A prohibition against psychiatrists discussing the mental health of public figures — a rule that has become especially controversial, and sometimes flouted, since the inauguration of President Trump — is “premised on dubious scientific assumptions,” researchers concluded in an analysis scheduled for publication in a psychology journal.
The American Psychiatric Association (APA) defends its “Goldwater rule” by arguing that an in-person psychiatric examination is the gold standard for diagnosing mental illness and psychological traits — given that there are no blood tests or brain scans for psychiatric disorders. In fact, however, numerous studies suggest that the interview-based exam can be misleading, psychologist Scott Lilienfeld of Emory University and colleagues argue in the paper, which will appear in an upcoming issue of Perspectives on Psychological Science.
Patients lie or hide facts, they often have poor self-insight, and psychiatrists err, the authors write. In contrast, the accounts of people who know the individual, plus his or her public behavior, writing, speech — and, yes, tweets — can provide more accurate insights into a public figure’s mind, they contend.
The flaws of psychiatric exams and the usefulness of other data make the Goldwater rule “scientifically indefensible,” said Dr. Leonard Glass, a psychiatrist at McLean Hospital and Harvard Medical School who was not involved in the new analysis and is a critic of the rule. “I sort of believed” that interviews offer the clearest window into someone’s mind, he said. “But I believe that a whole lot less now that I’ve read this paper,” which he called “thoughtful, thorough, and a major contribution.”
But a past president of the APA, Dr. Paul Appelbaum of Columbia University, called the paper “unpersuasive.” Despite the very real shortcomings of in-person psychiatric evaluations, he said, “without them you are very limited in what you can say about someone,” particularly the person’s innermost thoughts and feelings.
The Goldwater rule has its roots in a 1964 magazine survey asking psychiatrists their opinions of the mental health of Sen. Barry Goldwater, that year’s Republican presidential nominee. The majority of those responding said Goldwater was psychologically unfit to be president (they called him “emotionally unstable,” “grossly psychotic,” “paranoid,” “delusional,” and “a dangerous lunatic”). In 1968, Goldwater won a libel suit against the magazine, and in 1973 the APA adopted the rule barring its members from sharing their views of the mental health of public figures.
Trump’s behavior as president, including claims that President Obama had him wiretapped and that his inauguration crowd was the largest ever, has triggered a flood of commentary by, for the most part, psychologists, speculating that his narcissism may be extreme enough to qualify as a personality disorder or that he has other dangerous mental traits, including impulsivity. Psychiatrists have been mostly, though not entirely, absent from the discussion, owing largely to the Goldwater rule.
During the 2016 campaign, the then-president of the APA, Dr. Maria Oquendo, justified the rule by arguing that making diagnoses-at-a-distance “would be irresponsible.” (Oquendo said she is traveling and unable to comment on the upcoming paper.)
The American Psychological Association has no Goldwater rule per se, but its code of ethics says that “opinions of psychological characteristics” must be based on a psychological exam.
The argument in the new paper has two parts: that a large body of scientific research shows such exams can mislead the examiner, and that inferences about a public figure’s psychological makeup and mental health based on his or her public behavior and the observations of close associates can be valid. Together, the data undermine the claim that psychiatric exams provide the highest-quality information on someone’s mental state.
The flaws of in-person exams are no surprise to experts. “People can snow you,” said Dr. Sally Satel, a psychiatrist and resident scholar at the conservative-leaning American Enterprise Institute. “The in-person interview can be highly misleading, especially with people who are superficially charming”: They’re good at “impression management,” have no self-insight, lie, or otherwise deceive the psychiatrist, intentionally or not. Satel supports the Goldwater rule, however, as a guard against politicizing psychology and psychiatry.
“Psychiatrists are taught that if a patient says he has three drinks a day, double that,” said Glass, the McLean psychiatrist. “The psychiatric interview is flawed.”
His and other psychiatrists’ clinical experience is backed up by studies going back to the 1970s in which patients were examined by two psychiatrists back-to-back. The rate of agreement was so low (often around 20 percent) that “the unreliability of psychiatric diagnosis has been and still is a major problem in psychiatry,” researchers concluded. Later studies reported similar discrepancies, especially for personality disorders, finding that examination-based conclusions by a psychiatrist often disagree with assessments in a structured research setting.
Can a public figure’s public behavior and speech, which experts who ignore the Goldwater rule rely on, provide a better window into the mind? “Personality traits are pretty stable over time,” Lilienfeld said. Moreover, markers of, say, pathological narcissism — grandiose self-importance, entitlement, exploitativeness, and lack of empathy — can be seen in someone’s public behavior, especially in the case of a public figure whose behavior and speech has been documented in hundreds of hours of TV interviews, speeches, offhand remarks, and tweets, plus the accounts of people who have lived or worked closely with him. This evidence can also be more accurate than information from formal examinations, the new paper argues.
That is especially true for antisocial and narcissistic personality disorders, the authors argue. One study found that accounts of a person’s behavior from those close to the individual were more accurate than the person’s own (the basis of psychiatric exams); another found that reports from “informants” did a better job at capturing an individual’s personality traits and predicting future behavior than self-reports did.
Columbia’s Appelbaum, who supports the Goldwater rule, agrees that “information from the outside can be extremely helpful in getting a more complete [psychological] picture of a person.” But direct evaluation, he argues, allows a psychiatrist or psychologist “to do things that observations of public behavior and third-party accounts do not,” such as getting a glimpse “of what’s going on inside someone’s head.”
For the Goldwater rule, the question is whether those glimpses are so crucial that they override other arguments against it, including that it robs the public of expert opinion on important questions.
“Is it better to have an in-person interview? Probably,” Lilienfeld said. “Is it necessary to get deep, accurate insights into someone? Probably not. Justifying the Goldwater rule on that basis just does not have scientific support.”