Is it ethical for mental health professionals to diagnose public figures?

Published: April 16, 2019 / 0 Comments

Malignant Narcissism

Prominent mental health professionals have publicly diagnosed President Trump as a malignant narcissist. What are the ethical implications of this act?

The study of psychology necessitates an exploration of the ethics that govern the profession, hence why psychology programmes generally include a course in ethics. You may assume this will be a straightforward rundown of the client-confidentiality agreement, but ethics is not a simple matter for psychologists; it’s one of the fundamental pillars of the profession.

This is especially poignant in the face of the increasing influence of mass media, and the relationship between public figures and society at large. One recent case that perfectly illustrates this is that of the Goldwater rule, and its relevance to the current president of the United States.

Mental health professionals in the United States sparked a serious ethical debate within the profession, when they claimed that their ‘duty to warn’ compelled them to warn the public about President Trump’s potentially unstable mental state. Some of their colleagues argued that the ‘Goldwater rule’ expressly forbids them from diagnosing public figures without having personally consulted with them. Each side of the debate continues to plead their case and the controversy serves as the perfect example to psychology students of the kind of complex issues they will have to grapple with.

What is the Goldwater rule?

In 1964, Republican senator Barry Goldwater ran against the incumbent Democrat Lyndon B. Johnson for the presidency of the United States, and lost by a landslide. He held Fact Magazine, and their article “The Unconscious of a Conservative: A Special Issue on the Mind of Barry Goldwater”, responsible for his defeat. The magazine had polled psychiatrists regarding the mental health of the candidate, and over 1,000 of them had declared him unfit for office, with one doctor describing him as “a dangerous lunatic”. He sued the magazine editor Ralph Ginzburg and managing editor Warren Boroson, and received damages totalling $75,000.

Psychiatrists also attacked the survey and its participants, claiming that their lack of professionalism risked bringing the field of psychiatry into disrepute; and in 1973, the American Psychiatric Association (APA) implemented the ‘Goldwater rule’, which stated the following:

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 American Psychological Association supports the ruling, albeit with slightly different wording. As one of psychology’s most influential regulatory bodies, their support effectively makes the Goldwater rule standard practice for many psychologists. However, the presidency of Donald Trump, continuing its penchant for shattering societal norms, has brought the old ruling into the public spotlight once again, with members of the profession questioning its relevance in the age of Twitter and 24-hour cable news.

What is the duty to warn?

In professional psychology, the confidentiality that exists between psychologists and their clients is sacrosanct, and critical not just to the wellbeing of the client, but the credibility of the profession as a whole. However, there are rare circumstances under which a mental health professional is permitted to break this sacred trust. Psychologists who have reasonable grounds to believe that a client may be in imminent danger of harming themselves or others, may break confidentiality to warn the appropriate parties.

One famous incident that highlights the significance of duty to warn is the case of Tatiana Tarasoff, who was murdered by Prosenjit Poddar in October 1969. Poddar had told his psychologist, Dr. Lawrence Moore of UC Berkeley’s Cowell Memorial Hospital, that he wanted to kill Tatiana, and Moore subsequently notified the authorities. Poddar was detained for questioning, but soon released, as his mental state appeared to be stable. The director of the department of psychiatry at Cowell Hospital then ordered that Poddar’s therapy notes be destroyed. No one ever warned Tatiana Tarasoff, and following her murder, her parents filed suit against Dr. Lawrence Moore and several other employees of the university.

The California Supreme Court ruled in the Tarasoff family’s favour, declaring that “the confidentiality of the therapeutic relationship is subordinate to the safety of society and its members”. Even so, psychologists such as Max Siegel, a former president of the American Psychological Association, claims that Dr. Lawrence Moore should not have broken the confidentiality agreement, as doing so resulted in Prosenjit Poddar being taken out of treatment that might otherwise have prevented him from committing the deed.

So what happens when the ‘Goldwater rule’ and ‘duty to warn’ collide?

Ever since Donald Trump announced his candidacy for the presidency in June 2015, a number of prominent psychologists and psychiatrists have commented publicly on his mental state. This has only increased in urgency since Trump won the election in November 2016, with various mental health professionals warning that the president displays signs of personality disorders such as grandiosity, lack of empathy, and ‘malignant narcissism’. William Doherty, a psychologist at the University of Minnesota, described him as “a threat to democracy itself”.

While mental health professionals such as Dr. Paul Appelbaum, a professor of psychiatry, medicine and law at Columbia University, call this a violation of the Goldwater rule; others claim that their duty to warn trumps (excuse the pun) the Goldwater rule, with the general public being the potential victim that needs to be warned. Others went even further, claiming that the Goldwater rule is based on outdated notions of what the profession of psychology entails.

