How a Telescopic Lens Muddles Psychiatric Insights

By RICHARD A. FRIEDMAN, M.D.

Published by the New York Times: May 23, 2011

No sooner had Dominique Strauss-Kahn been arrested on sexual assault charges in New York than a parade of psychiatrists stepped forward to offer their expert opinion in the news media.

This cover story in 1964 set a legal precedent that helped change medical rules for psychiatrists for good.

Mr. Strauss-Kahn, who subsequently resigned as chief of the International Monetary Fund, will experience “a terrible grief because he is in prison,” said one. Another offered that he would have “terrible mourning” for “the loss of social status, image and glory.”

Of course, it’s only natural for the media to seek comment from experts. But as a psychiatrist, I cringe at statements like these, for they cross an ethical line that goes back to a presidential campaign nearly half a century ago.

Just before the 1964 election, a muckraking magazine called Fact decided to survey members of the American Psychiatric Association for their professional assessment of Senator Barry Goldwater of Arizona, the Republican nominee against President Lyndon B. Johnson.

Ralph Ginzburg, the magazine’s notoriously provocative publisher, had heavily advertised the issue in advance, saying it would call Mr. Goldwater’s character into question.

A.P.A. members were asked whether they thought Mr. Goldwater was fit to be president and what their psychiatric impressions of him were. It was not American psychiatry’s finest hour.

The survey, highly unscientific even by the standards of the time, was sent to 12,356 psychiatrists, of whom 2,417 responded. The results were published as a special issue: “The Unconscious of a Conservative: A Special Issue on the Mind of Barry Goldwater.”

The psychiatrists’ assessment was brutal. Half of the respondents judged Mr. Goldwater psychologically unfit to be president. They used terms like “megalomaniac,” “paranoid” and “grossly psychotic,” and some even offered specific diagnoses, including schizophrenia and narcissistic personality disorder.

Only 27 percent of the respondents said Mr. Goldwater was mentally fit, and 23 percent said they didn’t know enough about him to make a judgment.

There were several attempts at a psychodynamic formulation of Mr. Goldwater’s character. One unsigned comment called the candidate “inwardly a frightened person who sees himself as weak and threatened by strong virile power around him,” and added that “his call for aggressiveness and the need for individual strength and prerogatives is an attempt to defend himself against and to deny his feelings of weakness.”

Say what you will about their motivation, these doctors had given very specific and damaging psychiatric opinions, using the language and art of their profession, about a man whom they had not examined and who surely would not have consented to such statements.

The remarks were immediately condemned by both the American Medical Association and the A.P.A., and Mr. Goldwater brought a $2 million libel suit against Fact and Mr. Ginzburg. The Supreme Court awarded the senator $1 in compensatory damages and $75,000 in punitive damages — and, more important, set a legal precedent that helped change medical ethics for good.

In 1973, the A.P.A. defined a set of requirements for communicating with the media — the Goldwater rule — stating that psychiatrists can comment on mental health issues in general, but that it is explicitly unethical for them to offer a professional opinion about an individual without directly examining that person and getting his or her permission to comment.

So it would be fine for a psychiatrist to say that someone who experiences hallucinations and delusions appears psychotic, but to offer a diagnosis of schizophrenia would cross the line.

The distinction between general description and diagnosis may seem like splitting hairs. But for two reasons, the Goldwater rule is just as important today as it ever was.

First, it is intellectually dishonest for a mental health professional — or any physician — to give a diagnosis without examining the patient. A professional opinion is supposed to reflect a thorough and rigorous evaluation of a patient and all relevant clinical data obtained under the protection of strict confidentiality. Anything short of that misleads the public about what constitutes accepted medical practice and invites distrust of the profession as a whole.

Second — and especially timely as we enter another presidential campaign — the Goldwater rule prevents the misuse of medical authority as a political weapon to denigrate an opponent.

Of course, there are exceptions to all rules. Patient confidentiality is not absolute, for example: If a patient of mine told me he was thinking of killing someone, I would have an ethical and legal duty to violate confidentiality and warn both the person at risk and the police.

And one could reasonably argue that an exception should be made for psychiatric profiles of foreign political leaders, which United States intelligence services (and those of other countries) have been doing at least since World War II. An evaluation of Col. Muammar el-Qaddafi of Libya, for example, might well be in the national interest because it could help guide how we deal with this difficult figure.

Colonel Qaddafi’s ruthlessness, near-delusional grandiosity and love of absolute power all suggest a severe personality disorder called malignant narcissism. Because people with the disorder have a defect in moral conscience, they lack empathy, so there is no room to appeal to them on human terms. Instead, they are more likely to respond to the right mix of flattery, power and a credible threat of force.

Whether the foregoing diagnosis is correct or useful, I have no idea, but it is ethically defensible.

Despite what some of us might believe, though, none of our celebrities or politicians is likely to rise to the level of a national threat that justifies violation of the Goldwater rule.

It’s not sexy and probably won’t make headlines, but experts should just stick to the facts and educate the public, and leave the pleasure of diagnostic speculation to the amateurs.

Richard A. Friedman is a professor of psychiatry at Weill Cornell Medical College.