November 27, 2016

Nov. 27, 2016

Place Holder: Point - Counterpoint on Goldwater Rule from July 20, 2017 Psychiatric Times>

Dealing With American Psychiatry’s Gag Rule | Psychiatric Times
POINT
For the Counterpoint, see The Goldwater Rule Is Still Relevant
Dr Glass is a psychoanalyst and Associate Professor of Psychiatry (Part-time) at Harvard Medical School and a Senior Attending Psychiatrist at McLean Hospital. He was a distinguished life fellow of the American Psychiatric Association until he resigned in protest in April 2017.
Since 1973, the American Psychiatric Association’s (APA) Code of Ethics has considered it “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.”1 This measure, commonly referred to as “the Goldwater Rule,” was part of the fallout from psychiatrists offering their armchair diagnoses of Barry Goldwater for Fact magazine, which was successfully sued for libel by the losing presidential candidate. APA’s chastened leaders then acted to protect their professions’ reputation by including in their code of ethics a prohibition that was widely understood to prohibit future diagnosis of public figures.
This February, 33 psychiatrists signed a letter to the New York Times2 that decried the silence from mental health professionals caused by the Goldwater Rule. While it refrained from diagnosis, the letter concluded the “grave emotional instability indicated by Mr. Trump’s speech and actions makes him incapable of serving safely as president.” Notably, none of us had interviewed the President nor had we obtained his permission to speak out.
The following day, the New York Times printed a letter from a supporter of the Goldwater Rule, Dr. Allen Frances, who “wrote the criteria that define(d) narcissistic personality disorder,” calling us to task for “psychiatric name-calling,” although no diagnosis had been asserted.3 This brought the conflict to a head in a very public way.
One month later, perhaps in response, the ethics committee of the APA issued a new interpretation of the Goldwater Rule. While the language of the underlying code remained unchanged, the committee’s new opinion made it clear that the prohibition was not restricted to making diagnoses, stating that it “applies to all professional opinions offered by psychiatrists, not just diagnoses.”4 The APA statement continues:
Making a diagnosis, for example, would be rendering a professional opinion. However, a diagnosis is not required for an opinion to be professional. Instead, when a psychiatrist renders an opinion about the affect, behavior, speech, or other presentation of an individual that draws on the skills, training, expertise, and/or knowledge inherent in the practice of psychiatry, the opinion is a professional one. Thus, saying that a person does not have an illness is also a professional opinion.
Thus any psychiatrist making a comment about the mental functioning of any public figure would be in violation of the profession’s code of ethics. Specifically, the new interpretation stated that comments about a public figure’s affect and behavior constituted an unethical professional opinion.
In this way, a significant shift was made from the decades-long common understanding that psychiatrists should refrain from making diagnoses or interpretations about the unobservable inner life of public figure to prohibiting all comments about easily observable phenomena. At the same time, the APA noted that psychiatrists were allowed to comment as citizens, as long as they didn’t identify themselves as psychiatrists; a statement that many found gratuitous and oddly self-defeating, insofar as it intentionally devalued psychiatric expertise.
My colleagues and I were shocked by what we felt was the APA’s “gag rule.” Since I had previously agreed to write an article that contained a more detailed delineation of the issues broached in the first Times letter, I wrote to the APA leadership, expressing my profound disagreement with the new interpretation and urging them to rescind it. I argued that the new, more literal application of the Goldwater Rule made a fundamental error conflating a “professional opinion” that one might provide in a clinical setting and be the basis for a treatment plan with the “opinion of a professional” who is making an observation in a non-clinical context, in the public domain.
There is no patient-doctor relationship in the latter instance and hence the standards that apply to clinical assessment (thorough history, mental status exam, interview with relevant members of the patient’s support system, etc; necessity for confidentiality and authorization from “the patient”) are not applicable. One might be interested in the “opinion of a professional” (which wouldn’t be the foundation for a plan of medical care) when selecting an investment, choosing a catering menu, or learning more about the Civil War.
I acknowledged that caution needs to be used when commenting on matters from afar. It is always appropriate in those circumstances to qualify one’s impressions in accordance with one’s methodology. I said, if the APA had advised its members to exercise such caution, I would have no objection. But I argued that to ordain a gag rule out of concern that fully trained professionals might misspeak privileged the protection of the profession’s public image over members’ rights to follow their consciences, even if it turned out that some persons spoke imprudently.
Dealing With American Psychiatry’s Gag Rule: Page 2 of 2
I said the APA confused the personal and necessarily private doctor-patient relationship with the right, some would say duty, of psychiatrists to publicly add their understanding of widely available but bewildering behavior of political leaders that is regularly and haphazardly analyzed by non-professionals. I was not advocating diagnosis, although that is frequently what is being objected to.
