Psychiatry, “Dangerousness,” and the President

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It’s hard to keep up with the flurry of books, articles, op-eds and letters addressing the issue of President Trump’s mental state, many written by well-known psychiatrists ^1-5. Reaction to these writings has sometimes been extreme, including reported “death threats” in response to one recent book about the President’s alleged “dangerousness.”⁵

In an op-ed piece in the Boston Globe, the editor and one contributor to this book argued that they are not “diagnosing” Mr. Trump-which would violate psychiatry’s now famous “Goldwater Rule”-but rather, focusing “squarely on Trump’s dangerousness.” Furthermore, they argue that “dangerousness” can be “reliably established from public records” and “does not require a face-to-face interview.” They go on to depict their portrayal of Mr. Trump as nothing more than “expert commentary,” provided “… for the purpose of enhancing the public’s understanding, awareness, health and safety.” ⁵

We don’t doubt the good intentions of these colleagues, and we recognize that opinion among psychiatrists is often sharply divided, as regards the Goldwater Rule. Nevertheless, we find the above claims regarding “dangerousness” deeply problematic. When psychiatric terms of art are used capriciously to label a public figure, this stigmatizes not only the person labeled but also those with genuine mental illness. This impedes our ability to provide vitally important psychiatric care and diminishes the credibility of our profession.

Accordingly, in this essay, we attempt to (1) update readers’ understanding of the “Goldwater Rule” in its latest incarnation; (2) describe what the term “dangerousness” ordinarily means in clinical psychiatry, and how it is properly ascertained; (3) examine the claim that a psychiatrist can determine a public figure’s “dangerousness” without having evaluated the person clinically; and (4) discuss the psychiatrist’s ethical responsibilities and legitimate options when he or she believes a public figure is “dangerous,” absent a clinical evaluation of that individual.

Goldwater redux

First, a quick update regarding two recent clarifications (or modifications) of the Goldwater Rule (GR) from the American Psychiatric Association. (One of us (RP) discussed and critiqued earlier formulations of the GR in a piece published on this website in October, 2016).⁶

In March, 2017, then APA President Maria Oquendo MD, PhD, issued this statement:

…APA’s Ethics Committee asserts that while it is perfectly fine for a psychiatrist to share their expertise about psychiatric issues in general, it is unethical to offer a professional opinion about an individual without conducting an examination. The committee clarified that the rule applies to all professional opinions offered by psychiatrists, not just diagnoses. For example, saying an individual does not have a mental disorder would also constitute a professional opinion.⁷

The Ethics Committee defined the term “professional opinion” as follows: “…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.”⁸

These clarifications (or modifications) of the GR stimulated a robust “pro and con” exchange in Psychiatric Times between psychiatrists Leonard Glass, MD, and Rebecca Brendel, MD, JD.^9,10

Then, in a statement released Jan. 9, 2018, the APA vigorously upheld the principles articulated in the Goldwater Rule, writing:

We at the APA call for an end to psychiatrists providing professional opinions in the media about public figures whom they have not examined, whether it be on cable news appearances, books, or in social media. Armchair psychiatry or the use of psychiatry as a political tool is the misuse of psychiatry and is unacceptable and unethical. . . A proper psychiatric evaluation requires more than a review of television appearances, tweets, and public comments. Psychiatrists are medical doctors; evaluating mental illness is no less thorough than diagnosing diabetes or heart disease. The standards in our profession require review of medical and psychiatric history and records and a complete examination of mental status…¹¹

Three features are worth noting in the latest iterations of the GR:

1 The word “opinion” is always preceded by the term “professional” or “professional medical”

2 The rule is always applied to public statements about a particular individual, not about policies.

3 The rule says nothing-and evidently does not apply-to private communications between a psychiatrist and an appropriate official.

Thus, a psychiatrist who writes or states publicly, “In my opinion, the President doesn't understand climate change” is not expressing a professional opinion as defined by the rule (because the opinion does not draw on the skills, training, expertise, etc., inherent in the practice of psychiatry). By the same token, a psychiatrist who writes or states publicly, “I believe the proposal to end the Affordable Care Act is ill-advised” is not voicing the kind of professional opinion covered by the Goldwater Rule (which applies to public statements dealing with “the affect, behavior, speech, or other presentation of an individual.”). Finally, a private or confidential letter from a psychiatrist to, say, an appropriate member of the US Congress, expressing concerns about a public official's behavior, does not appear to be prohibited by the Goldwater Rule. We stress these fine points because they directly affect the ways in which psychiatrists can enhance the public's “health and safety” without violating professional ethics.

