The Ghost of Barry Goldwater and the Censorship of American Psychiatrists

Psychiatrists like myself aren’t supposed to speak up about politicians’ mental health. That needs to change.

In middle of the 1964 presidential campaign—just a year after JFK’s assassination—a minor media spectacle erupted that still resonates today. The publisher of Fact magazine sent a survey to psychiatrists asking about Republican nominee Barry Goldwater’s fitness for the presidency. In a nuclear age, Goldwater’s extremism-in-defense-of liberty philosophy scared many liberals, who are overrepresented among psychiatrists.

The cover story that followed wasn’t presented especially scientifically. The questionnaire was sent to 12,356 psychiatrists, only 20 percent of whom responded. Of those, almost one-half said they didn’t think Goldwater had any psychiatric problem that precluded fitness for the presidency. Still, the magazine presented the results with a sensationalist headline: “1189 psychiatrists say Goldwater is psychologically unfit to be president!” Specific statements from those respondents included claims that Goldwater was a classic schizophrenic, paranoid, and delusional; “I believe Goldwater has the same pathological make-up as Hitler, Castro, Stalin and other known schizophrenic leaders,” wrote one psychiatrist.

After the 1964 election, Goldwater sued Fact magazine for libel, won a $75,000 verdict, and ran it out of business. A few years later, the leadership of the American Psychiatric Association (APA) came to terms with its role in the Fact magazine affair, and published ethics guidelines forbidding member psychiatrists from commenting about the mental state of public figures.

Fast-forward a half-century. President Trump increasingly appears to be erratic and impulsive, with incoherent tweets sent at the crack of dawn villainizing the media and his detractors. In a digital age, pundits abound, but hardly a psychiatrist is heard. The “Goldwater Rule,” as it has come to be called, has censored them all, even as calls for Trump’s removal from the presidency based on his mental state —via the 25th Amendment—have swelled.

America’s psychiatrists continue live under Barry Goldwater’s shadow, and the American public elects its presidents without any psychiatric knowledge about them.

That’s a problem. Voters should care about having access to candidates’ psychiatric information because severe mental illnesses can render one unfit to be a political leader. But, it’s useful for a counterintuitive reason too: some psychiatric conditions, especially when mild, may be exactly what we need in our best leaders. The greatness of figures such as Winston Churchill and Abraham Lincoln, among others, may have been due in part to their psychiatric illnesses.

If our current president has a psychiatric condition, it’s useful to know how it might have helped him reach his current place of power, and also how it potentially could direct his actions as president.

The Goldwater Rule exists for two reasons. First, psychiatrists are ethically forbidden from revealing diagnoses without the consent of a patient, and second, it’s not professionally sound to diagnose a patient without directly examining that individual. Neither justification makes sense for public figures, though. The consent of a public figure is irrelevant to a psychiatric opinion, because consent and confidentiality only holds when there is a doctor-patient relationship. If the public figure isn’t my patient, I don’t need his consent to say anything I’d like to say about him.

Also, public figures give up some of their privacy rights. Most people will guard their taxes and their medical records jealously; they’re private. But it’s widely accepted that all presidential candidates should release their taxes—the current president being a glaring exception—and make their medical examination public knowledge. In a democracy, the public has a right to know about its leaders’ medical health. Why should psychiatric conditions be excluded?

Second, direct examination isn’t essential to psychiatric practice, nor is it uncommon to make diagnoses without relying on the direct examination of the patient. There is a unique phenomenon in psychiatry called “lack of insight,” which means that part of having a mental illness is that the patient doesn’t realize that she has an illness. Lack of insight is especially present in delusions, like with schizophrenia, and often with addictions. In the emergency room setting, it’s common to ignore what delusional or addicted patients will claim, and to rely on the report of family, friends, police, and others. In short, “direct examination” isn’t central to psychiatric diagnosis—often it’s useless.