For example, recently Dr. Prudence Gouguechon assessed President Trump’s capacity for leadership using the US Army’s Field Manual 6-22 for Leadership Development (the criteria are trust, discipline and self-control, judgment and critical thinking, self-awareness, and empathy.)5 This non-diagnostic assessment by a psychiatrist and psychoanalyst was highly illuminating and also in clear violation of the Goldwater Rule.
I agreed that making diagnoses of public figures without interviewing them (as opposed to commenting of their widely available videotaped behaviors and remarks) is not relevant or helpful, as there have been many great leaders with diagnosable mental illness who functioned superbly (Abraham Lincoln and Winston Churchill to name two.)
In short, I found this new interpretation of the Goldwater Rule to be an unacceptable infringement on my right and duty to participate in public dialogue about issues that confuse the public and where the perspective of psychiatrists could be very relevant and enlightening. It unduly and misguidedly forced me to refrain from speaking in a manner I considered responsible or to do so under an unwarranted cloud of ethical doubt.
The APA’s response was to offer a dialogue with a colleague who was a consultant to the ethics committee with the hope that some common ground could be found. Over the next two weeks we had “a frank and cordial” conversation, ending in our agreeing on two points:
1. There is a respect-worthy moral foundation for both the decision to refrain from statements about the apparent impairments in psychological functioning of a public figure and for making them, as long as the statements are offered circumspectly and without offering a diagnosis.
2. As things currently stand, those APA members who feel compelled to speak out about such perceived impairments and act on their convictions will be in violation of the APA’s ethical code.
I concluded that the APA is trying to protect American psychiatry from looking bad by prohibiting its members from using their professional expertise and experience to comment on the readily observable behavior and remarks of public figures. The APA appears to have preemptively decided that its members cannot be allowed to exercise their own good judgment and self-restraint in these matters, but must be muzzled to protect the profession. This stance in and of itself devalues American psychiatrists and thus defeats its purpose. To my knowledge no other medical specialty is constrained in this manner.
Because I intend to continue to speak out in these manners and am unwilling to practice under a cloud of ethical suspicion cast by my own professional organization, I resigned in protest from the APA after 41 years of membership. I had hoped it would end differently, but, in retrospect, once the APA insisted its members couldn’t join the conversation in the public square and reference their professional experience and expertise, the outcome was preordained.
Two Comments:
I've debated this with colleagues like many probably have. I'm very clear the Goldwater Rule and its reinterpretation are 100% correct. Calling it a 'gag' is already a loaded, biased term and suggests a fundamental lack of understanding of its rationale, as does wording like: "I agreed that making diagnoses of public figures without interviewing them (as opposed to commenting of their widely available videotaped behaviors and remarks) is not relevant or helpful...."
Eh, no. Diagnosis of any person in the absence of a psychiatric interview is intellectual buffoonery more like it, rather than not of relevance or help and is deserving of condemnation. It's simply completely unprofessional at the most foundational level.
Psychiatrists are also 'gagged' from discussing their patients outside the consulting room without at the very least their patients' permission. Or if subpoenaed. Gagged is not the right term. Forbidden is correct terminology and forbidden within an ethical framework and with very good rationale.
I completely reject the idea that any psychiatrist should feel they can comment upon public figures' mental states when they would not know anymore about the person than the next person reads or sees in the media. Not to be confused of course with special circumstances when a psychiatrist has been called in as an expert witness in a medicolegal context. Just a few random thoughts while snacking between consults; by no means a complete response.
replyLarry @ Thu, 2017-07-20 19:23
The old Goldwater rule was decent, and I think an exception could be made for commentary on obvious cognitive errors (i.e. Pelosi, McCain). I agree with the author that the new modifications go to far and basically gag psychiatrists as citizens. Their hypothetical example of not identifying as a psychiatrist is specious, because in the Internet age, it is impossible to keep that hidden.
I'm agreeing with you even though you and I probably see differently on the issue of publicly diagnosing Trump, which I find abhorrent simply because it means that all this phony sanctimony about not stigmatizing mental illness was a ruse. Psychiatrists have been all to eager to use stigma to score political points. And also because almost all politicians are narcissistic if not sociopathic including the politicians that these critics voted for.
The real ethical issue the APA ought to be focusing on is that it should be unethical to stigmatize a person with a speculative, non-empirical mental illness for partisan purposes. There is no 25th Amendment issue with Trump, although there might be with McCain if he were President right now, and there are legitimate uses of the 25th Amendment if there is cognitive decline or even the mere presence of a glioblastoma. In other words, empirical evidence.

