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Wednesday, January 30, 2019

Tragedies of anti-Trumpism: Extra-clinical and public mental health diagnoses

Statement of the problem

I have been critical of others' decisions to issue extra-clinical and public diagnoses of Mr. Trump's mental health. (See asterisked* footnote below about my word choice here.) While it seems almost everyone (who opposes Trump) does it, I have reserved much of my criticism for mental health professionals who do so. (See, for example, this post, cross-posted with Hit Coffee. Be sure to read this comment on Hit Coffee from Dr. X, who disagrees with what was then my argument.)

I have since come around, albeit grudgingly, to admitting that mental health professionals are not violating professional ethics when they make well-considered statements about Mr. Trump's, or any other public figure's, mental health. I still believe that these professionals, even those for whom I have a lot of respect, too often fail to parse what they know from observing Mr. Trump and what they can't know without further knowledge to which they don't have access. They also seem to flounder when it comes to distinguishing between their views as citizens and their views as professionals. Or, if they believe the roles of "citizen" and "professional" are so entwined as to be inseparable, they tend not to acknowledge the problems inherent in mixing professional opinions and political opinions. Finally, I suspect the claims that mental health professionals "can't" offer such opinions to be greatly exaggerated.

With that out of the way, though, I'll stipulate for the sake of this blog post that such public discussion and diagnosis of Mr. Trump's mental health are necessary. I'll also stipulate that mental health professionals participate in these discussions as responsibly as we can expect in a free society when an important matter of public controversy is at hand.

Tragedies of extra-clinical and public diagnoses

With those stipulations, I find "tragedies" from the extra-clinical, public diagnoses:

Extra-clinical, public diagnoses stigmatize mental health problems

No matter how much mental health professionals say that identifying dangerous tendencies is not the same as saying all, or even most people with mental health problems, members of the public will likely infer that from those professionals' public pronouncements. That's on the members of the public for not heeding what is said. But it's a predictable result nonetheless.

Extra-clinical, public diagnoses creates a backlash

Trump supporters, or even people who purport to oppose Trump but who question the tenor of some of the opposition, will respond negatively to these diagnoses. These diagnoses will help solidify some persons' support or temper some persons' opposition.

Extra-clinical, public diagnoses create a dangerous precedent

There's always going to be some mental health professionals, or at least people with the appropriate credentials, who will offer an assessment of a politician's mental health. And there will always be at least superficial evidence to support that assessment. That doesn't mean every situation is equivalent. Sometimes people are peculiarly unfit for their position and that unfitness needs to be assessed and acted on. But offering public, extra-clinical diagnoses in the one instance makes it marginally easier for others to do so later.

Send off

I've said a lot about professionalism. As a layperson in this area, I realize I'm speaking out of turn. A professional, speaking as a professional, needs to conform to the rules of that profession or at least note when they depart from those rules. As someone trained in U.S. history, for example, I must state in good and honest conscience that the Civil War was primarily a war over slavery and that the South seceded from the North primarily to protect slavery, even though my saying so might anger a good number of people who in other circumstances and on other issues I might wish to count as friends. (Why I'd want to count them as friends is perhaps a different question. But just suffice it to say that we all have friends and family who we love but cannot agree with everything they believe in.) That's burden of professionalism, and I recognize that members of other professions share like burdens.

I also wish to remind readers that I'm speaking of what I think are almost inevitable outcomes, of outcomes that are part of the expected costs people pay for doing what they believe is the right thing. Those costs, or "tragedies," as I call them, are there whether or not it's necessary to incur them. I'm less convinced than some mental health professionals that declaiming against Mr. Trump's mental fitness is as necessary as they seem to believe. But even if it is necessary--and even though it's unfair to all those mental health professionals who make public, extra-clinical diagnoses out of a sense of duty and with the fullness of caution their ethics require--those costs will nonetheless be exacted.

See introduction and table of contents for this series

*Footnote about word choice

By "extra-clinical diagnoses," I mean diagnoses offered without the benefit of the typical face-to-face evaluations mental health professionals usually engage in before making diagnoses. I also mean diagnoses offered without the follow up information gathering that may lead a mental health professional to revise (or confirm) their diagnoses. Finally, I mean "diagnoses" that venture to state what can't be known. It's one thing, for example, to say that Mr. Trump "probably won't change" or will "find it very difficult to change" or even, "on the basis of everything I've seen so far, and acknowledging that there's a lot I can't know from my vantage point, Mr. Trump can't change." It's another thing to say simply that "he can't change." I'm just a layperson, but I find it hard to believe that responsible mental health professionals say a person "can't" change without ever having had a chance to evaluate and work with that person for a time. I might be overly exacting in my demands on others' word choices. But professionals who purport to speak as professionals should be exacting in their word choices.

