What a Psychiatrist Won’t Tell You About the Candidates

Why the Goldwater Rule Gags Psychiatrists

News clipping about Goldwater libel suit (top left), Goldwater for President poster (bottom left) and APA President-Elect Maria A. Oquendo, M.D. (right).  Photo credit: Google News Archive, Goldwater for President 1964 / Wikimedia and American Psychiatric Association
Reading Time: 10 minutes

In 1964 over 1,200 psychiatrists passed judgment on Barry Goldwater’s mental health and fitness for the presidency. Goldwater sued for libel and won.

In 1973 the American Psychiatric Association (APA) adopted the Goldwater Rule, which prohibits its members from offering opinions on the mental health of anyone they have not personally evaluated.

In this week’s podcast, WhoWhatWhy’s Jeff Schechtman talks to the president of the APA, Dr. Maria Oquendo, about this rule and why so much attention is being focused on it right now.

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Jeff Schechtman: Welcome to the program. I’m Jeff Schechtman.

Usually when we conflate talk of politics with talk about mental health, it’s usually about public policy. It’s about federal or state dollars for mental health programs, about mental health coverage and the Affordable Care Act, or some other related issue. It’s rare that talk turns to politics, politicians and their mental health. Nonetheless it does happen. It’s happened during some bruising battles in early American history and then again in 1964, and now in 2016. Those two campaigns are connected by what the American Psychiatric Association calls: The Goldwater Rule. Joining me to talk about what this is and what it means for popular discussion of the mental wellbeing of candidates is my guest Dr. Maria Oquendo. She’s the president of the American Psychiatric Association. She’s soon to be the new chair of the Department of Psychiatry in the Pearlman School of Medicine at the University of Pennsylvania, she’s currently on the faculty of Columbia University where she’s vice chair for education and director of residency training for the New York State Psychiatric Institute. She’s an international leader in the treatment to neurobiology of mood disorders with a special focus on suicide and global mental health. It is my honor to welcome Dr. Maria Oquendo to Radio Whowhatwhy. Dr. Oquendo, thanks so much for joining us.

Dr. Oquendo: Thank you so much, it’s a pleasure.

Jeff Schechtman: First of all, tell us what the Goldwater Rule is and how it evolved within the ranks of the American Psychiatric Association.

Dr. Oquendo: So the Goldwater Rule essentially provides guidance to psychiatrists about ethical approaches to dealing with information that’s available publicly on people who are in the news, if you will. And so the idea is that for an individual psychiatrist to make a comment about a person’s mental health, they must have examined that person themselves, personally, and that making diagnoses without the benefit of an examination is not really ethical. One of the things this stems from is, as you mentioned, in 1964 when Barry Goldwater was running for president, there was a survey conducted asking psychiatrists whether they thought Mr. Goldwater was fit to be president. And many psychiatrists stated that they thought that he was not and on the heels of that, Mr. Goldwater sued for libel and won. Although it was started by this very sort of sentinel event, with a lawsuit that was very visible and a lot of discourse, really if you take a few steps back and think about why it makes sense to have a rule like this, it becomes apparent very quickly, and maybe I could just give you a couple of examples. For example, although abnormal behavior may be due to a psychiatric condition, often times it’s due to other things. One example is, for example if a person has a very high blood sugar, they might develop very abnormal behavior and that behavior will go back to normal if the sugar is normalized. If you just observe the behavior, you would have no way of knowing that this was actually secondary to diabetes, for example, and you could actually make a very life threatening mistake by calling something a psychiatric condition when in fact you have a medical emergency on your hands. So that’s just one example of the kinds of problems that can come up if you try to diagnose simply based on behavior without the benefit of an examination, not only of the person’s mental status but also of their physical condition.

Jeff Schechtman: It seems that the key word in this is the word “diagnosis”. Is there a difference of kind or substance between a psychiatrist saying that so and so exhibits behavior that might be outside some kind of prescribed norm as opposed to making an actual diagnosis?