Welcome to the ex-APA club. I haven't been in since residency. Getting out before private practice was a wise and financially prudent decision. There are better and cheaper ways to get CME and stay in touch with colleagues. As a guild it is self-destructive and ineffective. It's embrace of collaborative care is a professional suicide pact, in my opinion.

The Goldwater Rule Is Still Relevant | Psychiatric Times
COUNTERPOINT
For the Point, see Dealing With American Psychiatry’s Gag Rule
Dr Brendel is a consultant to the American Psychiatric Association (APA) Ethics Committee as well as Director of the Master of Bioethics degree program at the Harvard Medical School Center for Bioethics, a practicing clinical and forensic psychiatrist at Massachusetts General Hospital, and an Assistant Professor of Psychiatry at Harvard Medical School.
On November 8, 2016, voters elected Donald J. Trump the 45th President of the United States. Trump’s supporters saw strength in his anti-establishment rhetoric, unorthodox public persona, and channeling of resentment of the political status quo. His detractors felt otherwise. Post-inauguration, President Trump continued to behave the way he had as Candidate Trump. Those who supported the President rallied behind him. Those who never did or could no longer support the new President continued the critique.
Some mental health professionals (including Dr Glass), troubled by the new normal, went to the New York Times, without examining the President, without his consent, and based only on the limited knowledge from publicly available data about the President, to publicly air their opinion that the “grave emotional instability indicated by Mr. Trump’s speech and actions makes him incapable of serving safely as president.”
A small number of psychiatrists have been critical of our profession’s restraint regarding public comments by psychiatrists about the mental health of the 45th President. I am the unnamed colleague mentioned in Dr Glass’s article and therefore appreciate the request from Psychiatric Times to offer this critical engagement of the Dr Glass’s critique of the Goldwater Rule, the ethics position of the American Psychiatric Association that prohibits psychiatrists from volunteering public professional opinions about individuals in the public eye.
Precisely in response to questions about the role of psychiatrists in the situation that a psychiatrist, in good faith, believes a public individual poses a threat to the country or national security, the APA Ethics Committee, to which I serve as a consultant, in March of this year clarified the APA’s longstanding Goldwater Rule. One misconception about the APA’s position was that it only applied to rendering a psychiatric diagnosis of a public figure.
However, the Goldwater rule has, since its inception, referred broadly to “professional opinions,” not just to diagnosis. The March 2017 Ethics Committee Opinion sought to clarify the meaning of “professional opinion” and reaffirm the rationale for the APA position. It was not an expansion of the decades-old APA position, and it is not a gag rule. It does, however keep medical diagnosis in a medical setting and out of the media.
At the core of Goldwater doctrine are the fundamental considerations that psychiatrists do their work and formulate psychiatric opinions with respect for persons (including permission and privacy) and through established methods, including examination, history-taking, and collateral inquiry. Dr Glass attempts to obfuscate this ethical underpinning of the Goldwater position, in part, by drawing an artificial distinction between the professional role of the psychiatrist in clinical and non-clinical settings. However, the sound principles of ethics and professionalism apply regardless of whether an encounter is what he would define as clinical or non-clinical.
A first consideration behind Goldwater is the fundamental ethical principle of respect for persons. In order to respect persons, psychiatric evaluation of an individual occurs with consent or other authorization and with clear parameters of expectations regarding privacy of the encounter and assessment. Respect for persons in the setting of rendering professional judgments does not require that an individual establish a clinical relationship. Even absent an examination, making professional judgments about an individual’s mental health is intrusive and can have negative consequences. We need not look further than Barry Goldwater to see that these conclusions, even when “non-clinical,” can be harmful.
A second justification for the Goldwater Rule involves the methods of the profession: psychiatric evaluation and diagnosis is a medical endeavor that occurs in the context of an evaluation, based on thorough history taking, examination, and collateral information. Psychiatric opinions based on insufficient data and/ or method, whether they include diagnoses, compromise both the integrity of the individual psychiatrist and the profession. This behavior also has the potential to lead patients to question the rigor and confidentiality of their own care, or discourage those suffering from mental illness from seeking help for the same reasons.
It is simply not the case that there are separate standards for “clinical” and “non-clinical” contexts. Rendering an opinion, as a psychiatrist, is a medical opinion in any context. The difference is that when it occurs in the media based on observation from afar, or what the author considers a “non-clinical” context, the opinion is given without the rigor and methodology that justifies its conclusions. It is conjecture, albeit based on general psychiatric knowledge and accumulated experience, masquerading as medical truth about a particular individual. The statement, in other words, seeks validation by proxy of the professional qualifications and general psychiatric knowledge of the speaker as a substitute for the actual work and expertise of the profession required to justify the conclusion. And the public nature of the statement draws attention to the speaker rather than focusing on the medical interest of the subject of the statement.
The ethical psychiatrist’s conduct in the media is no different from the ethical conduct of any other physician. In the example of an orthopedist offered by the author, the orthopedist may consult to the media with clear articulation of the parameters that he or she has not examined the particular individual, does not have permission to speak about the particular individual, but will offer general information about types of injuries or other conditions and their care. Alternatively, if a diagnosis is publicly known, the orthopedist may discuss, in general, the features of the condition, its treatment, and expected course. The Goldwater position permits, even encourages, the same from psychiatrists in order to educate the public about psychiatric illnesses and their treatment.
The Goldwater position also aims to prevent stigma by delineating the bounds of professional norms and creating separation between the discourse of capacity to govern and the diagnosis of a mental illness. Linking capacity to govern, a political and legal determination, with mental illness per se stigmatizes mental illness by erroneously characterizing the mere presence of psychiatric symptoms as incompatible with performance of one’s responsibilities for governance. Especially for those in the public eye, this linkage may perpetuate a chilling effect on seeking treatment for mental health concerns. Instead, public education that psychiatric symptoms are treatable, common, and even expected in some situations has the potential to destigmatize treatment-seeking.
Uncoupling the public discourse of capacity to govern from the rubric of mental illness further allows the determination of fitness to govern to remain squarely where it constitutionally belongs, in the government itself. In the case of the president, the 25th Amendment provides a framework for addressing concerns of presidential fitness. Within this framework, if a psychiatrist has actual knowledge or serious concern about the mental health and fitness of a president, the appropriate audience with whom to share this concern is not the New York Times or other media outlet, but privately with the medical or other government personnel whose role it is to evaluate the health and fitness of the President to continue in that role.
The difference in the audience and public nature of the professional opinion separates politics from medicine, and gives the psychiatrist who feels strongly about the ability of the president to govern an appropriate forum to voice his medical concerns. As Dr Glass states, there are indeed two interests at stake in this discussion: the issue of the profession’s public image and members’ rights to follow their conscience. Taking the discussion out of the media and into the medical realm addresses both of these considerations.
The key to Goldwater is that psychiatrists should not be rendering professional opinions on their own account in the press or on TV without license and inconsistent with the methods of the profession. Goldwater has always intended to protect the integrity of psychiatric practice by highlighting the perils of proceeding publicly, without license, and with insufficient data in making assessments about the mental health of public figures. It is not meant to and does not exclude psychiatrists from important work in the public interest.