There’s also an unspoken rationale for the Goldwater Rule which has nothing to do with ethics or standards of practice. The real concern is the enactment of personal political opinions behind the cloak of psychiatric legitimacy. In every election cycle over the past four decades, psychiatrists regularly have had opinions about candidates on both the left and right that follow their own political preferences. In a cacophony of politically-driven opinions, the Goldwater Rule is a mechanism of forcing psychiatrists to behave.

That’s the real motive behind the Goldwater Rule: psychiatrists are behaving badly, misusing their clinical terms to justify their political opinions. This certainly was the case in 1964. And it can be the case today. But need it be the case?

In recent years, APA leaders have added another justification to their rationalization of the Goldwater Rule. Making comments about public figures is stigmatizing, they claim.  Stigma, or discrimination against psychiatric conditions ultimately is a reflection of society’s ignorance and biases. The reason to end discrimination against psychiatric illness is the same reason why many fight against racism and sexism: it’s immoral. But I would emphasize that it’s also not factual: psychiatric illnesses aren’t necessarily bad, harmful, terrible things. In some ways, those with psychiatric illnesses are better than those who are mentally healthy.

Take Winston Churchill. His doctor, Lord Moran, published diaries about a decade after the statesman’s death, in which he revealed Churchill’s life-long severe depressive episodes, for which he was treated with amphetamines, the first modern class of antidepressants. Churchill’s doctors also diagnosed and treated him for manic-depressive illness. His family included several severely depressed and psychiatrically hospitalized relatives, as befits this highly genetic condition. (His own daughter committed suicide.)

Abraham Lincoln was diagnosed with severe melancholy, the 19th century term for severe depression, and was treated with mercury pills. He was suicidal at times, and his friends hid knives from him. His family also was known to have a number of members with insanity.

Yet Churchill and Lincoln—among others—were great leaders in times of crisis, perhaps not only in spite, but because, of their conditions. Research over the last few decades shows some benefits exist with depressive and manic states. In psychological experiments, people with depression are more realistic than normal, mentally healthy, non-depressed persons. People with depression score higher on tests of empathy than normal mentally healthy individuals. Mania is associated with creativity, both in psychological tests and in studies of creative professions. Writers and artists have much higher rates of bipolar disorder and major depressive disorder than control groups.

Put inversely, being mentally healthy has some disadvantages; people are generally less realistic, less empathetic, and less creative compared to those with manic-depression. These are the leadership traits needed in crisis, while being sane, solid, and predictable works well for a leader during non-crisis times. In times of peace and prosperity, the mentally healthy leader, who gets along well with others and conforms to society’s norms, is popular. Calvin Coolidge and Neville Chamberlain were excellent and popular leaders in the 1920s, before war and economic crisis. Winston Churchill was a failed leader in the same period, a terrible chancellor of the exchequer in the 1920s who fiddled with an economy that didn’t need fiddling. He was a failure in peacetime, a victor in war.

So mental health and mental illness aren’t as simple as some would like to believe: one or the other isn’t always good or always bad. Some famous failed crisis leaders were quite mentally healthy, normal, sane, pleasant, solid persons: Chamberlain and General George McClellan are two classic counterexamples to Churchill and Lincoln, both in their sanity and their failure as crisis leaders.

Of course, there also are negative historical examples. Adolf Hitler, for instance, clearly had severe manic-depressive illness. From his adolescence onward, he had weeks to months when he would be grandiose, active, highly energetic, talking endlessly—a manic episode—alternating with weeks to months where he had no energy at all, couldn’t speak, would lay in bed, uninterested in everything, sometimes suicidal—a depressive episode. His personal physician diagnosed him with manic-depressive illness. There even was a plot by generals in 1938 to arrest him and then to have the prominent psychiatrist Dr. Karl Bonhoeffer declare Hitler insane and unfit for office.

So is Donald Trump more like Churchill and Lincoln, or more like Hitler? Here is where most commentators would make their psychiatric judgments based on their political preferences. But let’s be as objective as possible.

