What Might Prevent Psychiatrists From Speaking in Public About Their Opinion of the Mental State of a Public Figure? The so called Goldwater Rule

What Might Prevent Psychiatrists From Speaking in Public About Their Opinion of the Mental State of a Public Figure? The so called Goldwater Rule

In the United States the first amendment protects our right to free speech. Although I am not an attorney, I do believe that while you can’t be put in jail for expressing negative things about other people, there are laws that protect people from untrue damaging statements.. These laws provide recourse for people who believe that their careers reputations finances and/or health have been damaged by harmful statements. The Supreme Court has weighed in on this issue as recent as 1990 and the criteria involves whether the statements are true and the context in which they are made. Things get even more complicated when the object involves public officials and public figures who are in the public view because the law encourages free speech especially when it involves this category of people

What does all this have to do with psychiatry? In 1964 Barry Goldwater was running for President against the incumbent Lyndon Johnson. A magazine by the name of Fact published an article titled The Unconscious of a Conservative: A Special Issue on the Mind of Barry Goldwater . The magazine polled psychiatrists about American Senator Barry Goldwater and whether he was mentally fit to be President of the United States.Screen Shot 2017-07-07 at 11.24.30 PM In response to this question, 2,417 out of 12,356 responded. Of those, 657 said he was fit, 1,189 said he was not, and 571 said they didn’t know enough to answer the question. In response to the survey some of the comments that were made by the psychiatrists who responded were as follows (as reported in article in THE BLOG by Jonathan Moreno 8/26/16):

“The Presidency should not be used as a platform for proving one’s manhood . . .”

“Inwardly he is a frightened person who sees himself as weak and threatened by strong virile power around him . . .”

“Since his nomination I find myself increasingly thinking of the early 1930s . . .”

“Unconsciously he seems to want to destroy himself. He has a good start, for he has already destroyed the Republican party . . .”

Moreno in his article also made mention that in 1931 there was a debate at the annual American Psychiatric Association whether Abraham LincolnScreen Shot 2017-07-07 at 11.26.19 PM was a “manic schizoid personality whose depressive moods stopped short of mental illness.” The article went on to state that “analysis of the dead is not a legal violation, but nonetheless raises the question of fairness as the dead cannot defend themselves. He went on to say that to analyze a living person without data is not only bad practice, it also runs the risk of making the analyst look foolish if the individual later behaves in a way that was not predicted. The editor of that article about Goldwater was Ralph Ginzberg and he was sued for libel and lost the case and had to pay Goldwater $75,000 in damages which is approximately $579,000 in todays money value.

Several years later in 1973, the American Psychiatric Association issued the first addition of Principles of Medical Ethics which is still in effect as of 2017. I will list Section 7 , 1-5 but it is #3 that has informally known as the “Goldwater Rule” which is most relevant to the topic we are discussing. Screen Shot 2017-07-07 at 11.32.00 PM

Section 7

A physician shall recognize a responsibility to participate in activities contributing to the improvement of the community and the betterment of public health.

  1. Psychiatrists should foster the cooperation of those legitimately concerned with the medical, psychological, social, and legal aspects of mental health and illness. Psychiatrists are encouraged to serve society by advising and consulting with the executive, legislative, and judiciary branches of the government. A psychiatrist should clarify whether he/ she speaks as an individual or as a representative of an organization. Furthermore, psychiatrists should avoid cloaking their public statements with the authority of the profession (e.g., “Psychiatrists know that”).
  1. Psychiatrists may interpret and share with the public their expertise in the various psychosocial issues that may affect mental health and illness. Psychiatrists should always be mindful of their separate roles as dedicated citizens and as experts in psychological medicine.
  1. 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.
  1. The psychiatrist may permit his or her certification to be used for the involuntary treatment of any person only following his or her personal examination of that person. To do so, he or she must find that the person, because of mental illness, cannot form a judgment as to what is in his/ her own best interests and that, without such treatment, substantial impairment is likely to occur to the person or others.
  1. Psychiatrists shall not participate in torture.

There are very detailed procedures for filing an ethics complaint and how such a compliant will be evaluated on the local district branch level and then up to the national level which are spelled out in detail and include an appeals process. Potential sanctions to a member of the American Psychiatric Association who has been found to be in violation of one of the ethical rules are reprimand, suspension or expulsion from the national organization.