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Previous November posts here

Read Read the nearly 200 of my Daily Kos articles or don’t.  Some of my photos  

Sunday, Nov. 27, 2016

Excerpts: Donald Trump, and the Republican majorities in the Senate, are poised to wipe out the signature victories of his predecessor in areas ranging from health care to the environment. He will enter office as the first explicitly anti-free trade president since Herbert Hoover, committed to unraveling a series of agreements that underpin the root assumptions of global commerce. His list of potential Supreme Court nominees include judges who reject not simply the jurisprudence that led to the gay marriage and abortion decisions, but the arguments that led the Court to uphold New Deal legislation some 80 years ago and to bind states to the protections of the Bill of Rights.
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… the idea of a Republican House and Senate acting as a brake on Trump seems almost fanciful. Yes, Rand Paul’s civil libertarian and anti-globalist impulses may lead him to oppose a nomination of an Attorney General Jeff Sessions or a Secretary of State John Bolton. But his would be a lonely voice—especially given the fact that the Republican base is in the hands, at least for now, of an incoming President who won by running head-on against the congressional wing of the party.
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Is it odd that a Ronald Reagan, who won historic landslides, could change so little while a president who “lost” by a million or more votes might change so much? Chalk it up to the quirks of the Electoral College, or a late intervention by an FBI director, or a tone-deaf Democratic candidate, or to a simmering fury at the political-media elite by just enough disaffected voters to turn three states red, or to whatever contingent forces you choose. But the reality is those forces have brought us to the very real prospect of the most profound, unsettling changes in public policy in close to a century.