“Dangerousness” in clinical and forensic psychiatry

In general, the term “dangerousness” usually refers to legal, rather than psychiatric criteria.12 Most psychiatrists will be familiar with the term in the context of civil commitment, when “dangerousness” is defined by state statute. This usually involves behavioral evidence that an individual has already engaged in a behavior that presents a danger to others-either by threats or acts.¹³

In forensic psychiatry, the terms “violence risk” or “risk of violence” are preferable to “dangerousness.” Determining violence risk entails a clinical or forensic assessment of an individual at a particular time. In addition to assessing violence risk, the goal is to discover any psychosocial or modifiable risk factors that may targeted in a risk reduction plan. The key point is that mental health professionals cannot successfully “predict” low base rate human behaviors (such as violence) with long-term accuracy. Furthermore, because violence risk (like suicide risk) is dynamic and influenced by many variables, periodic assessments over time are required.

Misuse of psychiatric terminology

Unfortunately, in the popular media, psychiatric terms of art are often used in a casual or reckless manner. Take, for example, the forensic-legal phrase “duty to protect,” stamped into the annals of psychiatric history by the 1976 Tarasoff ruling. This ruling created a legal “duty to protect” which overrode the confidentiality of the therapist-patient relationship in California. The final ruling in Tarasoff emphasized that therapists have a duty to protect individuals who are being threatened with bodily harm by their patient.¹² Thus, the forensic/legal phrase “duty to protect” applies only to therapists who have a therapist-patient relationship in the eyes of the law-not broadly to psychiatrists and the public at large.

Consequently, there is no legal sense in which psychiatrists are called upon to assess “dangerousness” in relation to large groups or communities-much less entire nations. Thus, those who use the terms “dangerousness” or "duty to warn" in a general, socio-political sense-as in, “Trump is a danger to the country and we have a duty to warn the public”-are misappropriating these terms from their legitimate medico-legal context.

Indeed, in clinical and forensic psychiatry, the putative “dangerousness” of a patient must be assessed according to well-established norms and procedures, including but not limited to a thorough, face-to-face, clinical evaluation. Elements of the evaluation include such factors as the specific person threatened; presence of a specific plan; past history of violence; psychiatric diagnosis, presence of command hallucinations; history of impulsivity; alcohol and other substance misuse, and many other factors that cannot be assessed without an in-person evaluation.¹²

Dangerousness without a clinical evaluation?

So: can dangerousness be “established from public records” alone? In general, the answer is no. In rare cases, the "public record" may reflect documented instances of assault, domestic abuse, arrests for disorderly conduct, etc., such that one might reasonably consider the individual at “high risk” for future violence. But in general, publicly attributing “dangerousness” to an individual one has not assessed clinically is inconsistent with both good medical practice and the intent of the Goldwater Rule. Reliable risk assessment cannot be based solely on a public figure's television appearances, tweets, and public comments. Psychiatrists must assess clinical risk as thoroughly as other physicians assess risk in heart disease or cancer.

One important, albeit implicit, goal of the Goldwater Rule is to prevent the arbitrary and capricious stigmatization of public figures. As Dr. Brendel notes, at the ethical core of the rule is “respect for persons”, and “…making professional judgments about an individual's mental health is intrusive and can have negative consequences. We need not look further than Barry Goldwater to see that these conclusions, even when 'non-clinical,' can be harmful.”¹⁰

In our view, labeling a (clinically unexamined) public figure as "dangerous" can do as much or more harm as promulgating a specific psychiatric diagnosis. Thus, the supposed distinction between "diagnosing" a public figure and labeling that individual as “dangerous” is spurious and misleading.

