The Goldwater Rule: A Mouthpiece, Not a Muzzle

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COMMENTARY

Back in 2017, when life was simple and we were all young and innocent, I remember seeing a bumper sticker 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 important and a sign for us to pay attention. It animates us to face what is wrong and then to act. 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 little, but they agree that things must change. With polarization and extremism on the rise, threats at home and abroad, and a deepening sense of pessimism and cynicism, things need to change. And with a 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 noted in a recent editorial in The New York Times.¹ Maybe.

A Time for Peace?

Although we need emotional energy for change, cooler heads must eventually prevail if we are going to do anything effective to solve our problems. Emotional arousal is great at creating energy for change but terrible at directing that energy. Lashing out in fear or anger rarely improves the situation, and neither do other unreflective, knee-jerk reactions. Effective change requires much time for reflecting, understanding, taking multiple perspectives, and weighing 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 emotion and reflection is the bread and butter of what we do in clinical practice. On the one hand, individuals cannot be healthy while living lives of avoidance and denial, repressing their emotions, and ignoring their needs. On the other hand, emotions must be processed and integrated thoughtfully into a better way of life, not simply blasted at those around us. Much of our work involves helping patients balance and coordinate these 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. These brain regions are heavily interconnected, so 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. As psychiatrists, we must 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 that 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 it. 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 should not use this power to psychoanalyze public personalities. We hold back, even when it is difficult, to do good rather than harm, as well as to maintain the trust and respect of the public. Whatever good we could do in the short run by undermining problematic politicians would be far outweighed by harm in the long run due to alienating sections of the public and launching ourselves 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, it needs help activating its frontal lobes rather than further arousing its amygdalae. There is too much heat (emotion) in 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. Internists, neuropsychologists, neuroscientists, neurologists, and neurosurgeons have prominently weighed in about US President Joe Biden’s health with various diagnoses: superaging,³ age-related cognitive decline, dementia, or Parkinson disorder.^4-6 Similarly, other professionals have suggested diagnoses for the health of former US President Donald J. Trump, including dementia, psychopathy, narcissism, psychosis, and bipolar disorder.^7-11

Although there are some glaring exceptions, psychiatrists seem to be more restrained than other health professionals in postulating about Biden’s and Trump’s health.^12,13 This says something extraordinary about our profession. It says that, as a group, we can be mindful of our own passionate political feelings while expressing them reflectively in the long-term interests of our patients and the cause of mental health generally.

The Role of Psychiatrists

For those who feel convicted about expressing themselves, nothing prevents psychiatrists from taking 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 our world needs more culture warriors or that our political scene needs 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 some time. 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. It 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 taking sides. It is a way of being that leads to polarization and deepening conflict. With multiple crises in our country and worldwide, 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 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 whether 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.

Acknowledgment: The author would like to thank Stephen A. Goldman, MD, for his comments on an earlier version of this article and for the idea behind its new title.

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

References

1. Spiers E. Democrats need to wake up from their ‘West Wing’ fantasy. The 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):1376-1385.

3. Clionsky M. Is Joe Biden a “super ager?” 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. The 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? The 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. Accessed September 10, 2024. https://www.psychiatrictimes.com/view/the-goldwater-rule-preparing-for-the-upcoming-election

8. Gartner J. 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