Joy Reid, on MSNBC, is doing a story about how Scots feel about Trump… she showed this newspaper:

Saturday, Nov. 26, 2016


We keep reading about the possibility that Trump will make major changes to policy that the majority of Americans don’t support. Some fly in the face of logic, climate change for example, and others in attitudes about issues like abortion and most forms of birth control.
We read today on Daily Kos that a radical anti-abortion group is ready to help Attorney General designate Jeff Sessions prosecute Planned Parenthood. Most Americans support Planned Parenthood.
We have a president that supposedly has no objection to same sex marriage but a vice president that doesn’t, and who actually believes in conversion therapy. Most Americans support same sex marriage and know that sexual orientation is not changeable by therapy.
I don’t have time to find citations for the following, but I hope the polling statistics back up my conclusions. Even if “most” isn’t exactly correct, I would say that it can be said that a significant number, i.e., close to 50%, feel this way about these issues. 
Can you think of any more besides the following? 
  • Most Americans don’t want us using torture.
  • Most don’t believe in a registry for Muslims.
  • Most don’t think undocumented children should be deported.
  • Most don’t think Hillary did anything that should end her up in prison.
  • Most don’t think we should undo the newly established relationship with Cuba.
  • Most don’t want the most important parts of Obamacare rescinded.
  • Most won’t want the wall to be built if it increases the deficit.
  • Most don’t want the very rich to have a tax cut.
  • Most don’t want us out of NATO.
  • By far most want medical marijuana both legalized and researched.
  • Most want recreational marijuana to be legal.
  • At least most seniors or soon to be seniors do not want Medicare privatized.
The more unpopular changes Trump makes, the less he will have the nation’s support. 
He ran like he didn’t care what half the nation thought, what the most educated segment of the population thought about him, and what the press thought. But now he is about to be president of all of us. 
I doubt he really will feel good just because he’s admired by thepeople who buy the National Enquirer, which as of this week is blaring “Trump Must Build That Wall” on its front cover (I was at the supermarket this morning). Plus, when he doesn’t build the wall, even those people will be angry at him.
The power of the president through executive order and through the various departments is vast.  He has the power to royally fuck up the country and the world. In doing so may find the adoration he enjoyed from his supporters has eroded to the point where this narcissistic who thrives on admiration may not be able to maintain his psychological equilibrium. 
My fellow psychotherapists know that the ego of a narcissist is fragile, and that even a successful boisterous blowhard like Trump has a breaking point. We can expect protests around the country, marches on Washington, ever more irreverent SNL sketches, and more snarky New York Daily News front pages. There are likely to be continued investigations and revelations about his conflicts of interest. He will be called out on every unpresidential utterance and Tweet.
Even his poor grammar will be mocked: "I join the many Cuban Americans who supported me so greatly in the presidential campaign….” “So greatly!”
I expect that we’ll see failures of signature programs so obvious that even Fox News has to report on them.
My online support group of psychotherapists debate whether deep down inside, or as we say, in the unconscious, Trump just wants to get the love he never received from his parents. He certainly seems to need to be admired and thought to be the smartest and best looking person in the room, irritable to attractive women and worthy of fealty from powerful men.

When Trump looses all this he could become a dangerous president.
Back from the emporium of stuff, Fred Meyer’s (right), I still don’t have an original thought worth sharing, so will offer a good quote:


This election, American voters elected a con man, a swindler, a bluster bag who articulated a twisted set of mores and a horrific vision for our country. In fact, that Pew graph effectively shows voters knew exactly what they were doing and did it anyway. 
The inescapable message was that a candidate being overtly racist, sexist, and downright ignorant and unqualified was forgivable and even laudable as long as he wasn't a she.Any Trump voter who is now surprised by what they get from his administration—whether it be in the form of horrors they didn't take seriously or broken promises they had counted on—will be getting exactly what they asked for and deserve.  By Kerry Eleveld, "The rampant sexism of 2016 and the law of unintended consequences."
My caption
Excerpt from Politico article:
Romney, for his part, who remains interested in the role, “is taking all of this stuff in stride, and would like to serve the country,” according to a person in his orbit who has spoken to him since he met with Trump last week. The person denied published reports that Romney was drafting a formal apology for his comment during the GOP primaries that the developer-turned-reality-TV-star was a “phony, a fraud,” who was “playing members of the American public for suckers.” 
The idea of forcing Romney to sign some kind of mea culpa is being mulled by transition officials hostile to his nomination, several senior Republicans said.
Even less clear is where Trump’s increasingly influential son-in-law Jared Kushner, a fierce supporter of Israel, stands on the candidates. Transition sources told POLITICO Kushner has said broadly positive things about both men, 
As that battle plays out, there are indications advocates for both candidates may be losing – and that the Trump team is looking to Petraeus, the four-star general who served as President Obama’s director of the Central Intelligence Agency until 2012 when he was removed for sharing classified documents with a biographer who was also his mistress.
My hunch is that Gen. Petraeus will be the eventual selection.

I haven’t thought of anything to write about yet. I’m sitting here waiting for inspiration: 

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