Psychiatry & Psychotherapy Podcast - Where Psychiatry Meets Politics: The Goldwater Rule

Episode Date: August 7, 2024

There is an extensive history of psychiatry and politics intersecting. Perhaps the most visible flashpoint occurred during the 1964 presidential campaign and gave rise to a movement in organized psychiatry that has resulted in issuance of formal ethical guidance (the "Goldwater Rule"). In this episode, Dr. David Puder and Dr. Mark Mullen discuss the pros and pitfalls of the Goldwater Rule and psychiatry's role in politics.  By listening to this episode, you can earn 1 Psychiatry CME Credits. Link to blog. Link to YouTube video.

Welcome to the Psychiatry and Psychotherapy Podcast. I'm your host, David Puter. This is your gateway to the intriguing world of mental health. As one listener put it, this is the podcast that your psychiatrist listens to. And we're incredibly proud of that endorsement. Whether you're a loyal, active listener who's been kind enough to reach out, maybe send an email at DM or put in a review, or you're new to this community. We have an exceptional opportunity for you, not only to learn, but to also, earn continued medical education credits with each episode. Our credits are meticulously designed to empower you in your field, demystify complex mental health topics, and transform your learning journey into a truly rewarding experience. To access this and more, just visit Psychiatrypodcast.com. We're grateful to our valued subscribers who are already reaping the benefits of these credits. Your support is instrumental in allowing us to devote time each week to curate. this podcast, sharing cutting-edge insights featuring top professionals and exploring the latest

research. Whether you're here to learn, earn credits, or both, we're thrilled to have you with us. Get ready to deepen your understanding of psychiatry and psychotherapy, one enlightening episode at a time. All right, welcome back to the podcast. I am joined today with Mark Mullen. He is a now assistant professor of psychiatry. Congratulations at St. Louis University School of Medicine. He is also the host of the psychiatry boot camp, which trains residents to get ready for psychiatry residency. And I would say it has value to those also who are in practice. And today we are going to be talking about where psychiatry meets politics, the Goldwater

Rule. Welcome to the podcast. Thank you. Thanks for having me. And thanks for being such a good mentor. and really now a friend throughout this whole process. Yeah, so tell me a little bit about the Goldwater Rule and why this is important to us as psychiatrists.

So the idea for this podcast kind of came from, I put this together for my grand rounds at Creighton University as the chief resident. And we were talking about it and I said, I'm surprised there's not more out there kind of in the podcasting sphere about this. And I think that your listeners would really find that interesting right now. Now, when I initially put this together, I was pulling some survey data from, like, May of

23 that showed that the general public is worried about the quote, unquote, mental fitness of presidential candidates. Now, as you and I record this in July 24, we're in a lot different political environment. I think it's almost obvious to most people who are consuming, you know, daily media that people have real questions. about mental fitness of certain political candidates. And the Goldwater Rule gives guidance to psychiatrists about what we should or should not say when we are commenting on public figures and giving a professional psychiatric opinion about public figures. There's a long history to the Gold Bloss rule.

It's been around since the 1960s. And I think really now, just over the last couple of weeks, has taken on a lot of new relevance in terms of the types of opinions that physicians are being asked for in the media about public figures. And the Goldwater Rule applies specifically to psychiatrists and prohibits psychiatrists from commenting on, giving professional opinions on public figures

to the media. Yeah, and we're going to get into all the details on the evolution of the Goldwater Rule. We're going to talk about some people have possibly broken the Goldwater Rule. We're going to talk about what defamation is and what defamation lawsuits might entail. And we're going to talk about duty to warn. And, yeah, so I think it's important to mention that, you know, there are supposed

experts in this, but we are people who are just reading this and reading what people say from both sides and trying to. to summarize it for you and trying to get to the heart of what it means to be a psychiatrist as well. I think this is one of the most controversial issues in psychiatry. And the more I read about it, the more I cannot make my mind up about how I feel about it, because I think that reasonable people can disagree about the Goldwater Rule. And most people who are experts on this have been entrenched in this debate for a long period of time now. And so I'm hoping that the perspective that you and I can bring as people who have not been entrenched in this debate is sort of a 50,000 feet look where we give, we're not arguing for or against the Goldwater Rule, but we're just sort of giving a perspective to your listeners.

You might want to learn more about how to make these decisions for themselves. Yeah, one thing that occurred to me as I thought about this was like, okay, what is a rule? You know, what is, who came up with this rule and who disciplines this rule? and has it been disciplined? And yeah, so where do you want to begin? I think we should begin with kind of why the rule exists in the first place, where it came from, because the historical context is really rich for the Goldwater Rule. Do you think we should start there?

Yeah. Yeah, absolutely. So the Goldwater Rule is really the colloquial nickname given to Section 7.3 of the APAs, the principles of medical ethics with annotations, especially applicable to psychiatry. So in 1968, the APA formally adopted the AMA's Code of Ethics as central to psychiatric ethics and then gave their own annotations about how these might apply to psychiatrists. And that includes Section 7.3, which reads, in part, well, I'll read the full rule. On occasion, psychiatrists are asked for an opinion about an individual who is in the light of public attention

or who has disclosed information about himself or herself through public media. In such circumstances, a psychiatrist may share with the public his or her expertise about psychiatric issues in general. However, it is unethical for a psychiatrist to offer a professional opinion unless he or she has conducted an examination and been granted proper authorization or consent. Let me underscore the professional opinion. That seems broad. And their requirement for professional opinion is that you have examined. you know, conducted an examination, history and physical, and been granted proper authorization to make such a statement. But okay, tell me, has that changed?

So in the initial iteration of the Goldwater Rule, 1968, it did not read professional opinion. It read that a psychiatrist may not offer a diagnosis. Now, the APA issued updates to the Goldwater rule, the Code of Medical Ethics with annotations, especially. especially applicable to psychiatry in 2013, and the 2013 version uses the verbiage professional opinion, which the APA has clarified repeatedly includes not only a diagnosis, but also here, I'll get you the exact quote. Yeah, what is a professional opinion? That's the...