Though most of Trump’s opponents emphasize “narcissism,” this term is dubious as a psychiatric diagnosis. (The validity of the concept of “narcissistic personality disorder” has been found to be questionable in clinical research studies.) The adjective may have meaning: someone is arrogant and self-absorbed; but that’s an English descriptor, not a scientifically proven disease. We need not censor any such discussion with the Goldwater Rule, but we also shouldn’t misuse psychiatric concepts for personal or political purposes.

Instead, there are other features of the president that reflect a clear psychiatric diagnosis, without any need for hand-wringing about “direct examination,” since the president admits, even revels in, many of these traits: he brags that he has little need for sleep; he’s very talkative; he’s high in energy; he’s very self-confident; he’s very distractible. This combination of traits adds up to a manic episode, which would be part of manic-depressive illness. Yet Trump doesn’t have “episodes”; his symptoms are constant. These symptoms add up to a hyperthymic temperament, a concept that has been scientifically validated for almost a century, and is genetically and biologically related to manic-depression. This condition is especially common among entrepreneurial leaders, and was likely present in both Franklin Delano Roosevelt and John F. Kennedy.

How does this psychiatric assessment relate to any political judgments about the president?

Whether you agree with his politics or not, Trump’s methods in the 2016 election broke many norms of political campaigning, and yet still proved effective. He clearly was more creative than his opponent, realizing that traditionally blue Midwestern states could shift against the Democrats.

Since the election, his political failures—the initial Muslim ban, the health care bill, the tension with NATO allies—raise concerns about whether he is attuned to reality. His impulsive decisions and self-inflicted wounds regarding the FBI’s Russia probe raise questions about his ability to manage the office of the presidency. The possibility of legal risks, including potential impeachment, have quickly surfaced for the beleaguered president. All these factors suggest that the same manic features which helped a candidate creatively now serve a sitting president poorly.

We’ve so far avoided a major national crisis, like a terrorist attack or a major economic jolt. So, Trump’s actions may be creating crises where none exist, or turning small ones into larger ones. Psychiatrically, Trump is no Neville Chamberlain, and, though he may share some psychiatric traits, he’s no Winston Churchill either. Rather, like Hitler or Kennedy, if he is taking steroids or some other substance that could worsen his baseline hyperthymia, he could veer towards harming himself and his office.

Making a psychiatric diagnosis in a public figure need not be a political death sentence.  Maybe we should be looking for some conditions, like manic-depression, in our leaders. I’m not claiming that there are no disadvantages to manic-depression, and other psychiatric conditions. When severe, depression renders you nonfunctional and suicidal; when severe, mania can lead to delusions and harmfully impulsive behavior. The advantages conferred by these states are more prominent when the symptoms are mild to moderate. This would require more engagement, not less, between psychiatry and political life.

The fact that the American Psychiatric Association thinks it’s so terrible to make psychiatric diagnoses of public figures shows that APA leaders themselves are discriminating against psychiatric illnesses. The assumption is that any psychiatric diagnosis will be harmful to the public figure. Instead of trying to fight society’s stigmatizing beliefs, the APA accepts them.

Instead, psychiatrists should publicly engage to fight the stigmatization of psychiatric illnesses. They should speak about psychiatric illnesses freely, to inform and educate, and not as a weapon to harm others.

Presidential candidates should make their medical records open to the public, including their psychiatric records. Medical evaluation of candidates should include a psychiatric evaluation, conducted by independent examiners. Identified illnesses shouldn’t be viewed as disqualifying, but as informative, having both positive and negative aspects.

In politics, discrimination based on race, gender, and sexuality is slowly receding relative to past decades.

Now it’s the turn of psychiatric illness. It’s time to use psychiatric knowledge for the benefit of political life. It’s time to put an end to the Goldwater Rule, an act of censorship based on faulty assumptions that derive from and worsen the stigma against psychiatric disease.

Nassir Ghaemi

Nassir Ghaemi is a psychiatrist at Tufts and Harvard universities and author of A First-Rate Madness.