Should mental health ‘diagnoses’ be allowed to become another weapon of political warfare?

′Should mental health practitioners give the media opinions about the mental health of public figures they’ve never examined?  Do we want such ‘diagnoses’ to become the next weapon of political warfare?  Would doing so aggravate the stigma that already bedevils mental illness?

Here’s why this is an issue.  Currently, what is known as the “Goldwater Rule” makes it an ethics violation for mental health providers to, as psychiatrist John Martin-Joy summarizes it, “comment on the mental health of public figures…without a personal examination and consent” of the targeted person.  Nevertheless, in a recent blogpost Martin-Joy advocates upending that rule, something I believe would be a serious mistake.

The President’s stumbles and gaffes

Although Martin-Joy makes it clear he is thinking about former President Trump, it is – somewhat ironically – President Joe Biden’s mental health that is raising questions of late.

A March survey shows that after a series of stumbles and gaffes by President Biden, a third of voters have “doubts about his mental fitness for the country’s top job.”  Even more recently, another poll shows that only slightly more than half (53%) of voters believe he is “mentally fit.”

Should mental health practitioners enter the “mental fitness” political fray?  Martin-Joy argues that even without examining the individual, a psychiatrist who “believes the public’s safety is at stake” should openly make “good faith comments about a public figure’s mental health.”  Martin-Joy seems to agree that psychiatrists ought to act as a “crucial check on powerful political figures.”

Does it matter that nothing in our democratic tradition suggests assigning any such special role to psychiatrists or any other mental health practitioners?

The dangerous potential to ‘weaponize’ mental illness

Of course, Martin-Joy’s well-meant proposal would, whether intended or not, create an unprecedented opportunity for those in the mental health business to use the sheen of their professional credentials to exploit the unfortunate stigma associated with mental illness to influence politics and to advance a partisan agenda.

Who would arbitrate what was a “good faith” comment?  Think about it: what would prevent a psychiatrist from labeling a point of view as illustrative of a “mentally unfit” person simply because they disagree with it?  The aura of a “professional opinion” by someone with medical credentials could give unwarranted gravitas to what are really partisan attacks on public figures.

A targeted person would then have to obtain their own mental health professional’s opinion to counter.  We could then see the spectacle of politicized strike and counter-strike by persons who are supposed to be treating the ill and not waging ideological wars.  Is that in the Nation’s interest?

Let’s face it, as a 2019 article in the Washington Examiner pointed out, “[m]ental health-related epithets are sometimes still used by politicians against their enemies.”  It discussed a then planned event in “which psychiatrists and experts in other disciplines will testify about how they believe Trump’s mental state makes him dangerous to the country.”

This drew criticism from former Congressman Patrick Kennedy, someone who has had his own struggles with mental illness.  Kennedy said “I’m very much shocked when a lot of my fellow Democrats level that kind of attack against the president because I think that plays unwittingly toward the whole stigma around mental illness.”

The Examiner story also went on to observe:

Psychiatrists interviewed for this article agreed that most people with mental health conditions who get treatment can do well, but noted that many people don’t seek help because they’re worried about how they’ll be perceived. As a result, their condition can get worse…For politicians, there’s always the risk that seeing a therapist or taking an antidepressant will become a liability if it gets out.

Prevalence of mental illness

Obviously, departing from the Goldwater Rule could chill the inclination of tens of millions of Americans to serve in public office.  It is entirely plausible that the dread of being branded by the stigma of mental illness could sideline many whose service could benefit the Nation.

After all, according to the National Institute of Heath (NIH), 51.5 million adults aged 18 or older in the United States – 20.6% of all U.S. adults – suffer what it calls “any mental illness” or AMI.  (The NIH says AMI is “a mental, behavioral, or emotional disorder [that] can vary in impact, ranging from no impairment to mild, moderate, and even severe impairment.”)

As suggested above, fear of being publicly accused of mental illness by a “professional”- especially one with whom they’ve never even met- could aggravate an already serious problem in this country.  According to the American Psychiatric Association:

More than half of people with mental illness don’t receive help for their disorders. Often, people avoid or delay seeking treatment due to concerns about being treated differently or fears of losing their jobs and livelihood. That’s because stigma, prejudice and discrimination against people with mental illness is still very much a problem.

