The Goldwater Rule

You may have heard of the Goldwater rule, given the state of the world and our current American politics.

What is it, how did it come to be, and why was it considered necessary? Is it relevant today, or does it need to be modified or abolished? I will attempt to explain the Goldwater rule, answer these questions, and then put the rule in the context of our current political climate, leaving you to make your own decisions about its relevance.

Barry Goldwater was an American politician and businessman who was the Republican candidate in the 1964 presidential election. He was a staunch conservative from Arizona who had labored in his family business, was a transport pilot in World War II, and was later a member of the Air Force Reserve. He had been elected senator from Arizona twice before the 1964 contest, and went on to be elected to that post three more times after losing the presidential race by a landslide.

In 1964, a publication called Fact published an article entitled “The Unconscious of a Conservative: A Special Issue on the Mind of Barry Goldwater”. In this piece, Fact had asked 12,356 psychiatrists during the political campaign with Lyndon Baines Johnson about Goldwater’s fitness to serve as president. The publication’s cover piece screamed “1189 Psychiatrists Say Goldwater Is Psychologically Unfit to Be President!”

The comments made by many of the psychiatrists who responded were harsh, negative, and sometimes just downright odd. They referred to Goldwater’s state of “chronic psychosis, grandiosity and paranoid schizophrenia”. They compared him to Mao, Hitler, Castro, Stalin, and “other known schizophrenic leaders”. It was thought that some of the responders might well have been couching their political biases in psychiatric terms. Although some of them seemed to be frightened of Goldwater and what he stood for, they could not state in specific terms that he was indeed unfit to be president of the United States.

The piece in Fact may have cost Goldwater a large number of potential votes on the way to his loss. He later sued Fact for libel and won $75,000.

The American Psychiatric Association (APA) is the oldest medical association in the United States, founded in 1844. It was the largest psychiatric organization in the world, with 37,000 physician members who specialize in the diagnosis, treatment, prevention and research of mental illness. The APA quickly responded to this piece and stated that the Fact article was not medically valid, was a hodgepodge of personal political opinions and would be disavowed by the organization. In 1973, a more formal response was formulated in the text and substance of the Goldwater rule. This rule became section 7.3 in the APA’s Principles of Medical Ethics.

It said that it was unethical for a psychiatrist to give a professional opinion about public figures that they had not personally examined, and from whom they had not obtained consent to discuss their mental health in public statements. It was also noted that a psychiatrist could offer expertise about psychiatric issues in general.

Other professional organizations had their own views on this issue. The American Psychological Association had a similar rule in its Ethics Code. The AMA, in the fall of 2017, revisited this concern through its Council on Ethics and Judicial Affairs, revising its own AMA Code of Medical Ethics. In 2016-17, several psychiatrists and clinical psychologists faced criticism by their peers and others for supposedly violating the Goldwater rule.

Related to this, in the APA Newsroom section of their website, Joseph Schachter, MD, PhD, retired and living in New York City, said that “mental health providers and psychiatrists may make political comments as any other citizen, but without selecting a psychiatric diagnosis.”

Fast forward to the presidential campaign of 2016 and the subsequent election of Donald J. Trump as president of the United States. A veritable firestorm of accusations, suppositions, outright guesses and armchair diagnoses have flooded the media in recent months, all concerning themselves with the fitness of the forty fifth president of he United States to occupy his office and carry out his many duties in a rational and professional way.

In March of 2017, the APA modified the Goldwater rule and prohibited any comments on the mental health of a public figure.

In October of 2017, the APA released a statement that reiterated the intent of the Goldwater rule, and also explained the importance of public education about mental illness. As there was already a cohort of professionals who were beginning to feel a sense of urgency about enlightening the public about the dangers of the current presidential administration, the APA also stated that a “duty to warn” was a legal concept that only applied if there was a bonafide physician-patient relationship in place.

On January 6, 2018, a vox.com article by Elizabeth Barclay examined “the case for evaluating the president’s mental capacity-by force if necessary”. At issue for some psychiatrists including Bandy Lee, associate professor in forensic psychiatry at the Yale School of Medicine, was whether the president was really unwell, or sometimes just behaving badly.

