Contemplating the Goldwater Rule

James L. Knoll IV, MD, recently wrote a response, “Gilding the Goldwater Lilly,” to our article “The Goldwater Rule Is Fine, if Refined. Here’s How to Do it.” We have each written a response to Dr Knoll and, as you can tell, each of us brings a different perspective to the topic. But together we have a common core belief that refinements to the Goldwater Rule will advance the cause of psychiatry’s mission as a helping profession.

The Goldwater Rule Needs Refinement to Reach its Goal

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The Goldwater Rule Is Fine, if Refined. Here’s How to Do it.

Alan D. Blotcky, PhD, Ronald W. Pies, MD, H. Steven Moffic, MD

Gilding the Goldwater Lily

James L. Knoll IV, MD

Alan D. Blotcky, PhD

First, I appreciate Dr Knoll’s time and effort in responding to our article. Frank discussion about an issue or matter is always healthier than silence or stubborn withdrawal. In our country today, there is far too little conversation between individuals who have opposing views. I am glad that as mental health professionals we are being role models for open and respectful dialogue that can lead to a deeper understanding and a search for common ground.

Second, today we have access to hundreds, if not thousands, of hours of political figures’ speeches, interviews, books, recordings, tweets, and much more. We also have research showing that clinical interviews, while very important, should not be the sole basis of a diagnostic formulation.¹ In truth, rarely—if ever—do we base our diagnostic decisions solely on an interview. Nor should we.

Third, a stated mission of psychiatry is the betterment of society and improvement in public health. As such, psychiatry must change and adapt to the times. Ethical guidelines are not meant to be static and fixed in a vacuum detached from community and societal changes.

Fourth, our 5 refinements to the Goldwater Rule do not give permission for the definitive diagnosis of a public or political figure without professional contact. That, for certain, is our common ground.

Fifth, “character flaws” do not equate with personality disorder. If a psychiatrist or a psychologist is competent and experienced, he or she knows that a personality disorder is diagnosed based on a variety of criteria, one of which is problematic and maladaptive behavior vis-à-vis others. No well-trained, competent, and experienced psychiatrist or psychologist would—or should—politicize a medical or psychiatric illness by simply focusing on “character flaws.” Flip, inflammatory, or pejorative comments are unacceptable. But personality disorders are real, definable, and well-researched entities.

Sixth, all psychiatrists and psychologists should already know that any professional comment in the public domain or otherwise must be accurate, scientifically based, measured, balanced, within one’s area of expertise, and with a recognition of one’s limitations. If that ethical standard is broken, the professional should be reprimanded strongly.

I want to reiterate what we asserted in our original article. The mission of psychiatry is to better society and improve public health. That mission cannot be accomplished in a clinician’s office. It requires contact with the community, often through the press. There must be ethical ways for psychiatrists and other professionals to achieve this stated mission. After all, we are the ones who are experts on mental processes, pathological behavior, disturbed family and group relationships, problems in communities, and ills in society. Let us take on this mission in a full-throated way, not shy away from it.

I believe the best way for psychiatry as a profession to enhance its credibility is for psychiatrists to show their competence, expertise, and reliance on scientific underpinnings in dealing with community and public health matters. Credibility cannot be achieved by retreating into one’s office and blocking out the world. We need to be visible, expressive, helpful, and responsible.

One final comment: If psychiatrists are supposed to better society and improve public health, then serious occasions call for—nay, require—comment and opinion. I believe all mental health professionals have a duty and responsibility to warn the public if, for example, democracy is being overturned in real time. That is exactly what we faced 1 year ago. Psychiatry could have improved its credibility and standing had it engaged with the scary and potentially tragic reality of January 6, 2021. Instead, in my opinion, psychiatrists and psychologists looked weak and inconsequential in their collective silence. How sad for our field. What a missed opportunity.

I believe the Goldwater Rule needs to be refined so that psychiatry and psychiatrists can achieve their overarching mission: to better society and improve public health. It is an achievable mission.