By "public," I mean information and evaluations offered about the mental health, or personality constellation, of a person that a mental health professional would not be permitted to offer without that person's consent if that person were a client. I suppose there's a gray area here, where a mental health professional may sometimes be permitted or even required to alert the public about a client who, for example, may hurt themselves or others.

By "mental health," I mean not only the distinction between "healthy" and "unhealthy" mental states, such as is indicated by finding a given person suffers from OCD, bipolar disorder, or psychosis. I also mean comments about "personality constellation" or other attributes that don't fit as easily onto a spectrum of what is mental health and what is mental illness.

Saturday, December 29, 2018

Tragedies of anti-Trumpism: The Russian investigation

The investigation

Most are aware of the charges that Russia may have somehow tried to influence the 2016 presidential election and that Russian interests have a disproportionate influence in the operations of the Trump administration. One claim is that a Russian agency, the Internet Research Association, somehow manipulated social media to target certain groups of people in the United States to influence their vote with "fake news." Another claim is that high-level operatives, like former National Security Advisory Michael Flynn, was somehow in the pay of Russian operatives from other countries. A third claim is that Trump is deeper in cahoots with the Russians, receiving difficult to trace contributions from Russia in exchange for Trump advancing Russian interests. As I understand it, Russia isn't the only foreign power alleged to exert undue influence, but the news I've seen focuses on "Russia" and Putin.

In light of these charges, part of the investigation into Trump has to do with his, his administration's, and his campaign's dealings with Russian and other foreign operatives. The questions behind this investigation seems to be what did they know, when did they know it, and how might they be compromising national security because of it?

This investigation needs to be done, and if it uncovers illegal actions, those actions must be prosecuted. Even if what it uncovers is not illegal, it may uncover questionable dealings that should call into question the competence and good faith of the Trump administration.

Three tragic consequences

But however necessary the investigation is,  into Trump's dealings with Russia may do, I see three potentially unfortunate consequences. unfortunate, potential consequences. First, the investigation feeds into a narrative of knee-jerk anti-Russianism and hyper-American nationalism and all the unsavory historical associations that come with that narrative. Second, the investigation glamorizes Putin.

Un-reflective attacks on free speech

One concern the Russian investigation has brought out is that "fake news" bombards social media and manipulates people to vote a certain way or not to vote at all. One possible reaction to "fake news" is advocacy for more gate keeping in the distribution of information. I fear that gate keeping can be unduly strict and may limit what can be said.

It all depends on what kind of gate keeping we're talking about. The fewer and more centralized the gate keepers--and the more formal and rigid the gate keeping process--the more danger. The more diffuse the gate keepers and the more access we have to alternative, non-gate-kept information, the better. To be clear, I haven't yet seen any serious proposal that might raise concerns. The only proposal I've actually seen (and at secondhand, so I don't have a link) is combat trollery on social media so as to provide more transparency about who is providing what information and in whose interests that information is being provided.

Another red scare?

The investigation revives our periodic obsessions with Russia and with anyone who may plausibly be smeared as "pro-Russian." That isn't too different from our other periodic obsessions, such as the war on terror or the anti-Japanese sentiment in the 1980s. But I'd just like to point that we've seen this movie before. The sides seem to have changed a bit. Those who say "but there really is a danger" tend now to be more on the left. Those who say "this is hysteria" or "this is a nothingburger" are probably more on the right. (Here I'm using commonsense, and therefore overbroad and vague, definitions of "the left" and "the right.")

That the sides have switched doesn't mean there's no danger. I should be wary of reasoning by analogy or assuming that because two situations have one thing in common, they have other things in common. But the similarity to other campaigns about "foreign intervention" should give at least a moment's pause. Will the allegations of "pro-Russianism" go overboard and start to ruin lives? Will anyone who raises the possibility that Russia isn't as great of a danger eventually be branded as "traitors"?

Probably not. I said the similarity to concerns the US has seen about foreign intervention should give us "a moment's pause." But I wouldn't say it should give us two moments' pause.