Lee and some of her colleagues have been leading the call for an evaluation. She and Judith Herman of Harvard and Robert Jay Lifton of Columbia have previously stated that President Trump was “further unraveling”. Some of her opposition psychiatrists have stated that she is violating the Goldwater rule by speaking and writing on the issue. She counters by stating that her opinions and position are her own. “We are not diagnosing him-we keep with the Goldwater rule.” She maintains that they are concerned with behaviors, tweeting patterns, paranoia, being very susceptible to fawning, denying his own voice on tape, and other behaviors that bode poorly for professional performance and good judgment.

Some prominent psychiatrists, such as Jeffrey Lieberman, former APA president, disagree with Lee and colleagues, although she maintains that she is making an educated assessment of dangerousness based on years of study and experience. She does not purport to make a diagnosis of the president, but says that she and her collaborators are simply “fulfilling a routine, public expectation of duty that comes with our profession”.

A January 10, 2018, Politico article by Bandy Lee and Leonard Glass was titled “We’re Psychiatrists. It’s Our Duty to Question the President’s Mental State”. These authors made the claim that by altering and modifying the Goldwater rule over the last twelve months, the the APA has basally turned it into a gag rule. They posit that “an individual’s dangerousness, however, can be reliably assessed by interviewing coworkers and intimates, reviewing the individuals past statements and behaviors, reviewing police reports, and, crucially, assessing context. While an in-person interview can be quite useful, it is not strictly required to assess danger.”

So, now you know what the Goldwater rule is, how It came about and why, who it impacts, and how it is being modified and challenged in our current political circumstances.

Are some rules made to be broken?
Does the current political climate call for, or even mandate, the injection of psychiatric principles into politics?

As a psychiatrist, I have my own opinion. I hope that by sharing this information with you, I have stimulated you to form your own.

 

 

Advertisements

Calling Dr. Watson

Will there come a time when computers or robots will replace human doctors? I know I’ve thought about it. Have you?

An article in the Sunday, June 4, 2017 Augusta Chronicle (“Researchers use IBM’s Watson to assess tumors’ genetic markers”) addressed the use of IBM’s super computer to help in the diagnosis and treatment of cancer. From that article, we learned that a physician at the Georgia Cancer Center was feeding raw genetic data sequenced from a very rare cancer into IBM Watson for Genomics, a computer system that is endowed with artificial intelligence that has helped it conquer other frontiers such as competing on the game show Jeopardy. Less than one minute after he had finished entering his data, he had a report back from the computer database that not only addressed the particular genetic mutations that he was concerned about, but also told him about ten medication trials that were already underway that might have implications in the treatment of his own patient.

This is astounding. I can remember the days when researching anything meant going to the medical library, looking in card catalogues for physical cards, cross checking references, pulling large, heavy textbooks off of shelves and taking notes or making copies of relevant passages, then taking all of that back to the dorm or apartment or on call room to read and digest and make sense of it all. Even then, there was very little certainty that one had found everything that was known about the topic at hand. This type of research could take hours or even days.

One thing that a computer with artificial intelligence is good at is taking huge data sets and analyzing them, making sense of them and then offering things that are truly helpful to the human who queried the data base in the first place. Another thing that these systems offers is time savings. As I mentioned above, the sheer amount of time that it would take one human, or even a team of humans, to sift through so much data is prohibitive in a normal clinical setting.

You might remember that another activity that Watson and similar computers are good at is playing chess. According to Wikipedia, chess computers were able to beat strong chess players starting in the late 1980s. One of the most famous chess matches between man and machine was when Deep Blue played then world champion Garry Kasparov in 1997, defeating him. Interestingly, what has been found as the years have passed since that match is that man can defeat machine and vice-versa, but the strongest combination of all is what is called a Centaur player, meaning the combination of both man and machine playing together as one. Rather than the mythological half horse-half human, a Centaur chess player combines all the intuition, creativity and feeling of a human player with the brute computational strength of a supercomputer. Centaur chess is not about computers taking the place of humans, but in fact augmenting and strengthening them to the point that they are many times better than before.

Does this play out elsewhere in medicine? You might also be familiar with the da Vinci® machines that are being used in the area to do surgeries of various types. These robotic machines are used not to take advantage of augmented intelligence, but to fine tune minute surgical techniques that a human hand might not be able to accomplish. Through very small incisions, the surgeon, who is in control of the machine at all times, is able to do very complex procedures in very small, tight spaces. The machine is being used not as a replacement for the human surgeon, but as an extension of him.

