Politics and Psychiatry — Bad Is Mad

THE OPEN MIND
Host: Richard D. Heffner
Guest: Harold I. Schwartz
Title: “Politics and Psychiatry: Bad is Mad”
VTR: 1/30/91

I’m Richard Heffner, your host on THE OPEN MIND. Nearly three decades ago when conservative republican Barry Goldwater ran for the presidency against democratic incumbent Lyndon Baines Johnson, one publication entitled, a well publicized article, “What Do Psychiatrists Say about Goldwater?”. It seemed designed to do in the republican shot at the White House by indicating that large number of psychiatrists professionally, rather than politically, which is all they could legitimately do, since they had never met or personally evaluated the candidate in a traditional doctor/patient relationship; that they had concluded, or diagnosed that Goldwater would be bad for the country.

But “bad” was somehow made to seem “mad” when in fact all that psychiatrists could do within the framework of professional ethics was to express their partisan conclusions, which actually should count for no more than yours or mine. At the time the American Psychiatric Association attacked the whole incident as administrating a low blow to all who had worked to institute the treatment and care of the mentally ill in America. For “bad” doesn’t mean “mad”, and to imply that it does borders on the unethical. The APA proclaimed in the 1964 incident, “A physician can render a psychological opinion on the fitness or the mental condition on anyone, only in the traditional doctor/patient relationship in which findings are based on a thorough clinical examination; and then such findings would, of course, be confidential.” A far cry from the “bad” is “mad” formulation; and seemingly, from the present continuing relationship between psychiatry and politics that surfaced, for instance, in the televised 1991 senate confirmation hearings on the elevation of Judge Clarence Thomas to the Supreme Court. During the hearings psychiatric evaluations weren’t made en masse and in public, but the effect was very much the same. As The New York Times reported, “While the drama of the Clarence Thomas hearings unfolded on television screens, republican defendants of the Supreme Court nominee and their democratic opponents engaged in a behind-the-scenes struggle to try to use psychiatry to guide strategy, and in some cases provide ammunition for their arguments. Terms like ‘schizophrenic’, ‘out of touch with reality’, ‘delusion’ and ‘fantasy’ were threaded through the testimony against Professor Anita Hill without any medical substantiation, but with a lot of psychiatric advice”. Indeed, The Times reported that senate offices were inundated with letters and text messages from psychiatrists with off-the-cuff opinions about Professor Hill, indicating that the marriage between psychiatry and politics…and perhaps we should include the law, too…is stronger than ever, for good or for bad; which is why I’ve invited to THE OPEN MIND today a skilled professional who has long addressed himself to the “bad” is “mad” conundrum Dr. Harold I. Schwartz, Director of the Department of Psychiatry at Hartford Hospital in Connecticut. And first, I would ask Dr. Schwartz if the off-the-cuff instant, but then made public analysis of public figures is still as bad for his profession’s health as it was in the 1964 Goldwater incident.

SCHWARTZ: Well, I certainly think that it is. I think this incident with its use of all the diagnostic labels directed at Anita Hill has really spoken badly for the profession. The willingness of psychiatrists to jump forward; and above and beyond sending letters and making telephone calls, the willingness of some experts in forensic psychiatry and psychiatry and law to appear in the offices of various senators who were involved in the hearings to coach from behind the scenes, I think is every bit as damaging as the psychiatrist who publicly comes forward in front of the television camera; might render the diagnosis essentially a verdict with regard to an individual which he or she has not interviewed or examined in any clinical way.

HEFFNER: But in every aspect of public life we do turn to experts, expert witnesses in courts. You know a great deal about that. You have your questions about that too, but we do. Why do you find this so hard? Why does your profession find this so hard to stomach? And still the professionals go ahead and do it.

SCHWARTZ: Well, it is a very complicated issue. And as an expert, as a professional, when you’re called to give an opinion it’s always flattering and it is seductive. And I’m sure that psychiatrists who were invited into this affair felt flattered and felt a seductive pull. The problems are two: Expert opinions in psychiatry carry in our society a very special kind of meaning and power. They are…they can be extremely damaging. I think we have seen with the Anita Hill affair that a diagnosis is raised for a delusional disorder, erotomania, schizophrenia; it’s raised and no examination has ever taken place, so it certainly hasn’t been put forward on the basis of any kind of clinical standard. But once it’s raised how do you defend it? If you were Anita Hill, what do you do? Do you bring another psychiatrist who says, “Well, I’ve never examined Anita Hill, but I’d have to disagree on the basis of my non-examination that she carries this diagnosis.”? So once the issue is raised it carries a power that is damaging. I think we saw with Senator Eagleton when he was running for the vice-presidential nomination that once a diagnostic label was attached, the treatment course, his nomination was over. And so I’m particularly concerned that psychiatrists are not just experts. They’re experts offering opinions in areas that are highly emotionally charged, and in which questions of…and in which you have described, “badness” and “madness” are easily confused…so that behaviors that we might find objectionable, behaviors which we may find non-mainstream can easily wind up leading to diagnostic labels on very little evidence.