Which includes not only making a diagnosis, but also declaring that a person does not have a certain diagnosis or illness or rendering any opinion which, quote, relies on the rendering any opinion about the affect, behavior, speech, or other presentation of an individual that draws on the skills, training, expertise, or knowledge inherent in the practice of psychiatry. So the APA is really asking us to draw a line

between where we are making a comment as a human being, concerned citizen, moral agent, person, and where we're making a comment as a professional psychiatrist who is relying on their professional. training to make that professional opinion. Let's rewind a little bit and talk about the specific case that led to this, because there was, you know, Barry Goldwater, who was running for president in 1964, and Fact Magazine published and touted this person as someone who should not be president. So tell me about that case.

So, 1964 is Barry Goldwater versus Linda B. Johnson. Barry Goldwater was a U.S. Senator from Arizona. He was a former World War II pilot. He was a major general in the Air Force Reserves. And he wrote a bestselling book called The Conscience of a Conservative. In the run up to the 1964 election, a person named Ralph Ginsburg, who was sort of a provocateur, a journalist, someone continually pushing the boundaries of free speech. published a periodical called Fact Magazine where he surveyed board-certified psychiatrists about what they thought about Barry Goldwater. So Ginsburg and Fact Magazine mailed

questionnaires to over 1,200 board-certified psychiatrist and asked one question. Do you think that Barry Goldwater is psychologically fit to serve as president of the United States? Now, graciously, Ginsburg proceeded this by talking about Goldwater's public temper tantrums, occasional outburst of profanity and two alleged nervous breakdowns that were later denied by Goldwater and his family. Okay. So just to be clear, when he wrote the letter to psychiatrists and psychiatrists opened this letter, it gives them those details and then ask the psychiatrists is Barry Goldwater psychologically fit to serve as present? Pretty much the least scientific survey you could possibly imagine. I think, fair to say.

So potentially you could argue fact magazine was priming psychiatrists to give a certain type of answer. I think almost unquestionably that is the case, for sure. Okay. Keep going. The responses. So the big headline in fact magazine was 1,189 psychiatrists say Goldwater is psychologically unfit to be president. Interestingly, 657 said that he was fit. fit, and to me, this is the most interesting thing that I'll say today, 571 declined to weigh in. So they received about 2,200 responses, and the least number of psychiatrists said, you know, maybe I don't know enough about this person who I've never met, evaluated, have only seen,

maybe listen to recordings on. I mean, we're talking about the 1960s. They didn't have constant 24-7 news cycle. The fewest number of psychiatrists said, maybe I shouldn't weigh in on whether or not this person is psychologically fit to be president. So I think that that says a lot about humans and hubris. I think we have to get in the mindset of what it was like to view a presidential election back then versus what it is like now. Now we know so much more because there's a video camera that literally follows each of the candidates every day and social media and, you know, so many new angles. And this is part of the argument for the people who say, like, hey, this is times have changed. Okay.

So back then, very little information that the psychiatrist knew about this person compared to the depths of information that we may know now, right, about different candidates. Okay. Go ahead. But it didn't stop the psychiatrist from being very verbose about what they thought and what they had to say. So Fact Magazine published 41 pages of excerpted responses in what they said was the most intensive character analysis ever made of a living human being. And I got to give you some of these. I love it. Yeah.

Some of these are just. You have to, right? They're just, this is amazing. Okay, go for it. Quote, Barry Goldwater's mental instability stems from the fact that his father was a Jew while his mother was a Protestant. Quote, I believe Goldwater's. has the same pathological makeup as Hitler, Casgrove, Stalin,

and other known schizophrenic leaders. Schizophrenic leaders. Yeah. Other known schizophrenic leaders. From TV appearances, it is apparent that Goldwater hates and fears his wife. He is a mass murderer at heart

and a dangerous lunatic, and any psychiatrist who does not agree with the above is himself psychologically unfit to be a psychiatrist. This is just, this just shows you the, uh, you know, the clarity and the, the extremeness of, you know, this is kind of like what you would hear at a bar if you went with a bunch of psychiatrists to a bar.

You know, like, this is the type of like, like, everyone is, everyone who disagrees with me is absolutely psychologically deranged themselves, you know? Hopefully not until they'd been at that bar for several hours. Are they quite this outlandish? Called them an anal character, counterfeit figure of a masculine man, said he had a strong. under identification to his mother than to his father. And in case this is not obvious, this was widely viewed as pretty embarrassing for the field of psychiatry. Especially comments like an anal figure, an anal character. You know, like these, or these kind of, like, you know, comments like, his mental instability stems from the fact that his father was

a Jew while his mother was a Protestant. It's like, like, that really discredits. a lot of the work that we do. Okay. Yeah, I think you hit the nail on the head. And that's why at the time, APA was really pretty upset about it. And I should say APA is the American Psychiatric Association. They're the professional organization for psychiatrists in the United States. It's a voluntary membership organization. But they sort of organize us and the organized medicine branch of psychiatry. That a lot of psychiatrists have opted out of paying, you know, yearly fees to be a part of. of it is the biggest yearly psychiatry conference, probably by just a number of people that go.

But it's like not a board certification, right? There's a big difference between, like, you're board certified by different states. This is a nonprofit group. That, I might add, is sometimes politically oriented itself. Like, I remember going to the APA, and they had Bill Clinton speak at it, you know? So it's like it's not that the APA doesn't choose to have political figures come and talk about mental health issues or lobby.

They may lobby mental health issues. But go ahead. That's one of their primary functions, right? I mean, that's one of the reasons that psychiatrists and give them money is to advance the political agenda of psychiatry. Now, at its best, and I think usually that it is lobbying on behalf of patients to get us greater access to men. mental health services to make sure we have appropriate training, you know, et cetera. But they, you know, they are frequently filing lawsuits in the political arena and funding different political ventures. That's a big part of what they do is they represent psychiatry on the political level.