Are there already automated procedures or robotic elements in use in mental health today? Yes, there are already automated history taking computers and programs, automated treatment planning, and even algorithms that point toward a particular drug or other treatment for a certain disease. Genetic testing is on the rise, both to help make an accurate diagnosis and to target a specific disease with a specific treatment. Computers and computerized diagnosis and treatment are everywhere in medicine, and that includes mental health.

Once again, the role that computers might play going forward is to access and analyze vast databases of information on millions of medical topics, more than a single physician could access and understand in a lifetime. Computers can search this data with lightning speed, and they can test all known hypotheses and possibilities for intervention in mere seconds.

Is there still going to be a need for human empathy, human contact, human touch? Is there still going to be room for the human interactions that we now take for granted to impart hope to patients suffering from illnesses physical and emotional? I would argue yes, as human physicians have a unique perspective, bond and ability to heal that will most likely never be replaced by a machine alone.

Future physicians may be cyborgs, at least in principle, but the computing part of a practicing medical doctor will, like Watson, always be a tool. According to Dr. Kohle in the article above, “the physician will remain responsible for the conduct of patient care and for evaluating the clinical relevance of the information provided by the tool”.

I believe that computers will continue to enhance our ability to provide good care to patients, but that they will not be replacing us any time soon.

Always On

The ad is compelling.

A surfer rides a blue wave, seen from below in crystal clear reflection. The Apple Watch on his left arm cuts through the surf, elegant, sparkling ripples trailing behind. Suddenly, it breaks the surface, and the screen lights up, announcing an incoming call.

Let’s face it, shall we? We are always connected. We are always wired in. We are always on.

We have become a world of interconnected people, carrying oversized cell phones in our jean pockets, toting oversized tablets in our back packs, jumping from phone to watch to tablet to laptop to desktop to talking cylinders on our kitchen counters with ease. We start a thought on the subway, work on it at the office, add to it on the bus or in the car, and finish it in our home office. We email things to ourselves, text I love yous to our boyfriends across town or our spouses upstairs. We store emails, copy and paste notes and publish selfies to Instagram as easily as we used to sign checks.

We have taken to social media sites and platforms like ducks to water, or more appropriately like toddlers to tablets. Since 2004, Facebook has grown from a small platform to rate college students by their looks to a worldwide behemoth with over two billion monthly active users. It has been followed by Twitter, Snapchat and Instagram. Message apps, apps for sharing pictures, apps for selling things, apps for hooking up, and apps for buying things have skyrocketed in popularity.

It has become harder and harder to disconnect from this grid of talking, picture taking, messaging and buying. Telephone calls? Passé. Carrying a point and shoot or 35 mm camera? Negative. Writing a note or sending a post card to the folks back home? In the dead letter box. Using cash to buy anything at the local department or grocery store downtown? A bankrupt proposition.

We are becoming locked in, signed in, tuned in, connected, interlinked, and on the grid twenty four hours per day. We may fool ourselves into thinking that we set limits on our use of these technologies, but we are inadvertently challenging ourselves to circumvent the very limits that we impose. In addition, technology is so good that it will continue to maintain our connections while we work, sleep or eat, leaving us little reason to actively think about how it all happens. Hello Skynet.

Are there advantages to being always on? Of course there are.

We are able to start and maintain meaningful relationships across great distances. We can find those that we might have lost touch with years ago. We can search for literally anything in real time. We are raising the first generation of nimble multitaskers who will find it second nature to listen to a physics podcast while ordering a latte, paying their mortgage, hailing a ride downtown and buying tickets to the game all at the same time. Our children and grandchildren will be able to crowdsource solutions to almost any problem, and their ability to gather new knowledge and expertise online will astonish us. The tech that they use will soon seem to disappear, to become part of the actual and virtual fabric of their lives, to be so embedded in their daily routine that they will only have to think to make something happen on the grid. Online learning will mushroom to unfathomable heights.

Are there also disadvantages to being always on?

We have already seen that we sit too much, and that we are idly watching our screens more and more hours during the day and night. Instead of sending the kids outside to play, we queue up a virtual game of basketball or hide and seek and allow them to sit on the floor and play. It keeps them quiet, it decreases our stress, but it gives them precious little physical exercise.