The psychiatrist’s ethical responsibilities to the public

Some psychiatrists have defended their public allegations of the President's "dangerousness" on the basis of psychiatry's professional duty to contribute "…to the improvement of the community and the betterment of public health." Indeed, this duty is set forth in Section 7, subsections 1 and 2, of the APA Code of Ethics.14 The psychiatrist is therein encouraged "…to serve society by advising and consulting with the executive, legislative, and judiciary branches of the government"; and to "…interpret and share with the public their expertise in the various psychosocial issues that may affect mental health and illness."

We strongly agree that these forms of public education and engagement are part of the psychiatrist's ethical responsibilities. However, this should not serve as a rationalization for breaching the much more specific directives of Section 7, subsection 3 of the Code, which states, "…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."¹⁴

A similar view is expressed in a report from the American Medical Association's Council on Ethical and Judicial Affairs.¹⁵ In its recent Guidance for Ethical Physician Conduct in the Media,15 the AMA notes that “the media industry can have interests and goals that are out of step with physicians' ethical obligations to patients, the public and the medical profession,” and that "Disseminating a message that is inaccurate, questionable, or false may be perceived as authoritative when it comes from a physician in a position of public trust."

When unreliable or biased medical information is given to the media cloaked in the mantel of medical authority, this tends to undermine public trust in the medical profession. Accordingly, the AMA policy states that physicians should "refrain from making clinical diagnoses about individuals (eg, public officials, celebrities, persons in the news) they have not had the opportunity to personally examine."¹⁵

The legitimate purview of psychiatry

Psychiatrists are trained primarily to diagnose and treat mental illness according to specific professional standards and methods-not to offer opinions on what constitutes good or bad leadership. Neither are psychiatrists specifically trained to define “fitness”or “unfitness” to hold public office. With respect to the presidency, “fitness” is to be determined through the political process outlined (albeit sketchily) in the 25th amendment to the US Constitution. Of course, as psychiatrists Paul Summergrad and Stephen N. Xenakis point out, medical opinion regarding a president's physical and mental health may be one component of this determination.¹⁶

Unsubstantiated, "armchair" opinions from psychiatrists often appear foolish with the passage of time. Consider the Goldwater Fact Magazine fiasco, and one psychiatrist's carefully considered opinion, preserved for the ages: "[Goldwater] is a mass-murderer at heart and . . . a dangerous lunatic. Any psychiatrist who does not agree with the above is himself psychologically unfit to be a psychiatrist.”⁷

In short, the crux of the problem is the misapplication of psychiatric labels in order to vent displeasure at a public figure. This not only trivializes genuine mental illness, it also perpetuates the stigma long associated with mental illness and confuses the general public as to what serious mental illness is-and is not.

Ethically responsible input from psychiatrists

To be clear: psychiatrists do not relinquish their first amendment right to freedom of speech by virtue of being psychiatrists. There are several ways psychiatrists can voice concerns about the mental state and fitness of a public official who has not been clinically evaluated.

• First, they can express concerns or misgivings as private citizens, so as to avoid "…cloaking their public statements with the authority of the profession…" (APA Code, Sec. 7.1). The Goldwater Rule does not "gag" psychiatrists; rather, it defines the conditions under which psychiatrists may render a professional opinion.

• Psychiatrists may criticize specific policies of public officials or their administrations. Indeed, the APA itself has criticized a number of policies or legislative initiatives associated with the Trump administration, such as repeal of the individual mandate component of the Affordable Care Act.¹⁸

• Psychiatrists can publish educational pieces and participate in media interviews concerning, for example, the differential diagnosis of impulsivity, cognitive impairment, aberrant behavior, etc.

• In rare instances in which a public figure is deemed an immediate or serious threat to the public safety, psychiatrists can communicate their concerns privately to appropriate civil authorities, congressional representatives, or magistrates.

Despite the rancor and confusion surrounding the Goldwater Rule's integrity, perhaps the silver lining is this: the debate has opened a broader discussion about the importance of recognizing genuine psychiatric illness and the requirements of psychiatric ethics.

Dr. Knoll is Editor in Chief Emeritus of Psychiatric Times. He is Professor of Psychiatry at the SUNY Upstate Medical Center in Syracuse, where he is Director of Forensic Psychiatry, and Director of the Forensic Psychiatry Fellowship at Central New York Psychiatric Center. Dr. Pies is Editor in Chief Emeritus of Psychiatric Times, and a Professor in the psychiatry departments of SUNY Upstate Medical University, Syracuse, NY, and Tufts University School of Medicine, Boston.

