Psychiatric Ethics

by Phil Hickey on September 6, 2016

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.

 

 

 

 

  • Mark Eccles

    A great list of 11 ethical transgressions. Nice work.
    That people ask psychiatrists for their opinion on public people , I think is similar to asking the Clergy/Rabbi /Priest/synagogue leader what kind of sinner is Trump?
    Does Trump make the decision to sin, or does his unbalanced brain chemicals make him a sinner?
    But as the general public today have been tricked into believing psychiatry is a science, they feel the psychiatrists judgement of “right” and “wrong” more valid.

  • Phil_Hickey

    Mark,

    Yes, and psychiatrists aren’t going to acknowledge the reality, that it is all a hoax, any time soon.

    Best wishes.

  • Cledwyn’s Pus Poetry

    Trump does make the decision to “sin”, but, as with a scale on which two unequal weights are placed, the heavier wins out, so the mind weighing motives decides in favor of the stronger, as Flaubert pointed out. So the decision isn’t freely made.

    True, this goes against the common (non)sense intuition that we are free agents, that something in our supposedly exceptional make-up grants us special dispensation from the deterministic laws by which the rest of the universe abides, but all our motivations, feelings, thoughts, choices (not free) and actions can be traced to antecedent causes, and take their place in a causal chain stretching back to well before our birth, a chain whose links are countless, impossible to comprehensively identify, and of which we are so ignorant, the illusion of freedom is afforded.

    Nietzsche, understanding this, said that “to judge is always unjust,” and I might add, to judge those who judge is unjust, and to judge those who judge those who judge, is unjust, and so on and so forth.

  • Mark

    Yup. Mostly, the APA doesn’t want their members slapped with libel suits, and they *really* don’t want the public to realize that following a checklist of behaviors isn’t medicine. A moment’s thought should be enough to understand how little the Goldwater Rule has to do with ethics.

    Incidentally, did you catch this throwaway line from Dr. Pies? “In many cases, laboratory and/or neuroimaging studies are also a part of the psychiatrist’s clinical diagnosis.”

    Really, Dr. Pies?!? Do tell. Unless the psychiatrist is trying to exclude physical disorders, I know of no scientifically legitimate use of laboratory of neuroimaging studies in the making of a psychiatric diagnosis. If true, this is big news! Or maybe Dr. Pies is simply deceiving the public about the use of physical tests in psychiatry…

  • Phil_Hickey

    Mark,

    Well spotted!

  • Cledwyn Gallows Buffoon

    Minority hatred, imperial ambitions, habitual dishonesty, constitutional indifference, etc..

    Sounds overqualified to me…

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

    What, such a person exists, who DOESN’T cause suffering? Make him known, so that the circus can sign up the poor freak, so that comedy and tragedy alike may profit from its misery!

    To be condemned to such a martyrdom! To forswear vengeance, and forebear the plentiful poundings visited upon one’s bottom! To bear one’s cross up the Calvary to which we are daily condemned by the thoughtlessness of our parents without the consolation of being able to beat others over the head with it!

    Show me a man who doesn’t make other people suffer, and I’ll show you a corpse.

    “…including children as young as three years…”

    That’s progress for you…

    One of the worst ethical transgression of organized psychiatry though is that it plays courtier to the mob, homo mobiens, measuring against the yardstick of its madness (otherwise known as common (non)sense, even though, ironically, that sense is common property, as is commonly believed to be the case, isn’t borne out by experience; on the contrary, its testimony seems to run the other way, given the record of the many contagious infirmities to which the meager faculties that fall to the lot of man in the mob are incessantly a-prey, and the superficialities he lays stress on in gauging the merit of a man or a work of art, with all the injustice that that entails) the sanity of individuals, or lack thereof.

    Nevertheless, this is understandable. If one is to win the support of men, one must indulge their vanities, value them, at least outwardly, at their own grandiosely delusional estimate.

    Of all the offenses men perpetrate, or those that are commonly adjudged to be so, none are generally so unforgivable as those that offend against the vanity of the mob, hence the lofty position occupied in contemporary demonology by the “pseudo-intellectual”, the high-cultural snob, the gravamen of the charge brought against whom is not that they transgress (perhaps non-existent) standards of humility and tolerance, honored more in the breach than the observance, but that they think themselves more intelligent and tasteful than the mob, thus offending against its vanity and thereby invading its perceived prerogatives, in the exercise of which it indulges in the kind of behavior it finds so abhorrent in others, for if man, in the individual, can be said to be arrogant, judgemental, pretentious, and disdainful towards the tastes and opinions of others, how much more so can this be said to be the case of man in the mob, a historical survey of whose behavior does not bear out the democratic delusion that homo mobiens is wise, tolerant, sound in his judgment, humble, and a general all round salt-o-the-earther, his every thought, every feeling, and every deed just a-quivering with cleanliness.

    No, homo mobiens is a bully, inhospitable to all tastes and opinions but his own. Ruling by a reign of terror, he regiments by force and intimidation all who fall under his sway, drilling all into conformity with its ways, deviation – omitting sundry other punishments – punishable under pain, in our society, of the invidious labeling wherewith the psychiatric career of the Other often begins; or under pain of the punishing gauntlet of stares, guffaws, and taunts which he who dares to be different must run in expiation of his crime, who the mob then labels “mad”, or “pretentious”, or “evil”, or some such other epithet, directly the misfit requites the sentiment.

    And given that men are mostly mediocre, foolish, and wicked, and praise and value in others what most closely corresponds to themselves, it is mostly mediocrities, fools and scoundrels who are praised and valued by the mob, while good men rot in mental hospitals, genius languishes in obscurity, and wisdom goes unrecognized.

  • all too easy

    Yawn

  • Rob

    Our behaviors often reveal our inner turmoil.

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