Psychiatry,“Dangerousness,” and the President James L. Knoll, IV, MD Ronald W. Pies, MD Psychiatric Times, Thursday, January 25, 2018

Psychiatry,“Dangerousness,” and the President James L. Knoll, IV, MD Ronald W. Pies, MD Psychiatric Times, Thursday, January 25, 2018内容摘要：

Psychiatry, “Dangerousness,” and the President James L. Knoll, IV, MD Ronald W. Pies, MD Psychiatric Times, Thursday, January 25, 2018 Dr. Knoll is Editor in Chief Emeritus of Psychiatric Times. He is Professor of Psychiatry at the SUNY Upstate Medical Center in Syracuse, where he is Director of Forensic Psychiatry, and Director of the Forensic Psychiatry Fellowship at Central New York Psychiatric Center. Dr. Pies is Editor in Chief Emeritus of Psychiatric Times, and a Professor in the psychiatry departments of SUNY Upstate Medical University, Syracuse, NY, and Tufts University School of Medicine, Boston “All opinions are not equal. Some are a very great deal more robust, sophisticated and well supported in logic and argument than others.” ―Douglas Adams, The Salmon of Doubt It’s hard to keep up with the flurry of books, articles, op-eds and letters addressing the issue of President Trump’s mental state, many written by well-known psychiatrists.1-5 Reaction to these writings has sometimes been extreme, including reported “death threats” in response to one recent book about the President’s alleged “dangerousness.”5 In an op-ed piece in the Boston Globe, the editor and one contributor to this book argued that they are not “diagnosing” Mr. Trump—which would violate psychiatry’s now famous “Goldwater Rule”—but rather, focusing “squarely on Trump’s dangerousness.” Furthermore, they argue that “dangerousness” can be “reliably established from public records” and “does not require a face-to-face interview.” They go on to depict their portrayal of Mr. Trump as nothing more than “expert commentary,” provided “… for the purpose of enhancing the public’s understanding, awareness, health and safety.”5 We don’t doubt the good intentions of these colleagues, and we recognize that opinion among psychiatrists is often sharply divided as regards the Goldwater Rule. Nevertheless, we find the above claims regarding "dangerousness" deeply problematic. When psychiatric terms of art are used capriciously to label a public figure, this stigmatizes not only the person labeled but also those with genuine mental illness. This impedes our ability to provide vitally important psychiatric care and diminishes the credibility of our profession. Accordingly, in this essay, we attempt to (1) update readers' understanding of the "Goldwater Rule" in its latest incarnation; (2) describe what the term "dangerousness" ordinarily means in clinical psychiatry, and how it is properly ascertained; (3) examine the claim that a psychiatrist can determine a public figure's "dangerousness" without having evaluated the person clinically; and (4) discuss the psychiatrist's ethical responsibilities and legitimate options when he or she believes a public figure is "dangerous", absent a clinical evaluation of that individual. Goldwater redux First, a quick update regarding 2 recent clarifications (or modifications) of the Goldwater Rule (GR) from the American Psychiatric Association. (One of us (RP) discussed and critiqued earlier formulations of the GR in a piece published on this website in October, 2016).6 In March 2017, then APA President Maria Oquendo, MD, PhD, issued this statement: …APA's Ethics Committee asserts that while it is perfectly fine for a psychiatrist to share their expertise about psychiatric issues in general, it is unethical to offer a professional opinion about an individual without conducting an examination. The committee clarified that the rule applies to all professional opinions offered by psychiatrists, not just diagnoses. For example, saying an individual does not have a mental disorder would also constitute a professional opinion.7 The Ethics Committee defined the term "professional opinion" as follows: “When a psychiatrist renders an opinion about the affect, behavior, speech, or other presentation of an individual that draws on the skills, training, expertise, and/or knowledge inherent in the practice of psychiatry, the opinion is a professional one."8 These clarifications (or modifications) of the GR stimulated a robust "pro and con" exchange in Psychiatric Times between psychiatrists Leonard Glass, MD, and Rebecca Brendel, MD, JD.9,10 Then, in a statement released Jan. 9, 2018, the APA vigorously upheld the principles articulated in the Goldwater Rule, writing: We at the APA call for an end to psychiatrists providing professional opinions in the media about public figures whom they have not examined, whether it be on cable news ap