A recent article by Dr. Nassir Ghaemi lays out the dilemma facing Psychiatry and its role in politics: adhere steadfastly to the Goldwater Rule and skirt a constitutional mandate under the 25th amendment, or engage in the protection of society from psychiatrically compromised leadership and risk the politicization of psychiatric assessment. Additionally, Dr. Ghaemi argues that psychiatric illness can be (and likely has been) an asset to national leadership throughout history, an admirable and Tolkien-esque position.

A brief review of the attitudes of APA leadership and other senior psychiatrists that led to the codification of Section 7.3 in the Principles of Medical Ethics with Annotations Especially Applicable to Psychiatry suggests that the core concern of the Goldwater Rule was the protection of an individual’s right to privacy. The APA did not want our field to play fast-and-loose with protected health information. Recklessness of that kind would certainly backfire.

The mandate to protect the privacy of everyone, no matter how public or powerful a figure, ought to bring a dead halt to all conversations about dropping Goldwater. A violation of privacy is an automatic violation of Primum non nocere. Hence, if we are going to be available to fulfill our mandate under the 25th amendment the question becomes, “How do we provide assessments to politicians — behind closed doors?”

The impaired practitioner model

Interestingly, fields such as medicine, aviation, and law already have programs that could serve as a template for confidential mental health oversight for politicians. Impaired practitioner programs in medicine acknowledge that employment in the field cannot be withheld on the basis of the mere presence of a psychiatric condition, while paying respect to the potential risks that those conditions pose to the public. Impaired practitioner programs are heavily supported by state medical boards because they improve public trust presumably by reducing the number of mental health-related events, while providing some assistance to the afflicted practitioner. The adaptation to politics is fairly straightforward: a mandatory, confidential assessment upon election to public office, and mandatory compliance with treatment should any issue be identified.

In practice, presidents, for example, who tend to have narcissistic traits and who might be vulnerable to alcoholism, would likely be mandated to attend weekly psychotherapy, and to be tested quarterly for excessive alcohol intake.

Criticisms of impaired practitioner programs are abundant however, and well-founded. These programs are often led by physicians who have had their own substance use issues, and who therefore tend to be heavily valenced toward over-diagnosis and over-management; they gain ego-integrity by painting program participants to be just as “defective” as they were, and handling them as such. These programs can be financially brutal for younger physicians, and conflicts of interest (i.e. assessment performed by a physician with a stake in a rehabilitation program) are rampant. Physicians entering these programs are effectively blackmailed into compliance in order to continue on paths they have spent their entire lives sacrificing for.

Another large problem facing impaired practitioner programs is the method of referrals. The Florida program has a “rat clause” that effectively stipulates that any participant is obligated to refer a non-participant with a suspected mental health problem. Meanwhile, other physicians with deadly problems stay below threshold through years and years of suffering and damage in the absence of mandatory, universal screening.

Finer consideration of the subtleties would be necessary were these programs to be adapted into impaired politician programs.

Characterological assessment model

The following proposal is as concerned with honoring the potential role of psychiatry in executing a 25th amendment assessment as it is with the true spirit of anti-Goldwaterian sentiments currently rising within the field. It is suspected that vocal anti-Goldwater advocates are not reeling exclusively on their detection of pathological narcissism or dementia in prominent public figures; it is likely that they are using those stated observations as stand-ins for traits that they know intuitively to be even more problematic: poor insight, corruption, and anti-sociality. These traits pop out of the screen to practiced psychiatrists and Michael Moore alike, but they are much riskier, more confusing, and potentially more unfair to talk about publicly. They are, however, valid and ostensibly more salient disqualifications to public office in the eyes of the American people.

Can a politician’s potential for corruption be reasonably guessed at prior to taking office? I personally suppose that it would be possible to perform such a characterological assessment with interviewers blinded to the aspirant’s policy objectives and ideology, considering only a few dimensions. The first of these character dimensions might be the desire for “secondary gain” emerging in the act of taking office.