Notably, the proposal could disproportionately stigmatize women.  The NIH says the “prevalence of AMI was higher among females (24.5%) than males (16.3%).”  Furthermore, the NIH says the prevalence of SMI [Serious Mental Illness] was higher among females (6.5%) than males (3.9%).

Veterans can be especially vulnerable to allegations about mental fitness, as inaccurate perceptions persist.  The Military Times reported in 2016 (“Americans think more than half of vets have mental problems, survey says”) that the “general public vastly overestimates the number of post-9/11 veterans with mental health conditions, a misconception veterans advocates say threatens the overall well-being and employment prospects of former troops.”

We all want to eradicate the stigma of mental illness.  Sometimes public figures can help to do that by voluntarily disclosing their own mental health challenges to the public. But that is a personal decision of the most intimate kind and one that should, in most cases, be up to the individual.

Distinguishing between legitimate processes to protect the public, and what is really politicized commentary

Procedures already exist as to how health care professionals should handle documented diagnoses and other information that involve threats to people, and specific processes exist concerning the removal of public officials when necessary in the public interest.  And, of course, judicially-ordered civil commitment can be an option in many cases.

Such temperate procedures need to be distinguished from giving to the media what could simply be capricious opinions from mental health practitioners whose claims about someone’s supposed mental health are really little more than than political partisanship.  

Even when well-meant, such commentary could too easily devolve into ideological ‘weaponry’ employed by others to delegitimize elected leaders for political purposes.  This would not, in my view, serve our democracy, let alone the mental health community of patients and providers.

As a society, we support the privacy of health records and we’ve established that discussions between mental health professionals and their clients are protected and confidential.  Why then, would it be acceptable for a professional in the field to attempt to diagnose or offer medical fitness comments on an official they’ve never treated?

Publicly accusing people of having mental illness for the purpose of questioning their fitness for political office only serves to perpetuate stereotypes that enhance the stigma. It is, in fact, a form of bullying and shaming; and isn’t that something we’ve been saying we’d like to stop?

Political bias?

Let’s also not forget that mental health practitioners do not seem to have much ideological diversity, so we have to wonder if their public comments would be free of political bias.  A study reported in the New York Times shows that psychiatrists are overwhelmingly Democrats.

An article in FiveThirtyEight found psychologists likewise “tend to fall on the liberal end of the political spectrum.”  It added this important point as to what this political preference means in terms of diagnoses:

Social psychology’s left tilt has been widely discussed, yet it has been difficult to measure how political leanings influence the work that the field produces.  But a new study has tried to quantify just that, and it found that social psychologists assess conservatives differently than liberals.

Additionally, the Wall Street Journal reported in a 2018 article that “Therapy Is No Longer a Politics-Free Zone.”  It noted that “at a time of intense division, patients and doctors alike are increasingly ready to discuss views that were traditionally kept private.”

Misdiagnosis? 

Beyond the potential impact of political bias, how accurate are mental health diagnoses?  Even in a medical setting where a person is actually examined, the data is troubling.

A Canadian study found that in a primary care setting, “[m]isdiagnosis rates reached 65.9% for major depressive disorder, 92.7% for bipolar disorder, 85.8% for panic disorder, 71.0% for generalized anxiety disorder, and 97.8% for social anxiety disorder.”

In 2013 The Atlantic reported on a psychotherapist who contended that the Diagnostic and Statistical Manual (DSM), “psychiatry’s ‘bible’ that defines all mental illness, is not scientific but a product of unscrupulous politics and bureaucracy.”

In 2019 ScienceAlert discussed a study of the DSM.  It found:

Researchers from the University of Liverpool argue that today’s diagnoses forschizophrenia‘, ‘bipolar disorder’, ‘depressive disorders’, ‘anxiety disorders’ and ‘trauma-related disorders’ are scientifically worthless as tools to identify these conditions.

According to the researcher, this “study provides yet more evidence that the biomedical diagnostic approach in psychiatry is not fit for purpose.”  And this study was of cases where the individual was actually examined by a practitioner.

Should mental health issues necessarily be disqualifying? 

Though not well known, some of our greatest presidents suffered from mental illness.  In 2016 Psychology Today reported a study that showed that half of all presidents suffered mental illness, including such eminent leaders as Lincoln and Theodore Roosevelt.  Furthermore, a 2019 BBC article contended that George Washington lapsed into a “catatonic state” in the midst of a 1776 battle and “apparently attempted suicide.”