HEFFNER: But look the matter of Senator Eagleton…he did get the nomination. It was after he got the nomination that the revelation about his shock treatments forced the candidate, the presidential candidate, to ask him to leave the ticket.

SCHWARTZ: Yes.

HEFFNER: And another person was substituting. What was wrong with making that knowledge available to the public? After all, we were going to be responsible and going to have to take responsibility for his actions as Vice-President, and he might have become President. Don’t you think it was important that we know that the public, indeed, be informed what psychiatrists can tell us?

SCHWARTZ: Oh, I think that an argument can be made that in certain high-risk professions that that information is germane to the individuals who are going to put a person in the position of authority or power. Certainly a psychiatric history, a history of alcohol abuse or substance abuse is germane to the airline industry or the airline company that is going to hire a particular pilot. I mean, it’s germane to the public in that instance. I guess you could say the voting public…

HEFFNER: The flying public.

SCHWARTZ: The flying public, yes. (Laughter)

HEFFNER: …germane…

SCHWARTZ: Yes. And in the instance of the President, in the presidential position it is the voting public. I think you could say making that information available in that instance is reasonable. The objection I would have is…the reason I believe that is a good example of the power of psychiatry and the damage it can do in the political process is what we saw happened to Senator Eagleton. Once that information was public he was considered to be unacceptable and an unsuitable candidate for Vice-President and probably ultimately for President as a result. This is a kind of stigmatization of individuals who have mental illness, and it is powerful, as we saw in this case.

HEFFNER: But as I read many of your writings, I know that you are concerned with the sense of victimization that prevails in our society. And I know that you urge that we not step off our sense of responsibility and say that others are responsible for this, that, or the other thing. But that’s the case. Don’t we need the expert opinion that you as a psychiatrist, even without examining one-on-one, face to face, a certain individual, might be able to provide us? Don’t we need your expertise?

SCHWARTZ: Well, I think we need to look carefully at the particular situation. The American Psychiatric Association, following the Goldwater affair, changed its code of ethics to include a statement that it was unethical for a psychiatrist to render a diagnostic opinion on any individual who might be in the public light, without having examined them. Then stipulated, of course, that if they had examined them the information would be confidential anyway…

HEFFNER: (???)

SCHWARTZ: …it sure is. It’s saying psychiatrists really ought to stop talking about the mental health of public figures. But then, there are obvious questions. Does that mean that on a show like this we couldn’t talk about Hinckley? Hinckley is certainly now a public figure and the question of his mental status has been put before us and before the world. I certainly wouldn’t feel that I couldn’t talk about it. I think that that ethical statement is there to advise us very specifically about situations like the Anita Hill situation; about situations in which, clearly, the use of psychiatric…call it a diagnosis, call it a label…is geared for political purposes, not truly to enlighten the public discourse about issues of great importance.

HEFFNER: Tell me about this matter of co-dependency. It sounds like a jump, but I’m so intrigued about reading what you have written…

SCHWARTZ: Yes.

HEFFNER: …about our sense…our diminishing sense, or diminishing willingness to assume responsibility for our actions.

SCHWARTZ: Yes. I really don’t think the jump is so great. The issue of psychiatrists stepping into the public light and…and have…has bearing on our sense of responsibility…the…certainly the courtrooms…and the insanity defense is a primary example of that…But the co-dependency movement reflects another aspect of a trend in American culture influenced by psychiatry, though it’s a trend that has gotten away from psychiatry. There’s been a kind of dilution of the concept of personal responsibility paralleled by a sense in American life in which everyone seems to be a victim. And so we have moved from the notion of alcoholism as a disease and the treatment Alcoholics Anonymous recognized as affective, or more affective than most, to an expansion of the notion of addictive behavior. Co-dependency means that an individual becomes addicted either to a substance or to a behavior or becomes addicted to managing to live with another individual, a spouse or husband, who is addicted. So the original co-dependent was the wife of an alcoholic who spent a life facilitating or enabling…creating a family life that would allow the alcoholic husband to go on. We’ve seen co-dependency groups for such individuals develop and then we’ve seen developments in addictions to sex, addictions to shopping, addiction to scratching your bald spot in public and embarrassing yourself that way. The co-dependency movement has seduced into it individuals who feel that their lives are taken up by addictions or compulsions. Just about any kind of behavior that has a compulsive aspect to it has come to be labeled as a co-dependent behavior. The individuals join co-dependency groups in which they’re asked to give themselves over to the group, give themselves over to a 12-step recovery program based on the Alcoholics Anonymous 12-step kind of religiously-oriented program; the idea being that people can assume responsibility for themselves, giving over responsibility to the group. This kind of treatment, by and large, is replacing standard notions of individual or even traditional group types of psychotherapies in which people are required to look into themselves, to come to understand the underpinnings that fuel their behavior. And so they abandon the process in which they would really be required to take on responsibility, for a process that is labeled one which leads people to assume responsibility for their lives, but really in a rather banal way.