The greater glory of Putin

The investigation serves Putin's interests. Or rather, Putin will find it easy to spin the investigation in a way that buffs up his domestic standing. Maybe Putin is a danger to the US and maybe what Trump and his friends have been doing really does compromise national security or at least signals corruption. But every revelation of how Russia engineered a "fake news" campaign or somehow influenced the 2016 election likely plays into Putin's hands. Maybe Russian experts can tell me where I'm wrong, but I strongly suspect Putin gets a lot of leverage, in the form of bragging rights, by portraying himself as the guy who messed with the American elections.

That perhaps is the most "inevitable" of the tragedies from the Russian investigation. It's obviously (to me) something that needs investigating and it's impossible to investigate in a way that won't redound to Putin's interests.


My warnings about the potential attack on free speech and the next "red scare" are slippery slope arguments. My warning about how Putin may shape the investigation to his own interests is, if not trivial, perhaps to be expected and not particularly in anyone's control. But I believe there's no harm in keeping these concerns in mind.

See introduction and table of contents for this series

Friday, December 28, 2018

Tragedies of anti-Trumpism: Introduction

I write this post to introduce a new series that I call "the tragedies of anti-Trumpism."By Trumpism, I mean the facile appeal to bigotry and to authoritarianism that Trump--but not only Trump--represents. By "anti-Trumpism," I mean opposition to Trumpism.

Yet any serious effort to combat Trump and Trumpism entails, almost necessarily, certain costs to anti-Trumpists' own integrity and to those in whose name they pursue their activism. These costs are "tragic," not because they are too high to justify opposing Trumpism, but because opposing Trumpism almost necessarily exacts these costs.

I mostly join those who say we must remove Trump from office by any legal means necessary and that we must combat Trumpism. I say I "mostly join" and not "completely join" because I'm not convinced that just because a means is legal it is therefore the right thing to do. But that's a conversation for another day. And I certainly am not endorsing illegal means.

I'm aware I'm doing what is sometimes called "anti-anti-Trumpism." That term refers to those who oppose (or at least don't support) Trump but who are bothered by the way others oppose him. I'm aware of the allegation that this "anti-anti-Trumpism" is a bad thing, akin to support for Trump and what he stands for by way of nitpicking and finding fault with any and all criticisms but not actually doing or saying anything meaningful to call Trump and Trumpism to account.

In light of that allegation, I must concede several points:
  • My series of blog posts will be a species of anti-anti-Trumpism.
  • On some level I am indeed offering something like support for Trumpism inasmuch as Trump's supporters take refuge in criticizing his opponents.
  • Other than penning a few criticisms of Trump (an exercise that, like talk, is cheap) and other than voting for Hillary Clinton, I have done nothing substantive to oppose Trump.
  • I have less to fear from Trumpism than others who are more marginalized than I am and therefore it's easy for me to criticize those who have more to fear and more to lose.
  • I feel a certain amount of personal defensiveness when I hear people criticize Trump, Trumpism, or Trump supporters. That defensiveness has more to do with my own pride and perhaps baser inclinations.

At the same time, I find it inadvisable to remain silent. Whatever incidental support for Trump or Trumpism my series offers,* I believe that even anti-Trumpists can benefit from reflecting on the costs to themselves and to others that result from their activism. At the very least, I believe it's preferable for activists of any stripe to go into their activism with eyes wider open.

Table of contents for the series

*Let's face it, my blog doesn't exactly have a wide readership. I've thought of posting this series, or parts of it, over at Ordinary Times, but for now I am not doing so. In part that's because I'm not prepared to deal with the (in my opinion, mostly legitimate) pushback I'd receive.

Wednesday, October 10, 2018

Attributes of the APA's "gag order"

In her introduction to The Dangerous Case of Donald Trump: 27 Psychiatrists and Mental Health Experts Assess a President (2017), Bandy X. Lee briefly discusses the American Psychiatric Association's (APA) recent reassertion of what is known as the Goldwater Rule. According to the APA, the Goldwater Rule states that

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.
Lee argues that when the APA reaffirmed that rule in March 2017, it "essentially placed a gag order on all psychiatrists and by extension all mental health professionals." [p. 11 of Kindle edition]

She goes on to explore some of the good and bad of the rule. She then makes an argument for a countervailing rule. That argument deserves more attention than I'll give it in this blog post, but I want to admit that while I choose now to focus right on her "gag order" language, I'm neglecting the meat of what she's really arguing.

In what ways is the APA's rule actually a "gag order" and in what ways is it just hyperbole?

Monday, August 7, 2017

Gabriel's recent blog posts elsewhere

Here are some posts I've written recently. Feel free to comment here or there if you have something to add. As always, thanks for reading my blog.

