Psychiatric Ethics

Philip Hickey, PhD
51
294

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)
  1. 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).
  1. They routinely present these labels as the causes of the problems in question, when in reality they are mere labels with no explanatory significance.
  1. 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.
  1. 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.
  1. They routinely administer these neurotoxic drugs and high voltage electric shocks to the brain coercively.
  1. 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.
  1. 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.
  1. 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.
  1. 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.
  1. 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.

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51 COMMENTS

  1. From blaming Colin Powell for her email scandal to ducking sniper fire in Bosnia, Hillary can’t seem to tell the truth !

    Pathological lying (also called pseudologia fantastica and mythomania) is a behavior of habitual or compulsive lying. It was first described in the medical literature in 1891 by Anton Delbrueck…

    The one that really sticks out to me is the ducking sniper fire in Bosnia lie, you have to watch the video to see how bad that one really is, its less then 2 minutes https://www.youtube.com/watch?v=f-woL6zF43c

    I just can’t stand story maker uppers, the funniest one ever was this guy that came into the substance abuse treatment place I volunteer at claiming he was busted manufacturing methamphetamine by the DEA with the chemicals and everything and his lawyers sent him to treatment. So I asked what chemicals and how much of them and it seemed like he didn’t know what heck he was talking about cause I read all about amphetamines surfing ADHD stuff online and by watching breaking bad.

    It was really funny when another client Googled his name did some searching like the court website and found out that the true story was he was busted for domestic violence against his girlfriend and got sent to treatment. That was funny as hell to me cause I just can’t stand story maker uppers.

  2. Contrasted with this reticence when it comes to diagnosing candidates for office A First Rate Madness: Uncovering Links Between Leadership and Mental Illness by psychiatrist Nassir Ghaemi, a book I have no intention of reading, by the way, would attribute successful leadership skills, in some instances, to “mental disturbance”. Also, you can find a List of mentally ill modern era world leaders on Wikipedia that links to a List of mentally ill monarchs. A funny thing about the “mentally ill modern era world leaders” is the number of them who would be described as totalitarian, or despotic. Apparently, there are three sort of politicians who have “mental illnesses”: 1. those thought to be superlative leaders, 2. those who have absolute, and undemocratic power, and who are not reluctant to use brute force, and 3. those who can be shown to be really lousy politicians. After Barry Goldwater whose slogan “in your heart you know he’s right” Lyndon Johnson’s people transformed into “in your guts, you know he’s nuts”, political candidates that lose are safely immune from such innuendo. (You think?) I see all psychiatric diagnoses as insulting, and so I’m not surprised at all that Allen Frances would follow his dismissal of a diagnosis for Donald Trump with a string of insults parroting his rival, Hillary Clinton’s, “incompetence” claims. Wow! He might as well have said he had a “bona fide mental illness”, the message is certainly something along the lines of ‘don’t vote for this man, everything about him, kind of like with a nut-job, even though he is not a nut-job, is wrong’..Of course, Frances, being an authority on ‘nut-jobs’, must know. His expertise has him, after all, spouting all sorts of “legitimate” nonsense.

    • Oops, apparently I didn’t close the tags for the book title properly, giving the rest of the comment emphasis. Ignore the emphasis if you can. As others have said, it’s a shame we can’t edit our comments.

      Anyway, thanks for this post. There isn’t much to these diagnostic labels, and in politics, especially, the squabbles around the idea can get particularly amusing as well as nasty. All sorts of politicos are inclined to pathologize their opposition. More, following Goldwater, off the record than on.

      • Right, “thinking” is “mental”. “Considering themselves to be superlative leaders” is speculative. When other folks “consider” them “superlative leaders” you are much less likely to get “diagnostic labels”, however, as Nassir Ghaemi shows, it happens. Delusions of grandeur, apparently, are more a threat to the powers that be than delusions of humility. Where would the mighty Hulk, after all, be if it weren’t from some kind of radiation contamination? Ditto a certain amount of arrogance and Alexander the not so great, Julius Caesar, Napoleon, etc. It’s all, as they say, relative.

  3. Dr Hickey, I always love reading your posts!

    Are we all in agreement that Trump is a “wack job”?

    Everyone in agreement, please raise your hand. The ayes have it.

    Doesn’t that sound familiar? Just replace your favorite symptom in place of “Trump” and symptom of your favorite diagnosis for “wack job” and you have the DSM committee meeting.

    Very, very scientific.

  4. So Dr Frances declares that Trump has no Personality Disorder. My next question would be ‘are his chemicals balanced though? And if so, how is that chemical balance being achieved?’

    I think Trump would treat a remote diagnosis from Frances with about as much credibility as Papa Doc making a voodoo doll and sticking pins in it.

    Good article Dr Hickey.

  5. Allen Francis saving normal?

    I used to joke that no one can earn a PhD without having a touch of OCD, but its not funny anymore. Running for president requires irrational self confidence and the ability to lie, manipulate, and fake sincerity. These are preliminary, fundamental job requirements.
    But in an age where every problem of thinking feeling and acting translates easily into a diagnosis, Francis cant find anything wrong with Trump?

    Thank you Dr Hickey
    Mike

  6. Hi Philip,
    Thanks for the amusing and serious article. I think I agree with nearly everything you say here.

    I was 20 in 1980 when I was introduced to Psychiatry at the Maudsley Hospital in South London and I couldn’t believe the amount of young people there (with very little wrong with them) that were going around the hospital describing themselves as “schizophrenic” and “manic-depressive”.