In a article in the Journal of American Academy of Psychiatry and the Law about one year ago Kroll and Puncey concluded that while some third party assessments are reckless but they do not negate legitimate reasons for providing thoughtful education to the public and voicing psychiatric concerns as acts of conscience. They concluded that the Goldwater Rule was an excessive organizational response to what was clearly an inflammatory and embarrassing moment for American psychiatry. A counter view with which I agree was expressed by  Paul Applebaum, Screen Shot 2017-07-07 at 11.44.22 PMM.D. , a past president of both  the American Psychiatric Association and the American Academy of Psychiatry and the Law in the current issue (2017) of the same journal. He said the following : “Weighing the real harms that can arise from psychiatrists’ comments on the diagnoses and personality traits of persons whom they have never examined against the likely inaccuracies and hence limited value of such endeavors to begin with, I am left with the conclusion that the Goldwater Rule remains a valuable component of the ethics of psychiatry. However, some modification of the Rule may be necessary, to indicate more clearly that it is not meant to cover analyses that are  intended to be shared with the public or works on deceased persons of historical interest.”

As far as I know there have been no sanctions by the APA regarding the Goldwater Rule thus far but this is still a topic which is being discussed both within and outside the psychiatric profession.

Any thoughts are welcome in the comments section below

 

Psychiatric Ethical Position on Role of Psychiatrists in the Interrogation and Torture of Prisoners

The ethical position of the American Psychiatric ( APA) Association and the code of ethics for psychiatrists about torture came to prominence about 10 years ago when I was Speaker of the Assembly of the American Psychiatric Association. At this time the Assembly endorsed the position of the Board of Trustees of the APA about this issue. Recently this topic has surfaced again as described in the article below in the the APA News . I would suggest that this article should be read  and then for further clarification I would like to present a video interview that I had  in 2009   with the late Dr. Abraham Halpern. Dr. Halpern was a prominent American psychiatrist who was leading spokesperson  on number of ethical issues.

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And now please view the interview that I did with Dr. Halpern on this subject in October 2009.     https://www.youtube.com/watch?v=oULhHzC8E_8

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Please feel free to add any comments that you have about this subject in the comment section below and they will be published shortly.

 

 

FIve Days At Memorial: Life and Death in a Storm Ravaged Hospital by Sheri Fink A BOOK REVIEW

9780307718969_custom-c5e860538756bdf498808fb3144c77d4a46dce7f-s6-c305 Days at Memorial: Life and Death in a Storm Ravaged Hospital by Sheri Fink – This is a great book for anyone who works in a hospital especially doctors and nurses who realize they could be on call when a disaster might strike. Also include yourself in this group if you are a  hospital administrator or someone who likes to wrestle with ethical dilemmas. Be prepared for a lot of repetition, medical details that may all seem to be almost the same to most people as well as for some dips into the history of this hospital, other disasters and a course in ethics over the years even dating back to ancient times. If you can handle all of this, you really have an exciting, intellectually stimulating book with a look at disaster medicine, making medical and ethical decisions under difficult circumstances and some good legal battles. The main event was the 2005 Hurricane Katrina, which was the costliest natural disaster, as well as one of the five deadliest hurricanes in the history of the United States. At least 1,833 people died in the hurricane and subsequent floods. This book deals with the impact of the storm on Memorial Hospital in New Orleans, which was a 312-bed hospital, which included patients receiving intensive care and a larger section of the hospital where critically ill patients were treated. As the floodwater rose, most of the power in the hospital was irretrievably lost. There was no sanitation, and they were running out of food. Indoor temperatures were as high as 110 F degrees. At one point there were over 2000 people in the hospital as the numbers swelled with families of patients and staff as well as refugees from the surrounding city. The hospital became surrounded by water and there was no way to leave by car. A makeshift helipad was established on the roof but to get there patients, had to be carried up several flights of stairs usually in the dark and passed through a hole in the wall to get to another part of the hospital complex and up additional stairs. There was limited oxygen for these patients and for some the nurses had to squeeze a balloon like device to get the air into their lungs and drip an IV into their veins while going up the stairs. It was difficult getting enough helicopters to remove all the people from the hospital. Decisions had to be made which patients to evacuate first. Should it be the ones that were barely alive and wouldn’t be expected to even survive the trip to another location or perhaps already had a fatal illness where their demise was expected in a few days or should the patients go first who had a better long term outlook but still required hospital care?? Should the preference or order of care be influenced if the patient had a DNR order, meaning do not resuscitate the patient if their heart stops or if they stop breathing. As the first three or four days passed most of the people were evacuated (where they were evacuated to was another problem). There was confusion and questions about the actions by the corporation that owned the hospital and what arrangements they were making to help the stranded hospital’s need for evacuation. Outside the hospital gunshots were heard and there were concerns that looters might enter the hospital by boat. There was a concern about the physical integrity of the old hospital walls. You would think that the National Guard and the US Government should have done a heroic operation to save everyone from the beginning. They apparently were saving people from rooftops of their homes, helping out in the Superdome, which was the place of last resort for the people of New Orleans who weren’t able to escape before the flood, as well as sporadically appearing on the helicopter pad.  In the end there were a small number of doctors and nurses trying to care for the remaining and sickest patients. There was concern that even moving some of them would be fatal. One man was so obese that they couldn’t figure out how to move him. Some patients were clearly in the last hours hours of their lives. Others would soon be that way if they didn’t get more intensive care. One of the remaining doctors along with two nurses was Dr. Anna Pous, a very compassionate and brilliant ENT surgeon who had a history of reconstructing patients with advanced cancer. She found herself faced with the task of trying to relieve the suffering of several remaining patients. It is well known to physicians and nurses who treat dying patients, that morphine often in combination with a rapid acting tranquillizer such as Versed, given intravenously will relieve the pain and agonizing difficulty breathing in the final stages of life. It is also known that this treatment could hasten their demise. Dr. Pous appeared to made the  decision to have several patients receive large doses of morphine and Versed which would peacefully end their lives. At a later point in time this was felt by some people to be murder. In fact, Dr. Pous  was actually arrested, handcuffed and was with two nurses charged with second-degree murder. The response of the medical community from this hospital and from across the country, the legal and emotional reactions of some of the patient’s families, the media hype and the ethical questions which were being asked, were an important part of this book. The book provides few answers and lots of stimulating questions. The author won a Pulitzer Prize for her reporting on this subject in the New York Times Magazine. If you are drawn to this subject you will not be disappointed. 