Secondary gain usually refers to the benefits accrued by a patient when they adopt a sick role. We mean to extend the meaning here to include any unstated benefit that an individual obtains through any action, such as running for public office.

Some secondary gain is just flat out unavoidable. For example, we know that almost no one goes to medical school for entirely altruistic reasons. Almost no one is a saint. But there are forms of secondary gain, such as narcissistic fulfillment, that detract from the integrity of the office. These character traits are readily guessed at up front, difficult to hide, and may be disqualifying.

Another dimension of character that could be assessed up front is the aspirant’s sincerity. In such an assessment, an “ideologically matched” psychiatrist could, for example, evaluate whether a person’s life history is consistent with their stated policy objectives. All preoccupation and belief have their roots in past experience. Candidates who exceed a certain threshold of likelihood to mis-represent themselves for the purpose of obtaining office might be disqualified for a period of time through this method.

Experts in Human Engineering

None of the ideas expressed above are novel proposals, really; a 1948 statement from President Harry Truman to the American Psychiatric Association is frequently quoted by historians of our field:

Never have we had a more pressing need for experts in human engineering. The greatest prerequisite for peace, which is uppermost in the minds and hearts of all of us, must be sanity… We must continue to look to the experts in the field of psychiatry and other mental sciences for guidance in the evaluation of our mental health resources.

70 years later, no one ends up being quite so practiced and so lonely in their considerations about secondary gain as psychiatrists and psychologists. Meanwhile, many politicians appear to rely on the fantasy that secondary gain does not exist, and to have higher than average levels of anti-social and narcissistic traits. As national attention to corruption in Washington mounts, it could be good for the country if mental health and government agreed to team up to address these basic human realities.

Particularly at the apex of psychoanalysis’ popularity in America, in the time after Freud and before the rise of the DSM and biological psychiatry, there was an idealistic aspiration among analysts (an elite subgroup of psychiatrists trained in that distinct form of psychotherapy) to lay a hand on government. There was a somewhat naive belief that psychoanalysis could serve to relieve kings, senators, justices, CEOs, and presidents alike of their problematic unconscious conflicts; with analysis world leaders would be enlightened, peaceful and prosperous alliances between societies would be forged, and the most dangerous threats to life in the nuclear era might be contained.

It’s entirely appropriate that psychiatry has since tempered its stated aspirations. Our field is infamous for its abuses of public trust (e.g. nearly systemic sexual misconduct in the Viennese and early American circles, lobotomies, misogynistic theoretical roots). Jeffrey Lieberman has convincingly portrayed academic growth in psychiatry as plagued by internal self-deception.

Like all good narcissists, we were simply not ready for the responsibilities and status we wanted. We may still not be. Even today the field is rightly considered several decades behind other medical disciplines in terms of the sophistication, specificity, and efficacy of available treatments. Our standard nosology, the diagnostic and statistical manual, is considered by some physicians in other fields to be anti-physiological and hence irreconcilable with designation as medicine.

Given the mistakes we’ve made, the ideal psychiatrist of the last 50 years may have been the one who worked quietly and effectively to heal as many individual patients as possible, avoiding public recognition (and envy), in order to generate firm root-level support for the field.

We need that earned public trust, and that earned self-respect. To echo a sentiment of Dr. Ghaemi, our societies are likely on the verge of asking much more of mental health as a repository of knowledge and skills that are profoundly organizing and salutary in the chaos of colliding cultural forces. The educational background required to enter this field takes a tour through fertile grounds on the four corners of the humanities, sciences, and medicine for good, conciliatory solutions to the divisive preoccupations that define our era. And the skillset — the ability to assess character in a reliable, reproducible fashion — wed to an empathic understanding of how characterological elements originate and perform— has virtually unlimited applications for any society that is quite sincere in its desire to persist. This field becomes more relevant, more accepted, and more equipped to play an important role every day.

I don’t think we need to shy away from making a contribution, so much as to examine carefully what it would need to look like.

The author is a psychiatry resident with interest in classification and pathophysiology of psychiatric illnesses in Miami, FL