Dr Blotcky is a clinical and forensic psychologist in private practice in Birmingham, Alabama. He is also a clinical associate professor in the Department of Psychology at the University of Alabama at Birmingham.

The Right to Comment With Respect and Dignity

Ronald W. Pies, MD

Thanks to my friend and colleague, Dr Knoll, for his comments, which I find lighthearted in tone but serious in purpose. Readers may recall that Dr Knoll and I coauthored an article on the Goldwater Rule¹ and, in most respects, we share a similar perspective. What follows is not a rebuttal of Dr Knoll’s commentary, but an elaboration of why I believe the Goldwater Rule needs to be illuminated, not eliminated. More centrally, I want to clarify my views on psychiatric diagnosis in general. First, though, I want to thank Dr Blotcky for inviting me to participate in this article, and Dr Moffic for his many contributions advocating a wider role for psychiatrists in societal and community issues. I completely agree with them that this is an important part of psychiatry’s mission.

My coauthors and I charted a “middle way” between the 2 poles of either eliminating the Goldwater Rule or keeping it as is, as Dr Knoll wishes. My hope is that the 5 ways we outlined will help psychiatrists apply the Goldwater Rule, particularly when members of the media ask us to comment on living public figures. The 2 hypothetical vignettes in our article are, to be sure, idealized cases, but I do not regard them as unrealistic.

It is clear from several articles and books that many psychiatrists regard the Goldwater Rule as a kind of “gag rule.”² I understand their frustration with the Goldwater Rule in its present “unrefined” form. But as Dr Knoll and I have argued, the Goldwater Rule does not gag psychiatrists from speaking out against injurious or dangerous policies on the part of government or its officials; rather, it defines the conditions under which psychiatrists may render a professional opinion vis-à-vis a living public figure—and that requires a professional psychiatric evaluation.¹

To be sure, a public figure’s tweets, speeches, and observable interactions with others can provide useful insights into the individual’s psychology and personality, but a professional psychiatric opinion cannot be rendered solely on the basis of such external data. In my view, many charismatic public figures adopt a public persona that may seem dramatic, impulsive, or even a bit unhinged, but do so for political or other strategic purposes—hence the well-known expression “crazy as a fox.”

It is only through a deep understanding of a person’s developmental issues, ego defenses, interpersonal conflicts, family life, and so on that a professional diagnostic opinion can emerge. This also entails a process of diagnostic rule-outs. For example, the DSM-5 criteria for a personality disorder require that 1) there is evidence of “significant distress or impairment in social, occupational, or other important areas of functioning”³; 2) the enduring pattern of behavior is not better explained by another mental disorder (eg, a mood disorder); and 3) the behavioral pattern is not attributable to substance abuse or an underlying medical condition. There is simply no way these rule-outs can be investigated properly, absent a thorough clinical evaluation.

I am aware of critiques pointing out deficiencies in the direct interview, and I do not claim that a single, clinical assessment is an infallible guide to diagnosis.⁴ Often, in my experience, a patient’s diagnosis will not emerge until 2, 3, or even more evaluative sessions have been completed, sometimes augmented by interviews of family members, imaging studies, a review of school records, and psychometric or neuropsychiatric testing. But limitations and deficiencies in our present gold standard of evaluation are no argument for diagnosing public figures—or pronouncing on their “dangerousness”¹—without a comprehensive clinical evaluation. Tweets, speeches, and public appearances may sometimes be useful adjuncts to the standard clinical evaluation, but they are no replacement for it.

On the other hand, I believe it is professionally appropriate and consistent with the Goldwater Rule for psychiatrists to offer a differential diagnosis of a set of signs, symptoms, and behaviors, absenta clinical evaluation⁵—but, in my view, only if the differential diagnosis is uncoupled from the public figure in question. That is why, in our article, the responses to hypothetical media queries were phrased so impersonally. Yes, I know: Some in the media will portray this practice as merely a coy or covert way of diagnosing a public figure. Such misrepresentation is not something psychiatrists can easily control, but we can control our adherence to professional standards.