So APA immediately wrote a letter to fact magazine and basically said, you know, this survey is garbage. They said by attaching the stigma of extreme political partisanship to the psychiatric profession as a whole, fact has in effect administered a low blow to all who would advance the treatment and care of the mentally ill of America. So APA was pretty embarrassed. They wanted to distance themselves from fact magazine. They were very clear that this was not a scientific survey, that it had no validity whatsoever. And it later came out that APA had privately communicated this to the people conducting the survey before it ever launched, and that they had been preparing their response the whole time because they sort of knew that this would not go well.

Yeah, I think it's worth mentioning that President Johnson won the election in a landslide. Senator Goldwater then sued the editors of fact magazine for defamation and libel, and Goldwater won the lawsuit, and the jury agreed that there was specifically malice. Okay, so when we talk about defamation, the elements needed for defamation lawsuit. So he successfully argued all of these elements was that false statements were made. Statements that were, so they have to be untrue statements. They have to be essentially lies, right? False statements were made.

It's published, so you cannot be accused of defamation if you're making statements to friends. If you're making statements to the person himself, that's not defamation. but this is on a third party. So if I were to publish something on my podcast, defaming a character, a person, that would be a publication, right, type thing. So it has to be a publication, a third-party publication. There has to be identification. So if you identify them by name or by this is the only person doing this type of thing, right?

So if I were to say a black president, since we've only had one black president, everyone would know who I was talking about. So that would be identification. So the fourth one is harm. You actually have to do harm to the person. So Goldwater could say, I lost the election. I spent a lot of money on this election. You making me lose the election caused harm, right?

So if someone wrote a hit piece on a psychiatrist and it caused him to lose his license and it caused him to not be able to work, that could be harm. potentially, right? And then the fifth is fault. So for private individuals, there needs to be at least negligence in making the statement. If it's a public individual, there needs to be actual malice. And so it was found that there was actual malice in the preparation and the writing of this article. Okay. Anything else we want to comment on that? Just to reinforce, it's a little bit higher bar

for a public figure to launch a defamation suit, and that bar was cleared in this case, which is really pretty remarkable. Yeah, I mean, to prove malice is tough. To prove a statement is false, you know? Like, think about, like, so if you're only saying true statements about someone, like, this person said this on this state, that is not a false statement.

That is not defamation. but to prove malice is, uh, is, is tougher. So, so one of the reasons that the APA created the Goldwater rule, and they have explicitly said this, is to protect the profession from making these big mistakes, embarrassing ourselves, um, psychiatrists making themselves liable for civil lawsuits. And actually, the APA has commented as well that one of the reasons I did it was to protect public figures from this sort of professional, mudslinging, which is an interesting statement from the APA that they would have any role in protecting

public figures. But it has been said. I think it's important to put the Goldwater rule in context, though, because one way that the Goldwater rule is sometimes kind of pitched or read is the APA is prohibiting psychiatrists from becoming politically active. And it is putting limits on what psychiatrists can or should say in the political sphere when they're speaking with a professional opinion. But it's important to put it in context within the document. So that's section 7.3, 7.1 and 7.2, both explicitly encouraged psychiatrists to engage with public figures, with public health. It encourages them to share their expertise on various psychosocial issues that may affect mental health and illness. So the APA wants us to be concerned, engaged, politically

active citizens, they just draw a line that says when we are speaking as a professional, when we're using a professional opinion, we should not make professional opinions about public figures specifically without being granted consent or authorization and having a comprehensive diagnostic interview. So I think it's worth reiterating your point that 7.1, it says, quote, a physician shall recognize a responsibility to participate in activities contributing to the improvement of the community and the betterment of public health. And section 7-2 reads, psychiatrists may interpret and share with the public their expertise in various psychosocial issues, in the various psychosocial issues that may affect mental health

and illness, psychiatrists shall always be mindful of their separate roles as dedicated citizens and as experts in psychological medicine. And the APA is really firm on this point, that every psychiatrist has two separate rules, that of a concerned citizen, and that is a psychiatric professional. And I think that that's a really difficult line probably for most of us to draw. I know certainly for me personally to draw. I thought the way we could do this because this is such a controversial rule would be to talk about a few of the rationales that some of the rationale that the APA cite as their reasoning for the rule,

and then go over some of the most common critiques that people have of the rule so that we can kind of look at both sides of this argument and let your audience make up their mind for themselves. Awesome. Yeah, let's start with the consent or authorization. So this is, and a lot of this comes from an APA Ethics Committee opinion issued in 2017

because the Goldwater Rule came under specific fire in 2017 during the Trump administration. And so the APA said, okay, here's sort of why this rule exists and what we're using to defend it. So the consent or authorization rationale is the APA would say it's a fundamental principle of practicing medicine, practicing psychiatry, that an evaluation requires consent or authorization. Now, the relationship between the doctor and the patient is one of mutual consent and mutual understanding. The APA does note that there are some circumstances where it might be acceptable to render a professional

psychiatric opinion in the absence of consent or authorization from the patient. So, like, we can think about forensic examinations where a defendant is not willing to cooperate with a psychiatrist, but the court needs an opinion on something like competency to stand trial or a not guilty by reason of insanity evaluation, you know, the psychiatrist can offer an opinion without personally evaluating the defendant because he has consent or authorization from some authority in this case, the court. Likewise, another area, that kind of butts up against the Goldwater Rule is psychological profiling done by government agencies like the CIA, which is well documented by now. And, you know, the CIA is preparing

psychological profiles of world leaders without the consent or authorization of that world leader. But in this case, the authorization comes from the government. Other examples, collaborative care, right? A psychiatrist talks to a therapist or a primary care provider, offers an opinion on a patient. The psychiatrist has not seen that patient, but they have the consent or authorization so they're able to do that even without an in-person evaluation. So that would be the first, that you need consent or authorization in order to practice psychiatry. There are people like Dr. Gerald Post,

who famously wrote about Saddam Hussein, created a psychological profile on him. So there have been places in, you know, where psychiatrists have kind of like moved away from that. But do you want to get to that later as we kind of go into the duty to Warren? or? It's like a deep dive on that a little later for sure. Okay.

