Psychiatrists Reminded To Refrain From Armchair Analysis Of Public Figures

Earlier this week the American Psychiatric Association cautioned psychiatrists against taking part in a feverish new national hobby.

Catching Pokémon wasn't mentioned. Psychoanalyzing Donald Trump was.

On the organization's website APA president Maria A. Oquendo wrote: "The unique atmosphere of this year's election cycle may lead some to want to psychoanalyze the candidates, but to do so would not only be unethical, it would be irresponsible."

Dr. Oquendo was referring to the "Goldwater Rule," a guideline adopted by the APA after a 1964 survey of psychiatrists found that nearly half of those polled felt that GOP presidential candidate Barry Goldwater was psychologically unfit to be president.

The rule states that despite the shiny diagnostic tee-ball Trump has propped in front of them – his volatility, his grandiosity, his entitlement — professional code holds that if they haven't performed an in-person evaluation, psychiatrists should keep quiet on the mental character of public figures (unless of course they have that person's permission to speak out).

The professionalism is sound. But what happens when, in the minds of many, a candidate crosses the line?

On Tuesday of this week, at rally in Wilmington, N.C., Trump suggested that perhaps there is something gun owners – or, "the Second Amendment people" – can do if Hillary Clinton is elected and appoints judges who oppose gun rights. Though he didn't specify just what they could do, the implication was ominous.

A few months ago, speaking about nuclear weapons, he reportedly asked a senior foreign policy adviser, "If we have them, why can't we use them?"

One could argue that a presidential candidate casually evoking the possibility of nuclear war – even if joking – could be seen as crossing a line.

Many mental health specialists feel that short of saddling politicians with formal diagnoses, we still need a realistic way to assess and discuss their mental states. In his recent cover story for The Atlantic, Dan McAdams, a psychology professor at Northwestern, did just that.

McAdams used scientifically backed personality and social psychology research to develop what he calls a "psychological commentary" on the life and the personality of Trump. It's a reasoned, rational account of a hulking persona: careful to avoid a specific diagnosis. McAdams simply concludes that the Republican candidate has "narcissistic motivations and a complementary personal narrative about winning at any cost."

"These constructs give you a richer understanding of his life and personality than you might get from, say, offering a clinical diagnosis," McAdams told me in an email.

Tufts psychiatrist Nassir Ghaemi agrees that mental assessments can be important, whether by psychiatrists, psychologists or other mental health professionals: "I think in principle [this] kind of detailed psychological analysis can be legitimate, and certainly shouldn't be verboten for being unethical." Yet, he says, objectivity and a scientific rationale are key, as opposed to what he considers catchphrases rooted in Freudian jargon. The media's frequent verdict on Trump's "narcissism" especially bugs him.

Ghaemi also proposes a few amendments to the Goldwater Rule. He believes that the in-person examination requirement should be nixed – assessing psychiatric patients often requires outside input: from colleagues; from family; from friends – he also feels that psychiatrists should be able to weigh in when a candidate poses a societal threat that overtakes professional oath.

Still, Drs. Ghaemi, McAdams and the other mental health experts I interviewed in reporting this piece all staunchly advise against diagnosing public figures from afar – armchair psychiatry, they feel, is a great irresponsibility.

But many also feel that even in the absence of a diagnosis, the more general psychological interpretations common to cable news and other media outlets – not under the rubric of the Goldwater Rule, psychologists show up with exceptional frequency as talking heads — can be ethically dubious.

"I think offering semi-psychological interpretations is a poor idea for psychologists and psychiatrists," says Arthur Caplan, a bioethicist at New York University's Langone Medical Center. "How can anyone give an in-depth character analysis on psychological or mental health grounds without knowing or examining the person at all?"

Caplan feels doing so not only stirs up gossip — gossip that demeans those suffering from diagnosed mental illness – but risks pathologizing what could be normal, if off-putting, personality traits. "Positions or attitudes that are outside of the mainstream or outside the pale can be ascribed to mental illness, when in fact there are plenty of racist, sexist, classist bigots all over the place who are not mentally ill."

Insight into the health of our politicians has been a campaign concern, well, probably forever.

But a few recent examples come to mind. FDR had a deal with the press corps to cover up the extent of his paralysis. John F. Kennedy's Addison's disease, a disorder of the adrenal glands, was cleverly concealed until after he was elected. President Eisenhower, after being hospitalized for a heart attack, was red-faced when his doctors publicly applauded his first "good bowel movement."

The voluntary release of select physical health data has since become commonplace among presidential candidates. Obama's enviable blood pressure is one thing. Unfortunately, mental health is another. Stigma still runs deep.

In her statement on behalf of the APA, Oquendo makes clear her strong support for the Goldwater Rule. She – and Caplan for that matter – also feel the guidance should apply not just to psychiatrists, but psychologists and other mental health practitioners as well.

One reason that Oquendo is resolute in pointing this out is that plenty of people with mental illness attain great success: CEOs, performers and even psychiatrists.

"Whether we like it or not, many have the notion that an individual with a psychiatric condition is less capable than others," she laments. "The fact is that's simply not true."

Ghaemi has written extensively on how mental illness can positively contribute to character and success in many ways – whether it's the empathy and realism sometimes imparted by depression (Lincoln, Gandhi and Martin Luther King come to mind) or the ambition and creativity brought on by mania. A 2006 study out of Duke University reviewed the historical records of 37 presidents and concluded that 18 of them met criteria of psychiatric diagnoses.

One idea occasionally floated through the psychiatry community is instituting a mandatory mental and physical health screen for aspiring presidents, the results of which would be made public.

In 2008, for example, a panel of high-level health experts recommended that both presidential and vice-presidential candidates should be required to undergo a health screen by an independent team of doctors. To this end, Ghaemi argues that if someone is in a position to send our sons and daughters into war, we deserve a more in-depth glimpse into his or her psyche – one interpreted and presented to the public by mental health experts.

"I've been arguing for a presidential health screen for over 20 years!" laughs Caplan. "But I see it as a panel that simply provides information for the public to assess, not one that qualifies or disqualifies anyone. If you want to vote for FDR with polio or Reagan with incipient Alzheimer's, you should be able to."

However, much like the 2008 recommendation, Caplan's efforts, he admits, have gone nowhere.

Oquendo's not sold on a standardized mental health screen, pointing out that upward of 20 percent of the population experience mental illness in a given year — and also that a public screen could bolster the erroneous notion that having a psychiatric condition renders someone an unfit candidate.

So assuming no screening process is implemented anytime soon – and also that asserting psychiatric absolutes remotely is probably irresponsible and ultimately unhelpful — how are we to assess the mental character and capacities of our candidates?

According to Oquendo, the answer is simple: behavior.

"So many factors can influence behavior. And, for example, not everyone with bipolar will be overly creative or ambitious, so you can't predict somebody's behavior just based on diagnosis," she explains. "But how someone acts is right there for people to see; voters can then decide if a particular behavior is acceptable or not."

In other words, the cause of someone's conduct – whether mental illness or not – is beside the point.

Bret Stetka is a writer based in New York and an editorial director at Medscape. His work has appeared in Wired, Scientific American and on The Atlantic.com. He graduated from University of Virginia School of Medicine in 2005. He's also on Twitter:@BretStetka.