As with many topics of discussion in psychology, the answer is not clear-cut. All one can do is examine both sides of the argument and draw their own conclusions. Here is a brief overview of some of the arguments being made for and against the Goldwater rule:

Arguments for the Goldwater rule

Public persona and private persona are two different things
When President Trump engages with his audience on Twitter, or at various rallies, he is projecting a public persona that is distinct from who he is in his private life, as is the case with most politicians. Of course, many are drawn to Trump because there is a sense that he “shoots from the hip” and is not a conventional politician, but it’s difficult for anyone to determine how much of this is performance art, including psychologists who attempt to diagnose Trump based on what is essentially a public performance. That is tantamount to diagnosing an actor with a mental condition based on the behaviour of the character he or she plays.

Potential damage to the subject’s personal and professional life, and to the public trust
The stigma of having a mental disorder is damaging enough to private individuals; one can only imagine the hurt it can do to a public figure. In the 1972 US presidential election, George McGovern’s running mate, Senator Thomas F. Eagleton of Missouri, had to withdraw from the race, following revelations that he had undergone psychiatric counseling and electroshock therapy.

Furthermore, the very individual for whom the Goldwater rule is named continued to serve in public office, and following his death in 1998, was described as “one of his party’s most respected elder statesmen” by the Washington Post obituary. This, despite psychiatrists having warned that he was ‘unfit for office’. If Goldwater had won the election, his presidency would have been marred by such accusations; his mental capacity constantly coming under public scrutiny both at home and abroad. Is a public diagnosis that might not even be accurate worth the risk of damaging the public trust?

Politicising the psychology profession
While many psychologists have argued for increased political activity within the discipline, on account of the inextricable link between policy, politics and human wellbeing, others have warned of the danger of public commentary. Psychologists risk bringing the entire profession into disrepute when they make statements that are interpreted as politically biased. In this divisive era, many important institutions have suffered a loss of public trust due to perceived political partisanship. Imagine if people in Trump-supporting areas became reluctant to seek mental healthcare due to feelings of alienation by what they perceive as a left-leaning profession?

There is already constitutional mechanism
The 25th amendment to the US Constitution allows for the Vice President and a majority of the cabinet to temporarily remove the president if they feel he is “unable to discharge the powers and duties of his office”. Congress could enlist the aid of mental health professionals if they decide to implement this measure, but it is up to them to make the call. A president of the United States can only be removed via a constitutional process. Mental health professionals do not have the authority to declare him unfit for office, only Congress does; just as law enforcement does not have the authority to impeach a president if they find evidence of crimes, only congress does.

Arguments against the Goldwater rule

The Goldwater rule is founded on flimsy science
A paper by psychology professor Scott Lilienfeld of Emory University argues that the Goldwater rule is based on the false assumption that psychologists cannot accurately diagnose a subject without conducting regular interviews. Lilienfeld told the website Tonic that interviews are actually an unreliable method of diagnosing patients, as “people mislead or even lie to their doctors during the interview, or may not be very self-aware”, and that a person with narcissistic personality disorder could “come off as charming and fun, only to be revealed as manipulative and abusive over time”. Indirect observation, he claims, can be more valuable in assessing a subject’s mental state.

The power of the presidency
In a well-functioning democracy, a subject with great political power should be subjected to more scrutiny, not less. After all, with great power comes great responsibility, and there is no office more powerful than the presidency of the United States, which commands the world’s greatest military, along with the immense destructive capability of nuclear armaments. Should such power exclude the President of the United States from the kind of protection and professional courtesy that would apply to other public figures?

The power of the media
In this age of mass media, people are bombarded with information at a much greater rate than they were at any previous point in history. The Goldwater rule never took into account a world where a person’s ‘public persona’ could be so pervasive. In fact, Dr. Doherty argues that it is the president’s public persona that is being diagnosed, rather than his private persona, because it is the public persona that is causing so much damage. “One can talk about his public behavior without knowing whether he is fully that way with his children, his wife, his friends,” Doherty claims.

Freedom of speech
Psychologists claim that the importance of the Goldwater rule is being overstated as a result of the controversy regarding Trump. They say it was originally viewed as a form of professional etiquette, rather than a binding agreement. There is concern that the Goldwater rule will be used in bad faith to silence public inquiry; and many psychiatrists have described the APA ethics committee’s recent “reaffirmation” of the Goldwater rule as a “gag order”.

Ethics in the field of psychology

So, what do you believe? Every student of psychology may be required to grapple with their own ethical dilemmas at some point, hence the role that philosophy and ethics plays in the profession of psychology. For this very reason, SACAP offers a range of psychology courses that include ethical studies as a module. If you’re interested in learning more about the principles of psychology, and perhaps pursuing a career in the field, you can enquire now.

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