The Country Needs Us, and We Need the Goldwater Rule

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AFFIRMING PSYCHIATRY

A Time for Fighting?

Back in 2017, when life was simple and we were all young and innocent, I remember seeing a bumper sticker appear all over the city where I lived: “If you’re not outraged, you’re not paying attention.” Doubtless this was the case. As the bumper sticker not-so-subtly implied, there were plenty of things to be outraged about. As it also implied, things were not going to change without some outrage, or at least some emotional arousal. Emotion, as I like to tell my psychotherapy patients, is a marker for what is really important and a sign for us to pay attention. It animates us to face what is wrong and to take action. And as it is psychologically, so it is socially. It takes a great deal of energy to change things politically or culturally. Without emotion to provide the motivation to make things different, or at least to declare the current state of things to be unacceptable, nothing will ever change.

Fast forward to 2024. Americans now agree on very little, but they do agree that things need to change. With polarization and extremism on the rise, with threats at home and abroad, with a deepening sense of pessimism and cynicism, things need to change. With 1 major presidential candidate subject to an assassination attempt and another bowing out under intense pressure, things really need to change. So maybe this is a time for passion and outrage, a time for “all out war” in politics, as a recent editorial in The New York Times put it.¹ Maybe.

A Time for Peace?

While we need emotional energy for change, cooler heads must eventually prevail if we are ever going to do anything effective to solve our problems. Emotional arousal is great at creating energy for change, but it is terrible at directing that energy. Lashing out in fear or anger rarely makes the situation better, and neither do other unreflective, knee-jerk reactions. So effective change requires a great deal of time for reflecting, understanding, taking multiple perspectives, and weighing multiple arguments. We must truly understand what we are trying to change if we want any chance of changing it for the better.

As psychiatrists, working with both emotion and reflection are the bread and butter of what we do in clinical practice. On one hand, individuals cannot be healthy living lives of avoidance and denial, stuffing their own emotions and ignoring their own needs. On the other, emotions must be processed and integrated thoughtfully into a better way of life, not simply blasted at those around us. So much of our work is to help patients balance and coordinate these 2 critical aspects of mental life.

Our current metaphor for this balance of emotion and thought is between the amygdala and the frontal lobes.² While the amygdala is at the center of fearful and angry reactions, the frontal lobes are associated with self-awareness, understanding, and self-control. The 2 brain regions are heavily interconnected, such that it is possible for the frontal lobes to calm amygdala activity, and for the amygdala to inhibit frontal lobe function in times of great emotion. So as psychiatrists, much of our work is to give the amygdala its due, but go on to help the frontal lobe develop its work of insight, awareness, and integration with other perspectives. Naturally, all of this is a gross oversimplification of neuroscience, but clinicians and patients often find it useful for clinical work as an image which captures so much about the challenges of human psychological life.

The Goldwater Rule

What does any of this have to do with the Goldwater Rule? In my mind, it has everything to do with the Goldwater Rule. The Goldwater Rule—more of a guideline, really—says that psychiatrists should not publicly diagnose or analyze political figures. We are healers whose power depends on maintaining safety and confidentiality in treatment, and we do not use this power to go after people in public. We hold back, even when it is difficult, in order to do good rather than harm, and in order to maintain the trust and respect of the public. Whatever good we could do in the short run by taking down problematic public figures would be far outweighed by harm in the long run due to alienating large sections of the general public and launching ourselves out into treacherous political waters. We are physician-healers, not political infighters.

More deeply, the Goldwater Rule reminds us that once we enter a fight on one side or the other, we become incapable of helping both sides resolve the fight. To put it another way, once we move into the role of the amygdala, we are no longer in the role of the frontal lobe. And if our current culture needs anything from psychiatrists in our public life, I believe it needs some help activating its frontal lobes rather than further arousing its amygdalae. There is too much heat (emotion) in our public life these days, and not enough light (reflection).

I am proud that very few psychiatrists have decided to step away from the Goldwater Rule (even though it is more of a guideline than an actual rule). Internists, neuropsychologists, neuroscientists, neurologists, and neurosurgeons have prominently weighed in about President Biden’s health, variously diagnosing him as a super-ager,³ as having age-related cognitive decline, or dementia, or Parkinson disorder.^4-6 Yet in spite of great temptation, relatively few psychiatrists have made public pronouncements. Though there are some glaring exceptions, psychiatrists seem to have been a good bit more restrained than other health professionals about publicly diagnosing former President Trump’s issues.⁷ Trump has been publicly diagnosed with dementia, psychopathy, narcissism, psychosis, and bipolar disorder,^8-12 but the vast majority of psychiatrists have held their fire.¹³ I think this says something extraordinary about our profession. It says that, as a group, we have an ability to be mindful of our own passionate political feelings, and yet to express them reflectively in the long-term interests of our patients and the cause of mental health generally.

What’s A Psychiatrist to Do?