HEFFNER: Isn’t this related, too, to the enormous degree in which, in our time, we look for the responsibility of everyone in every institution around us for what it is we do. In court, “I wasn’t responsible, Judge, it was broken when I got it”, or “She made me do it”, or “He made me do it”, “I’m not responsible for my illness from a cancer because this company or that company sold me the cigarettes”, or whatever other items there may be. So I lose my sense of responsibility there. Now, to what degree is the psychiatric profession, in terms of the testimonies that psychiatrists have offered and medical experts generally have offered in court cases – what responsibility do they have to bear for this?

SCHWARTZ: Well, I think psychiatry does bear a fair amount of responsibility for it. Of course, it’s a double-edged sword. Increasingly, as we learn individuals in certain areas have been legitimately victimized, for instance…American psychiatry is coming to a time now when we’re beginning to realize that in the last generation or generations, there probably has been more incestuous child-abuse than we have been willing to recognize, and this has contributed to a variety of psychiatric disorders that we presently see.

HEFFNER: …let me interrupt…

SCHWARTZ: Yes.

HEFFNER: You say that there is more, or that we recognize it better now?

SCHWARTZ: Well, clearly we recognize it better. That I can say for sure. It’s almost impossible to say “Was our inability or unwillingness to recognize it in our earlier years related to the fact that there was less of it? Or is it happening more now?” So I would beg off from coming to a conclusion about that. I will say that as we are better able to recognize it, it seems to be coming out of the woodworks. So this kind of victimization, specifically through sexual abuse in families is a considerable problem that’s gone unrecognized before. So on the one hand, there’s some legitimate growing emphasis on victimization and the role of victimhood in personality development. And this is contributing to reformulation of our diagnostic thinking in terms of individuals who have been subjected to chronic trauma through the abuse of others, legitimately victims. At the same time, in other arenas, such as the courts, we’ve seen an expansion of the concept of victimhood. So that anybody who has subjected to some harm, or who has had a negative outcome from the behavior, perhaps the behavior that they willingly chose to engage in – cigarette smoking is a good example – can be found to have psychological damages on a variety of behaviors. Pathological gambling, for instance, came upon the scene as a new diagnosis in psychiatry some, oh, ten, twelve years ago – don’t quote me exactly on that. and before you knew it we were finding people claiming an insanity defense for their thefts and embezzlements engaged in to support their gambling habits. Now, with cigarette smoking, we find that in the courthouses in a number of places around the country that individuals who have been smoking for 10, 20, 30, 40 years and who have developed cancer, are suing tobacco companies, claiming that though…even though they were made aware at a certain period of time – usually 1964 with the Surgeon General’s report – and the warning on the package that cigarette smoking can lead to cancer; despite this knowledge, they were unable to stop smoking. And they were unable to stop smoking because the nicotine in tobacco is an addicting substance. And if it is an addicting substance it constrains free will. Therefore the knowledge of the danger becomes irrelevant. They’ve been supported in these arguments by psychiatrists who are offering psychiatric testimony that, indeed, nicotine is addicting, which, of course, we know that it is. But the result of the addiction is a constraint on free will. Now I have yet to understand how a psychiatrist or anyone else really can get inside the mind. We haven’t been able to do that yet. We’ve been able to get inside brains, and we’re learning more and more about the brain on the anatomical and physiological level, but we have yet to have been able to jump into the mind, and come to any real conclusions about how to balance psychic determinism with free will; the biochemical pull of a particular substance which may, indeed, have attached to specific receptors in the brain and which may, indeed, cause a certain physiological discomfort upon withdrawal. We haven’t been able yet, to make a leap from that phenomenon to the constraint of will. So…

HEFFNER: You’ll find a way, the psychiatric profession will find a way, I’m sure.