We all know that we grab our phones, only meaning to quickly check our messages or Facebook, but then finding that we have spent the last thirty minutes perusing Instagram pictures or checking out the latest fad on Pinterest. A mindless waste of a few minutes leads to a few hours.

The jury is still out, but we think that internet addiction, and by extension addiction to social media, may be very real indeed. Like any addiction, cutting down on the use, especially if it is done abruptly, may lead to very real withdrawal symptoms such as decreased interest in other activities, lack of sleep, decreased appetite and irritability.

The American Academy of Pediatrics has already warned against the negative effects of social media, including cyber bullying and so called “Facebook depression”.

Some studies have also shown that increased use of online resources such as social media may actually result in less happiness, not more, by undermining one’s sense of well being. Comparing your life to others on line, whether positively or negatively, may result in more emotional dysregulation. Jealousy may lead to one upping behaviors and a vicious cycle.

Also somewhat counterintuitively, increased connection time may actually cause one to feel more isolated from friends and family, not less. More “friendships” online may portend less actual physical and real world social interactions, leading to more isolation and mood changes.

You may have read that humans can only keep track of so many actual friends and relationships in real time, usually around one hundred to one hundred fifty. Having five hundred Facebook friends or ten thousand Twitter followers does not necessarily mean that you are fully engaged with all of those people. How could you be, given the other tugs on your time from other parts of your life that demand your attention?

The generation that is growing up always connected may have trouble with always wanting instant gratification, having less overall patience and making quick, impulsive choices. Decreased face time, not FaceTime, may lead to a stunted growth in social skills and normal social engagement with others. Although they may grow to be master multitaskers, they may find that it is very difficult for them to think long and deeply about a subject that is particularly perplexing.

As you can see, there are good and bad things about being always on.

If you decide that you want to try to disconnect, at least part of the time, what should you do?

Physically leave your gadgets at home once in a while. Ditch the phone, the watch, the tablet. These devices are wonderful at recording any communication you get in real time, so that when you get home you can always see what happened while you were away, acting on anything important and deleting the rest.

Even if you have your devices with you all the time, turn them off for half a day. Rest your batteries, your ears and your fingers in the meantime. Uninstall apps that keep you always connected and always on.

Consider limiting social media time, especially on phones and tablets. Set a schedule for checking your Facebook, Twitter or Instagram accounts, perhaps once in the evening after dinner. You don’t have to stop using them all at once or at all, but limiting the exposure to these platforms has shown greater overall happiness in some studies.

Set an email away message when you are out of the office, out of town or on vacation, and then stick to it. Do not try to access your email from the beach or the mountains or the amusement park ride.

It is true that we are becoming a hyper-connected world, always on.

I’m not saying that you should give up everything all at once, or even give some of it up at all. Just considered whether or not you really want to receive and take that phone call from your watch when you’re catching the biggest wave of your life, in the sparkling sea with the bright sunshine overhead.

Character

“I hope he’s going to turn the corner.”

“When he’s not drinking or drugging, he’s a really great husband.”

“As long as he can do the job, I don’t care what he does on his own time.”

The Meriam Webster definition of character is as follows: “The complex mental and ethical traits marking and often individualizing a person, group, or nation; moral excellence and firmness.”

I have been thinking about character and how it impacts individuals and groups a lot lately. In the mental health field, we are often faced with complex histories, stories and situations that we have to make sense of, and then help our clients make sense of. We hear tales of decisions made, relationships entered into, job related difficulties and financial dealings that cause problems for our clients. Repeatedly, they are faced with choices, dilemmas and challenges that must be dealt with in order to heal and move on with their lives. Does character enter into response to problems, how people make decisions and how they treat others and themselves? I would argue that it does.

We all have a certain baseline character or makeup that drives us as we go through life. Our character, personality and temperament are inextricably interwoven with our behavior, decision making and perception of others and the world. This baseline is fairly constant by the time we reach adulthood, and it manifests itself in various ways as we face situations in our lives. It appears to me that our basic character may be unwavering, but our actions, ways of coping and flexibility in learning new ways to deal with challenges may change many times over our lifetime if we are open to that change.