Let's mention it later. Okay. So number one would be consent or authorization. And I think that's, I think that's, you know, like, if I've thought about this, if someone came out and said something critical of me, it's like I, I still can't say anything back about their care, their case. They are protected by HIPAA, by. you know, all sorts of different,

and by just how I view the practice of medicine, confidentiality. So, yeah, we need authorization before we talk about someone. And there's a sacredness in that, I think, for a psychiatrist. It's like, for me, there needs to be a really good reason to break that.

You know, like if you're treating an adolescent and they're about to kill themselves, you're going to talk to the parents. You're going to be like, hey, we need to admit them. This is what's going on. If, but, by and large, most of this stuff patients tell us is completely confidential. And I once had a patient tell me, you know, I really love telling you stuff because I know I could sue you if you told anyone else.

And it was kind of in jest that the person said it, but it's true. Yeah. I'll say that to patients sometimes. If I do, you can sue me. Go ahead. Yeah. Okay. So consent or authorization. Anything else on that? No, I think that we'll go over the critiques here at a second. Okay. So then number two is standard of care. So the APA says that the gold standard for making a psychiatric diagnosis, and I think now they would say the gold standard for having a professional psychiatric opinion is a comprehensive psychiatric interview. For years, they've said an in-person psychiatric interview.

I'm sure maybe that's changed a little bit since 2020. It seems like a lot is virtual. But that is the goal standard for having a professional opinion. the opinion would say it's a departure from the methods of the profession to render an opinion without an examination or evaluation. So in a case where you are rendering opinion based solely on, you know, watching videos, reviewing documents, talking to collateral sources, your opinion may still be valuable, but it's not consistent with the gold standard of psychiatry. And what the APA says is that when we as psychiatrists offer a professional. opinion in the media in a way that is not commensurate with the standard of care. We're compromising both the integrity of ourselves as a psychiatrist and of the profession itself. We're sort of implying, you know, I can do this job without even actually meeting with someone. I don't need to interview them myself. I have enough information right here to go ahead. And personally, I do see where that is

very problematic as a psychiatrist, as a patient. I think that there's something sacred about sitting down with someone asking the questions yourselves, getting to know them, getting to react. to what they say, changing what you asked based on that. And I don't think you get the same quality of an evaluation without that very fundamental piece of interviewing a person yourself. Yeah, there's something about being face to face with someone, especially public figures who often have a facade of sorts. They often present themselves in a way which is different than how they present themselves in that confidential space where there's a trusted space. So there's that. Now people might argue, but nowadays we have so many angles to view someone in. They're constantly being videotaped. There's many collateral stories. Like, is it, do you have a more in-depth picture of someone just by viewing what's publicly available about that person? So they might argue that. But there is something about being in that space with someone where,

it gives you information that I do not get just by viewing them publicly, personally. That's the way I view it. The APA often says, like, we don't practice armchair psychiatry. And I think that's a really apt way of describe me. We don't just sit back and lean back and watch some videos and make a professional opinion. We have to do our full job that we were trained to do in order to have an opinion that is, I think, really worth saying out loud. I think as well, there's, from the other side, there's an argument of, like, okay,

even if someone does come into the room, they can pretend to be a certain way when they're really not, right? And so this is where, like, for myself, the MMPI could be very valuable because there's very tricky questions in the MMPI about, like, narcissism, where they're not asking the questions directly.

They're looking at people who have narcissistic personality and would answer questions, questions that don't give a red flag to the person themselves that this is a question asking about narcissism, if that makes sense. Or there's also neuropsychological tests, which are very accurate engaging the functionality of different parts of the brain. And I might add, though, that those don't necessarily give the diagnosis. A psychological test, an MMPI or a neuropsychological test doesn't give the m the diagnosis the clinician gives the diagnosis and i have cases of this that i see where a patient comes in with a diagnosis of ADHD i look at the neuropsychological test and there is no issues

with attention and maybe the neuropsychological test even said this person has ADHD at the end of it but i look at the actual data and i as a clinician say like well no this person's scoring in the 95th percentile for their ability to focus on this test. They do not have ADHD. Their frontal low function, their working memory is in the 80th percentile. They do not have ADHD. So I think there's, there is also, I would say, a sacredness to the ability to give a diagnosis as a clinician. And that comes from pulling together lots of forms of information, but it is through the history and the physical and the relationship that that is done. Yeah, of course, patients minimize things.

Sometimes patients are directly dishonest for reasons of secondary gain. And do psychiatrists get things wrong all the time? Of course. You know, if you're a psychiatrist and you think that you don't get things wrong, having been attending all of two weeks, I will scold you. Then you will diagnose them directly. No, I'm joking. Right, exactly.

You yourself are mentally unfit to be a psychiatrist. You have anisinomia. You have low insight into your... Yeah. I worry the most about people who are extremely sure of themselves in all circumstances. It's like, those are the people that I'm like, ooh, come on, you've been practicing one year. Let's tone it down here a little bit. Yeah. Because, you know, like having practiced a number of years, at first you'll see something, you'll think it's one way, and then a couple years in, you'll figure out something else was going on, you know? I've had a couple of those cases just in the last couple months where it's like, oh, this person is true bipolar.

You know, they are not just, you know, borderline person high disorder with like some affect dysregulation. You know, like this person truly went, it's starting to go hypomanic. They're starting to go manic. So it's only sometimes in the longevity of the relationship that we even know as well. So it's for those listening into this and who are who are, thinking like, oh, so what a psychiatrist needs is just an hour with a patient to make a diagnosis. What I'm saying is like, no, like sometimes it takes a relationship over years to form a clear picture of what's really going on. And we always have to be willing to admit that

maybe we misunderstood something. Maybe we have more data now that changes our formulation. The worst thing we can do is let either sloft or our ego get in the way of doing what's right for the patient. Yeah. And I think ego So, yeah, the ego is specifically an important thing to note here, as well as that sort of like not knowing what you don't know, you know, that's sort of like insight into the not knowing. You know, like, and I would say when thinking about public figures, you know, if you only watch one type of media, you know, and you don't look at the primary writings and you don't watch the hour-long episodes of someone speaking.