Tenure reviewed: A review of Michael Berube and Jennifer Ruth. The Humanities, Higher Education, & Academic Freedom: Three Necessary Arguments. New York: Palgrave Macmillan, 2015.

A case for the conscience exemption: I propose permitting an opt-out "conscience exemption" for union shop agreements, particularly for public-sector unions.

Monday, June 12, 2017

Professional opinions

[This is cross-posted with Hitcoffee here.]

Walking back

It's presumptuous to criticize members of a profession for acting "unprofessionally," especially true when I have not acquainted myself with the specific norms of that profession. I did that when I said recently that some mental health professionals "are acting unprofessionally and to a certain extent dangerously in their public diagnoses" of Mr. Trump. Part of what I meant was that mental health professionals ought not to comment publicly on a public official's mental health.

I no longer believe that. Dr. X--both in his comments here at Hit Coffee [for example] and in some posts at his own blog [here and here]--has convinced me that it's sometimes appropriate for mental health professionals to make such public commentary and that whether or not it's "professional" is more arguable than I allowed.

Cautions are still in order

I still urge caution when it comes to public diagnoses, but before I proceed, I'll note a few terms I am probably using wrong, or at least too globally. "Mental health" and "diagnoses" here in this post are catchalls and may not necessarily encompass what public commentary on public officials is really about. "Mental health professional" is a broad term, too. It can include MD's, PsyD's, PHD's, LCSW's, and probably others--the key point is that I'm referring to people who are licensed or otherwise credentialed to counsel others or to people who study mental health academically. While my use of these terms is sloppy, I ask your indulgence. Now, on to the cautions...

Caution #1: "can't" is a sliding scale

It's important not to confuse the general sense and professional norm that such commentary is "improper" with a strict prohibition against such public commentary. I understand the Goldwater rule is somehow encoded into the American Psychology Association's code of ethics. I suspect, however, a mental health professional who offers public diagnoses does not usually risk being hauled before an ethics board or otherwise sanctioned in the same way he or she might by, say, inappropriately breaking confidentiality.

Anti-caution: We should presume that professionals take the established norms of their profession seriously. Even if they disagree with the norms and seek to revise or ask others to reconsider them, we should presume the professionals feel in some way answerable to those norms or at least believe the norms something that merit discussion and are not to be lightly disregarded. Even without a strong enforcement mechanism, these injunctions still act in some ways as a prohibition.

Caution #2: There is never enough information

I submit that any public diagnosis has to be upfront about what is not known and ought to be open to the concern that the diagnosis might be too hasty. In the meta-sense we just cannot see into other people's minds. In the non-meta-sense, there's always something we don't know about others' history or actions or influences.

Anti-caution: Thus is it always and everywhere. No matter how much is known there are always unknowns. And yet, we have to come to conclusions and mental health professionals are no different. I am informed that in at least some cases, the mental health professional can diagnose an individual in a matter of minutes. I am also informed that in other cases, mental health professionals may be called upon to create psychological profiles of others whom they have never met (say, psychological profiles of employees or profiles of foreign leaders for state intelligence). And regardless of these examples, some persons' actions do demonstrate what they are likely to do in the future, and if a mental health professional can yield discipline-specific insights into those actions that a layperson cannot offer, then that's probably okay.

Caution #3: my corollary to the McArdle rule

Megan McArdle often says that just because there's a problem doesn't necessarily mean there's a solution to the problem. My corollary is that just because a public diagnosis is correct doesn't mean it tells us what to do with the person so diagnosed. (I'll add here that a good model is Dr. X. He may offer opinions grounded in his area of expertise, but when he discusses policy solutions he takes care to distinguish what his expertise can and cannot tell us.)

Anti-caution: My corollary doesn't mean such public diagnoses are worthless. A diagnosis might very well and very rightly warn us, for example, against false assurances that someone will "pivot."