For those who feel convicted about expressing themselves, nothing prevents psychiatrists from taking a full part in the political process or even the culture wars, as long as we do it outside of our roles as psychiatrists. Yet I cannot convince myself that that our world needs more culture warriors, or that our political scene needs yet more urgent and impassioned voices. Since 2017 (if not before), American political life has been marred by deepening divisions, sporadic and tragic violence, and accusations of hate on all sides. The volume of our public discourse has been stuck on 11 for a while now. If psychiatrists have a role in public conversation, maybe it should be to help people calm themselves, reflect, take multiple perspectives, and think before acting. This, after all, is what psychiatrists are good at. This is what we do when we counsel patients and families. And this is what our culture needs right now.

In our current political climate, once politics becomes the subject, most individuals are listening with 1 and only 1 question in mind: “Are you on my side, or are you on the other side?” In other words, every word is sifted through the filter of “Are you one of us, or one of them?” And this kind of vigilance is not reflection. It is not even listening. It is othering and side-taking. It is a way of being that leads to polarization and deepening conflict. With multiple crises in our country and around the world, can we as a body of psychiatrists maintain the insight that our only way out of polarization and deepening conflict is to calm ourselves, stop adding to the conflict, and start reflecting on it? If we think we have been ordained to some role in our national political process, maybe this is it. And if we do have a role in such the political process, then the first thing to do is to calm ourselves and practice reflecting on these fraught matters with understanding and compassion for all. I do not know that doing so will solve most of our national problems. But I do know that it will keep us from adding to them. Then at the end of the day, we will still be doctors and healers who have guarded the sacred public trust. First do no harm.

Dr Morehead is a psychiatrist and director of training for the general psychiatry residency at Tufts Medical Center in Boston. He frequently speaks as an advocate for mental health and is author of Science Over Stigma: Education and Advocacy for Mental Health, published by the American Psychiatric Association. He can be reached at dmorehead@tuftsmedicalcenter.org.

References

1. Spiers E. Democrats need to wake up from their ‘West Wing’ fantasy. New York Times. July 15, 2024. Accessed August 14, 2024. https://www.nytimes.com/2024/07/15/opinion/democrats-west-wing.html

2. Arnsten AFT. Stress weakens prefrontal networks: molecular insults to higher cognition. Nat Neurosci. 2015;18(10):1376-85.

3. Clionsky M. Is Joe Biden a "SuperAger?" Psychology Today. July 27, 2023. Accessed August 14, 2024. https://www.psychologytoday.com/us/blog/dementia-prevention/202307/is-joe-biden-a-superager

4. Ranganath C. I’m a neuroscientist. We’re thinking about Biden’s memory and age in the wrong way. New York Times. February 12, 2024. Accessed August 14, 2024. https://www.nytimes.com/2024/02/12/opinion/neuroscientist-on-biden-age-memory.html

5. Neurologist argues Biden ‘likely suffers’ from vascular dementia. Fox News. July 13, 2024. Accessed August 14, 2024. https://www.foxnews.com/video/6357869451112

6. Should democrats press Biden to step aside? New York Times. July 10, 2024. Accessed August 14, 2024. https://www.nytimes.com/2024/07/10/opinion/joe-biden-democrats-withdrawal.html

7. Varas EA. The Goldwater Rule: preparing for the upcoming election. Psychiatric Times. February 6, 2024. https://www.psychiatrictimes.com/view/the-goldwater-rule-preparing-for-the-upcoming-election

8. Our diagnostic impression of Trump is probable dementia: for licensed professionals only. Change.org. Accessed August 14, 2024. https://www.change.org/p/our-diagnostic-impression-of-trump-is-probable-dementia-for-licensed-professionals-only

9. Our mission. Duty to Inform. Accessed August 14, 2024. https://dutytoinform.org

10. Alford H. Is Donald Trump actually a narcissist? Therapists weigh in! Vanity Fair. November 11, 2015. Accessed August 14, 2024. https://www.vanityfair.com/news/2015/11/donald-trump-narcissism-therapists

11. Devega C. Former Harvard psychiatrist Lance Dodes: Trump's psychosis is still an "enormous danger". Salon. June 14, 2021. Accessed August 14, 2024. https://www.salon.com/2021/06/14/former-harvard-psychiatrist-lance-dodes-trumps-psychosis-is-still-an-enormous-danger/

12. Rosenberg KP, Ornstein N. Trump history and behavior suggest destructive mental processes that put America at risk. USA Today. November 20, 2020. Accessed August 14, 2024. https://www.usatoday.com/story/opinion/2020/11/20/trump-behavior-history-suggest-mood-personality-disorders-column/6332417002/

13. Moffic HS. What can and should psychiatrists say about the presidential races in the United States and elsewhere? Psychiatric Times. January 25, 2024. Accessed August 14, 2024. https://www.psychiatrictimes.com/view/what-can-and-should-psychiatrists-say-about-the-presidential-races