Projection Writ Large in American Politics.....

 

Recent events lead me to the conclusion that I should comment on them with the hope of breaking up the current pattern.  I see a lot of “hopes and prayers” commentary and “we need to unite like we did after 911” – but I don’t think that gets us very far.  What might help is recognizing the pattern, what it means, and using that knowledge to move ahead.    

Let’s start with the pattern.  To me it looks something like this. 

1:  Gun extremism for the past 20 years (as previously defined).  This results in no adaptive solutions for the problem for one of the major parties.

2:  Normalization of name-calling, blame, and rage by the President.  I don’t think any footnotes or references are needed at this point.  He posts something on almost a daily basis on his social media platform consistent with these activities. As Robert Jay Lifton said in 2017 commenting on the Trump Presidency as a descent into darkness “With Trump of course malignant normality becomes the rule because he’s President and what a President does tends to normalize potentially bad, evil, or destructive behavior.”

3:  Secondary spread of these patterns of behavior to everyone in his party – reinforced by mandatory compliance with his wishes using direct threats.

4:  Attributing all of the bad behavior to other people and another political party and acting as if that is true. 

In psychiatric parlance, 1 -> 4 above is referred to as projection.  I notice today that it is also used by commentators who are not psychiatric professionals.  A basic definition of projection is: ‘’Feelings and desires are not seen and admitted in oneself, but excluded from one’s experience and attributed to another.” (1)  In dealing with a person who uses that defense – it is common to feel like you are being blamed for something you are not responsible for and experience the associated anger.

But it can get even more complicated.  Kernberg writes:  “In contrast to higher levels of projection characterized by the patient’s attributing to the other an impulse he has repressed in himself, primitive forms of projection, particularly projective identification are characterized by: 1) the tendency to continue to experience the impulse that is simultaneously being projected onto the other person, 2) fear of the other person under that projected impulse, and 3) the need to control the other person under the influence of this mechanism.” (2)  In other words, the accuser in this case may be doing the same behaviors that he is accusing the other person of doing. In the cases I am referring to another party or member of another party is being accussed of radical politics that leads to political violence by a party or member of a party that has advocated and conducted radical and violent politics for years.

Before anyone invokes the Goldwater Rule here – let me say that I am not making any diagnosis of any individual.  I am simply observing patterns.  Observing patterns at a macro level is different from observing them in an individual patient in an intersubjective setting.  That field is profiling and it was invented by Jerrold Post, MD.  Post observes that in the case of paranoia projection distorts reality (3).  More specifically:  “Attempting to discredit Clinton’s popular victory in the 2016 election, he claimed massive voter fraud by illegal aliens.  As the 2018 midterms approached Trump expressed his concerns that the ‘Russians would be fighting very hard for a Clinton victory’.  So in his fevered imagination, there was a real basis for voter fraud.  And this suggests, given his reliance on the defense mechanism of projection that he would consider voter fraud.”  He subsequently refused to consider any polls that did not show him leading and called them fake news. (4).  Given his role in concessions to Putin and uniting China, Russia, and North Korea – the original suggestion of voter fraud was not consistent with reality.           

Sure you can say it’s just entertainment.  You can say like a recent District Court Judge that it is just rhetorical hyperbole that no reasonable person should take seriously.  You can say that Trump is “just joking” and that nobody takes him seriously but that misses two critical points.  First, this pattern of thought had to start somewhere.  Most of us are familiar with it from early to mid-adolescence when it is a developmental stage.  We can recall when it ended and we made a conscious decision to take responsibility rather than blaming other people for our problems.  Second, there are obviously many people who take this pattern of thought seriously and who can blame them?  I have seen trained mental health professionals fooled and reacting to it.

It is at the point where it cannot be ignored.  If you “do your own research” all the facts are out there. The current situation is the result of a decades long process that values gun extremism and political divisiveness – all leveraged by one party.  As long as you are caught up in that process – things will only get worse.  The results of future violence will be predictable and the soonest anyone can hope for change is 3 more years.  Stop the problem now by seeing this for what it is – a pattern of thought and behavior that most people grow out of.

Are there concrete steps you can take?  I suggest the following.  First, recognize what is going on. I am an old man and I have never seen a President behave like Donald Trump before.  All the projection going on needs to be ignored.  When you see news stations and social media sites trying to amplify his rage and name calling – just shut them off or ignore them.  You will not be missing a thing.  Think of the good old days when we had Presidents from both parties that did not demand our constant attention and outrage.  Presidents that acted in good faith for all of the people.  Presidents you could criticize and it would be taken seriously.  The government ran quietly in the background.  It was never perfect but it was a lot better than what we currently have.  Second, recognize that one of the provocative strategies associated with projection is to devalue some and overidealize others.  Civil servants, scientists, military officers, veterans, women, the disabled, low income people, and minorities have all been devalued while Confederate Generals, dictators, and white supremacists and neo-Nazis are praised and idealized.  It is a consistent dynamic over time.  Third, projection is a mechanism for producing bogeymen. One good example is the alleged left-wing organization Antifa.  Whenever I encounter that trope, I typically ask for evidence the organization exists and find none.  The Wikipedia page suggests there have been more hoaxes than action. For comparison, I was in college during the time of the Weather Underground and a collection of other radical underground left wing organizations were responsible for 2,500 domestic bombings in 1971 and 1972 (5).  That included attacks on universities and munitions plants. There is no possible way that any organizations like those exist today.  Fourth, recognize that the mechanisms I am referring to are intertwined with rhetoric and a distorted sense of reality. The best example I can think of is the constant accusation that you must hate a politician because you disagree with them. That is a recent development in the political landscape and it is a direct product of projection. You attribute hate to someone else if you really hate them and (per Kernberg) may experience it at the same time, fear the person you are projecting onto, and feel the need to control that person.  You also don’t have to think about it too long to see that the person(s) doing this has to see themselves as being extraordinarily important in your life.  That is also not consistent with reality.

There has never been a time in my life when ignoring rhetoric and focusing on reality has been more important.  I hope that I have provided a few pointers on how to get there and am confident that most mature adults in the country can do this.  When that happens it will be the unifying factor we are all looking for.  

 

George Dawson, MD, DFAPA

 

 

 

References:

1:  PDM Task Force.  Psychodynamic Diagnostic Manual.  Silver Springs, MD.  Alliance of Psychoanalytic Organizations. 1980:  p. 643.

2:  Kernberg OF.  Severe Personality Disorders: Psychotherapeutic Strategies. Yale University Press, New Haven.  1984: p. 16-17. 

3:  Post JM.  The Psychological Assessment of Political Leaders. University of Michigan Press.  Ann Arbor, MI. 2003: p. 96.

4:  Post JM, Douchette SR.  Dangerous Charisma: The Political Psychology of Donald Trump and His Followers.  Pegasus Books, New York. 2019: p. 222.