Discussion of Patient Who Heard Neighbor Say He Put Someone to Sleep

The following is the second case originally presented in this blog several weeks ago for comments. Included are two invited comments and any further comments from the readers are welcome

Case #2

A senior psychoanalyst  is supervising a junior colleague who is treating the  following case. The patient is a single 36 year old dental hygienist living in Manhattan who is in her second year of three times / week psychoanalysis. She entered treatment because of difficulty trusting men which has been related to an inconsistent and insensitive father who shared with the patient the fact that he was cheating on her mother. The therapy has been going well and the patient has made progress in her ability to accept interpretations, have her own insight and utilize insight through her understanding of the transference.

The patient came into a recent session a little anxious and perplexed. She related the following incident . The other day after coming home from work she  rode up in the elevator with a young man a few years younger than her  who lives across the hall from her with whom she has a causal acquaintance. She believes he has a minor position in the union and always viewed him as trying to act like a wannabe tough guy but “a nice kid.”  He was pacing back and forth and seemed scared and she asked if everything was Ok. He asked her if she had a beer or a drink. She invited him and gave him a beer. She distinctively heard him say half to himself, “ I can’t believe I helped put someone to sleep.” When she asked him what did he say, he said it was nothing. They chatted about incidental things and he thanked her for her time and left. She wondered if that were something serious like someone being killed but then became scared and changed the subject and got into talking about her family, dreams and other things that were all continuation of issues she had been recently talking about. The therapist didn’t see any direct or indirect references to this subject in the next two sessions leading up to the  supervisory session.

Does the supervisor  have any obligation to either to suggest  or urge his supervisee  to try to influence the patient to report this information to the authorities and  is the therapist or the supervisor  obligated to do so.? What are clinical and therapeutic implications for the therapist  to spontaneously bring up this incident if the patient is not talking about it ? 

Response from invited discussant Sheldon Frank. M.D.  Dr. Frank is a child and adult psychiatrist practicing in South Florida.

The implications from this patient’s statement about her neighbor are not clear. Legally, there doesn’t appear to be enough factual information to warrant any kind of report by the therapist. Therapeutically, it is warranted that the anxiety around the interchange be brought up to the patient for examination / reaction on her part. The result could be, for instance more (or less) of a hint by the neighbor as to possible criminal activities and/or plans; and perhaps  even a conflict within the patient as to whether she needs to contact the authorities.

