Responsible Dialogue on the “Goldwater Rule” Must Continue

“We must do all we can to maintain a harmonious household.” — Thomas Jefferson, played by Gabriel Ebert, at a moment of conflict in Suzan-Lori Parks’ play Sally & Tom, based on Jefferson and Sally Hemings, at the Public Theater in New York City, where the American Psychiatric Association (APA) Annual Meeting was held in May of 2024

The medical profession is guided by beneficence and not doing harm.

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I don’t think there’s a psychiatrist in the world who doesn’t responsibly offer insight into challenging relationships in their patient’s social milieu during therapy. This should always be for the patient’s benefit and not the physician’s.

But what happens when the “patient” is society, and the psychiatrist is concerned with the social, cultural, and political fields? Can trained, knowledgeable psychiatrists inform the public about dangerous influences in our environment and provide rational commentary on, for example, how leaders manipulate information and spew hatred in order to advance their self-interest and increase the likelihood of political violence against their chosen enemies? Don’t knowledgeable psychiatrists have an ethical duty to inform and warn? Doesn’t the public deserve a reasoned professional opinion on the cognitive, empathic, and relational capacities of candidates for higher office?

Since 1973, the official answer has been a resolute “no.” The Goldwater Rule has become a shibboleth: “Do not diagnose from a distance.” Ironically, many psychiatrists (and many in positions of authority) seem to have accepted the Goldwater Rule without careful examination.

Psychiatrists Jerome Kroll and Claire Pouncey wrote in 2016 (1):

“Section 7.3 of the code of ethics of the American Psychiatric Association (APA) cautions psychiatrists against making public statements about public figures whom they have not formally evaluated. The APA’s concern is to safeguard the public perception of psychiatry as a scientific and credible profession. The ethic is that diagnostic terminology and theory should not be used for speculative or ad hominem attacks that promote the interests of the individual physician or for political and ideological causes. However, the Goldwater Rule presents conflicting problems. These include the right to speak one’s conscience regarding concerns about the psychological stability of high office holders and competing considerations regarding one’s role as a private citizen versus that as a professional figure. Furthermore, the APA’s proscription on diagnosis without formal interview can be questioned, since third-party payers, expert witnesses in law cases, and historical psychobiographers make diagnoses without conducting formal interviews. Some third-party assessments are reckless, but do not negate legitimate reasons for providing thoughtful education to the public and voicing psychiatric concerns as acts of conscience. We conclude that the Goldwater Rule was an excessive organizational response to what was clearly an inflammatory and embarrassing moment for American psychiatry.”

At the 2017 American Psychiatric Association's annual meeting, the issue was debated in a contentious session entitled “The Goldwater Rule: Pro and Con.” Former APA presidents Paul Appelbaum and Paul Summergrad vied with Jerrold Post, Nassir Ghaemi, and Claire Pouncey. Ghaemi is a psychiatrist, scholar, and author of the 2012 New York Times bestseller A First-Rate Madness: Uncovering the Links Between Leadership and Mental Illness. He is now president of the Massachusetts Psychiatric Society. The aforementioned Pouncey is a psychiatrist, philosopher, and co-author of the 2016 paper “The Ethics of the Goldwater Rule,” published in the Journal of the American Academy of Psychiatry and the Law.

Post, who died of COVID-19 in 2020, founded the program in political psychology at George Washington University and the Center for the Analysis of Personality and Political Behavior at the CIA. He advised presidents about the potential risks of leaders around the world. President Carter credited the Camp David peace agreement between Israel and Egypt to Post’s “picture-perfect” analyses of Menachem Begin and Anwar Sadat. He came under fire by the APA for potentially violating the Goldwater Rule” but was never sanctioned. His New York Times obituary stated (2):

“To Dr. Post, such criticism was ridiculous, if not irresponsible. He believed that it was his ethical obligation to offer his insights on political figures, especially if they presented a threat to the country. Besides, he would add, he wasn’t offering Saddam Hussein medical advice.”