5:  Burrough B.  Days of Rage: America’s Radical Underground, The FBI, and the Forgotten Age of revolutionary Violence.  Penguin Press, New York. 2015

6:  Lifton RJ.  The Nazi Doctors.  Basic Books, New York.  1986.

The Unspoken Punchline...

 

The American promise—that you can be anything you want—is a mantra we internalize from childhood. It's the foundation of every commencement speech, the hopeful message on every career guidance poster. But what if the whole thing is a setup for a punchline? Comedian Chris Rock delivered it perfectly: "As long as they are hiring."

It’s a funny line, until it isn’t.  As someone who grew up in a blue-collar household, I found it to be a devastatingly accurate summary of the modern American condition. It captures the humor, the tragedy, and the stark reality all at once. For years, I have used Labor Day as a moment to reflect on the deterioration of the physician's work environment—a topic that, for those of us in the field, feels more hopeless with each passing year. But this year, I find myself thinking less about my own profession and more about the foundation on which it all rests: the simple, hard-won dignity of work itself.

My own trajectory began in a family of five children, where my father was a railroad fireman, then an engineer. In my earliest memories, he was a figure of physical toil, shoveling coal into steam locomotives. Then he became an engineer on diesel locomotives.  His schedule was chaotic, defined by the whims of the railroad's system. He would take a train 180 miles south, sleep on a station bench, and turn around the next day. We would often have to pick him up in some distant town, 30 or 40 miles away, a small sacrifice for a man who seemed to belong to his work more than to us.

The railroad was a union shop, governed by a ruthless seniority system. The most tenured engineers got their choice of routes and hours, leaving the newer men like my father with stretches of unemployment, even while he was still officially on the company's books. He hated the union dues and the men at the top who seemed to prosper without working very hard. He was, in a way, his own harshest critic, constantly engaged in home improvement projects that were more like feats of engineering than weekend hobbies. I remember a day when seven of his friends showed up to help bend a warped 16-foot plank of wood into a sill plate. The conversation, as they worked, was a symphony of railroad stories, a shared language of labor and hardship.

The values of that world were rarely spoken but deeply embedded. We were taught to mind our own business, which meant a steadfast refusal to gossip or, more importantly, to ever speak of what happened within the family. It was a kind of principled isolation. We were expected to work hard and to be rewarded for it, yet my family lived paycheck to paycheck. The meals were predictable, built from a half-pound of ground beef. Good grades were a given, but a future beyond high school was an unwritten page. Nobody in my family had ever gone to college. I ended up there on a football scholarship, and even then, in the early years of my studies, I tried to get a job on the railroad. The men who interviewed me knew my father's name, even though he had been gone for six years. I didn't get the job. It was one of the best things that ever happened to me.

 I look at that world now and see a profound contrast with the one we inhabit today. The honesty, the direct exchange of labor for value, seems to have been replaced by a system of ever-increasing abstraction and exploitation.

The promise of American capitalism—the idea that free-market competition drives innovation and success—feels more like a myth. We no longer buy products; we license them, signing up for a lifetime of monthly payments that invariably increase. There are minimal guarantees, but a large extended warrantee business where you can purchase one.  The company that employed my father, a place of hard work and honest wages, is now nothing but a ruin. In its place, we have a system where businesses compete not on the quality of their product, but on gimmicks designed to guarantee a perpetual revenue stream.

This is a world defined by stark, growing inequalities. The gap between the richest and everyone else has widened dramatically. Just in the past 10 years the number of billionaires and their net worth has doubled. Tax cuts for the wealthy, deregulation that degrades our environment—these are not accidental byproducts of the system but deliberate mechanisms for concentrating wealth. We see the rise of a managerial class that seems to exist solely to siphon value from the real producers of goods and services. The largest managed care company in the U.S. is a behemoth with a gross annual revenue that rivals the GDP of a small country. They produce nothing but profit, denying care to their subscribers while extracting billions from the system. It is a world where a billionaire, who surrounds himself with other billionaires, can convince working people he represents their interests.

The most unsettling change, however, is the erosion of fundamental values. The robber-baron mentality is back, with CEOs and corporations shamelessly pursuing power with no regard for the environment or the well-being of the working population. The truth itself has become a flexible commodity. It is now routine for a President to lie to and troll the American people, a new norm that has been embraced by those who claim to represent the very people who value honesty above all else. This particular form of ad hominem is most frequently used to attack the work done by other politicians and government workers.  Expertise is openly mocked, and the social contract with workers has been grossly violated.

Perhaps the most visceral example of this new ethos comes from a quote by a current director of the Office of Management and Budget. He stated, “We want the bureaucrats to be traumatically affected…We want them to not want to go to work because they are increasingly viewed as the villains.” He talked about starving them of funding and putting them "in trauma." As a man who grew up watching my father work, I cannot comprehend a world where a manager openly declares his desire to inflict trauma on his employees. Here is a novel concept – your employees are working hard enough already and most are struggling to get by.  The idea that a manager could view the very people who do the work—the civil servants who keep the country running—as villains is a profound moral failure.

 Labor Day was created to honor the accomplishments of the American worker. It was a recognition that we needed a social contract to ensure job security, a share in prosperity, and freedom from exploitation. In the last seven months, that progress has not just been halted; it has been violently reversed. The contempt for workers, the willful destruction of their professional and living environment, and the disregard for their security is palpable.

How can this possibly end well?

George Dawson, MD, DFAPA

References:

1:  Abelson R, Rosenbluth T.  Medicare Plan Would Let A.I. Companies Determine What Is Covered: [National Desk].  NYTimes, August 29, 2025  https://www.nytimes.com/2025/08/28/health/medicare-prior-approval-healthcare.html

2:  Nehamas N.  DOGE Put Critical Social Security Data at Risk, Whistleblower Says.  New York Times.  August 26, 2025. https://www.nytimes.com/2025/08/26/us/politics/doge-social-security-data.html

3:  Wikipedia.  Mass federal lay-offs.  Accessed August 30, 2025. Link.

4:  Malakoff D. How Trump upended science. Science. 2025 May 8;388(6747):576-577. doi: 10.1126/science.ady7724. Epub 2025 May 8. PMID: 40339033.

“Many fear that in just 14 weeks, Trump has irreversibly damaged a scientific enterprise that took many decades to build, and has long made the U.S. the envy of the world”.

5:  Kaiser J. NIH under siege. Science. 2025 May 8;388(6747):578-580. doi: 10.1126/science.ady7725. Epub 2025 May 8. PMID: 40339032.

“The atmosphere is one of “chaos and fear and frustration and anger,” said a senior scientist with NIH’s intramural research program who, like others, spoke on condition of anonymity to protect themselves and others from retribution. This scientist added: “It’s this feeling of utter powerlessness and repeated insults.”

A former top NIH official who was forced out believes that’s the intent. “I think the plan is to sow as much chaos as possible. … I think they want a dispirited workforce at NIH so people will just say ‘to hell with it’ and leave.””

