Where Silence Is Not Golden: Collegial Responses to My Columns on the Upcoming Presidential Election

Lustre/AdobeStock

PSYCHIATRIC VIEWS ON THE DAILY NEWS

Today, February 19, is Presidents’ Day. Last Monday was the 215th birthday of President Abraham Lincoln, renowned for his successful moral leadership toward unity, forgiveness, and freedom in a time of war. He also was thought to have depressive episodes, which he largely overcame and likely increased his empathy.

Over 100 years later, President Ronald Reagan is thought to have said this about our country’s history: “If we forget, which we did, we won’t know who we are.” Sounds pretty psychiatric to me! It is no wonder then that psychiatry is so potentially relevant right now. In much of our work, knowing and examining a patient’s personal history is a necessity.

Historically, now decades after President Reagan, we are in the midst of a volatile national presidential nomination process. Simultaneously, the American Psychiatric Association (APA) has an ethical “Goldwater Rule” not to use our professional knowledge to make any public comments about public figures without their permission. In the last cycle 4 years ago, many ignored the admonition, including with the publication of an edited book on the possible societal and psychological risks of one of the candidates.¹ However, despite current media concerns about the candidates’ age, mental capabilities, and even criminality, all seems eerily quiet on our national election front for psychiatry right now.

As important as this election is in the middle of 2 wars and many upcoming international elections, as well as escalating political divisiveness in our government, how might psychiatrists contribute to the public discourse? I first discussed this dilemma recently in my column, “The Mental Health Implications of Dictatorships.” That column discussed the risks of authoritarian leaders for their citizens mental health. That runs from the traumatic genocidal attempt by the Nazis against Jews and other social groups to more general decreased freedom of mind.² In medicine and psychiatry, for-profit managed care in the United States, set into motion by President Nixon,³ is connected to the burnout epidemic of physicians.

James Fleming, MD: The First Response

My colleague James Fleming, MD, responded with his own cogent recommendation in his letter to the editor “The Goldwater Rule: Removing the Gag on Free Speech,” posted February 8, 2024, by Psychiatric Times. He correctly noted that I did not focus on the United States. He went on to make a strong case for the Goldwater Rule being antiquated, and that there are other very important psychiatric ethical principles which counter the Goldwater Rule that are often ignored, as well as pointing out some of the exceptions to the rule.

I did follow up that article with a more recent column titled, “What Can and Should Psychiatrists Say About the Presidential Race in the United States and Elsewhere.” What psychiatrists have been collectively saying so far in the United States is very little.

Internationally, there seems to be more attention. One international group of psychiatrists recently warned against psychiatric labelling of politicians internationally.⁴ Another European group of psychiatrists recommended broader discussion of the advantages and disadvantages of the Goldwater Rule.⁵ Interestingly enough, about half of European countries did not have something like the Goldwater Rule, so it clearly is not universally embraced.

Elizabeth Varas: The Second Response

There was another collegial response to this second column of mine, this time by Elizabeth A. Varas, MD, in her article, “The Goldwater Rule: Preparing for the Upcoming Election.” She contended that despite the Goldwater Rule being in place, in the last election there was quite a bit of psychiatric interpretation of a President’s mental state and about all were negative. Many reminded her of some of the same questionable labels that were put on candidate Barry Goldwater by psychiatrists back in 1964, and eventually led to the Goldwater Rule. As far as commenting on presumed public dangerousness, she sides with the views that labelling a leader as dangerous will do more harm than good. She does affirm the use of commenting on political policies as a viable alternative.

My Conclusions

We must be very grateful for the responses of Drs Fleming and Varas. In my opinion, they were psychiatric gold. They publicly break the relative silence of psychiatrists in this election cycle. If I understand them both well enough, Dr Fleming does go much further than Dr Varas in his recommendation for revising the Goldwater Rule.