Caution #4: there will be blowback and it will be unfair

In one of my posts, I referred briefly to objections that Rabbi Michael Lerner of Tikkun magazine has about public diagnoses. I don't agree with everything he says there, and I agree with less of it now that I've heard Dr. X's counterpoints. Still, the following objection from Mr. Lerner rings true to me:
I believe that making these kind of diagnoses without the benefit of having a carefully constructed private relationship with the public political personality being analyzed leads many of the tens of millions of supporters of the political character who has been labeled in this way to believe that implicitly they too are being judged and dissed. This plays into a central problem facing us in the liberal and progressive world....When we use the kind of psychiatric labeling suggested by those who insist that Trump is a clinical narcissist, that is heard by many who support him as just a continuation of the way the liberal and progressive forces continually dismiss everyone who is not already on our side as being racist, sexist, homophobic, xenophobic, Islamophobic, anti- Semitic, or stupid. This makes many of these people feel terrible, intensifies their self-blaming, but then often generates huge amounts of anger at those who have made those judgments without ever actually knowing the lives and details of the people that are thus being dissed. And this contributes to the ability of right-wing demagogues like Trump (not a psychiatric term, but a political judgment) to win support by telling a deep truth to many Americans: “many on the Left know nothing about your lives, but they have contempt for you, think that if you are white or if you are a male you are specially privileged and should spend your energies learning how to renounce your privilege.”....
First, I should say my quotation is deceptive. The ellipses elide quite a bit. If you go back to read Lerner's comment in full (I'm quoting from his point no. 4, but I recommend reading all his points), you'll see his argument is not merely pragmatic, but enmeshed in a broader, ideological critique of the faults he finds with capitalism and meritocracy. I don't necessarily share that broader critique and if I hadn't elided those points, the quote would have been not only longer, but would have seemed more contestable as well.

Second, what Lerner seems to me to be saying (in part) is that however accurate a public diagnosis, it might elicit a stronger reaction and in the process do little good. His point is at least partially about prudence. We live in the world, and the world is going to react. It's not fair, but that's what will happen. Anti-caution: We out not overlearn that lesson and make an idol of prudence. If someone speaks the truth, that is a value unto itself. The truth is an end. If that truth is commanded or informed by one's professional memberships and professional training, then sometimes (maybe always?) it must be uttered and pursued, regardless of prudential considerations. And as Mike Schilling Over There has reminded me, the principal bearers of blame are those who don't acknowledge the truth and those who create or pursue or gainsay the lies.

If you're right, you're right

I'll probably never be comfortable with public diagnoses. But that said--and in contrast to a point I made very recently--those public diagnoses of Mr. Trump that I've seen seem to be correct. Even if they're not correct, they're correct enough. Mr. Trump's actions have shown him to be a dangerous, petty man. So I'll end where I began above. I retract my blanket statement that mental health professionals ought never issue public diagnoses of public figures.

Wednesday, April 19, 2017

Auguries of a pivot?

[This post is cross-posted at Hit Coffee]

I better be quick about writing this because the underlying facts probably have a short shelf life. I learn that Mr. Trump now is expressing support for NATO [hat tip Noah Milman], seems to be taking a seemingly less extremist stance stance regarding China, and seems to be distancing himself from his alt-right advisor, Steve Bannon [paywall probably applies]. Are these indications of a sometimes-discussed "pivot" toward more responsible governance?

Maybe....but we have to decide what kind of pivot we're talking about.

There's the personal pivot. This is personal change resulting from an honest self-assessment. It can come quickly, as in a road to Damascus conversion experience. Or it can come gradually, and observable only long after the pivoting began. I don't see any fish scales falling from Mr. Trump's eyes, and if he is on the painful, gradual road to a personal reevaluation, we won't know for at least a few years.

Then there's the institutional pivot. This doesn't preclude a personal change, but it relies on the sets of incentives and constraints that work on the presidency. As I have tried to argue before,
But the argument that Mr. Trump will grow into the presidency doesn’t rely only on the proposition that he’ll become a better person. It also relies on the claim that our system of checks and balances might actually work and that the federal bureaucracy will do what bureaucracies do and somehow condition what Mr. Trump can accomplish.
I'd add other factors to "checks and balances' and "federal bureaucracy": federalism, civil society, the press, individual acts of resistance. In this second sense, it's possible we're about to see a pivot.

However and as with the first sense, we probably won't really know it's a true pivot for several years. One reason among many I distrust Mr. Trump is that he seems to change his mind on a whim. Pivoting hither and yon from one day to the next isn't the type of pivot I'm hoping for.

We also need to keep perspective. I think it's a good thing that Mr. Trump seems to be (this week) distancing himself from Mr. Bannon. But he shouldn't have hired him in the first place. He should have laughed away the suggestion when it was made. And "distancing himself from" isn't the same as firing.

There's finally the disturbing point that we are--or at least I am--looking for any sign of change and clinging to it, hoping it's change for real or at least contenting ourselves that it's not quite as bad at he moment as it seemed and may again seem at other times. Maybe the king won't show up to parliament in his underwear. Maybe the emperor will put on some clothes for once. I suppose it's kind of like dreading the moment an abuser comes home only to be relieved that tonight he's in a good mood.