6:  Jacobs P.  Trump administration quashes NIH scientific integrity policy.  Science.  2025 April 3; https://www.science.org/content/article/trump-administration-quashes-nih-scientific-integrity-policy

7:   McNicholas C, Sanders S, Bivens J, Poydock M, Costa D. 100 ways Trump has hurt workers in his first 100 days.   April 25, 2025   https://www.epi.org/publication/100-days-100-ways-trump-hurt-workers/

8:  Greenhouse S.  ‘He’s brazenly anti-worker’: US marks the first Labor Day under Trump 2.0.  Advocates say Trump has hurt workers in many ways, often by cutting their pay or making their jobs more dangerous.  The Guardian.  September 1, 2025.  https://www.theguardian.com/us-news/2025/sep/01/labor-day-workers-trump

9:  Borosave RL, Steffens S.  Trump’s War on Workers. Buried beneath the bluster is a systematic assault on labor. Nation.  August 29, 2025.  https://www.thenation.com/article/politics/trumps-attack-workers-labor/

10:  Su J, West R, Stettner A.  Trump’s Department of Labor Continues Its Onslaught against Workers.  The Century Foundation.  July 22, 2025.  https://tcf.org/content/commentary/trumps-department-of-labor-continues-its-onslaught-against-workers/

 I truncated the references at this point.  Any Google search will show hundreds of references about how Trump has attacked and derided workers and degraded the work environment.  

Graphics Credit:

The background for the photo is a blueprint of railroad yards and the Chicago and Northwestern Railroad in my hometown.  If you look closely at the right lower corner you can see the turntable where locomotives were turned and directed into the roundhouse for repair.  This was posted by the Ashland Wisconsin Historical Society.  I still have vivid recollections of accompanying my father to this complex, the smell of diesel fuel, and the constant loud thrumming of the engines making everything else inaudible.

Letter to Gov. Walz About Guns

 

Dear Governor Walz,

 I am a psychiatrist and have practiced for most of my career in Minnesota. Much of that time was spent running an acute care unit at St. Paul-Ramsey and then Regions Hospital.  In acute care psychiatry we spend most of our time addressing psychiatric emergencies involving violence and aggression directed at self and others. The goal is to prevent injuries including suicide and homicide and we do a good job with that.  Addressing any associated firearms is part of that job.

I was driving around yesterday and heard on MPR that you may be planning to introduce legislature to toughen gun laws based on the recent tragic events.  I encourage you to do this and have written extensively about this issue and the surrounding politics.  It is quite unbelievable that nothing is ever done to address the problem solely because we have a political party that supports gun extremism.  I offer some posts off my blog to give you necessary data if you need it.

The first looks at the issue of permissive gun laws and how they affect the gun death rate of children and adolescents.  Firearm deaths are the number one cause of preventable deaths in this age group and the United States is the only high-income country where this is true.  In the study I reviewed, Minnesota is classified as a state with intermediate permissiveness in terms of gun laws.  In states in this category there were 1,424 excess firearm deaths.  States in the most permissive category had 6,029 excess firearm deaths.  I have a table in this post that compares Illinois, Minnesota, and Wisconsin as examples of strict, permissive, and most permissive gun law states:

https://real-psychiatry.blogspot.com/2025/06/pediatric-deaths-from-firearms.html

In a second post I address the issue of likely and unlikely causes of mass shootings.  There is always a lot of excuse making by gun extremists when these events occur.  Recently that has included blaming mental illnesses and even psychiatric treatments.  As an expert in treating aggression and violence I can attest to the fact that psychiatric treatment does not cause aggression.  Beyond that I would invite you to look at the data in this post clearly illustrating that the major variable in mass shootings is gun density.  Countries using the same number of antidepressants or more bracket the US in the first table and neither country has mass shootings and nowhere near the number of gun suicides or homicides. Even considering mental illness as a risk factor, people with that problem do worse in the US due to firearm availability.

 https://real-psychiatry.blogspot.com/2023/03/likely-and-unlikely-causes-of-mass.html

And finally, I have a few posts about gun extremism in the US and how it has evolved over the years.  We have gone from 19^th century local ordinances that require checking your firearms at the city limits to permitless concealed carry of much more deadly modern firearms.  And all of that is since the party pushing this agenda has no functional policies that would appeal to the electorate.  In fact, in one of my posts I point out that the same party that pushes gun extremism has pushed political violence.

Gun Extremism Not Mental Illness:  https://real-psychiatry.blogspot.com/2022/05/gun-extremism-not-mental-illness.html

Mass Shooters - The American Gun Extremist Superman:  https://real-psychiatry.blogspot.com/2024/08/mass-shooters-american-gun-extremist.html

Another Note on Gun Extremism - An Appeal to Grandparents:  https://real-psychiatry.blogspot.com/2023/01/another-note-on-gun-extremism-appeal-to.html

Current Political Violence In The USA:  https://real-psychiatry.blogspot.com/2024/10/current-political-violence-in-usa.html

You can find more posts on my blog by searching guns, firearms, or gun extremism. Good luck with your efforts to make Minnesota a safer place for all of us.

Sincerely,

George Dawson, MD, DFAPA

Additional Information:  I sent similar notes to both US Senators from Minnesota.

Photo Credit:  I took this shot of the crowd at the Minnesota State Fair on August 26, 2025. 

Existential Threats....

 

Mapping Existential Threats in the Medical Literature

 

I heard President Trump and several right-wing politicians complaining about the term “existential threat” in the press the other day.  Some of the clips were a few months old but the overall message was first – “I didn’t know what it means”, second – the people using the term (in this case former President Biden discussing climate change) don’t know what it means, and third you are an elitist if you use the term because the average family in American does not use the term and you should learn to talk like them.  Like most statements uttered by the current President and his unquestioning party I found it rhetorical, not useful, and decided to see what the medical literature said.  This is what I found.

On PubMed, there are 248 references to the term dating back to 1979.  As seen in the table most of the scenarios listed like climate change, COVID and other pandemics (in this case HIV), diseases, antibiotic resistance, artificial intelligence, and other threats to life are the commonest threats listed in medical literature.  By definition, an existential threat puts the future of some group (humanity, specified individuals) or person at risk.  The worst-case scenario is an extinction event like the Cretaceous-Paleogene (K-Pg extinction) event that occurred 66 million years ago.  That was caused by an asteroid strike and it led to the extinction of non-avian dinosaurs and 75% of all plant and animal species. 

