How a Psychiatric Association Sickened Society’s Mental Health

It is now happening. I once said that Donald Trump was more dangerous than Adolf Hitler, despite being less cunning, because of: (a) the power of the U.S. presidency; (b) the complacency of his opposition; and (c) the obvious gullibility of his followers. He may be partially gone, but the conditions he exploited and accelerated remain. What is unknown to most of the public is the active enabling of these conditions by the American Psychiatric Association (APA).

Our insistence that “it can’t happen here” all but guaranteed it would happen, and it is happening. Hitler and Trump both exhibited a personality structure that is very common — I have treated about a thousand in my twenty-year career — which is why mental health professionals were the first to recognize the dangers of the former president. The elevation of such a personality to a leadership position was a reflection of poor societal mental health, which is by definition self-destructive.

Fascism is not a political ideology but mental pathology in politics. It happens when pathology goes unrecognized, and power is placed in the wrong hands, often eagerly. Fostered by the flattery of underlings and buoyed by the adulation of crowds, certain personality defects predictably morph into grotesque delusions of grandeur and impunity, resulting in abuses of power and, eventually, atrocities. Awed by the exaggerated self-image of a leader, without recognizing that it is overcompensation for lack, those similarly predisposed willingly enlist in an authoritarian cult of personality. His position alone justifies any transgression, no matter how criminal, incompetent, or deadly.

Because journalists and intellectuals are the greatest threat to this type of power structure, institutions may take the initiative to censor themselves and to fall in line. When fear grips you, or you are met with the unexpected, rules are comforting to fall back on. By remaining “neutral” or “just doing my job,” you can avoid becoming the aggressor’s target at the same time as pretend that you are being ethical, consistent, or “professional” — even as you violate the principles of the profession. It is a known phenomenon and the reason why, after the experience of Nazism, the World Medical Association instituted the Declaration of Geneva, in 1948, to emphasize the principles of humanitarianism over obedience to destructive regimes.

It is no accident that the APA was the first to fall into compliance with the Trump administration. It was for me the first sign of fascism, worrying me enough as a psychiatrist that I felt I had a duty to speak up about it for the first time. When it publicly paraded “the Goldwater rule,” despite its being largely considered antiquated since 1973 when it entered the books, and arguably invalid since 1980, when diagnostic criteria changed to external observations rather than introspective interviews — and it not just “reaffirmed” as it falsely claimed but expanded it to prohibit any comment on any objectively observable feature of public figures, it was doing the new administration a favor: silencing professionals. Like the lawmakers who received inside information about the pandemic and used it to sell stocks but told the public there was nothing to worry about, the APA used the special knowledge it had to protect itself from retaliation but told the public psychiatrists had nothing to offer.

Its intentions became clear when a former president of the APA, championing its cause, compared us to Nazi and Soviet psychiatrists for “diagnosing” Donald Trump, when we were alerting about the dangers of the APA’s collusion with a destructive government (as Nazi and Soviet psychiatry had actually done). Accusing the other side of that which you are guilty was a basic principle for the minister of propaganda under Nazi Germany and the defense mechanism of “projection” commonly seen in psychiatric practice.

The APA not only prohibited any comment on public figures without an examination and without authorization (how often is this going to happen with public figures on whom the public truly needs to be informed about, and even if it happened, how often would it include the information that is critical for the public to know?), with the start of the Trump presidency, it made the rule absolute: the prohibition holds even in situations of a national emergency. It flies in the face of the very reasons why the First Amendment was established in the first place: to oppose and prevent tyranny, the obsession of the nation’s founders. And what do we expect would happen if we silenced the voices of those best positioned to recognize the tyrannical personality? For this very reason, no state licensing board has admitted “the Goldwater rule,” unlike all other codes of ethics. No other mental health association adopted the “rule”, and authoritative scholars of psychiatric ethics do not even consider it an ethical guideline but an etiquette that should not supersede our professional responsibility to society. Yet the APA gave it a status that no other ethical guideline has ever had: even the most sacrosanct principle in medicine of patient confidentiality — codified into law — must be broken in an emergency. Not “the Goldwater rule.”

The practice of psychiatry involves not just clinical psychiatry, which involves individual patients, but preventive psychiatry, or public health, which involves populations. Instead of educating the public on these nuanced distinctions and reducing stigma for the field, it chose the course of augmenting the public’s ignorance by playing on public misperceptions of confounding public health duty with the practice of clinical psychiatry; mental unfitness with mental illness; any comment, including warning against danger — a physician’s duty — with diagnosis; and its voluntary guild rule with patient confidentiality law. This allowed it to impose a gag order on an entire profession. Not even in the legal profession — very parallel to medicine — were legal experts restricted from weighing in on Donald Trump’s criminal or unconstitutional behavior every day, without representing him and getting permission from him before speaking. And much like what the German Psychiatric Association did under Hitler, by emphasizing a technical appearance of professionalism (silence at all times) and eliminating the physician’s autonomy, including moral agency, it allowed the medical profession to become a tool for atrocities.

The APA, by placing “the Goldwater rule” above the physicians’ universal pledge, which is the modern Hippocratic oath, forced psychiatrists to violate the core principles of medical ethics — and not just the Declaration of Geneva but its own principle that “the Goldwater rule” falls under: that a psychiatrist “shall recognize a responsibility to participate in activities contributing to the improvement of the community and the betterment of public health.” Indeed, how much does the fact that it went on public campaigns to exclude from the major media all mental health professionals who would speak up, rather than going through the legitimate route of ethics committee investigations of violations, has to do with the fact that its logic would never hold up under such scrutiny? To date, no one is known to have been disciplined for violating “the Goldwater rule,” and only 6 percent of practicing mental health professionals would fall under the APA’s jurisdiction anyway.

The atrocities of our day include, but are not limited to, the now more than 560,000 Covid-19 deaths — of which a Columbia University study has shown that up to 97 percent were unnecessary; which we ourselves were able to anticipate before it happened, based on the president’s mental state; and more of which is expected to be revealed in top pandemic doctors’ reports. The unspoken reality is that none of this was a mystery, and all could have been better avoided if the APA had not intervened, just as we had reached the number one topic of national conversation early in the presidency, when thousands of mental health professionals, all the major media, lawmakers, and the public were aligned. The author of the Twenty-Fifth Amendment himself stated that, in order for the Amendment to work, psychiatrists needed to be free to speak. When institutional leadership not only refuses to meet its own professional standards but inhibits independent mental health professionals from meeting their conscience — all in submission to power — fascism proceeds unchecked. “The Goldwater rule,” as the name suggests, originated from a political compromise, not ethical deliberation, science, or evolving practice, and was bound to be politically abused — and was.

The price has been more American casualties than all the wars of the past 100 years, a culture of violence and intimidation among lawmakers that no one can hold accountable (how and why when a president with those traits was maximally normalized?), and a “mass psychosis” that is not likely to abate soon. Not even Hitler managed to kill as many or was rewarded as much in his first four years of political life.

N.B.: I customarily put “the Goldwater rule” in quotes because: (a) an ethical guideline is not supposed to be a “rule”, according to our code of ethics; (b) it is not an official name but has become a household phrase, as a result of the APA’s public campaigning, far beyond its actual importance; and (c) it illustrates its political origins and does not meet the scholarly, conceptual, or practical standards as most ethical guidelines do.

Forensic psychiatrist, violence expert, president of the World Mental Health Coalition (worldmhc.org), and editor of "The Dangerous Case of Donald Trump.”

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