Editorial · MIC LEDGER · Michael Baltimore Ph.D.
I said something on my own podcast last week that I want to put in print, because it is the one line from a long and heated hour that belongs to this profession rather than to the news cycle.
I was in the middle of a rant. I am not going to pretend otherwise — my co-host Jeff Conklin and I spent an hour going, in his phrase, off the rails. But inside it I stopped and made a distinction that I have been making in classrooms for years, and I heard myself make it and thought: this is the part that matters.
People think schizophrenia. No, that person can be helped and managed in that situation. But the deceivers, the ones who are paranoid and can't fit into society and can't build relationships…
The public conversation about dangerous behavior reaches, reliably and immediately, for the diagnoses that respond to treatment. Schizophrenia is the standing example. It is the word that arrives in a headline within hours of any act of public violence, usually before anything is known, and it functions as a synonym for unreachable.
It is the wrong word, and we know it is the wrong word.
What the misuse costs
The person carrying a psychotic-spectrum diagnosis is, on any given day, far more likely to be in treatment, in care, and in contact with services than the population as a whole. The condition is manageable. Management is what our field does. Every clinician reading this has sat with someone whose illness is severe and whose life is organized, medicated, supported, and going on — and who is, statistically, in more danger from other people than other people are from them.
Meanwhile the patterns that actually produce sustained, large-scale harm are the ones that draw no headline diagnosis at all. Deception as a stable operating style. Suspicion that never resolves. An inability to form or hold a reciprocal relationship. Those are character patterns, they are notoriously resistant to intervention, and the people who have them are rarely in anyone's caseload — because they do not experience themselves as having a problem and therefore never present with one.
So we have a public vocabulary that points at the treatable and away from the intractable. That is not a neutral error. Every time a treatable illness is used as shorthand for danger, somebody who was thinking about calling a clinic decides not to.
Where the line is, and why it moved
I have to be honest about the second half of this, because the same episode gives me no cover.
Jeff and I also spent a stretch of that hour applying diagnostic language to public figures. Two licensed clinicians, on a microphone, describing symptoms in named people neither of us has ever assessed. I am not going to reproduce those passages here — they are held out of every artifact this show produces except the raw archive, deliberately — but I am not going to pretend they did not happen either.
The Goldwater rule exists because our predecessors did this at scale in 1964 and the profession spent decades paying for it. The objection to it has never been that public figures are off limits; it is that a diagnosis is a clinical act performed on a person, with their participation, in a relationship that has obligations attached. Broadcast at a stranger, the same words do none of the work a diagnosis is supposed to do. They only borrow the authority of having done it.
I think the honest position is this. Describing observable behavior is fair, and calling it by its ordinary name — evasive, cruel, incoherent, dishonest — is fair. The moment I reach for the clinical term instead, I am no longer using my expertise. I am using my credential, and I am spending it on something it was not issued for.
What I am asking of colleagues
Three things, and none of them require agreement about politics.
Refuse the shorthand. When treatable illness is invoked as an explanation for harm — in a case conference, in a faculty meeting, in a comment thread — say plainly that it is the wrong category. We are the people who are supposed to know.
Name character pathology as character pathology. Not as illness, and not as a diagnosis of a person we have never met. There is precise, ordinary, non-clinical language available for describing deception and exploitation. Using it is more accurate, not less.
Watch the credential. The letters after our names travel with everything we say in public, including the parts where we are ordinary citizens with strong opinions. That is a real constraint, and it applies to a podcast as surely as it applies to a chart note.
I stand by the distinction. I am also putting the rest of it on the record rather than publishing the flattering half alone, because an editorial that asks colleagues to hold a line has no business quietly exempting its author from it.
Editor's note on this piece. The episode passages referred to above are excluded from every deliverable this show produces and are retained only in the raw archive and the episode's internal register. Nothing in this editorial reproduces them, and no comment here constitutes a diagnosis or assessment of any individual.
Michael Baltimore is Publisher and Editor-in-Chief of MIC LEDGER, a counselor educator, and a clinical supervisor. He is not a clinical psychologist. Episode 33 of Mike & Jeff: Off the Record, "Off the Rails," is available now.