Dr. Oquendo: Psychiatrists like everyone else can make observations about behavior, but I think that it crosses the line when you start saying that an individual who you have not examined has features of a diagnosis or has a diagnosis. And one of the things that I think is very interesting about this polemic is that there’s been this idea that psychiatrists have an obligation to speak up to protect the public, but in fact, really, the behavior is evident for everyone to see. Especially in a situation for example, like an electoral situation like we had in 1964 and now, the citizens can observe the behavior and make their decisions based on the behavior that’s being manifest. In fact, what the underlying cause of it is isn’t all that relevant to the decision that they have to take.

Jeff Schechtman: The very fact that this issue has come up and that you felt the need to write something about it in the blog of the American Psychiatric Association, what does that tell us about what’s going on right now that there’s a need to revisit this Goldwater Rule?

Dr. Oquendo: Well, I think that we’ve seen that there are many conversations going on including amongst clinicians about diagnoses for the candidates and when you start seeing that kind of conversation bubbling up, you want to make sure that certainly the individuals who are members of our association, psychiatrists and ethics bind us to a certain type of behavior even if it seems to others that we should be acting in a different way.

Jeff Schechtman: Talk a little bit about ethically, what’s required beyond the Goldwater Rule itself as it relates to the Association, talk about it from the individual ethics of a particular doctor.

Dr. Oquendo: So I’m glad you brought this up because I think that if you think about this a little more broadly, I like to think about psychiatry as a member of the house of medicine as we like to refer to it, right, so no different from internists, no different from surgeons who are unlikely to make a diagnosis without examining a patient. And in a way we’re in exactly the same kind of situation, not only because we could be wrong, and egregiously wrong, but the other issue that I think is implied is that perhaps if somebody has a psychiatric condition, it means by definition that they’re not fit to run or not fit to serve. And I would argue that that’s actually not correct because we do know that there are many people who have treatment for their psychiatric condition who have very important and responsible positions and do an excellent job. And so I think there’s also a subtle stigma that comes through in trying to view behavioral or psychiatric conditions under a different light than the way you would view a neurological condition or the way you would view a medical condition or a surgical condition.

Jeff Schechtman: Isn’t that stigma at the heart of this discussion really, because I think that if an internist or a candidate or a public figure or a CEO of a company is acting in a certain way, bent over or having to drink water a lot or whatever it might be, they would feel less restricted to offer an opinion as to what might be wrong or what the problem might be for that particular person, but because of this stigma that’s often associated with mental health and mental illness, it becomes a larger potential problem. Talk about that.

Dr. Oquendo: That’s a very interesting point. I actually am not aware of situations where physicians have made comments about somebody’s physical condition, but it may be just that I’m not aware. But I think it would be very unusual for that to happen.

Jeff Schechtman: We’ve had situations where… I mean we’ll use politicians for example, where they’re talking too much, they get hoarse or they’re coughing. People talked about it even with Reagan, after he was shot and how he was recovering and Eisenhower after he had a heart attack and doctors were frequently willing to chime in with respect to “well, he seems better, he seems like he’s fully recovered, he’s out playing golf,” he’s doing this, doing that. So there have been historical precedents where doctors have been willing to comment on the physical health of an elected official or a candidate. There seems to be a different set of rules or a different stigma, as I say, with respect to mental health.

Dr. Oquendo: Well, there’s no question that there is more stigma associated with mental health. I would argue that it would be most prudent for physicians not to make comments like that. In a particular sense, it’s very difficult to judge somebody’s health condition without the benefit of a thorough examination.

Jeff Schechtman: Back when this incident happened with respect to Goldwater, one of the things that I found shocking, I had no idea the number was so high, that there were over 1200 psychiatrists who participated in this.

Dr. Oquendo: Well, there actually are in our organization, we have 36,000 members and we think that probably the bulk of psychiatrists do belong to the organization, so there are a lot of psychiatrists out there. I think that the fact that individuals responded to the survey is of interest, if nothing else, in terms of the level of engagement with the survey because as you may know, response rates to surveys tend to be very, very low.