It has been said that people show you who they really are, and that they teach you how to respond to them over time. It has also been said that you should believe them when they do. The best predictor of future behavior is, after all, past behavior. Not seeing a person’s true character, being blind to it for reasons of love or financial entanglements or business relationships, for example, can be problematic. Expecting that a person will change, that things will be better the next time, that they will treat you differently the next time a conflict arises, may be folly. You may have expectations for positive changes over time, but if the other party does not look toward those positive changes, you may be disappointed.

Does aging temper character flaws and negative behavior? Maybe, if a person is open to learning new ways of communicating, new ways to cope with stress and expanding relationships and networks. The other side of that coin? As we age, we sometimes get more entrenched in our existing coping skills and ways of interacting with others, leading to rigidity and further problems. Can a person really be taught to manifest a more solid, adaptable, positive character? Again, the underlying character may be immovable. The actions of the person may be subject to improvement and change.

I asked for the opinions of others I trust on these issues of character, actions and potential change and got some very thoughtful responses. I paraphrase some of the best ones below.

“We are all flawed human beings, and perfection is impossible in any of us, including our chosen or elected leaders. Sometimes the best we can do when dealing with a multiplicity of characters and values and cultural frameworks is to understand the starting point from a values perspective and try to achieve alignment. Hypocrisy, flawed character and deviant behavior sometimes create an environment that is incapable of alignment. Neither party has a good starting point, or can articulate similarities. Working together becomes difficult, or impossible. “

“Character is what you do when no one is watching. People who have poor character may dominate, but they cannot lead. “

“Character is indefinable. I know it when I see it. A person with poor character may be a productive member of society only in short bursts. Eventually he will expose his true self and be forced to move on.”

“Positive and encouraging examples yield a positive character. Negative examples yield either a poor character or one struggling to find its way.”

In my daily work in the mental health field, I see many people who are struggling. Struggling to deal with life’s daily problems and challenges. Struggling financially. Dealing with substance abuse. Trying to salvage a relationship that is foundering. Looking for a steady job that will allow them to support their family. Trying to reach a calm equilibrium in a world that seems to be more chaotic every day. I wonder sometimes if the overall character of our country is changing individual citizens, or if the changing character of individual citizens is fundamentally changing the country.

I believe that in these trying times a strong character, a sense of stable values and the will to be flexible, adaptive, innovative and courageous will see us through. Not just our mental health, but the health and prosperity of our world depend on it.

Aging Gracefully?

I turned sixty in October, and it was a wonderful milestone birthday. It also got me thinking about getting older, accomplishments, physical aches and pains and what it means to live a good life for the long run. Milestones, whether birthdays, marriages, graduation, getting a new job or anything else that marks the arrival at a certain signpost in life, tend to make us ponder.

I once listened to a podcast called The Truth. The title of one episode was Machine Men, and it was a real pleasure to listen to. It was blended truth and fiction, dealing with the need or the desire to make our physical bodies better than they are. The website’s own description of the episode was this:

“We hear passages from the novel Machine Man by Max Barry, about a man who slowly transforms himself, body part by body part, into a machine. And then we’ll meet a real life amputee, an MIT professor named Hugh Herr, who is building mechanical body parts for real.”

I also listened to a book from Audible.com called Amped. This audiobook also dealt with humans developing the technology to make themselves smarter, faster, healthier, stronger and potentially more dangerous via the use of tiny machines placed in the brain. I won’t spoil the listen for you, but suffice it to say that when some of us start to act and look different than others of us, and a tiny physical signpost on one’s temple marks one as an “amp”, trouble is bound to ensue.

This podcast episode and this audiobook really started to make me think more about our physical selves. How do we age naturally, even if we are in the best of health our entire life? What happens if we are severely injured, leading to loss of a limb or blindness or deafness or some other calamity? What happens if we develop a disease that doesn’t kill us, but slows us down and keeps us in pain most of the time? Many of you have experienced life changing accidents and illnesses that have altered your lives forever.

I myself developed acute polymyalgia rheumatica a few years ago, and it has taught me a lot about what chronic, subclinical pain feels like and how it impacts my daily functioning. Although my acute episode has long since passed and I no longer depend on low dose steroids to keep me moving, I once had days that it was hard to get out of bed, days when the aching in my shoulders made it hard to take off my own shirt, and times that my relatively sedentary day job made my hips and back so stiff that I felt like the Tin Man in the Wizard of Oz.

