The Rule Banning Psychiatrists from Diagnosing Trump Is Seriously Flawed

The one-year anniversary of Donald Trump’s election has come and gone, but the concerns about his behavior, public statements, and general frame of mind have persisted.

Most recently in October, the group A Duty to Warn—a coalition of mental health professionals and academics—held a series of town halls across the country to plead its case that Trump is mentally and emotionally unfit to hold office. They’ve further argued he should be impeached under the 25th Amendment, which allows for the removal of a president if they’re “unable to discharge the powers and duties” of their office.

But these denouncements have reignited a debate over whether it’s ethical for mental health experts to flout a longstanding tradition that discourages them from offering their opinions on a famous person’s mental state in the first place. The so-called Goldwater Rule, established in 1973 by the American Psychiatric Association, bars its members from diagnosing public figures or commenting on their mental state without having treated them. Other organizations that govern mental health experts, like the American Psychological Association, have similar, if informal, guidelines on avoiding armchair diagnoses.

The therapists and doctors who’ve ignored the Goldwater Rule have mostly justified themselves on moral grounds. Trump is so dangerous, they’ve argued, that to say nothing would be a betrayal of their responsibilities to the public. But a recent paper by Emory University psychology professor Scott Lilienfeld and two co-authors is taking a slightly different tack. Rather than saying Trump is a worthy exception to the rule, the group argues that the rule itself is based on outdated, flimsy science. (The paper has been released online and will soon be published in a print issue of Perspectives on Psychological Science.)

Lilienfeld, a former member of the American Psychological Association, says that the underlying scientific premise behind the rule is that experts can only glean enough insight into someone’s mental health via a psychological assessment done in person, which usually includes an interview. His case, supported by a fair amount of psychological research, is that these exams are actually horrible at doing that.

His team points out that people mislead or even lie to their doctors during the interview, or may not be very self-aware, while certain mental health problems are harder to pin down during a brief exam. A person with narcissistic personality disorder, for instance, can initially come off as charming and fun, only to be revealed as manipulative and abusive over time. Worse still, how these assessments are interpreted can widely vary: More than one study has found that the same patient can be diagnosed differently by different doctors in back-to-back interviews.

Lilienfeld also argues that indirect observations of a person’s behavior can sometimes be just as valuable in assessing their overall mental state, especially if that person has hypothetically spent decades in the public spotlight. And especially if they are clinically narcissistic, as some experts have speculated Trump to be.

“As I read more and more into this literature,” Lilienfeld tells Tonic, “the more apparent it became to me and my co-authors that this large body of research was ignored in discussions of the Goldwater Rule. And the more apparent it became that the rule was based on claims that were not all that widely supported.”

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Lilienfeld’s arguments have gotten some traction among researchers and practicing experts. But others haven’t been so easily swayed. Columbia psychiatrist Paul Applebaum, a past president of the American Psychiatric Association and a supporter of the rule, told STAT that he found the paper “unpersuasive.” He acknowledged that in-person psychiatric evaluations aren’t perfect but “without them you are very limited in what you can say about someone” including “what’s going on inside someone’s head.”

Nick Davis, a psychology professor at Manchester Metropolitan University in the UK, wrote in an accompanying rebuttal that while Lilienfeld and his team make a compelling case, the rule still matters because it keeps mental health professionals from crossing an ethical line and adding to the stigmatization of people with mental illness.

“A person should be judged by their actions and not by what we believe about them because we believe they have a certain mental state,” Davis tells Tonic in an email. “So giving a person (or a President) a label that is associated with mental illness allows us to make stereotypical judgements about their actions or intentions, even though those judgements may be false.”

Lilienfeld doesn’t agree with Davis that dropping the rule would lead to a slippery slope of stigmatization. “Ironically, there are defenders of the rule who have been way more critical of Trump than its opponents, so it’s not like the rule protects public figures” from being mocked, he says. But he also doesn’t think it should be abandoned entirely.

Because of how shoddy he views the science behind the rule though, Lilienfeld would want the rule to be treated not as a formal ban, but as a guideline. One that would “let psychologists and psychiatrists know that, in general, it’s not a good idea to speak out about the mental health of public figures, but that there might be cases in which you have to use your own discretion as to whether this figure could pose a real threat to the general public—and only if you’ve adequately consulted high-quality information [on the person in question]—that you might be able to weigh in.”

As for Trump himself, Lilenfeld notes there probably isn’t much more information you could get from giving him an in-person mental evaluation anyhow, which some members of Congress have been pushing for.

“When it comes to the major diagnoses most people are concerned about with Trump, such as narcissistic personality disorder or antisocial personality disorder, most of those things are evident in people’s behavior over long periods of time,” he says. “I don’t think that, somehow, we’re going to be able to sit down and discover something magical about him that we didn’t know before.”

Meanwhile, other mental health experts see the push to take down the rule not only as ethically fraught but a worthless distraction. Jeffrey Lieberman, the chair of psychiatry at Columbia University Medical Center, who wrote about the Goldwater Rule and the 25th Amendment for Tonic in September, says that if experts want to take down Trump, they should do so without acting as a medical authority. “It’s completely irresponsible” for anyone on the outside looking in to couch their political dislike of Trump as psychiatric wisdom, Lieberman tells Tonic. “It’s blatantly transparent bullshit.”

“At the same time, even if there was a reasonable suspicion [of Trump’s unhealthy mental state], which I think there is, there’s a mechanism to deal with it—in the government,” he says, referencing the 25th amendment. Specifically, he thinks mental health professionals who are concerned should use public pressure to try to convince Congress to enact the 25th Amendment and have Trump submit to medical and mental evaluations.

Lieberman, a Clinton supporter and adviser during the campaign, adds that psychiatrists like him could be a part of that process, as an independent panel asked to offer their professional opinion to Congress for instance, but they shouldn’t be protesting Trump under the guise of psychiatry. “If you’re saying that we have to do something now, then I agree. But the mechanism has to be Constitutional.”

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