The tables contain existential threats to humanity, many subgroups including physicians and the afflicted, school and businesses, other animals, and plants, as well as ecosystems.  It also includes the psychological component where the perceived threat is experienced as a threat to existence, but more at a symbolic level.  Yalom’s text (1) on existential psychotherapy breaks those threats down to death anxiety, freedom, isolation, and meaninglessness.  Other psychoanalytical writers point out that existential crises are more likely to occur at various points in human development.  In psychiatric practice it is common to see people experiencing crises in these areas across all settings.  Existential crises can exist at the level of group or individual psychology depending on the nature and scope of the threat. Some scientists hypothesize that we are currently in the midst an extinction event.  They describe this as the sixth mass extinction event and verify it by estimating the number of vertebrate species that have gone extinct and compare it to previous mass extinctions (3).  Human culture is a critical factor in this extinction and the conclusion are a massive effort is needed to head off this event and much of that effort needs to be directed at reducing overconsumption, transitioning to environmentally friendly technologies, and an equitable path to those transitions (2).  These authors point out obstacles to these changes including most people being unaware of the changes required to prevent ecosystem damage by human culture, the scope of the problem, and the necessary solution of scaling back human impact – both the scale and processes.

The political use of the term “existential threat” has been applied to the Trump administration and this is probably why Trump himself is trying to spin the term in his favor. He is focused on blaming the opposition party, but at this point it goes far beyond the Democrats.  The non-partisan Bulletin of the Atomic Scientists has posted that the well know extreme budget cuts of the administration pose an existential threat to the next generation of scientists. Various publications around the world have written about Trump as an existential threat to democracy, the American economy, former American allies, Social Security, freedom, black Americans, American colleges and universities, public health, science, and critical international food and medical aid.  In many of these areas the facts are clear.  I can think of no better example than USAID and the PEPFAR program.  Just defunding those programs could lead to as many as 14 million deaths if none of these changes are reversed by the courts.  

Paranoid people do not do well with existential threats.  They lack the ability to assign probabilities. They cannot see a car on the street and just see it as another car.  They get the idea that all cars or all red cars are threats to them. The defined threat may be elaborated as surveillance by Homeland Security to being attacked by microwaves being transmitted from these cars.  In some cases, everything is seen as a threat.  The anxiety is real but the threat assessment is wrong.

If you do not know what an existential crisis is – you should.  Most students in the US start reading existential themed literature in middle school and early high school.  The average person needs to know at what level the threat exists (personal, group, civilization-wide) and what can be done about it.  That means that it makes sense to break down the specific threat, adequately assess it, and not leave it hanging there as ill-defined.  For example, nuclear war, a massive asteroid collision, and climate change threaten all human, animal, and plant life on the planet.  Not being able to get a job in an area where you were trained in college or losing your first significant relationship can be existential crises at an individual level.  That can be life changing at a personal level and the good news is most people find their way back on track with the help of family, friends, and the occasional therapist. 

The outcomes of existential threats can lead to unexpected action.  When I was in college, one of my jobs was working in the local public library.  It was a multi-county library and the main part of my work consisted of mailing out books and films to all the co-operating libraries. One day the chief librarian came in and told me it was now my job to dismantle the fall-out shelter in the basement.  The year was 1972 just 10 years after the Cuban Missile Crisis. The library had two Fallout Shelter signs like the one at the top of this post.  I went down into the basement and found about 100 steel drums.  They were all about 30-gallon capacity. According to the instructions on the side they were supposed to be used for water storage.  When empty they were supposed to be used as latrines.  None of them contained water.  I guess the planners thought there would be time after a nuclear attack to fill them all. When I asked my boss what I was supposed to do with the drums he said:” I don’t care just get them out of here.”  I took them back to my neighborhood and handed them out to anyone who wanted them.  Apart from the steel drums there was no food or medical supplies.  Just a very large room full of steel drums.

It took me a long time to figure out what happened to the fallout shelters and how they went from a national priority to complete disrepair and abandonment in a decade.  The only explanation is that the planners knew there would be no survivors. A few groups here and there would survive the blast and radiation but nobody would survive the nuclear winter.  Even a limited nuclear exchange kicks enough dust up into the atmosphere that makes food production impossible. That marks the end of humanity – the ultimate existential crisis.

Shouldn’t the man with the power to end civilization quickly or slowly know something about this?  Shouldn’t everyone know the real existential threats we are facing?  Shouldn't we all be facing these threats realistically instead of denying they exist or pretending that we can survive them?

 

George Dawson, MD, DFAPA

 

References:

1:  Yalom ID.  Existential Psychotherapy.  Basic Books.  New York, 1980.

2:  Dirzo R, Ceballos G, Ehrlich PR. Circling the drain: the extinction crisis and the future of humanity. Philos Trans R Soc Lond B Biol Sci. 2022 Aug 15;377(1857):20210378. doi: 10.1098/rstb.2021.0378. Epub 2022 Jun 27. PMID: 35757873; PMCID: PMC9237743.

3: G. Ceballos, P. R. Ehrlich, A. D. Barnosky, A. García, R. M. Pringle, T. M. Palmer.  Accelerated modern human–induced species losses: Entering the sixth mass extinction. Sci. Adv. 1, e1400253 (2015).

Supplementary:

I thought I would list a few references to existential crisis as they occur:

Ford L.  Seymour Hersh Issues Grave Warning in Venice: “Trump Wants to Be Commander of America — He Wants to Not Have Another Election”  The Hollywood Reporter.  August 29, 2025.

https://www.yahoo.com/news/articles/seymour-hersh-issues-grave-warning-111210675.html

“There’s still integrity in America right now but as somebody said recently, we’re in existential crisis right now. And the president is a man who wants to be here for life. He wants to be commander of America. My belief is that’s his absolute sole mission. He wants to not have another election, because under the Constitution he cannot…. That’s what he’s going to be doing for the next three years.”

Lithium In The Drinking Water

 

Lithium In The Drinking Water

 

The title is an inside joke for any physicians trained in my generation. It was a standard line to indicate how common it is to prescribe a certain medication.  The first time I heard it I was an intern in the emergency department (ED) at St. Paul-Ramsey Medical Center.  It was (and is) a very busy ED and one of 3 Level I trauma centers in the Minneapolis St. Paul area with a population of about 3.6M people.  In those days there were no urgent care centers so the ED was informally split into a trauma and high acuity side and a low acuity side.  The interns would rotate from one side to the other every other day.  I had just assessed a couple of sisters on the low acuity side and diagnosed otitis media (ear infection) and was writing scripts for amoxicillin while I waiting for my attending to confirm the diagnosis.  He came out, agreed with the diagnosis and treatment plan and said: “We should put amoxicillin in the drinking water.”

And so it went.  Since that day I have heard the same thing about H-2 blockers, proton pump inhibitors, and statins.  All medications that are commonly prescribed for common problems.  Nobody has ever said that about lithium. In the conversations I have had about lithium over the past 30 years – people generally slow down, look concerned, and say something like: “That is a heavy-duty med isn’t it doc?” 