Jeff Schechtman: Talk a little bit about why it took so long, from 1964 until the Goldwater Rule was put in place in ’73.

Dr. Oquendo: That’s a very interesting question and I can’t say that I really understand the reason for that, but I think you’re right, it’s very interesting.

Jeff Schechtman: You touched on something before that I want to come back to a little bit and that is whether or not, if a doctor or psychiatrist sees something in the way of behavior in a public person, do they have any kind of broader obligation to say something, even if not publicly then maybe privately through other channels?

Dr. Oquendo: So this goes back to that point about whether psychiatrists have the duty to alert the public about a behavior that seems, quote, unquote, abnormal. And I think that the issue with making the statement in that particular way is related to the fact that if you have an abnormal behavior, we don’t know what the underlying cause is and it probably doesn’t take a psychiatrist to note that the behavior is abnormal. If it’s obvious from watching someone on television or reading about them in the newspaper or listening to on the radio, it really doesn’t take a psychiatrist to figure out wow, that’s not usual behavior. And so in a way I would argue that the psychiatrist has nothing to add given that they can examine the person and come to a diagnosis.

Jeff Schechtman: For individual psychiatrists that may go on television and say something or write an article or do a blog post or whatever, how is that looked on by the American Psychiatric Association? Are there sanctions? Are there reprimands? How is that dealt with?

Dr. Oquendo: Well, we strongly discourage our members from doing that.

Jeff Schechtman: But suppose they do. Just curious what the procedure, what the process is, if any.

Dr. Oquendo: Well, certainly we have a way of managing ethical breaches that can be activated if there is a complaint filed, for sure.

Jeff Schechtman: Have you seen any cases of this recently? Has this come up in an active way?

Dr. Oquendo: I’m not aware of any ethical complaints that have been filed at this time.

Jeff Schechtman: Talk a little bit about whether or not there has been pressure at all in this campaign season because all this is certainly talked about a lot. There has been pressure that really sort of bubbled to the surface, sort of encouraging you to talk about this Goldwater Rule at this point.

Dr. Oquendo: I would say that there has been some pressure and there’s a lot of attention and concern. Just today in the papers you could see that there’ve been even very senior people within the Republican Party making statements, and so whenever there’s a situation like that, you know that there’s going to be pressure on people who are specialists in behavior to render opinions, even though in our view it’s not ethical to do so.

Jeff Schechtman: What impact does all that have in a broader sense? What impact do you think that has on psychiatry in general, that you get so many people chiming in where everybody thinks they can offer an opinion?

Dr. Oquendo: I think that I would respond to this sort of on a slightly different tack by stating that for psychiatrists, once we start making armchair diagnoses, I think that our credibility is at risk and I think that making sure that we safeguard the credibility of the profession as a profession that sticks with facts and thorough information before rendering an opinion is very important. And in a way it’s kind of interesting because of course, if you were to do an examination of a particular individual, then you would be duty bound to actually keep their confidentiality, so you really could only reveal it if they gave you permission.

Jeff Schechtman: How do you view it when biographers of people, famous people – and they don’t necessarily have to be politicians – but when biographers engage in kind of armchair psychiatry in the context of doing detailed biographies of people? Is that something that the Association looks at as well, or thinks about?

Dr. Oquendo: We don’t specifically focus on the behavior of other professions including writers or biographers or historians, but I would say that caution is the better part of valor in these kinds of situations and that certainly will not stop individuals from writing what they will about an individual who they’re writing a biography for.

Jeff Schechtman: Do you know that when the Goldwater Rule was adopted in ’73, was this something that was unanimous on the part of the Association or was there controversy about it?

Dr. Oquendo: I can’t speak to that because I was not even a physician yet.

Jeff Schechtman: I mean, is it your sense, talking to colleagues today, that this is something that is accepted practice or do you sense any pushback to it nowadays?