I was reminded of a more extensive series of postings in Psychiatric Times on the Goldwater Rule, in which I participated just about 2 years ago. They included the “The Goldwater Rule is Fine, if Refined. Here’s How to Do it” by Alan Blotcky and Ronald Pies in January 6, 2022; “Contemplating the Goldwater Rule” from February 3, 2022, where Drs Blotcky, Fleming, and myself responded to an article by James Knoll, “Gilding the Goldwater Lilly”; and my response on February 14, 2022, “The Other Ethical Side of the Goldwater Rule Coin: What We in Psychiatry Can and Must Do,” in response to an earlier article of Dr Fleming, “Discouraged by the Goldwater Rule,” in which I recommended a yet to be established ad-hoc task force of experts in political psychiatry.

Why, I even associated to when Psychiatric Times, in its ongoing devotion to covering crucial societal issues in psychiatry, conducted a presidential poll preference during the presidential race in 2016, the results of which were discussed by me on September 12, 2016, in the posting, “The Results of a Psychiatric Poll on Presidential Candidates.”

Currently, given that the APA actually tightened the Goldwater Rule in 2017, not long after our poll, I strongly doubt that they would practically go in the other direction. Time is short to do so anyways. More debate about the rule might be more of an academic exercise, rather than focusing on what seems allowed by the rule, which is to focus on the administrative promises and policies of our national and international leaders. Education about related psychiatric principles is also allowed, especially about ethical leadership.⁶ There is also the risk of publicly humiliating anyone with high narcissism, which not infrequently results in a desire for some revenge. Nevertheless, calls for a revised Goldwater Rule can occur while other pathways are used to contribute to the political process. Some kind of psychiatrist participation would be consistent with the last comment of Dr Fleming. Nobel Prize awardee author and Holocaust surviver Elie Wiesel said:

“We must take sides. Neutrality helps the oppressor, never the victim. Silence encourages the tormentor, never the tormented. Sometimes we must interfere.”

I would conclude that the time to intervene more effectively is now as far as our presidential and related election processes, here and internationally. Some of us in the field of psychiatry keep coming back to the challenge of how to respond to presidential elections, as if there was still some unresolved Jungian collective unconscious conflict here. Perhaps like carefully, compassionately, and empathetically waiting for the right opportunity for an interpretation in psychodynamic psychotherapy, we need to do the same in addressing our societal political process. While all our processing and commentary will likely not be golden, they can bring some needed light and insight to these highly influential political processes.

Dr Moffic is an award-winning psychiatrist who specialized in the cultural and ethical aspects of psychiatry and is now in retirement and retirement as a private pro bono community psychiatrist. A prolific writer and speaker, he has done a weekday column titled “Psychiatric Views on the Daily News” and a weekly video, “Psychiatry & Society,” since the COVID-19 pandemic emerged. He was chosen to receive the 2024 Abraham Halpern Humanitarian Award from the American Association for Social Psychiatry. Previously, he received the Administrative Award in 2016 from the American Psychiatric Association, the one-time designation of being a Hero of Public Psychiatry from the Speaker of the Assembly of the APA in 2002, and the Exemplary Psychiatrist Award from the National Alliance for the Mentally Ill in 1991. He is an advocate and activist for mental health issues related to climate instability, physician burnout, and xenophobia. He is now editing the final book in a 4-volume series on religions and psychiatry for Springer: Islamophobia, anti-Semitism, Christianity, and now The Eastern Religions, and Spirituality. He serves on the Editorial Board of Psychiatric Times.

References

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

2. Hassan S. The Cult of Trump. Free Press; 2020.

3. Moffic HS. The Ethical Way: Challenges and Solutions for Managed Behavioral Healthcare. Jossey-Bass; 1997.

4. Mahdanian AA, Rosen A, Jureidnini J, Puras D. A call to avoid psychiatric labelling in a historic election year. Lancet Psychiatry. 2024;11(3):168-169.

5. Smith A, Hachen S, van Wijnkoop M, et al. The Goldwater Rule at 50 and its relevance in Europe: examining the positions of National Psychiatric Association members of the European Psychiatric Association. Eur Psychiatry. 2023;66(1):e34.

6. Moffic HS, Sabin J. Ethical leadership for psychiatry. In: Sadler J, San Staden W, Fulford KWM, eds. The Oxford Handbook of Psychiatric Ethics, Volume 2. Oxford University Press; 2015.