Lithium apparently got that reputation after it when it started to be widely used by psychiatrists for the treatment of bipolar disorder.  It was approved by the FDA in 1970 but was used as early as 1894 that for both bipolar disorder and melancholic depression (1).  It was also used in popular beverages and sought in the form of mineral water.  From 1929 to 1948 it was in 7-UP Lithiated Soda – a brand that eventually became 7-UP.  Lithium citrate was the active form and there is no reliable information on the concentration it originally contained.  One source suggests 5 mg/L (8) but it is not clear if this is as Li or a compound.  In psychiatry, that would be a trivial dose as either lithium carbonate or lithium citrate.  If it was really 5 milliequivalents (mEq) of lithium that would be roughly equivalent to 300 mg of lithium carbonate (Li₂CO₃) or 550 mg of lithium citrate (Li₃C₆H₅O₇).  Practically all the lithium prescribed by psychiatrists in the US is lithium carbonate in a range of 600-1800 mg/day.      

Lithium is considered a disease modifying drug in psychiatry for long term stabilization of bipolar disorder.  It is probably underutilized in the United States for both antidepressant augmentation and treatment of depression.  It may be underprescribed in general because it requires monitoring, has a narrow therapeutic index, can cause renal and thyroid complications, and has the potential for significant drug-drug interactions with a variety of medications that are commonly prescribed.  Investigations of its mechanism of action has led to some speculation that it may prevent neurodegeneration and be effective against psychiatric disorders even in very low doses.  These studies look at lithium exposure in the water supply and in animal models of neurodegeneration.  A recent paper suggests that lithium deficiency may cause Alzheimer’s dementia.

Before I get to a discussion of that paper, I thought I would review the ecology of lithium in the environment that is primarily focused on water chemistry.  I am referencing two major studies of lithium in the drinking water in the United States.  The first (3) looks at groundwater measurements at 18,027 states and uses that data to model lithium in the groundwater across the US.  They map that data and the maps are shown along with the original sampling sites at the maps at the top of this post.  As noted in the table, about 15% of these sites have a concentration of lithium that is greater than >30 μg/L.  That is significant because the Health Based Screening Level (HBSL) is 10 μg/L.  HBSLs are non-enforceable good faith benchmarks based on the latest drinking water and toxicity data.  Some of the sites measured in this study were exceeded by 1500 fold.  Lithium is the 32nd most abundant element in the Earth and distribution in nature is variable.  

The second study was more specific for drinking water because it looked at samples directly from drinking water treatment plants (DWTP) (4).  Even though DWTPs have no specific processes for removal of lithium, the levels are significantly lower in range than the groundwater survey.  The surface water had a median level below the HBSL and groundwater level was higher.   The authors noted that 56% of the groundwater and 13% of the surface water sources of DWTPs exceeded the HBSL. 

In terms of pharmaceutical doses of lithium – the lowest dose I have ever prescribed was 150 mg as lithium carbonate.  Lithium carbonate is 18.79% lithium; therefore, each tablet or capsule contains about 28.185 mg of Li or 28,185 μg.  Looking at the range of concentration in the Lombard study (3) it would take ingesting 1.88 to 28M liters of those waters to be equivalent to a single 150 mg capsule per day.  In the case of the median groundwater and surface water from the Sharma (4) study it would take 176 to 216 liters to take in the equivalent amount. That study also suggests that drinking water sourced for treatment for human use is less likely to have extraordinary levels but does have levels that are currently flagged as a potential health risk.  Most people on lithium maintenance for bipolar disorder have much higher exposure to lithium than is likely from any drinking water source.  There are some commercially available lithium mineral waters that advertise a lithium level of 490 μg as Lithium Bicarbonate (LiHCO₃). That is equivalent to 50.3 μg Li (per liter) putting it in the range of both studies.

What does all of this say about the ecology and water chemistry of lithium?  Cleary there is a lot of variability.  Most water sources are not problematic but some with very high levels may be.  Drinking water surveillance appears to be a good approach to reducing exposure to high levels and many municipalities test for uncommon elements and organic compounds. Any attempts to correlate lithium in the water with medical or psychiatric outcomes needs to account for this variability and it is significant.  In the study that used machine learning to predict lithium levels with meteorological and geological variables – the results were modest.  I agree with the opinion that since the long-term effects of Li as a micronutrient are unknown and there is some toxicological concern as evidenced by the HBSL it should be studied (4).

That brings me to the recent study that has been heavily covered in the news (9).  I have received several questions about it and the most common questions are: “Does lithium prevent Alzheimer’s Disease?” and “If it does should I take it.”  I will preface my comments by saying this is a very well-done study.  It is also an intense study that is typical of what is published in both Nature and Science.  There are a mix of experiments using state of the art technology and they are all presented as crowded and very small graphics in the paper.  There is also a supplemental document (in this case 13 pages) of additional graphs and figures). 

The experimental sections of the paper can be broken down into a naturalistic look at a panel of metals concentrations in the brain and blood of subjects with normal cognition versus Alzheimer’s Disease (AD) or mild cognitive impairment, the effect of lithium deficiency in normal and mouse models of AD (3xTg and J20Ag), the effect of lithium on glycogen synthase kinase 3β  (GSK3β), the effect of lithium replacement, the impact of lithium on brain ageing in wild type mice, and determining an optimal form of lithium for replacement. 

The human brain samples depending on the experiment were from groups with no cognitive impairment (NCI)(n=22 - 133), Alzheimer’s Disease (AD)(n=5 - 105), and mild cognitive impairment (MCI)(n=7 - 66).  Brain samples were fractionated to check for metallic ion gradients and 27 ions were investigated.  Only Li showed lower levels in the cortex in both MCI and AD and it was also concentrated in the Aβ plaques.  The authors conclude that this shows a significant problem with Li homeostasis in both MCI and AD.  Some of the sampled ions like lead and arsenic are known neurotoxins.

Results of the experiments in mice are depicted in the diagram below.  3xTg mice are transgenic mice with three mutations (APPswe, PS1M146V, and TauP301L) associated with AD.  As noted, they accumulate amyloid- β protein (Aβ) and tau protein.  The J20Ag mice are transgenic mice that results in overexpression of amyloid precursor protein (APP).  Both mouse lines are considered models of AD.  In all cases lithium deficiency leads to accumulation of amyloid-β protein and other processes (where measured) consistent with AD like neurodegeneration at the behavioral, ultrastructural, and biochemical level. 

The authors demonstrate that lithium supplementation in mice prevents these changes in wild type mice.  They illustrate how blocking GSK3β prevents AD like changes.  They also demonstrate how a lithium compound (lithium orotate) with low solubility prevents lithium from being sequestered in Aβ plaques.  All experiments considered, they provide a compelling backdrop for considering lithium as a therapy for MCI and AD.  Are there any other considerations?

First, there have been clinical trials of lithium in a number of neurodegenerative diseases including AD. After some initial isolated enthusiasm for Li in the 1970s and 1980s for Parkinson's, some syndromes associated with Parkinson's (on-off, anergia), and Huntington’s – most of the reported research started in 2009.   Since then, there has been research on AD (10-13), ALS (14-19), MSA (20), MCI (21-23), Niemann Pick Disease (24), Machado Joseph Disease (26-27), and Spinocerebellar Ataxia, Type 2 (28).  In most of these papers the authors cite putative mechanisms of action of lithium based on preclinical trials and some positive pilot studies – but the overwhelming results were negative.  In all cases, the trials were approached from the perspective of using lithium in pharmaceutical ranges except for the trial that states it used microdosing on the range of 300 μg.  Tolerability varied widely among research subjects due to varying diagnoses, but even from study to study using modest doses.