Moreover, Psychology Today also suggests a critical question with which Martin-Joy doesn’t grapple: “[does] a person’s mental health and potentially pathological personality characteristics necessarily mean they are unfit for office”?  The article points out:

Reviewing the list [of presidents with mental illness], we consider many of the presidents on it among the finest in our history.  Indeed, Dr. Nassir Ghaemi, who runs the Mood Disorders Program at Tufts Medical Center in Boston, argues in his book, A First Rate Madness: Uncovering the Links between Leadership and Mental Illness, that leaders with some mental illnesses can actually perform well in times of crisis as they may be more prepared to deal with upheaval and uncertainty.  (Emphasis added.)

Here’s another aspect of this issue that Martin-Joy doesn’t address: should mental health practitioners who are opining on those they have never examined be obliged to disclose any mental illness they themselves may have?

Evidently, this is a significant issue among medical practitioners.  A 2019 article on PsychiatryAdvisor (“Challenging Stigma: Should Psychiatrists Disclose Their Own Mental Illness?”) indicated that mental health providers suffer a significant rate of mental illness, but rarely disclose it much because they fear the associated stigma.

The point here is that there are many conditions that might be characterized as a “mental illness” yet do not – and should not – disqualify people from entering professions, including public service.  Shouldn’t mental health professionals, especially those competently practicing despite their own mental health issues, empathize with public figures who don’t want to be classified with a mental illness, especially by some who never examined them?

Concluding observations

Instead of commenting on the alleged mental state of public figures they’ve never examined, perhaps psychiatrists and other mental health practitioners ought to focus on improving their own discipline.

Why? In a recently-published article in the New York Times, science reporter Benedict Carey reflected on his 20-year career and came to what I found to be a startling conclusion.  He said that during his tenure the “science informing mental health” does attract “enormous scientific talent, and there were significant discoveries.”  However,

[T]he science did little to improve the lives of the millions of people living with persistent mental distress. Almost every measure of our collective mental health — rates of suicide, anxiety, depression, addiction deaths, psychiatric prescription use — went the wrong direction, even as access to services expanded greatly.

To be clear, no one wants a dangerous, unstable person as a public official.  In the case of the President, the 25th Amendment provides a process for removing such an individual.  In an interesting essay on The Conversation (“Why it’s hard to remove, or even diagnose, mentally ill or unstable presidents”) law professor John Rogan and medical doctor Joseph J. Fins analyze the practical challenges.

Fins says that “while psychiatric diagnoses cannot be made from afar nor confidences breached, physicians have a supererogatory obligation to share specialized knowledge.”  The writers then say:

This is especially important when discussing psychiatric conditions, which may be hard to apprehend.  The objective for mental health professionals is not diagnosis from afar but rather to educate the citizenry about these conditions so as to promote deliberative democracy.

Rogan and Fins essay still concludes that there are ways to effectively address the difficult dilemma of a psychiatrically infirm yet elected leader.  I won’t attempt to summarize their fascinating discussion, but they do close with this important observation:

Both the object of any intervention and its proponents are prone to human foibles, courage and timidity, grandiosity and prudence. When darkness descends, whether on Camp David or other halls of power, the nation is left to rely on the integrity and judgment of its leaders and its citizenry.

Even those who choose to enter public service should not therefore be obliged forgo all aspects of privacy.  If they somehow become mentally unstable and a danger to themselves or others, then protocols observant of existing professional standards of privacy ought to be employed consistent with legal structures that eschew politicization.

Should those processes be re-examined and, if appropriate, improved?  Of course.  And, yes, mental health professionals can conceivably have an important role to play, but not in the way some critics of the Goldwater Rule seem to suggest.

In my opinion, unleashing mental health practitioners to provide the media with ‘diagnoses’ or other medical commentary about the supposed ‘mental fitness’ of politicians or other public figures they never examined and whose permission they do not have, has too much ready potential to become blunt weapons of political warfare.  

It would benefit neither their profession nor the public if mental health practitioners become reduced to just another set of partisan actors in a nation already divided by political polarization. 

Keep the “Goldwater Rule” in place.

Still, remember what we like to say on Lawfire®: gather the facts, examine the law, evaluate the arguments – and then decide for yourself!

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