Like, you may be getting filtered. The bias of people who have bias themselves, right? And so that creates more complexity. And that's not a new phenomenon, right? Goldwater's biographers would say, in his private writings to his staff and his family, he was measured, he would weigh, cause and benefits of decisions.

He was quite rational, quite careful, but his public persona was, I think, intentionally bombastic, outlandish at times, somewhat chaotic, strong. And his biographers have noted a serious discrepancy between what he said and what he wrote in private and what he fostered as his public persona. So I think that's an important point there, too. Right. And also, I might add, there's some politicians where, like, they talk differently depending on who they're talking to. So if they're talking to, you know, a bunch of postgraduate people, their language changes in complexity, whereas if they're talking to a rally of people, you know, just off the, you know, just random people off the street type of thing. Maybe they tone their language to a very simplistic set. And then there's some politicians who talk the same in every context, you know. And, and, yeah, okay, let's keep going.

Okay, so rationale number three that we're going to mention is stigma. So, EPA says offering opinions without consent or authorization or an evaluation stigmatizes people with mental illness. They say patients may experience increased stigma about their own diagnoses in mental health problems. And for me, this justification also really hits home. I think what we're doing when we're violated on the Goldwater Rule, when we're offering a professional opinion about people in the media, pretty much all, I think always, in every case that I've seen, is we're pointing a figure at that public figure.

And we're saying, because of a psychiatric reason, that person is less than. That person is not able to do this job because of X psychiatric reason. And we're sort of implying that if you have a psychiatric problem, if you're being seen by a psychiatrist, you're in some way less than, or you can't do something, or it's bad, or it's wrong. And to me, that's cogent. You know, we are using the powers of the culturally sanctioned psychiatric healing profession, not to heal one individual to help them lead them more fulfilling life, but to point fingers and put people down. And I don't personally think that's the way that psychiatry should be used.

Yeah, I think that's a good point. I think that it's very rare that someone would give a diagnosis publicly about some public figure to build up that person or to decrease stigma. I think people have talked about themselves in a way and shared their mental health issues to decrease stigma or to gender sympathy. But I think you can imagine very rare cases where a psychiatrist would use it to decrease stigma.

I think maybe there's a difference in talking about historical. figures. I think Nasir Ghahimi did a great job in a first rate madness talking about historical figures and mental illness and how actually maybe some of the brilliance of different historical figures

was due to their mental health issues. Do you read that book? No, but it's a common thing and it comes up a lot with the Goldwater rule, right? Eric Erickson's profile of Maham Gandhi is a great example, right? Won a National Book Award. It was a bestseller. And the APA has said, that's totally

okay, you know, to profile historical figures as a way to educate the public about these things as a way to look at the past and ask questions about it. We had no problem with that. And so people have said, well, then why is that okay? If I haven't interviewed that person, if I don't have the consent of that public figure, why is it okay for me to write a historical profile on them? But when I have access to the same information and this person is alive and is going to be elected to have access to the nuclear codes. In this case, I have to remain silent. That's been seen as somewhat of a place with the Goldwater Rule fails.

Okay. So, point three, be sensitive to how it could change stigma, both towards mental health professionals and towards certain diagnostic categories. Okay, what are some of the common critiques of the Goldwater Rule? So I think the first and most obvious critique is freedom of speech concern. So you can say the Goldwater Rule impendos on an individual's fear-no speech as it pertains to civic duty, professional responsibility. and I think this point has been pretty successfully argued. Some people call the Goldwater rule American psychiatrary's gag rule, right?

And I think there's also a point here that if we're going to be having a national conversation, which we are right now, about someone's mental fitness for the presidency, we had the same conversation in 2017, I'll add, don't we want the people with the professional training at the table giving us their opinions? I mean, aren't psychiatrists the best situated? some of the people best situated to comment on these things. Again, in the 24-hour news cycle, I think this is pretty much been the 24-hour news cycle the last two weeks. And the voice that is missing is psychiatrists because our professional organization, the APA, has asked us not to do that.

So I think that's cogent, right? This is a freedom of speech concern. The conversation is happening. Don't want professionals weighing in on it. Is it right for a professional organization to expect that our professional responsibility always trumps our responsibility as an individual moral agent acting based on our conscience.

Difficult question, cogent critique. And this is where I think people who do violate the Gould Water Rule, I don't think it's done in bad faith. You know, very rarely. There are maybe some cases where people violate the Goldwater Rule

to sort of embellish their own self-image, to climb the professional ladder, to write a best-selling book. But in most of the cases that I've been able to look at, I think it's people who are following their conscience who are looking at this moral dilemma and saying, I understand the APA wants me to be silent, but I feel like I have a duty to speak out and I have freedom of speech, and so they do.

Yeah, I think that there is something about the Goldwater Rule when it says opinions, because we know that has changed, right? So at first it was diagnostic categories. You can't diagnose someone publicly, but to not be able to give an opinion, like a psychiatric opinion. So I can't describe if I see confabulation. I can't describe if I see these different diagnostic, not diagnostic categories, but ways that we would describe things

in psychiatry, like I can't even talk about like, oh, that is a grandiose statement or that is a defense against, you know, that's, like, how, we can't use language? Is that kind of like where the Goldwater rule goes? Like, doesn't that just restrict our freedom and ability to have a conversation publicly.

