Psychiatric Ethics

On June 9, 2016, the very eminent psychiatrist Allen Frances, MD, published an article on the Huffington Post Blog.  The piece was titled Trump Is Breaking Bad, Not Clinically Mad.

The gist of the article was that, although the Republican presidential candidate has many flaws, he does not have a mental disorder.

Here are some quotes:

“Trump obviously does have an outsize, obnoxious personality, but most certainly does not have a Personality Disorder (and there is no evidence that he has now, or ever has had, any other mental disorder).”

“This does not make Trump fit to be president, not by any means. He must be by far the least suitable person ever to run for high office in the US — completely disqualified by habitual dishonesty, bullying bravado, bloviating ignorance, blustery braggadocio, angry vengefulness, petty pique, impulsive unpredictability, tyrannical temper, fiscal irresponsibility, imperial ambitions, constitutional indifference, racism, sexism, minority hatred, divisiveness etc.”

“People who dislike Trump’s outrageous behavior should call him on it, but need not and should not, add to their critique a gratuitous and inaccurate diagnosis of mental disorder.”

Dr. Frances adduces some arguments in support of his contention.  For instance:

“Personality Disorder requires that the individual’s personality characteristics cause clinically significant distress or impairment. Trump’s behavior causes a great deal of significant distress and impairment in others, but he seems singularly undistressed and his obnoxiousness has been richly rewarded, not a source of impairment.”

and

“Most people with mental illness are nice, polite, well mannered, well meaning, decent people. They suffer, but don’t cause suffering.”

. . . . . . . . . . . . . . . .

I saw Dr. Frances’s article when it first appeared, and I considered writing a response.  My response would have been along the lines:  if “psychiatric diagnosing” is, as psychiatrists claim, a complex, detailed, painstaking, highly skilled activity involving close observation, discussion, and gathering of accurate collateral information, how can Dr. Frances legitimately conclude a status of “no diagnosis” in someone he has never met using information derived primarily from media reports?

In the event, there were other priorities, and I didn’t write the article, but on August 3, 2016, Maria Oquendo, MD, President of the APA, wrote The Goldwater Rule: Why breaking it is Unethical and Irresponsible.

The Goldwater Rule, or, more formally, Section 7.3 of the APA’s  Principles of Medical Ethics With Annotations Especially Applicable to Psychiatry 2013 Edition, states:

“On occasion psychiatrists are asked for an opinion about an individual who is in the light of public attention or who has disclosed information about himself/herself through public media. In such circumstances, a psychiatrist may share with the public his or her expertise about psychiatric issues in general. However, it is unethical for a psychiatrist to offer a professional opinion unless he or she has conducted an examination and has been granted proper authorization for such a statement.”

Incidentally, Section 7.3 is called the Goldwater Rule because in the 1964 presidential election campaign, many psychiatrists publicly assigned “psychiatric diagnoses” to Barry Goldwater and declared him unfit for the presidency.  Here’s Dr. Oquendo’s take on this matter:

“This large, very public ethical misstep by a significant number of psychiatrists violated the spirit of the ethical code that we live by as physicians, and could very well have eroded public confidence in psychiatry.”

Note that Dr. Oquendo condemns the activity in question because of potential erosion of public confidence in psychiatry, but makes no mention of the damage done to Senator Goldwater.

But Dr. Oquendo is clear on one thing:

“Simply put, breaking the Goldwater Rule is irresponsible, potentially stigmatizing, and definitely unethical.”

Dr. Oquendo doesn’t actually mention Dr. Frances, or his psychiatric delving into the media-reported thoughts, feelings, and actions of Mr. Trump, but it seems clear that her article was an oblique response to Dr. Frances, and a blunt warning to other psychiatrists who might be tempted to engage in this kind of activity.

. . . . . . . . . . . . . . . .

The highly esteemed and prestigious psychiatrist Ronald Pies, MD, also weighed in on this issue.  On August 25, he published on Psychiatric Times Deconstructing and Reconstructing the “Goldwater Rule”.

Dr. Pies expresses agreement with Dr. Oquendo’s general principle, but argues that Section 7.3 is in need of “substantial revision”, and he outlines the changes he would like to see.  He then concludes:

“For a mental health professional—or any physician—to publicly offer a diagnosis at a distance of a non-patient not only invites public distrust of these professionals, but also is intellectually dishonest and is damaging to the profession.”

Again, there’s no mention of Dr. Frances’s article in the text, but Dr. Frances’s article is listed under “Further Reading”, and is clearly the target of Dr. Pies’ criticism.

Note here also that with regards to the psychiatric evaluation of public figures on the basis of media reports, Dr. Pies’ concerns are:

– it invites public distrust of the psychiatrist(s) concerned
– it is intellectually dishonest
– it is damaging to the profession

As in Dr. Oquendo’s paper, the emphasis is on the damage done to the psychiatrist and to the profession, but there’s no mention of the potential damage to the individual who is subjected publicly, presumably without any invitation on his part, to psychiatric scrutiny and assessment.

