Psychoanalyst, Show Some Modesty

Recently the American Psychoanalytic Association reaffirmed its members’ right to pronounce on the mental health of public figures—in particular, the controversial Donald Trump. Making the issuance of this license a controversial act in its own right is the fact that the much larger and more influential American Psychiatric Association has expressly forbidden its members to render professional judgments on public figures for decades, a policy enacted after some 1200 of their number challenged the mental stability of the 1964 Republican candidate for President, Barry Goldwater—only for the magazine that polled them to be sued for libel, successfully, by the diagnosee.

The ban on armchair diagnoses of public figures by the American Psychiatric Association (which I will call by its common name, the APA, even though it shares those initials with the other body) is known to this day as the Goldwater Rule. As for Goldwater himself, he served in the United States Senate with every appearance of sanity until 1986.

Psychoanalysts may claim the authority to judge public figures, but in the United States the authority of psychoanalysis suffered a collapse decades ago from which it never recovered. Their practices and doctrines resistant to testing, Freudians or neo-Freudians ruled American psychiatry until their overthrow in the 1970’s cleared the way for the observational diagnostic system enshrined in the third edition of the APA’s Diagnostic and Statistical Manual (DSM-III), issued in 1980. (In sharp contrast to psychoanalytic judgments based on presumed or surmised causes, DSM-III deliberately omitted causal factors except in the case of a few diagnoses, notably PTSD.) The loose interpretive practices of the psychoanalysts made the strict empiricism of the new diagnostic system look good by comparison. At least people using DSM-III could agree on diagnoses.

Whereas the selling point of DSM-III was something called “reliability”—that is, its capacity to bring different observers to identical diagnostic conclusions—the disgrace of psychoanalytic judgments was their unreliability in every sense of the word. It was when that became intolerable, both as an affront to science and a public-relations liability, that the new DSM system was instituted.

To a good extent, then, we have the psychoanalysts’ abuse of interpretive license to thank for the DSM system that now rules—one that has proven only too effective at generating agreed-upon, that is, popular, diagnoses. Those concerned about runaway DSM diagnoses like ADHD (born as ADD in DSM-III) ought to reflect on the conditions that saw them into being and the downfall of psychoanalytic authority that made them possible.

Of the many factors that identify the DSM-III diagnostic system as a reaction or overreaction to psychoanalytic dominance, two stand out. First, whereas the psychoanalysts disdained specific diagnostic categories (a high priest of the sect, Karl Menninger, once proclaimed that “There is only one class of mental illness, namely mental illness”), such categories have multiplied ever since DSM-III came into being, to the point that the APA “manual” of mental disorders now approaches a thousand pages. Second, the architect of DSM-III, Robert Spitzer—whose organizational genius presides over the finished document a bit like Oppenheimer’s over the atomic bomb—trained as a psychoanalyst, only to reject psychoanalysis in favor of testable practices. The same path was taken by his successor, Allen Frances, now a critic of the overgrown and overweening DSM system itself, and most recently a defender of the Goldwater Rule.

In assessing the psychoanalysts’ fitness to pronounce on the mental health of public figures, let us remember the sort of florid absurdity that flourished when psychodynamic theories ruled. Those were the days when boys murdered their father and married their mother—and when the very nature of evidence was deformed. What meaning can evidence have if observed symptoms are less important than the “unconscious conflicts” that theoretically generate them?

The tyranny of theory figured in a notorious case reported in Science in 1973, wherein eight volunteers put psychiatry to the test by presenting themselves at the door of psychiatric hospitals claiming to have heard voices but acting perfectly rationally; transformed into clinical specimens and summarily dehumanized, they saw their own past “distorted by the staff to achieve consistency” with prevailing psychodynamic theory. (So wrote D. L. Rosenhan in his account of the hoax.) It was this sort of thing that eventually made psychoanalytic judgments an embarrassment in the eyes of the APA. Such were the excesses licensed by psychoanalysis that a figure didn’t need to have a past to become an object of Freudian judgment, even though neuroses theoretically trace back to early childhood. Literary critics under the influence of Freud used to make free pronouncements about fictional characters who do not, of course, possess an early childhood at all.

Over the construction of political difference as psychiatric deviance flies a black flag. In the Soviet Union dissenters were locked up in psychiatric hospitals; in Mao’s China incorrect thought was subject to the brutal correction known as thought-reform. In the light of such infamous abuses of psychiatry, we might have expected a principled psychiatrist to refrain from making political judgments. However, at least since the effort to identify the sources of “the authoritarian personality” following World War II, many have been strongly tempted to bend psychiatry to political ends. The APA itself could not refrain from instating in DSM-III a diagnosis born of intensely political opposition to the Vietnam War: PTSD, a hot spot in the DSM system.

At the root of the proclaimed right to issue psychiatric diagnoses of public figures despite all we know of the fallacies and risks of that practice, and despite the biodiversity of the labels applied, is hubris. When Jane Doe declares Mr. Trump reckless, she expresses a political view just as you or I do. When a psychiatrist declares Mr. Trump pathologically reckless (like his forebear, Mr. Goldwater), he expresses no ordinary view but speaks in the name of scientific knowledge, with its higher credentials, whether or not this knowledge actually exists. Such professional opinions on public figures have a way of tracking their authors’ merely political opinions, but costuming the latter as psychiatric findings gives them the appearance of something august and imposing. The offering of professional opinions on public figures turns out to be a higher form of character assassination.

When I was a kid we were taught not to use ad hominem arguments. “Stick to the issues and keep personal comments out of it.” Maybe this rule was intended to prevent debate from spiraling down into indecency, but I wonder if the thought behind it was as instrumental as that. Ad hominem argument was just dirty pool, and everyone knew it.

Like the many objectors to the Goldwater Rule in the APA itself, our psychoanalysts now act as if they were above such a trivial restriction. They are not. Reserving to themselves the right to argue ad hominem, claiming the higher truth of a dubious science for their political verdicts, they injure civil society even as they decry the object of their hatred as a threat to civilization.