So I can see that perspective. I really can. And if any speech is protected, shouldn't it be political speech? And if we as people who are educated who have experience seeing thousands, if not tens of thousands of clients over the course of our life,

don't we have a set of expertise that is relevant for the public to hear and understand? And I would say, like, I imagine you would have psychiatrists on both sides of an argument arguing in a public sphere potentially too. So it wouldn't be like there's 100% consensus. Like even with the Goldwater, we saw that being the case. But anyways, okay, this is a good point. Free speech. Is it, are we being overly restricted in what we can say? I agree with the initial way that Goldwater rule was written. We shouldn't diagnose someone in a way that we diagnose patients.

but should we not have any ability to speak in a public way about words and observations that are true and not jump into conclusion? And I think psychiatry has moved from the kind of internal, like the DSM used to be very like these internal things going on inside. Now it's more descriptive diagnostic categories. So if we're seeing descriptive things that are identified as like, this is a statement that is this, or this is the way that this is said is this or that?

You know, can we, can we not say those things? Like, is that, is that the extent that the Goldwater Rule extends now? What do you think? I think the line is pretty blurry at times, for sure. Okay. Let's go on to number two, standard of care. So the standard of care critique kind of looks at the APA's justification that you absolutely need, or the gold standard for a professional opinion is this comprehensive psychiatric evaluation.

And the standard of care critique says, is it? I mean, we do it all the time in psychiatry without having a comprehensive evaluation. We do it in forensic cases. We do it in collaborative care. We do it in historical profiling. The APA officially sanctions profiling of world leaders by government agencies. In none of those cases do we have a comprehensive interview. in all of those cases, society has largely agreed that the opinion of the psychiatrist is worth

something. And so, you know, is it really the standard of care that to have an opinion worth anything, we need to have a comprehensive in person evaluation? Now, the APA was saying, okay, fair, but in those cases, forensic cases, collaborative care, et cetera, the opinion must clearly identify the methods used and the limitations of those methods. So the opinion must say, this is my opinion however i have done so without a comprehensive evaluation which and then i think what's implied is i have done so but my opinion is not commensurate with the gold standard for making a psychiatric diagnosis having a professional opinion etc right but that that seems to me like that kind of does violate the gold water rule because you're giving an opinion that's a

from a psychological perspective so that doesn't it seems to be violating the Goldwater rule to give, like, for example, the Depp versus Heard trial, you know, and a psychologist using psychological tests that were done to come to conclusions about, you know, pathology, right? Right. So the psychiatrist in the Depp trial never even personally evaluated Johnny Depp, but his opinion was worth enough to get in front of all those people watching it and give his opinion, the court allowed it.

His opinion was worth something. So in that case, the opinion's worth something, but in the case of a psychiatrist wanting to follow their opinion and speak to the media about someone who they've not personally evaluated, the APA would say, well, whoa, whoa, that's not the standard of care. Maybe a bit of a double standard there that I could appreciate. Right, because the media was following that case so closely.

So essentially, you know, okay, you're giving it in a trial, but there is the media watching in. Like, so, okay, if there was a trial, of sorts in Congress, you know, that was heavily televised, could we as psychiatrists give our opinion in that case? That's an interesting question. You know, I think if you had consent or authorization, the APA would say, okay, go ahead. So what the APA has clearly said is, look, if presidential candidates want to subject themselves

to a psychiatric assessment and have that made public with their consent and authorization after a comprehensive evaluation, that is their prerogative. If we have no problem with that, that might be a way that psychiatry can help the country to make a difficult choice. In the case of a congressional hearing where, let's say the person being impeached did not give their consent to be evaluated, but Congress did give authorization to a psychiatrist to use collateral sources to make a professional opinion. That's a really interesting question, David. And I think probably people would fall on both sides of it. Yeah, I think the trick is, can we come to conclusions where we would be okay with it, irrespective of if it was our side of the political spectrum that we may align with?

You know, like, can we make decisions about this irrespective of how we may think it benefits or hurts our person? You know? So you may be on one side of the thing and you may say like, oh, I think we should do an MMPI on both candidates. And you may be on the other side and say, well, I think we should do a full neuropsychological exam. I would say we should probably do a full neuropsychological exam, make that public, do a full history and physical, make that public. I mean, to some degree, right, a duty to fitness, fitness for duty might need to be done.

But I would also argue the way that people campaign is kind of a public. proclamation of that, you know, and the public decides. The question is, does the public have the ability to understand things and the depth of psychological understanding that we have? Maybe that, I don't know. Well, and we all have to make up for, you know, does it just become sort of professional jargonistic mudslinging at that point, right? I mean, if the general public reads a comprehensive neurological evaluation and there is some deficit, Does it matter, you know, if you have a little bit of codwheeling and you want to be the president? I don't know.

Does it matter if you have, you can't, you know, if your MOCA score, let's say, I'll use the slum because I'm at San Luis University. Let's say your slum score is a 28 out of 30, you know. Do we care that you, you know, missed one of the questions on the reading comprehensive? I don't know that the public knows what to do with that information, but I agree that the public should have as much information as possible. for making such an important decision. Okay, let's go on to number three, duty to warn. So duty to warn, we all, everybody listening to this podcast, you know, if you're working in the field of psychiatry, you should know about duty of warn, duty to warn from the

Terraceoff case where it was found that psychiatrists have either a duty to warn or a duty to protect depending on the state when a psychiatrist has the knowledge that there is a person under imminent threat of danger. So if your patient says, I'm going to go kill Joe Schmo in two hours, you have a duty to warn or a duty to protect, depending on the state, to that person who Joe Schmo is planning on going at harming. In this case, sub-psychiatrists cite the duty to warn to say, this is a reason that I need to violate the Goldwater Rule.

This was Gerald Post, who we've mentioned, is sort of the most world-renowned government profiler. and before Congress, he cited this as his justification for engaging in the work that he was doing. He said, it is my sacred duty that when I have knowledge that public safety is under threat, I need to use that knowledge, share it with the public in order to prevent that harm from occurring to a society. So he's taking the Teresoff ruling, which is intended to apply specifically to the doctor-patient relationship. and he's applying it to sort of public safety at large and saying, I have a duty to warn. The APA says this is a misapplication of the TARISOP doctrine.