Dr. Pies’ characterization of this kind of activity as “intellectually dishonest”, coming as it does from an ardent promoter of a profession that is intellectually bankrupt, strikes me as ironic.  Indeed, for any psychiatrist to discuss the ethical or intellectual merits of publicly evaluating the “mental health” of prominent figures represents a high point in hypocrisy.

I’m certainly not condoning Dr. Frances’s activity, but in the context of psychiatry’s general lack of even a semblance of ethical behavior, his lapse strikes me as relatively minor.

Here are some of the major ethical transgressions that have constituted an integral part of psychiatric practice for decades.

1. They have created the bogus concept of mental disorder/mental illness, and have relentlessly and shamelessly expanded this concept to embrace virtually every significant problem of thinking, feeling, and/or behaving, even childhood temper tantrums (disruptive mood dysregulation disorder)

2. They have used this concept to formally and deceptively medicalize problems that are not even remotely medical in nature, including childhood disobedience (oppositional defiant disorder) and road rage (intermittent explosive disorder).

3. They routinely present these labels as the causes of the problems in question, when in reality they are mere labels with no explanatory significance.

4. They routinely deceive their clients and the general public that these illnesses have known neural pathologies: the infamous “chemical imbalances” that have been avidly promoted by psychiatry for decades.

5. They have shamelessly peddled neurotoxic drugs as corrective measures for these so-called illnesses, although it is well known that no psychiatric drugs correct any neural pathology.

6. They routinely administer these neurotoxic drugs and high voltage electric shocks to the brain coercively.

7. They have conspired with the pharmaceutical industry in the creation of a large body of questionable – and in many cases outrightly fraudulent – research all designed to “prove” the efficacy and safety of psychiatric drugs.

8. They have shamelessly accepted large sums of pharma money for very questionable activities, e.g., the ghost writing of books and papers which were actually written by pharma staff; the substitution of pharma infomercials for CEU’s; the acceptance of pharma money by paid “thought leaders” to promote new drugs and “diagnoses”; the targeting of captive and vulnerable audiences in nursing homes, group homes, foster care systems, juvenile detention centers, etc., for prescriptions of psychiatric drugs.

9. They have routinely disempowered millions of people by telling them falsely that they have incurable illnesses for which they must take psychiatric drugs for life.

10. By falsely convincing people that their problems are illnesses which are essentially out of their control, they have undermined ordinary human fortitude and resilience, and have fostered a culture of powerless and drug-induced dependency.

11. They accept no limits to their expansionist agenda, insisting that there are still vast numbers of “untreated patients” who need to be brought into their “care”, including children as young as three years, and elderly people in their final years.

. . . . . . . . . . . . . . . . 

In this general context of rampant institutionalized corruption and deception, a discussion of Dr. Frances’s ethical lapse in publicizing his psychiatric assessment of Mr. Trump strikes me as absurdly irrelevant.

The Real Issue

Interesting as these matters are, the real issue here is that Dr. Frances has let the proverbial cat out of the bag with regards to psychiatric “diagnoses.”  He has told us, indeed, he has demonstrated, that psychiatric “diagnosis” is nothing more than a facile sorting activity – a trite and simplistic algorithm – which has as much validity and intellectual rigor as astrology.  The point is that Dr. Frances conducted a psychiatric “diagnostic” assessment on Mr. Trump based entirely on media reports, and concluded unambiguously that the latter “… most certainly does not have a Personality Disorder.”  And to make matters even more glaring, in his preamble to this conclusion, Dr. Frances presents himself as highly qualified to make this judgment:

“I know something about Personality Disorders, having written the final versions in DSM III, DSM IV, and DSM 5 and also having been Founding Editor of the Journal Of Personality Disorders.”

And this is the problem that Dr. Oquendo and Dr. Pies seek to address:  when psychiatrists conduct “diagnostic” assessments on public figures in this way, they are drawing attention to the fact that psychiatry’s “diagnostic” system is more like a children’s matching test than a genuine medical nosology.  They are drawing attention to the fact that the Emperor has no clothes. And we all know where that leads.

Those of us who are members of what the most eminent psychiatrist Jeffrey Lieberman, MD, describes as the “virulent Anti-Psychiatry Movement” have been drawing attention to the invalidity and triteness of psychiatric diagnoses for decades.  But when the architect of DSM-IV demonstrates these realities in a public statement, it constitutes a major blow to psychiatry, which no amount of APA damage control can offset.  If psychiatric “diagnoses” can be performed on the basis of sensationalized media reports without ever meeting the individual or checking the accuracy of the reported information, then psychiatric “diagnoses” can’t lay much claim to validity, reliability, or usefulness.