My experience treating people with lithium in all age ranges leads me to a few conclusions that may apply here.  First, I have treated patients with lithium who have been on it for decades and developed AD. I recall one patient in particular who had marked cortical atrophy on brain imaging despite all of those years on lithium and no episodes of toxicity.  That obviously does not rule out lithium as a neuron sparing therapy but it does suggest that it will not work for everybody.  Second, part of the population will not be able to tolerate it or will not want to take it. I am fairly certain that any psychiatrist experienced in prescribing it will have no problems minimizing or preventing side effects.  In most 50-70 year olds that would be lithium carbonate in the range of 150-600 daily.  In the experiments cited above, microdoses of lithium orotate (4.3 μEq/L) for 12-14 months was the dose that prevented brain aging in mice (microgliosis and astrogliosis) and reduced pro-inflammatory cytokines.  That oral dose is roughly 1/1,000 the lowest prescribed pharmaceutical dose.  Third, I am not aware of any cases of lithium toxicity from people drinking groundwater or surface water with high Li concentrations.  The commonest reasons for lithium toxicity in people taking pharmaceutical doses include water and salt imbalances like dehydration, drug-drug interactions, and improper dosing and/or monitoring.   

The question on many minds is “Should I start taking lithium to prevent Alzheimer’s Disease?”  The answer lies in the way the authors frame the discussion section of their paper.  Despite a lot of positive findings they state that “Disruption of Li homeostasis may contribute to the long prodromal period of neuropathological changes that occur prior to the onset of clinical AD.”    And – “Li deficiency is therefore a potential common mechanism for the multisystem degeneration of the brain that leads to the onset of AD”.  It is going to take replication and more work before these findings are widely accepted.  There are still a lot of unknowns about GSK3β signaling.  There have been mistakes made extrapolating from the preclinical studies in mice in the past.  Some of those mistakes were attributed to differences in mouse and human genetics and less heterogeneity in mice.   

That said, I know that will not prevent people from attempts at biohacking and taking supplemental lithium. If you are in that category, you should keep a few things in mind.  First, you have to know about drug dosing and the difference between pharmacological doses and supplemental doses. Lithium at pharmacological doses has a low therapeutic index (toxic dose range to therapeutic dose range) and it can cause kidney, thyroid, and parathyroid problems.  Second, there are many lithium orotate supplements currently available in a wide range of doses (5, 10, 20, 130 mg). They are advertised for "memory, state of mind, and behavioral health". None of these are clinical or FDA approved indications.  Any use of these products has to be considered experimental at this time and I recommend waiting for further data.

In summary, this is an excellent study that synthesizes clinical and preclinical data across a wide array of parameters that I have just touched on here.  If I was a young researcher just starting out, this would be the kind of research team I would be interested in joining.  It was an exciting paper to read.  At the same time it is a good test of how research may or may not be reproducible.  A common misconception about a lack of reproducibility is that it means the researchers did something wrong.  It seems obvious that it can happen just based on the sheer complexity. 

 

George Dawson, MD, DFAPA

Technical Note:

I forgot to add a technical note to the above summary about why the authors chose lithium orotate as the source of their supplement.  They abbreviate it LiO.  All of the details are contained in Extended Data Figure 7.  In that data you will notice that they tested 16 different lithium salts - 8 organic and 8 inorganic for conductivity (µS/cm) (microsiemens per centimeter).  They were concerned about partitioning Li between the plaque and non-plaque fractions and chose the salt with the lowest conductivity.  This degree of precision is important in a tightly controlled experiment - but in the real world the conductivity of tap water can be a significant factor whether it contains lithium or not. 

Supplementary 1:

I am really interested in the mechanism of action of Li and all the links to GSK3β signaling.  I ran out of space in the above post and hope to elaborate on the mechanism soon.

Graphics Credit:

The lead graphic for this post is from reference 3 per the open access CC-BY-NC-ND 4.0 license. The remaining graphic and table were made by me from data in the given references.

 

References:

1:  Shorter E. The history of lithium therapy. Bipolar Disord. 2009 Jun;11 Suppl 2(Suppl 2):4-9. doi: 10.1111/j.1399-5618.2009.00706.x. PMID: 19538681; PMCID: PMC3712976.

2:  Coppen A. 50 years of lithium treatment of mood disorders. Bipolar Disord. 1999 Sep;1(1):3-4. doi: 10.1034/j.1399-5618.1999.10102.x. PMID: 11256652.

3:  Lombard MA, Brown EE, Saftner DM, Arienzo MM, Fuller-Thomson E, Brown CJ, Ayotte JD. Estimating Lithium Concentrations in Groundwater Used as Drinking Water for the Conterminous United States. Environ Sci Technol. 2024 Jan 16;58(2):1255-1264. doi: 10.1021/acs.est.3c03315. Epub 2024 Jan 2. PMID: 38164924; PMCID: PMC10795177.

4:  Sharma N, Westerhoff P, Zeng C. Lithium occurrence in drinking water sources of the United States. Chemosphere. 2022 Oct;305:135458. doi: 10.1016/j.chemosphere.2022.135458. Epub 2022 Jun 23. PMID: 35752313; PMCID: PMC9724211.

5:  Norman JE, Toccalino PL, Morman SA, 2018. Health-Based Screening Levels for evaluating water-quality data (2d ed.). U.S. Geological Survey web page, accessible at https://water.usgs.gov/water-resources/hbsl/, doi:10.5066/F71C1TWP

6:  Seidel U, Jans K, Hommen N, Ipharraguerre IR, Lüersen K, Birringer M, Rimbach G. Lithium Content of 160 Beverages and Its Impact on Lithium Status in Drosophila melanogaster. Foods. 2020 Jun 17;9(6):795. doi: 10.3390/foods9060795. PMID: 32560287; PMCID: PMC7353479.

7:  El-Mallakh RS, Roberts RJ. Lithiated lemon-lime sodas. Am J Psychiatry. 2007 Nov;164(11):1662. doi: 10.1176/appi.ajp.2007.07081255. PMID: 17974929.

8:  Neves MO, Marques J, Eggenkamp HGM. Lithium in Portuguese Bottled Natural Mineral Waters-Potential for Health Benefits? Int J Environ Res Public Health. 2020 Nov 12;17(22):8369. doi: 10.3390/ijerph17228369. PMID: 33198207; PMCID: PMC7696288.

One of the most popular soft drinks in the world was launched in 1929; the “Lithiated Lemon Soda” that was supplemented with 5 mg Li (as Li citrate/L) until 1948 [16], when it was banned by the government. It was believed to cure alcohol-induced hangover symptoms, make people more energetic and give lust for life and on the top of that shinier hair and brighter eyes [17]. In fact, it is still on the market but since 1936 its name changed to 7UP. In 1949, John Cade discovered that higher Li concentrations were toxic. Nowadays, according Seidel et al. [16] 7UP only contains 1.4 µg Li/L.