Indeed, as Dr Moffic wisely observed in 2016, “All of us have the right to comment on behaviors we observe and to voice our political opinions—but, from the mental health perspective, such rights should be exercised with respect and dignity.”⁶

Dr Pies is professor emeritus of psychiatry and a lecturer on bioethics and humanities at SUNY Upstate Medical University in Syracuse, New York. He is also a clinical professor of psychiatry at Tufts University School of Medicine in Boston, Massachusetts, and Editor in Chief Emeritus of Psychiatric Times^TM.

3. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. American Psychiatric Publishing; 2013:646.

5. Merikangas JR, Lateef TM. The myth of nuclear war. In: Lee BX, ed. The Dangerous Case of Donald Trump: 37 Psychiatrists and Mental Health Experts Assess a President. Thomas Dunne Books; 2019:399-411.

The Moffic-Gold Rules

H. Steven Moffic, MD

Although Dr Knoll concludes in his commentary that the Goldwater Rule is fine, period, by rolling out his Knoll-Water Rules, he instead conveys that they are inadequate as is. In that spirit, I would like to provide 8 comparative points to those he provides, but from the perspective of refining the Goldwater Rule. Although mine are meant to stand on their own, they are best appreciated in this discussion next to those of Dr Knoll, one by one. May our sets of new rules evoke more needed discussion and reconsideration on this controversy.

1. Psychiatry is in need of credibly and ethically “contributing to the improvement of the community and the betterment of public health.”¹ Participating more often in the discussion of various public issues that call for psychiatric expertise is one of the many ways to do so, as, for example, I have attempted to do in the weekday daily columns and weekly videos on Psychiatry and Society for Psychiatric Times^TM.

2. That a recent book on a political figure became a bestseller² and led in short order to an expanded edition³ suggests that the public is strongly interested in the opinions of psychiatrists. The challenge is how best to convey these without violating the current Goldwater Rule.

3. Without commenting on individual public figures, certain psychiatric disorders, such as personality disorders, by their very nature have symptoms that may be more readily seen in public interaction with other people than in an individual diagnostic evaluation.

4. Psychiatrists are trained to reduce the intrusion of personal opinions into their professional opinions by examining their own countertransference reactions.

5. Because the Goldwater Rule has inhibited psychiatrists from speaking out about US presidents, we do not know how helpful it might be for the restraints to be loosened without allowing for what Freud called wild analysis.

6. Whether the Tarasoff-type laws of risk to others can apply to public figures who are not patients may need a test case. Given the challenges of diagnosing and treating VIPs, the usual processes of civil commitment may be compromised and special social psychiatric expertise required.

7. In all professions, including politics and psychiatry, character flaws and psychiatric disorders may be helpful or harmful to those in leadership positions, as another bestseller by a psychiatrist has shown.⁴

8. Although psychiatrists may claim to be making political opinions solely from the standpoint of a citizen, the public may assume that it is a professional opinion unless the professional role is hidden or unknown.

Dr Moffic is an award-winning psychiatrist who specializes in the cultural and ethical aspects of psychiatry. A prolific writer and speaker, he received the one-time designation of Hero of Public Psychiatry from the Assembly of the American Psychiatric Association in 2002. He is retired from his tenured professorship at the Medical College of Wisconsin in Milwaukee.

1. American Psychiatric Association. The principles of medical ethics, with annotations especially applicable to psychiatry. 2013 ed. American Psychiatric Association; 2013.

2. Lee BX, ed. The Dangerous Case of Donald Trump: 27 Psychiatrists and Mental Health Experts Assess a President. Thomas Dunne Books; 2017.

3. Lee BX, ed. The Dangerous Case of Donald Trump: 37 Psychiatrists and Mental Health Experts Assess a President. Thomas Dunne Books; 2019.

4. Ghaemi N. A First-Rate Madness: Uncovering the Links Between Leadership and Mental Illness. 2nd ed. Penguin Books; 2012.