Acknowledgment: We wish to thank Dr. Paul Summergrad for his helpful comments on an early draft of this essay. The views presented here, however, are solely those of the authors.

This article was originally published on January 25, 2018 and has since been updated.

References:

1. Lee B (editor). The Dangerous Case of Donald Trump. 27 Psychiatrists and Mental Health Experts Assess a President. Thomas Dunne Books, 2017.
2. Pouncey C. President Trump's Mental Health-Is It Morally Permissible for Psychiatrists to Comment?N Engl J Med. Dec. 27, 2017.
3. Lieberman J. The Dangerous Case of Psychiatrists Writing About the POTUS's Mental Health. Psychiatric News. Nov. 15, 2017. https://psychnews.psychiatryonline.org/doi/full/10.1176/appi.pn.2017.11b13.
4. Frances A. We must not confuse Trump's bad behavior with mental illness. The BMJ Opinion. August 25, 2017. http://blogs.bmj.com/bmj/2017/08/25/allen-frances-we-must-not-confuse-trumps-bad-behavior-with-mental-illness/
5. Glass LL, Lee BX. We aren't diagnosing Trump. We're sounding an alarm. Boston Globe. January 10, 2018. http://www.bostonglobe.com/opinion/2018/01/10/aren-diagnosing-trump-sounding-alarm/Kx995paa5Wv7Ns6UEOdErO/story.html?event=event12.
6. Pies RW. Deconstructing and reconstructing the Goldwater Rule. Psychiatric Times. October 7, 2016. http://www.psychiatrictimes.com/blogs/deconstructing-and-reconstructing-goldwater-rule
7. Oquendo MA. APA Remains Committed to Supporting Goldwater Rule. American Psychiatric Association. March 16, 2017. https://www.psychiatry.org/news-room/apa-blogs/apa-blog/2017/03/apa-remains-committed-to-supporting-goldwater-rule.
8. American Psychiatric Association Ethics Committee Opinion. March 15, 2017. https://www.psychiatry.org/news-room/apa-blogs/apa-blog/2017/03/apa-remains-committed-to-supporting-goldwater-rule.
9. Glass LL. Dealing with American Psychiatry's Gag Rule. Psychiatric Times. July 20, 2017 http://www.psychiatrictimes.com/blogs/couch-crisis/dealing-american-psychiatrys-gag-rule.
10. Brendel R. The Goldwater Rule Is Still Relevant. Psychiatric Times. July 20, 2017. http://www.psychiatrictimes.com/blogs/goldwater-rule-still-relevant.
11. APA Calls for End to "Armchair" Psychiatry. January 9, 2018. https://www.psychiatry.org/newsroom/news-releases/apa-calls-for-end-to-armchair-psychiatry.
12. Simon RI, Shuman DW. Clinical Manual of Psychiatry and the Law. American Psychiatric Publishing, 2007.
13. Pinals DA, Mossman, D. Civil Commitment. In: The Encyclopedia of Clinical Psychology. Robin L. Cautin (Editor),‎ Scott O. Lilienfeld (Editor). Wiley-Blackwell, 2015.
14. American Psychiatric Association Code of Ethics. 2013 edition. https://www.psychiatry.org/psychiatrists/practice/ethics.
15. AMA Adopts Guidance for Ethical Physician Conduct in the Media. November 14, 2017. https://www.ama-assn.org/ama-adopts-guidance-ethical-physician-conduct-media.
16. Summergrad P, Xenakis SN. Congress is AWOL on the 25th Amendment. Boston Globe. January 12, 2018. https://www.bostonglobe.com/opinion/2018/01/12/congress-awol-amendment/IsjnwJuVbmWOni8m6gUXON/story.html.
17. Ginzburg R. Goldwater, the man and the menace. Fact Vol. 1, Issue 5. 1964. https://www.scribd.com/document/322479204/Fact-Magazine-Goldwater-1964.
18. APA Criticizes Tax Bill as Unnecessary Attack on Nation's Health Care. Psychiatric News. Dec. 20, 2017. http://alert.psychnews.org/2017/12/apa-criticizes-tax-bill-as-unnecessary.html.