9:  Aron L, Ngian ZK, Qiu C, Choi J, Liang M, Drake DM, Hamplova SE, Lacey EK, Roche P, Yuan M, Hazaveh SS, Lee EA, Bennett DA, Yankner BA. Lithium deficiency and the onset of Alzheimer's disease. Nature. 2025 Aug 6. doi: 10.1038/s41586-025-09335-x. Open Access.

The paper suggests that Li may be a critical micronutrient in terms of brain function.

AD: 

10:  Nunes MA, Viel TA, Buck HS. Microdose lithium treatment stabilized cognitive impairment in patients with Alzheimer's disease. Curr Alzheimer Res. 2013 Jan;10(1):104-7. doi: 10.2174/1567205011310010014. PMID: 22746245.

As lithium is highly toxic in regular doses, our group evaluated the effect of a microdose of 300 μg, administered once daily on AD patients for 15 months

11:  Hampel H, Ewers M, Bürger K, Annas P, Mörtberg A, Bogstedt A, Frölich L, Schröder J, Schönknecht P, Riepe MW, Kraft I, Gasser T, Leyhe T, Möller HJ, Kurz A, Basun H. Lithium trial in Alzheimer's disease: a randomized, single-blind, placebo-controlled, multicenter 10-week study. J Clin Psychiatry. 2009 Jun;70(6):922-31. PMID: 19573486.

“The current results do not support the notion that lithium treatment may lead to reduced hyperphosphorylation of tau protein after a short 10-week treatment in the Alzheimer's disease target population.”

12:  Macdonald A, Briggs K, Poppe M, Higgins A, Velayudhan L, Lovestone S. A feasibility and tolerability study of lithium in Alzheimer's disease. Int J Geriatr Psychiatry. 2008 Jul;23(7):704-11. doi: 10.1002/gps.1964. PMID: 18181229.

“Lithium treatment in elderly people with AD has relatively few side effects and those that were apparently due to treatment were mild and reversible. Nonetheless discontinuation rates are high. The use of lithium as a potential disease modification therapy in AD should be explored further but is not without problems.”

13:  Leyhe T, Eschweiler GW, Stransky E, Gasser T, Annas P, Basun H, Laske C. Increase of BDNF serum concentration in lithium treated patients with early Alzheimer's disease. J Alzheimers Dis. 2009;16(3):649-56. doi: 10.3233/JAD-2009-1004. PMID: 19276559.

“We assessed the influence of a lithium treatment on BDNF serum concentration in a subset of a greater sample recruited for a randomized, single-blinded, placebo-controlled, parallel-group multicenter 10-week study, investigating the efficacy of lithium treatment in AD patients. In AD patients treated with lithium, a significant increase of BDNF serum levels, and additionally a significant decrease of ADAS-Cog sum scores in comparison to placebo-treated patients, were found.”

ALS:

14:  Boll MC, Alcaraz-Zubeldia M, Rios C, González-Esquivel D, Montes S. A phase 2, double-blind, placebo-controlled trial of a valproate/lithium combination in ALS patients. Neurologia (Engl Ed). 2025 Jan-Feb;40(1):32-40. doi: 10.1016/j.nrleng.2022.07.003. Epub 2022 Aug 29. PMID: 36049647.

15:  UKMND-LiCALS Study Group; Morrison KE, Dhariwal S, Hornabrook R, et al. Lithium in patients with amyotrophic lateral sclerosis (LiCALS): a phase 3 multicentre, randomised, double-blind, placebo-controlled trial. Lancet Neurol. 2013 Apr;12(4):339-45. doi: 10.1016/S1474-4422(13)70037-1. Epub 2013 Feb 27. Erratum in: Lancet Neurol. 2013 Sep;12(9):846. PMID: 23453347; PMCID: PMC3610091.

16:  Verstraete E, Veldink JH, Huisman MH, Draak T, Uijtendaal EV, van der Kooi AJ, Schelhaas HJ, de Visser M, van der Tweel I, van den Berg LH. Lithium lacks effect on survival in amyotrophic lateral sclerosis: a phase IIb randomised sequential trial. J Neurol Neurosurg Psychiatry. 2012 May;83(5):557-64. doi: 10.1136/jnnp-2011-302021. Epub 2012 Feb 29. PMID: 22378918.

17:  Miller RG, Moore DH, Forshew DA, Katz JS, Barohn RJ, Valan M, Bromberg MB, Goslin KL, Graves MC, McCluskey LF, McVey AL, Mozaffar T, Florence JM, Pestronk A, Ross M, Simpson EP, Appel SH; WALS Study Group. Phase II screening trial of lithium carbonate in amyotrophic lateral sclerosis: examining a more efficient trial design. Neurology. 2011 Sep 6;77(10):973-9. doi: 10.1212/WNL.0b013e31822dc7a5. Epub 2011 Aug 3. PMID: 21813790; PMCID: PMC3171956.

18:  Chiò A, Borghero G, Calvo A, Capasso M, Caponnetto C, Corbo M, Giannini F, Logroscino G, Mandrioli J, Marcello N, Mazzini L, Moglia C, Monsurrò MR, Mora G, Patti F, Perini M, Pietrini V, Pisano F, Pupillo E, Sabatelli M, Salvi F, Silani V, Simone IL, Sorarù G, Tola MR, Volanti P, Beghi E; LITALS Study Group. Lithium carbonate in amyotrophic lateral sclerosis: lack of efficacy in a dose-finding trial. Neurology. 2010 Aug 17;75(7):619-25. doi: 10.1212/WNL.0b013e3181ed9e7c. Epub 2010 Aug 11. PMID: 20702794.

“Lithium was not well-tolerated in this cohort of patients with ALS, even at subtherapeutic doses. The 2 doses were equivalent in terms of survival/severe disability and functional data. The relatively high frequency of AEs/SAEs and the reduced tolerability of lithium raised serious doubts about its safety in ALS.”

19:  Aggarwal SP, Zinman L, Simpson E, McKinley J, Jackson KE, Pinto H, Kaufman P, Conwit RA, Schoenfeld D, Shefner J, Cudkowicz M; Northeast and Canadian Amyotrophic Lateral Sclerosis consortia. Safety and efficacy of lithium in combination with riluzole for treatment of amyotrophic lateral sclerosis: a randomised, double-blind, placebo-controlled trial. Lancet Neurol. 2010 May;9(5):481-8. doi: 10.1016/S1474-4422(10)70068-5. Epub 2010 Apr 1. PMID: 20363190; PMCID: PMC3071495.

