. Psychiatric Times. February 16, 2018. Accessed January 10, 2022. https://www.psychiatrictimes.com/view/psychiatry-dangerousness-president

3. Levin A. Goldwater Rule’s origins based on long-ago controversy. American Psychiatric Association. August 25, 2016. Accessed January 10, 2022. https://psychnews.psychiatryonline.org/doi/full/10.1176/appi.pn.2016.9a19

4. Friedman RA. Role of physicians and mental health professionals in discussions of public figures. JAMA. 2008;300(11):1348-1350.