That's not what it means, but the duty to warn was also cited in 2017 by a group that was taking a look at President Donald Trump's mental fitness and running a public campaign, meeting with Congress members to ask serious questions about his mental fitness. They were saying, we know we're violating the Gouldwater Rule, but we're following our own moral compass, we're following our conscience. think that due to the danger to the public, we have a duty to warn the public about a leader who is dangerous? This is the argument that Dr. Bandy X. Lee made when talking about Donald Trump, which, you know, she wrote a book with some colleagues. She, I listened to a couple interviews of her. She would publicly say, like, she agreed with the Goldwater Rule as it was originally written that we shouldn't give a diagnosis of someone we haven't treated ourselves. She makes the argument that she felt like she had a strong duty to warn. When Yale, University failed to renew her

contract, she sued Yale for breach of contract. And so Yale was acting upon the Goldwater rule, which is, I think, a risk of anyone who is in a... university, you know, like, how is the university going to see you having your free speech? You know, which is, I mean, I've heard a lot of different psychiatrists who tell me they wouldn't say things because of that more. Yeah, anything on that case that was interesting to you and specifically? I think that case is certainly the most recent example and the most cogent example of where there can be real consequences for violating the goldwater rule. Personally, I believe that Bandia Lee is acting as a moral agent. It's following her conscience is doing what she truly believes is right by sharing her professional opinion with

the country. I also believe that she was directly violating the Goldwater Rule in her activities. And she was warned in January of 2020 by Dr. John Crystal, who is the Yale Psychiatry Chair, that if she were to continue violating the Goldwater Rule, he would be compelled to terminate her teaching role. And she did continue. And then five months later, she was dismissed for quote, breaching psychiatric ethics, and she appealed multiple times to Yale to no avail. And so, you know, she's someone who lost her appointment at Yale for violating the Goldwater Rule. There aren't many other public cases of people really experiencing actual real world consequences for violating the Goldwater Rule. And that's kind of our final major critique of the Goldwater Rule. Is it really relevant, right? You don't lose your license for violating on the Goldwater Rule. You don't go to jail. Don't even really get sued. It's just the eighth. PA is saying, please don't do this. And if you do do this, we can remove you as a member. But as you kind of led with, there's a lot of psychiatrists that don't maybe agree with what the APA is doing or don't think that membership in the APA is worth their money. And so they don't belong to the APA anyway,

and they're still fully licensed psychiatrists doing good work in our community. So I think that it's important to look at this case to say, if we choose to violate the Goldwater Rule in accord with our own conscience, there could be consequences, especially if we're working for, like, a university that is under public scrutiny, maybe less so if you're in private practice. Yeah. I think, I think, okay, so the Goldwater Rule may lead to dismissal, or, you know, the university may use that as like, hey, this is violating our ethical standards. I could see, although I could not find any board actions based on the Goldwater Rule, I could see that as potentially a risk. You know, there's defamation lawsuits that come against you. That is a risk. So remember if you say things that are false and you know to be false and there's malice within it, you know, that could potentially cause you to lose a defamation lawsuit. You'll probably not lose a defamation lawsuit if you are speaking facts that are known facts, or that could be proven to be facts. You'd probably be less

likely to lose a defamation lawsuit. Yeah, so there's the Goldwater Rule, there's defamation, there's, you know, if you're working at a university, they may not like that you're representing them, you know, like every time she would go talk, it was like, this is a Yale professor. or you might not like the heat, right? You may be willing to be under the heat, but the university may not like the heat of the, you know, like she said she went into hiding for a month after she came out. She said she knew she would potentially have to do that. She said in one podcast I listened to that she had to hide her face in ways when she went out in public because she was publicly recognizable, which is a real stress. I think about that

and what that would be like, and that would be a real stress. It's like you have to, weigh, you know, the psychological weight of speaking out if you were to speak out. So, yeah, so I think, like, okay, in summary, there's the Goldwater rule. There's defamation. There's, you know, you could get sued for anything. There's the psychological burden of saying something. But then there's the weight of like, okay, do you say something if you really felt true concern? And, I think in the case of Dr. Bandy Lee, from what I heard, she felt like nuclear apocalypse was imminent. And that was her fear of duty to warn. That was behind it.

So for her, I think all of those risks were weighed. And I think that's the weighing that we need to do. And probably, like, you know, you should do with your colleagues. I think if you felt like you were going to do something, like jump out there with a very sort of strong statement. And the APA really doesn't give its members that leeway. You know, the Goldwater Rule is a fixed rule, and you can be in violation of it.

What the APA doesn't say is, you know, we understand this is ethically complicated. Please exercise extreme caution before making, before offering professional opinions about public fears, they don't say that. They say, don't do it. You know, it's not, we know this might be difficult, be careful. The UK would also say, you know, it's not your job to prevent nuclear apocalypse. Your job as a psychiatrist with your professional opinions is to heal individually suffering patients. And maybe by helping individuals live more meaningful lives, we can build a better society. But it's not your job to prevent nuclear

apocalypse. There are, there are government agencies, there are elected officers whose job it is to do that sort of thing. It's not your job as a psychiatrist, so don't violate the Goldwater rule. Certainly, I'm in agreement with you, Dr. Peter, that it's a lot more complicated than that, if you really feel like the world is going to burn. Maybe your own duty to your conscience is greater than your duty to your professional membership organization to which you pay dues, but it's a hard, fast rule. The APA doesn't really give a whole lot of leeway on it, and that's definitely a critique of it. Yeah, I think as we kind of look at our own psychology and our own desire at times to speak out or say something, you know, we also have to think about what we're

consuming and the emotional tone of the things that we're consuming. You know, all day long, we listen to people, we empathize. And so if we're listening, it was one point that I remember, I was like, I just have to stop listening to watching news. Like, I'm absorbing the affect and the emotion of these people. And, you know, that's what I get paid to do for a living. I feel other people's emotion. And so I think that we have to be careful to not overly absorb the fear and the, the emotionality of people that were watching.