Dr. Oquendo: Well certainly there is some dissent about whether we are being too rigid by taking the stance that it’s unethical to ever make comments, but I think we’re very careful to revisit our position on a regular basis and in our latest review of this rule and in fact the chair of our ethics committee was recently interviewed about this, and it’s very clear that this is at this point in time, a very reasonable position for us to take.

Jeff Schechtman: Dr. Maria Oquendo, she’s the president of the American Psychiatric Association. I thank you so much for spending some time with us today here on Radio Whowhatwhy.

Dr. Oquendo: Thank you so much.

Jeff Schechtman: Thank you. Thank you for listening and joining us here on Radio Whowhatwhy. I hope you’ll join us next week for another Radio Whowhatwhy podcast, I’m Jeff Schechtman.

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Related front page panorama photo credit: Adapted by WhoWhatWhy from Barry Goldwater (Library of Congress / Wikimedia) and APA President-Elect Maria A. Oquendo, M.D. (American Psychiatric Association)

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10 responses to “What a Psychiatrist Won’t Tell You About the Candidates”

  1. boxofvapor says:

    Although your average shrink understands the concept of Confirmation Bias this does not make them immune. This is the #1 reason why they shouldn’t be running around spouting off about politicians in particular. If you go looking for a diagnosis to fit your confirmation bias you WILL find it. Now I wouldn’t make a law against it, I would certainly let people know the effects that confirmation bias will play in anything they say. In other words when it comes to politics their opinions are no better or worse than anyone else.

  2. Vivek Jain says:

    Some physicians ask superficial questions, for example “Is Psychoanalyzing Our Politicians Fair Game?”

    Recall what Howard Zinn wrote:
    “Scholars, who pride themselves on speaking their minds, often engage in a form of self-censorship which is called “realism.” To be “realistic” in dealing with a problem is to work only among the alternatives which the most powerful in society put forth. It is as if we are all confined to a, b, c, or d in the multiple choice test, when we know there is another possible answer. American society, although it has more freedom of expression than most societies in the world, thus sets limits beyond which respectable people are not supposed to think or
    speak. So far, too much of the debate on Vietnam has observed these limits.

    “To me this is a surrender of the role of the citizen in a democracy. The citizen’s job, I believe, is to declare firmly what he thinks is right. To compromise with politicians from the very start is
    to end with a compromise of a compromise. This weakens the moral force of a citizenry which has little enough strength in the shaping of governmental policy. Machiavelli cautioned the prince not to adopt the ethics of the citizen. It is appropriate now to suggest to the Citizen
    that he cannot, without sacrificing both integrity and power, adopt the ethics of the Prince.”

    – from “Vietnam: A Matter of Perspective,” by Howard Zinn (from his collection, Zinn on War)

  3. (Comment by reader @Bandorino) For today’s job candidates, it’s
    routine to submit to personality, values,& skills testing. Why not
    the Presidency?

  4. Vivek Jain says:

    What does the APA have to say in opposition to the documented, indisputably massive, intrusive domestic and foreign spying programs and data collection–and the lies and fake-denials of US officials? (How does the APA reconcile the paranoia and delusions of some patients, who assert that the US government is eavesdropping, with the indisputable evidence that the US government, private sector entities, and other foreign powers are illegally listening and recording and using this information?)

    The APA discredits itself by its silence, by its feigned agnosticism, purported impartiality and invocations of professionalism. The time to decolonize the APA, to re-commit it to humanity and to make the APA live up to its professed principles, is NOW.