In fact, Post attempted to provide the American government with a critical political risk assessment of Saddam Hussein in the run up to the Iraq war, concerned with leadership and negotiation style. He called Hussein a “malignant narcissist” but a “rational decision-maker” and thus not the threat that President Bush’s team had made him out to be. He was ignored, and the rest is history. (3)

The May 2024 APA Annual Meeting featured a panel entitled “How to Avoid Foot in Mouth Disease: Navigating Conversations with Media, Friends, and Patients in an Election Year,” featuring Josepha Cheong, Howard Liu, and Charles Dike, as well as APA’s associate director of media relations Erin Connors. Dike is the chair of APA’s Committee on Ethics, Cheong has served as the chair of the APA’s Scientific Program Committee and practices in Florida, and Liu is chair of the University of Nebraska’s Department of Psychiatry. The panel members provided some solid advice about using political questions as a springboard to educate about mental health in general ways but recommended exploring and examining anxieties without divulging opinions that might reflect badly on psychiatry or violate the Goldwater Rule.

I believe Post might be turning over in his grave. This year’s panel fell far short of the ethical debate that occurred in 2017, though that panel ended with what I viewed as a dispiriting and shocking institutional and authoritarian dismissal of debate by those past presidents of the APA.

This year’s panel featured psychiatrists who are distinguished leaders in academic institutions and organizational psychiatry (Dike, Cheong, and Liu), but no one with expertise in political and social psychology. Cheong and Liu did not discuss how practicing in “red states” might influence their advice. There were no alternative viewpoints to the circumspection and avoidance espoused by the panel. Overtly political sessions were not approved for this year’s annual meeting, apart from one titled “Conspiracy Theories Gone Wild: Who Believes Them, Why, and How Can We Help,” featuring Joseph Pierre and John Rozel, which went into overflow from a totally packed auditorium, demonstrating that APA members are very much interested in issues affecting our cultural landscape. I know of at least two sessions on political psychology that were rejected, including my own.

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My sense is that the APA has retreated from the possibility of educating its membership and the public about dangerous influences in our political and social environment. The APA seems to have acquired a case of “political phobia” and, because of this, demonstrates a callous insensitivity to the potential harms in front of us.

This political phobia is in line with hoary psychoanalytic and cultural principles such as abstinence, neutrality, and individualism (as opposed to understanding social and cultural influences on individuals), but reinforces silence, avoidance, suppression, and cowardice. Psychiatrists are literally charged with exploring difficult material, and yet the APA’s studious disavowal of the difficult material facing “society as their patient” lands on me as a great abdication and failure, as a concerned physician, prolific writer, and otherwise loyal and appreciative member of this deeply knowledgeable, skillful, and inspiring assembly of outstanding accomplishment and potential.

Unimaginable violence lurked in Jefferson’s supposed “harmony,” a violence that continues to our day in all the effects of racism, sexism, and power imbalance, many of which are described in the APA’s important initiative on the social determinants of mental health, an initiative that came after much scholarly work and significant advocacy within the organization’s leadership and membership, and against notable resistance.

An outstanding APA session this year explored religious framings of anxiety in Judaism, Islam, Hinduism, and Christianity, and I commented there that “collegiality is an antidote to anxieties of all kinds.” It was on full display at that panel, giving me great hope for interfaith understanding, co-existence, and dialogue in a time of war, anti-Semitism, and Islamophobia. This collegiality is the kind of harmony that produces mental health and a deeper peace.

But insisting that trained, knowledgeable psychiatrists who are experts in political and social psychology and forensics not express themselves or gain an official platform about challenging topics functions to suppress thinking itself. As such, the prevailing trend tells us not only what we can say, but what we can think and who we can be. It ordains limits on dreaming a better country and world into being.

Should we maintain the hypocritical “harmonious household” of Jefferson? Or are there Lincolns among us?

(c) 2024 Ravi Chandra, M.D., D.F.A.P.A.