We've been hearing an awful lot about The Goldwater Rule lately: the American Psychiatric Association (APA) regulation that forbids psychiatrists from giving a professional opinion about a public person without their having been examined. Why the previously little known "section seven" of the APA's principles of medical ethics is in the public consciousness is clear. It hasn't been since Goldwater's 1964 candidacy was there so much concern about the personality of a potential head of state. Trump's behaviour begs a lot of questions.
However, answering these questions by using psychological models in a public forum invites severe criticism. Reading Trump's psychological mind, argue some, both excuses his behaviour by making him "mad" instead of "bad" while at the same time further stigmatises mental illness as a whole.
To confuse matters even more, last week the American Psychoanalytic Association (APsyA) clarified that its members were not bound to this rule (unless of course the member happened to be a member of the APA as well) arguing that it:
... takes the position that psychoanalysts should offer relevant psychoanalytic insights to aid the public in understanding a wide range of phenomena in politics, the arts, popular culture, history, economics, and other aspects of human affairs.
Why should one rule be right for psychiatrists but wrong for psychoanalysts?
Though allied disciplines, psychiatry and psychoanalysis (and psychotherapy in general) broadly operate on different underlying assumptions. I generalise here for brevity: Psychiatry works on a medical model that prefers to diagnose its patients into distinct categories of mental illness (usually based on the controversial Diagnostic and Statistical Manual of Mental Disorders) while Psychoanalysis tends to focus more on the meanings and motivations behind the symptoms and distress of the individuals they treat.
These approaches are not mutually exclusive, merely an aspect of focus. Psychoanalysts often rely on psychiatrists for the assessment and treatment of serious mental illness and psychiatrists often refer to talking therapists. An individual can also be both a psychoanalyst/therapist and a psychiatrist.
Members of both professions would agree that "mentally ill" or not, we are all psychological beings that struggle with the unwieldy aspects of our minds - our thoughts and emotions. The label "mental illness" only becomes useful when that struggle tips the balance and severely interferes with one's life. There is no fine line between mental health and illness: they operate on a spectrum. Someone who struggles with unwieldy moods may or may not develop a mood disorder; anxiety may or may not be debilitating; and one's relationship with food may be difficult or "disordered."
The Goldwater Rule, as an ethical guideline for psychiatry is quite right. It is unethical to diagnose an individual who has not been examined - and if they are examined, their diagnosis should be treated as confidential. But one does not have to make a psychiatric diagnosis in order to understand an individual from a psychological perspective: instead one applies psychological reasoning.
The trouble with the current controversy about the Goldwater Rule is that it conflates the idea of mental illness with psychological reasoning. To understand that Trump's behaviour may be motivated by narcissism is not to say he has a narcissistic personally disorder (nor is it to say he doesn't). Narcissism is a universal character trait and applying psychological understanding to it can help us all come to grips not only with understanding his behaviour, but our own too.
A further criticism of those breaking the Goldwater Rule is that using diagnostic language to describe a public figure is offensive to those who are living with mental illness. Detractors of the president and defenders of the rule state that Trump is a bad guy, not a mentally ill one: to say it's mental illness that informs his bad decisions is to insult all of those who live with mental illness.
However this thinking, rather than rescuing "mental illness" from stigma, further ingrains the idea that "mental illness" is something split off and quite a bit different from being "mentally healthy". It's not. People can be generous or nasty whether they are mentally ill or not. Mental illness no more protects people from being bad than being "totally sane" (were that to exist) ensures someone will be good. Secondly it denies that sometimes mental illness does interfere with decision-making. For example, it is well known that people having a manic episode are more likely to make impulsive and regrettable decisions: but so does drinking too much.
In the end, it is right that mental health professionals shouldn't go around labelling public figures with mental disorders as simplistic explanations for their choices. At the same time, professionals in the field of should be allowed to apply their expertise no less so than economists or constitutional scholars.
There should be no shame in mental illness. The application of psychological concepts, when deployed with respect with an aim towards understanding, can ultimately enhance rather than harm our psychological understanding of each other.