All of which leads me to several other questions and thoughts, which I’d like you to think about.

Is the normal progression of aging that we must all endure really normal, and is it to be tolerated with grace and patience? Do toleration, suffering, and perseverance make us better people?

When we are afflicted with disease or impairment, do we seek palliative treatment and soldier on, chalking this up to our lot in life, or do we seek to completely eradicate the malady if the treatment and technology exist to do so?

If we are not happy with how we look, do we seek out ways to bring back our youthful appearance, or do we proudly wear laugh lines and gray hair and other signs of age and experience like badges of honor?

If, in our lifetime, technology exists to make us stronger, faster, or better physically than perhaps we ever were before (listen to Hugh Herr talk about his climbing abilities before and after learning to use his prostheses), should we do everything we can, spare no expense, to procure them?

Finally, more philosophically, is suffering something that man must endure? Does he see his place in the biological world and seize it proudly, building on it within the natural course of evolution and environmental change? Or, does he “slowly transform himself, body part by body part, into a machine“.

Preventive Maintenance

IMG_7528My car has one hundred seventeen thousand miles on it after just three and a half years. It has taken me back and forth from here to Atlanta more times than I can remember, to the beach, to the mountains I love to hike, and across the country in a seven thousand mile trip four falls ago. It runs well, just like new as a matter of fact. I have pushed it, driven it fast and asked it to work hard for me.

What keeps it running that way? I am a fanatic about taking it in for regular service. Tire rotation, oil and filter changes, cabin air filter changes, alignments, and battery checks. I also pay attention to what goes into it, giving it good fuel to run on and high quality oil to protect its parts from abnormal wear and tear.

What would happen to my car and its performance if I neglected routine maintenance, filled it with cheap gas and oil and never had things aligned and replaced as needed? Would it keep running so smoothly? Would it be reliable enough to take out on the highway for a cross country trip?

In this fast paced world, we drive ourselves like I drive my car. We push ourselves to do more with less, compromise our recovery and rest times, and overextend ourselves. We fill our schedules. We have lots to do. We try to divide our time among our families, jobs, hobbies, church, travel, entertainment, sports and holidays. We use our phones and other tech gear to keep up with everything around us, all the time. We pay more attention to outside stimuli and less and less to our own wellbeing. Some of us already have a mental illness that we try to manage. Others of us may be prone to develop one or have a strong family history.

Ignoring our mental health is risky business.

What can we do to promote good health, both physical and mental?

If you have any kind of mental or physical illnesses, see your healthcare provider regularly. Your doctor cannot adequately treat you if he does not know your most recent signs and symptoms.

Take medications as prescribed. This means take your own medication as ordered by your doctor, do not share your medications with others, and never take medications that are given to you by someone else, are not labeled, or are not meant for you.

If you drink alcohol, do so in moderation.

Avoid use of illicit drugs.

Watch your diet and weight. Try to control the types of foods you eat, the portion sizes and limit processed foods and sugar. Maintain your weight as close to normal for your height as practical.

Get enough sleep. Seven or eight hours are usually enough for most people. If you want to make one simple change that will affect your overall physical and mental health for the better, go to bed an hour earlier and get those zzzzs.

Take frequent breaks. This means small breaks in the course of your busy day as well as longer breaks like vacations that take you completely away from your stressful daily environment. One tip for you: no one is going to freely give you this time in the real world. You simply must decide when you are going to break, how you’ll do it and schedule the time to get away.

Develop a hobby that you enjoy, and then spend enough time on it to develop a true love for the activity. Bike, read, paint, draw, play music, watch movies, build bird houses. Anything that takes you away from stress and focuses you on something pleasant and satisfying is good for your mental health.

Work on developing or strengthening your “real” relationships with family and friends. We have gotten so caught up in our virtual and online personas and friendships in the last few years that many of us have completely forgotten about the power of a smile, a touch, or a laugh. Being with others in a real time situation does wonders for mood, communication skills and bonding with the ones we really care about.

Finally, turn off the excess stimuli from the wider world every once in a while. In other words, unplug. Have a quiet cup of coffee and read a real newspaper. Take a walk in the woods. Nap. You’ll be surprised at how much you see and hear when your attention is off the screen and on the reality around you.

Ignoring your mental health is risky business.

Take the time and make the effort to do the things that keep you healthy and happy.