SCHWARTZ: Well, uh, of course, this is somewhat difficult for me because I would not want to make an argument that psychiatry will get out of the courtroom. I don’t believe it needs, or should be out of the courtroom. I don’t believe that it can be until we change the adversarial system. If we want to do that, then we can remove all expert witnesses from the courtroom and psychiatrists along with them. That might be…well, it would be interesting. I don’t know that it would be better.

HEFFNER: But Dr. Schwartz, short of that, and I noticed that suggestion, that the fault is not of the psychiatrist, and I’ve noticed it in your writings…

SCHWARTZ: Yes.

HEFFNER: …that it is with the adversarial system…

SCHWARTZ: Yes, it is.

HEFFNER: …There’s no likelihood that we’re going to change the adversarial system. Then doesn’t your profession have to take a harder line?

SCHWARTZ: I think that we do. I just want it to be balanced, since it’s so easy in a half an hour discussion to come out as if you’re making one argument as opposed to the other. Just to make one last balancing comment: I think that it’s important to point out that if a bridge falls down and a suit follows, and someone has been injured, there will be a mechanical engineer who will testify that the bridge was properly built. And there will be a mechanical engineer looking at the same evidence who testifies that it wasn’t properly built. And that, we think, is a harder science than psychiatry. So it’s perfectly understandable that there will be the battles of the experts which we see in the courtroom. That said, yes, I think that it is very important for psychiatry to…I hate to use the term, but I’ll say police itself. And in that regard, the American Academy of Psychiatry and the Law is attempting to formulate ethical standards for psychiatrists who do testify in court. And it is very, very necessary to approach questions of responsibility with enormous caution. I just recently saw a case in Connecticut in which an individual was found not guilty, not responsible by reason of mental illness or insanity on the basis of having PMS, Premenstrual Syndrome. It’s appalling.

HEFFNER: Well, you say you want to apologize a bit for using the term “policing itself”. Why? Why are you reluctant to use the…

SCHWARTZ: Well, I guess I’m reluctant only to use the word “policing” in that there’s a notion attached to it that could lead to the abridgement of legitimate difference in thinking on the subject. I would hate to see psychiatrists constrained by very stringent rules and regulations that left them legitimately afraid to say what they really thought.

HEFFNER: Wouldn’t this be resolved to some considerable extent if one depended only upon court-appointed psychiatrists, rather than this party has his or her own psychiatrist and this one his or her own, and then you set them at odds to each other?

SCHWARTZ: That’s kind of an appealing idea, and the kind of idea that I’ve advocated at some point in my thinking about this. But it is an idea that has some problems attached to it. One, it is of course, that when you have a court-appointed psychiatrist whose opinion comes down on one side of the case or the other, the defendant is left, if he’s unhappy, with that opinion, with the fact that he is in an adversarial system, and that system gives him that right…the very best possible defense.

HEFFNER: So you’re still defending the adversarial system.

SCHWARTZ: Well, no…I guess it has been said that the adversarial system, you know, is a terrible…but it is the best one in the world…or something like that. And not being a true authority in law, separate from aspects of psychiatry in law, I can’t say for sure. I haven’t studied every system in the world. But I don’t know that there are better legal systems.

HEFFNER: I’m getting the signal, one minute left. What do you think is going to happen regarding the whole matter of psychiatry and the law, psychiatry and politics?

SCHWARTZ: Well, I think that there will be some enhanced awareness via this Anita Hill/Clarence Thomas affair. I know that there have been discussions in the professional associations. I think that we are moving in the direction of psychiatry’s become increasingly circumspect and I think that with the development of ethical codes by professional organizations, we may see some reining in of some of the more apparent abuses of the insanity defense, and other diminished capacity defenses.

HEFFNER: Of course, Dr. Schwartz, as we end the program, I’m tempted to ask you your opinion about the Thomas/Hill affair. But I won’t do it. It wouldn’t be fair.

SCHWARTZ: (Laughter) Well, thank you.

HEFFNER: But thank you for joining me today on THE OPEN MIND.

SCHWARTZ: It’s been a pleasure.

HEFFNER: Thanks, too, to you in the audience. I hope you join us again next time. And if you’d like to share your thoughts about our program, the theories that were set forth by Dr. Schwartz, please write The Open Mind, P.O. Box 7977, F.D.R. Station, New York, NY 10150. For transcripts, send $2.00 in check or money order.

In the meantime, as another old friend used to say, “Good night, and good luck”.

Continuing production of THE OPEN MIND has been made possible by grants from The Rosalind P. Walter Foundation; The M. Weiner Foundation of New Jersey; The Edythe and Dean Dowling Foundation; The Thomas and Theresa Mullarkey Foundation; The New York Times Company Foundation; The Richard Lounsbery Foundation; and from the corporate community, Mutual of America.