  7. The title is an oxymoron!
    …and the remainder of the article goes on to highlight why, so thank you once again, Dr Hickey.

    This quote from Dr Frances stood out for me:
    “Most people with mental illness are nice, polite, well mannered, well meaning, decent people. They suffer, but don’t cause suffering.”

    Perhaps, then, this could be added to the next DSM as a new symptom across all “mental illnesses”.

    …. and behaving like a Trump could become the primary definition of “mental health”. After all, the DSM currently doesn’t have a clear definition of “mental health”.

    • “The title is an oxymoron! …and the remainder of the article goes on to highlight why, so thank you once again, Dr Hickey.” Yes, as always, thanks Philip. I love your commentaries.

      As to, “… and behaving like a Trump could become the primary definition of ‘mental health.'” I think this is already the current definition of ‘mental illness,’ according to the psychiatrists like Allen Frances, and this is the problem.

      The psychiatrists currently believe all people should function as fiscally irresponsible, short run only money worshipping, psychopaths. But if you actually believe in working towards long run goals, and helping people and doing good works out of the goodness of your own heart on a non-profit basis, which is not bringing in tax revenue for the state in the short run, that’s when the psychiatrists believe you have a “mental illness.”

      But, of course, this psychiatric theology is not beneficial to society in the long run. But destroying society in the short run, is potentially lucrative for psychiatry in the long run.

  8. Based on the articles below do we have reason to be concerned about psychological ethics in addition to the psychiatric ethics? (This is just a sample of articles I found by psychologists.)

    From the Guardian – A psychological trap: making sense of Donald Trump’s life and personality
    From Shrink Tank – A Psychological Analysis of Donald Trump.
    From the Daily News – This is the fuel that drives the Donald Trump train, as explained by a forensic psychologist.
    From The Atlantic – The Mind of Donald Trump

    Are we to believe that only psychiatrists but no other mental health professionals including psychologists are never guilty of the many of the “… major ethical transgressions that have constituted an integral part of psychiatric practice for decades” or would this be wishful thinking? In addition, when it comes to psychopharmacology as an ethical violation consider this, “APA [American Psychological Association] Applauds Landmark Illinois Law Allowing Psychologists to Prescribe Medications.”

  9. Psychiatric diagnoses are indeed a fraud.

    But if you were to ever have a perfect “match”, it would be hard to do better than Donald Trump and Narcissistic Personality Disorder. This dude is hyperloaded with narcissism and excessive self-belief.

    And Frances is not even correct that psychiatric diagnoses as a rule cause distress and impairment. Higher level functional narcissistic people do not experience this, as Masterson, Adler, Rinsley, Kernberg wrote about long ago. Their arrogance and self-assuredness is problematic for others, but they do not usually feel or function worse because of it, except in the sense of not being able to have intimate relationships.

    It is funny how psychiatrists keep getting in trouble with their public statements – it’s hard not to, when one is standing on the crumbling edifice of psychiatric non-diagnoses that Frances and his minions tried to conjure into “illnesses” for the DSMs. There is simply nowhere to turn when your diagnoses do not hold wáter as real valid concepts.

  10. There’s a psychoanalyst who wrote Bush On the Couch, and also Obama On the Couch, without examining them, which is of course considered inappropriate, but I like watching them all throw labels at each other over their corporate political preferences. I also found out in Bush On the Couch about how GWB as a kid used to stick firecrackers in frogs’ rectums and light them.

  11. As an unaccredited human being I have the exactly the same facility to observe Trump’s behavior and draw my own conclusions about his suitability for office. I don’t need the “mental health professionals’ ” bogus labeling system. And as appalled as I am by Trump, I find weaponizing psych labels a manipulative precedent.

  12. I find it difficult to believe that psychiatry actually has ethics. If they did they wouldn’t be drugging people to the gills with the toxic drugs without their informed consent. They wouldn’t be drugging babies and children under the lie that they are “bi-polar” or have “ADHD”. No, the psychiatric profession does not follow a true code of ethics or they wouldn’t be doing the very things that they do on a daily basis.

  13. It is ethically absent and professionally irresponsible to diagnose a person you have never met or interviewed, particularly a person who is, on the surface, a character. I do not care for Trump or his ideology, but his name, that ridiculous hairpiece that looks like a varmint mummified on his head, the orange skin, etc.. all of that is a logo. His politics… I believe they are just part of the ad campaign… Diagnosing him would be almost as helpful as diagnosing Sir Patrick Stewart as he performs Hamlet. Narcissistic, selfish, lacking empathy, grandiose, attention seeking, impulsive, self serving… I ground my teeth through years of psych courses. These are the terms that I am discussed in. This is the caricature of my experiences that psychiatry has created, and these are the pleasant terms used for a very broad definition.

  14. A brilliant thrust from you right at the end: If psychiatrist Frances can rule out a diagnosis of Disease X for Mr. Trump without ever examining him, or even knowing him, or even talking with him, then . . . . well, you get my point.

    The guy in question here, famous or not, just stepped in the stinky dog poop perhaps because he was so damned busy bragging that he was an expert on personality disorders that he totally overlooked a very simple and logical piece of lore known to even the most fumbling resident in his/her first year of training (regardless of specialty): Making the diagnosis “Absence of Disease X” requires precisely the same careful contact with, and detailed attention to, any patient as does making the diagnosis “Presence of Disease X”. Or does Dr. Frances have some kind of ESP here ?

    A well-written piece and one of your best ever.

    James T. Lee, MD PhD