You know, there's not much difference between like a screen. and a person right in front of you in terms of you're, like, you're gonna absorb their emotion to some degree. So I think that that's a, that's one thing to consider as we sort of try to navigate this ourselves as well. It's like, okay, how are we being influenced? And then do we use our intellect and our professional platforms to potentially say something

that could change the course of our life? You know, like, it's not my goal to be, be thrust into the public sphere in that way. I hope to just teach psychiatric knowledge to mental health professionals for the next decade or two, you know, and so that we can treat more patients and treat them better, you know? And so it's like, how much would I be derailed

if I came out with a public statement one way or the other about one or every applicant? You know, it's like, yeah, you'd probably be, you know, like would my values and my goals be derailed for what are my bigger values and goals for my life? Yeah, they would be, probably. I also think about the patients I treat because I have patients on both spectrums of the aisle and they have no clue what I believe. And it's nice to treat people without having that influence my treatment

because it doesn't matter what are differences in political views or, you know, religious, views are, I'm going to try to help this person get better. So I think about that as well. And to be honest, that's a big reason that I myself will always follow the Goldwater Rule is the therapeutic alliance is so important for healing. And that's what I want to do. I want to help people heal. And when I go out there and give my opinion to the news, a good portion of the population, which is probably a good portion of my patients, is going to think differently about me. and my job is too important to me. I think it's kind of like you mentioned earlier.

I think it's a sacred relationship between a doctor and a patient. And personally, I don't want to do anything that would jeopardize that relationship. And so I personally do choose to follow the Goldwater Rule. I have a couple of thoughts, though, about regardless of how you feel, one way that I'm going to suggest that we think about this, one way that I think about this.

So the Goldwater Rule only applies to public media, public figures, giving public opinions. I choose to apply it a little bit more intimately when I'm with family, with friends, et cetera, and I'm thinking about offering, you know, let's say I'm watching Love is Blind at home on the couch, right? I would not be violating the Goldwater Rule

to offer an opinion about what I thought about the behavior of a participant of Love is Blind. But depending on where I am, I might choose not to do it because I know that I did not personally evaluate that person. I did not have their consent or authorization. So I think that by looking at the lot, of the Goldwater Rule, it's helped me to understand how to balance being a psychiatric

professional and just kind of being a regular person out in the world. Okay. I would take that a step further, and I would go to reflective function. So those of you who listen to my recent episode on Reflective Function, it's like it's a way of understanding the complexity of how we describe early attachments in our life, how we describe them. And so if you were to say about an early attachment figure of this person, was a narcissist, and that's why they did these things towards me. It's actually a lower reflective function because we're using a term which may or may not have meaning.

And so it would be much more meaningful to go into a layered, nuanced description of something than just to give a blanket, monolithic, like diagnostic category towards someone in our early attachment figure. So to get a high reflective function score, you have to have a degree of nuance in how you describe something. And both your internal self at that time and they're in, you know, the parent figure.

So I would say, you know, if I was around with a group of family or friends or even with a patient, and the patient's like, oh, you know, this person's such a narcissist. I am leaning away from ever using that type of language. because of how it's lost, it's meaning, and it's sort of castigate someone into a category that is low reflective function. So that's been kind of a challenge is to not diagnose someone that I've never even met,

which patients like to diagnose their ex-spouses as that quite often. We have a lot of ways of coping, don't we? No, I agree. I think you hit that very well. I think when we reduce someone to a one-dimensional label, it's not the way that we should conceptualize human beings in general. Yeah, and I think that goes to, yeah, the complexity of the human experience. And, you know, not that there are people who are more dangerous or less dangerous.

There absolutely needs to be that evaluation. But it's a complex evaluation. It's not just like one diagnostic word will let me know much of, about that. So, yeah, I would say that's one way I think about it. But I come back to what we do in psychiatry is sacred. And the reason why I'm not on here spouting my political opinions and having people on here.

I've had to block a couple of people who wanted to come on here and talk about their strong opinions about such and such political figure. And I say no to that. And there's people who would want me to, you know, weigh in on different wars going on and and different political things like that. I don't bring that here either. It's because this is a place to equip the next generation of mental health professionals. And I may not be an expert or even know how to assess who is the expert in some of those fields of history and war current world affairs, whereas I can assess who's an expert in

psychiatry and have that person on here and talk about those things. And so that's where I feel my role is as a psychiatrist and as a podcast host. And it sounds like you are kind of similar in that line of thinking. Best way that I see it, and I don't think that psychiatrists are unique as a profession to have limits on what we can say in public as a duty to our profession. You know, I think about judges, for example. If you saw a judge going in public and talking about politics and talking about what they think about things, at least appointed judges, maybe judges running for election or different,

you would lack trust in the judiciary, depending on where you fell on the political spectrum. You know, we are not the only profession that is expected to temper ourselves in a public sphere in order to protect the integrity of our profession that really does not make us unique. And it's something that I have a lot of respect for and something that I choose to abide by.

Yeah. Well, this is, This has been a great discussion. Dr. Mark Mullen, congratulations on your new post doing C&L at St. Louis University School of Medicine. I know you are acting in this podcast is not a representative of them in any way, as I am not acting as a representative of any university. But congratulations on that. And yeah, I look forward to more things in the future from you.

Thank you. And it's been really fun kind of getting to know you personally over the course. the last year or so. And it's been, I was a listener first for many years and to all the listeners, you know, Dr. Peter really is as magnanimous, generous as he sounds on the podcast. You've been a wonderful mentor for me and I'm just so appreciative of you. Well, I, I'm happy to receive your gratitude and gratitude is the oil of society, as I say. And we will have this article on our website, Psychiatrypodcast.com. You can get CME for this episode if you go to Psychiatrypodcast.com.

And yeah, thanks for coming on. Thank you.