 

Response from invited discussant Myron L. Glucksman, M.D. Dr. Glucksman is a psychiatrist and psychoanalyst practicing in Redding Connecticut and New York City. He is a Clinical Professor at N. Y. Medical College and a training analyst at the Psychoanalytic Institute at N. Y. Medical College.

The patient’s recounting of her male neighbor’s comment is basically heresay, and therefore does not warrant her or the supervisor’s obligation to report it to the police.  However, the issue may connect with her distrust and fear of men. It certainly invites further exploration in regard to her father’s insensitivity and untrustworthy behavior. One might wonder whether her father was ever physically abusive toward her or her mother. If so, possible fantasies of being injured or killed by a man should be explored. I would also pay attention to dream material involving aggression by men. If the therapist is male, one would expect manifestations of a negative transference at this stage of treatment.

 Other comments received about this case :

 It seems quite clear that the patient has been told about a murder. If the therapist is denying this, he or she will not be able to understand any conflicts that the patient has in dealing with this information. Learning about a serious crime by a person who is likely to commit other such crimes does ethically obligate the therapist and the patient to notify the authorities. If you hesitate in doing this, is it because of the nature of the murder.? If it were immediately after 9/11 and the neighbor indicated that he was involved in the planning of that crime, would that push the therapist and the patient to action ? Does the ethical rule apply only to multiple murders? Of course, notifying the authorities could endanger the life of the patient and the therapist (and maybe even the supervisor) . Even if the information was given anonymously to the police, once they started investigating the neighbor, the hit man and his boss could soon figure out the only person who was told about the “putting to sleep” was the therapist. He or she could be eliminated or “made to talk ” and tell that the the other person that was told was the supervisor .  Then they both could be put to sleep.  So maybe it is best to just deal with the therapeutic implications of this interchange between the neighbor and the patient  as well as the interchange between the patient  and the therapist.  It must be significant that the patient and her father shared a big secret (that of the father’s affairs). Now circumstances have occurred where the patient and the therapist are sharing a special secret . Understanding this may move the therapy forward in a productive manner.  Dr. A (name withheld by request )

Comments are welcome in the comment section below and will be added to this blog.

Discussion of the Patient Who Slapped a Child

During a recent blog , I presented two case histories which I thought might stimulate different points of view on how to react to the situations described . I asked two  colleagues if they would respond . Today I will restate the first case and then I will present their views. I will also print comments from readers  I encourage anyone therapist or not to weigh in on these cases in the comment section .

Case #1

The patient is a 26 year old young women who came into therapy because she was depressed about her inability to complete things. She had started college twice and dropped out and as a adolescent she came home from sleep away camp twice. Her goal was to go to nursing school some day in the future. She had many friends but had trouble keeping a boyfriend, She was attractive but was somewhat inhibited and only on occasion would allow herself to have sexual relations which she would enjoy. Her parents were divorced when she was 6 years old. Her father is a physician would visit her periodically as a child and when she was older she would visit him and his new wife . She always felt close to them and their two children. Her own mother was an alcoholic and when she was younger her behavior was quite erratic. At time she was physically abused by being slapped around. Other times she would have to take care of mother by making food for her and sometimes would even stay home from school . Despite poor attendance she got good grades. She herself does not drink or take drugs. She shows no evidence of a major depression or psychotic symptoms. She is often moody but doesn’t appear to have hypomania. She becomes angry when she is disappointed. As a preadolescent she saw several therapists and she had 2 or 3 brief trials of therapy in the past 3 years including several weeks of a trial on an SSRI which she didn’t feel made any difference. She is currently in treatment with psychodynamically oriented psychiatrist who has decided not use medication at present. She has been coming for 4 months 2x/week ( Tuesday and Friday). She says this is the first time she is making progress in therapy as she feels she can talk freely and is not being judged.

During her last session on a Friday very close to the end of session, she said , Whatever we say here is completely confidential, isn’t it?” The therapist replied, “Why do you ask this question ?” The patient then went on , “ You know that baby sitting job that I have been doing every Saturday nite for Mr. and Mrs. Woodman my neighbor’s 15 month child.?” Well last week the kid was a real problem. He was whinning all the time and wouldn’t listen to me. The final straw was that he spit on me. I lost it and slapped him real hard across the face. His face got really red and swollen. I put some ice on it. I will never do that again.” The therapist, was stunned and before she could say anything, the patient said , “Well, I know my time is up” and got up and left.