  5. Vivek Jain says:

    Where have all the psychiatrists been since the US government was exposed for its torture programs? For its medical experimentation? For its gulags? Some psychiatrists mutter nonsensically about gun violence but say NOTHING about the tens of thousands of working class people who’ve been butchered by the police! (How many psychiatrists even know the class functions of the police or the military or other coercive agencies of the state?) Where has Oquendo and the APA been as the US government has launched one illegal aggressive war after another, invading and bombing and destabilizing country after country? How much of a priority is it for the APA and for Oquendo to examine the invention and uses of Islamophobia, and how this racist ideology is a handmaiden to imperialist violence and terrorism by the US government and the outlaw, apartheid, nuclear armed, colonizing state of Israel? Why the silence about COINTELPRO? Why the deafening silence about the US government’s entrapment programs? What about the arrogation of greater and greater powers by the Executive branch? Or the bipartisan destruction of the Bill of Rights? The NDAA? The Disposition Matrix? Terror Tuesdays? The US government’s program of assassination by drone-fired missiles and other deadly technologies? More than a quarter century of the US government killing millions of our Sisters and Brothers who are Muslim! These illegal wars and covert operations keep expanding, new false pretexts are offered in defense of this violence by the Officials and their mandarins. What kind of analysis and critique is the APA offering?

  6. Vivek Jain says:

    How many psychiatrists opposed the US government’s illegal and aggressive war on Vietnam? …or the numerous coups carried out by the US government and clandestine agencies?
    How many opposed the murderous Anglo-American foreign policy post-WWII?
    How many cried out after the revelations of the Pentagon Papers? …or the disclosures from the burglary of the FBI office in Media, PA, documenting massive internal surveillance by the FBI of political conscious and active groups and individuals?
    How many psychiatrists are politically developed, ethical, and courageous enough to speak out against government wrongdoing?

  7. editorsteve says:

    As The Atlantic pointed out a few months ago (in a story about being inside Trump’s brain… probably a smaller space than the volumes of his little hands), almost all politicians score high on narcissistic behavioral scales. Sort of comes with the territory, doesn’t it?

  8. Vivek Jain says:

    Hillary Clinton, Donald Trump, Barack Obama, Bernie Sanders, etc — they’re all psychopaths. No-one should shy away from saying that. Same goes for the propagandists of the mass media, from the anchors to the late night “entertainers” (who try SO HARD to endear the oppressors to their viewing audiences).

    Psychiatrists should be helping to liberate humanity, rather than keep it mentally shackled, obedient, sedated, or accommodated to the fears and bogeyman promoted by the ruling class. Too long has psychiatry silently aided the ruling class. To what degree is this complicity attributed to the economic conflict of interest, that because psychiatrists and other physicians receive six or seven figure incomes, they are not going to risk sticking out their necks for someone else’s skin, even if by doing so they would be doing the right thing? What (dis-)incentives are there for psychiatrists to continue to be so oblivious, cowardly, and detached?

    Why isn’t there a daily raising of awareness about the relentless propaganda that the public is subject to? What toll does this propaganda take on the minds and mental health of the public and of the workforce? How has the failure by mental health practitioners to point out the creation, existence and use of propaganda by the ruling class cost the public and Labor? How has the work force been impaired by this negligence, by this failure to understand how propaganda works? How has the inattention toward capitalism resulted in the disempowerment and vulnerability of American workers–vulnerability to Management, vulnerable to the capitalist boardrooms, vulnerability to xenophobia and racism and patriarchy, and the poison of nationalism?

    Psychiatrists exaggerate when they claim to use the biopsychosocial model; this needs to be expanded to include the political and economic dimension as well.

    We need a Critical Psychiatry, one that helps to liberate humanity and ready and able for collective self-defense–not a Collaborater Psychiatry that aids Empire and the imperial ruling class in keeping the public tranquilized, susceptible to propaganda, and incapacitated to fight back.

    Too bad Frantz Fanon wasn’t available for interview!

    Or Biko: “The most potent weapon in the hands of the oppressor is the mind of the oppressed.”

  9. grumpyhillbilly says:

    Given that the shrinks are ever expanding the list of disorders, why not admit we’re all nuts? End the not particularly good “science”, and toss their medications somewhere where they can’t pollute. But till then, this non-psychologist will declare Trump an extreme narcissist and Clinton a dangerous psychopath.

    • James says:

      I would distinguish between psychiatrists and pyschologists. The former have medical degrees and in my mind are more scientifically rigorous. Not to say that there may not be a problem with pill for everything solutions.