Should the therapist do anything with this information. Is the therapist required to notify anybody? What are the legal and therapeutic implications ?

Response from invited discussant Myron L. Glucksman, M.D. Dr. Glucksman is a psychiatrist and psychoanalyst practicing in Redding Connecticut and New York City. He is a Clinical Professor at N. Y. Medical College and a training analyst at the Psychoanalytic Institute at N. Y. Medical College.

In my opinion, the therapist has no legal obligation to report the slapping incident because, so far, it is an isolated episode and apparently did not result in a serious injury to the child. The therapist should explore the patient’s feelings about her behavior; in particular, her angry feelings when she feels disappointed. I suspect that her anger is, in part, connected to her feelings of rejection and abandonment by her alcoholic mother. Evidently, she was not adequately nurtured as a child, and was exploited by both her parents in regard to having to take care of her mother. As a babysitter, she again finds herself in a similar position and becomes enraged when the child spits on her – re-stimulating feelings of rejection and humiliation. However, I believe the therapist should warn her of the legal consequences of similar abusive behavior toward the child or others in the future.

Response from invited discussant Sheldon Frank. M.D.

Dr. Frank is a child and adult psychiatrist practicing in South Florida.

There is no doubt that the information must be reported to the state child protective services immediately, with, of course, communication to the patient that this is being done. The legal and ethical mandates are clear, regardless of effects on the therapy. The therapy may perhaps be unaffected or strengthened–though not necessarily. Certainly a therapeutic relationship which covers up a reportable abusive act and denies the possibility of future risk to this child or other children being cared for by the patient does not help her in the long run. The outburst of violence on her part was so impulsive, so over-reactive to the baby’s acting like a baby, that even her sincere conviction that she won’t do it again is suspect. In addition to dynamic interpretation, the patient might benefit from other psychiatric treatment tools. Her life pattern, her complaint about not finishing things, and, perhaps, this outburst, may reveal adult ADHD (a continuation of childhood ADHD). (One can’t say from the data in this case, but ADHD children are much more likely to be slapped, neglected, and/or abused than other children.) A trial on stimulant medications is a safe and effective way both of confirming the diagnosis and treating. Alternatively, a search for mood swings and bipolarity might establish a mood-based origin of her action, and a mood stabilizer could help her self-control. We child psychiatrists often confront these diagnostic alternatives, and usually opt to test first the ADHD possibility because of the rapid onset and cleaner side effect profile of stimulant medications.

Since the account came out at the end of the session a day before the next baby-sitting engagement, there is a quandary as to how and when communicating the report mandate to the patient is handled. Some state laws require a report within 24 hours of receiving the information–which is defined as information containing the suspicion of abuse/ neglect. (It is the agency’s job, not the therapist’s, to distinguish between abuse and, say physical discipline.) Hopefully, the child protective agency would act promptly. Professionals have the right to anonymous reporting, so the agency would not tell the patient the source of the report–it could have come, after all, from the child’s parents. Still, the chance of the therapeutic relationship being damaged is greater if the therapist waits until the Tuesday session to deal with this complication. If I were the therapist, I would call the patient and ask her to return the same day to continue the session, and use that extra time (? without extra charge) to communicate to her the necessity of reporting. The therapist didn’t answer directly the patient’s question on confidentiality; if pressed, he could have reminded her that the only exceptions were situations in which there was the danger of harm to herself or others.

Initial comments from readers of this blog :

Well, when you said “dilemma” you meant it. In the first case, it weighs the betrayal of trust of a confidential relationship for someone who appears to be genuinely interested in changing her anger responses, against the safety of a very young child from abuse. My response given the details here would be to file a CPS report, and talk to the patient about the legal reasons why that had to be filed in a candid way and trying to help her see the situation through several points of view. Though it would be tragic if the therapeutic relationship were not strong enough to withstand this, a child’s safety must take precedence.- Heather Fretwell

I certainly agree with Dr. Glucksman in this mater.  Dr. Franks by the book, rather concrete approach is useless and harmful, as long as the patient is cooperative and open to suggestions.  There is a question though of whether the child might need help in understanding and digesting what happened so that a traumatic scar is not left in his mind.  I might have insisted that the patient talk this over frankly with the parents and take whatever steps are needed to protect the child and see to the child’s mental health.
Arnold Robbins MD.
Cambridge, MA

Responses and opinions from any readers of this blog are welcome and will be added as comments. The second case will be discussed in a future blog