Multiple System Atrophy (MSA)

20:  Saccà F, Marsili A, Quarantelli M, Brescia Morra V, Brunetti A, Carbone R, Pane C, Puorro G, Russo CV, Salvatore E, Tucci T, De Michele G, Filla A. A randomized clinical trial of lithium in multiple system atrophy. J Neurol. 2013 Feb;260(2):458-61. doi: 10.1007/s00415-012-6655-7. Epub 2012 Aug 30. PMID: 22932748.

MCI: 

21:  Damiano RF, Loureiro JC, Pais MV, Pereira RF, Corradi MM, Di Santi T, Bezerra GAM, Radanovic M, Talib LL, Forlenza OV. Revisiting global cognitive and functional state 13 years after a clinical trial of lithium for mild cognitive impairment. Braz J Psychiatry. 2023 Mar 11;45(1):46-49. doi: 10.47626/1516-4446-2022-2767. PMID: 36049127; PMCID: PMC9976922.

22:  Forlenza OV, Radanovic M, Talib LL, Gattaz WF. Clinical and biological effects of long-term lithium treatment in older adults with amnestic mild cognitive impairment: randomised clinical trial. Br J Psychiatry. 2019 Nov;215(5):668-674. doi: 10.1192/bjp.2019.76. PMID: 30947755.

23:  Forlenza OV, Diniz BS, Radanovic M, Santos FS, Talib LL, Gattaz WF. Disease-modifying properties of long-term lithium treatment for amnestic mild cognitive impairment: randomised controlled trial. Br J Psychiatry. 2011 May;198(5):351-6. doi: 10.1192/bjp.bp.110.080044. PMID: 21525519.

Lithium treatment was associated with a significant decrease in CSF concentrations of P-tau (P = 0.03) and better performance on the cognitive subscale of the Alzheimer's Disease Assessment.

Niemann Pick Disease:

24:  Han S, Zhang H, Yi M, Liu X, Maegawa GHB, Zou Y, Wang Q, Wu D, Ye Z. Potential Disease-Modifying Effects of Lithium Carbonate in Niemann-Pick Disease, Type C1. Front Pharmacol. 2021 Jun 9;12:667361. doi: 10.3389/fphar.2021.667361. PMID: 34177581; PMCID: PMC8220070.

MS:

25:  Rinker JR 2nd, Meador WR, King P. Randomized feasibility trial to assess tolerance and clinical effects of lithium in progressive multiple sclerosis. Heliyon. 2020 Jul 28;6(7):e04528. doi: 10.1016/j.heliyon.2020.e04528. PMID: 32760832; PMCID: PMC7393418.

Machado Joseph Disease:

26:  Saute JA, Rieder CR, Castilhos RM, Monte TL, Schumacher-Schuh AF, Donis KC, D'Ávila R, Souza GN, Russo AD, Furtado GV, Gheno TC, Souza DO, Saraiva-Pereira ML, Portela LV, Camey S, Torman VB, Jardim LB. Planning future clinical trials in Machado Joseph disease: Lessons from a phase 2 trial. J Neurol Sci. 2015 Nov 15;358(1-2):72-6. doi: 10.1016/j.jns.2015.08.019. Epub 2015 Aug 14. PMID: 26297649.

27:  Saute JA, de Castilhos RM, Monte TL, Schumacher-Schuh AF, Donis KC, D'Ávila R, Souza GN, Russo AD, Furtado GV, Gheno TC, de Souza DO, Portela LV, Saraiva-Pereira ML, Camey SA, Torman VB, de Mello Rieder CR, Jardim LB. A randomized, phase 2 clinical trial of lithium carbonate in Machado-Joseph disease. Mov Disord. 2014 Apr;29(4):568-73. doi: 10.1002/mds.25803. Epub 2014 Jan 7. PMID: 24399647.

Spinocerebellar Ataxia Type 2:

28:  Saccà F, Puorro G, Brunetti A, Capasso G, Cervo A, Cocozza S, de Leva M, Marsili A, Pane C, Quarantelli M, Russo CV, Trepiccione F, De Michele G, Filla A, Morra VB. A randomized controlled pilot trial of lithium in spinocerebellar ataxia type 2. J Neurol. 2015 Jan;262(1):149-53. doi: 10.1007/s00415-014-7551-0. Epub 2014 Oct 28. PMID: 25346067.

Huntington’s Disease:

29:  Aminoff MJ, Marshall J. Treatment of Huntington's chorea with lithium carbonate. A double-blind trial. Lancet. 1974 Jan 26;1(7848):107-9. doi: 10.1016/s0140-6736(74)92339-3. PMID: 4130308.

A New Book From An Expert Psychotherapist

 

I first became aware of Mardi Horowitz’s work when I was researching adjustment disorders many years ago.  As an acute care psychiatrist that is one of the disorders that ends up on your unit that you must separate from severe mental illnesses and significant risks.  I wanted to do more than just make the diagnosis.  I also wanted to assist these folks with psychotherapy that might prove useful, even if I ended up discharging them the same day.  Dr. Horowitz has written extensively about that and many other topics.  I decided to buy his recent book Clinician Technique in Personalized Psychotherapy.  In the introduction he mentions watching decades of watching psychotherapy videotapes and trying to figure out what helped people change. 

In the forward by Roberta Isberg, MD – she mentions that therapists might see something in the book that they have been doing in practice for years.  That happened to me when I read the Chapter Confronting Dilemmas by Assertion of the Therapeutic Alliance.  In fact, I had mentioned this intervention just a few hours earlier in psychotherapy seminar that I coteach. In that seminar I discussed how making the therapeutic alliance explicit could be useful in resolving impasses.  Dr. Horowitz’s chapter uses a dyadic diagram of the therapeutic alliance (p. 103) that is good in that it delineates the roles of both the patient and the therapist and what the expected exchanges might be.  For example, the patient is disclosing and focused on problems while the therapist is intervening, supporting, and emphasizing adaptive changes by the patient. 

Dr.  Horowitz also presents a table of Common Dilemmas for a Psychotherapist.  He defines dilemmas as binaries where both poles are unlikely to be helpful.  A common example is encouraging further elaboration of a problem that the patient may find very problematic in terms of external relationships, the relationship with the therapist, or longstanding internalized patterns of thinking and behavior.  In the table he presents ten common dilemmas, the therapist’s intervention, and how it might be interpreted.  In the case of these dilemmas, he suggests clarifying the situation and trying to reach a middle ground:  “ The middle ground between the binaries of the dilemma may be reached if the therapists state the properties of the periodically experienced therapeutic alliance.” (p. 100).   

I thought I would present a frequent acute care dilemma as a vignette, but before doing that borrow another definition from Dr. Horowitz.  That is the idea that the vignettes are fictionalized composites of multiple therapeutic encounters.  In the case below it is hundreds of encounters:

Patient: “Are you the one holding me here?  Are you the one I have to talk to to get out of here?  I want to be released as soon as possible.”

MD: “I am the person who will make that decision….”

Patient: “Well what’s the hold up?  You can’t just keep me here.  There is no reason why I should be sitting in this hospital.”  

MD: “I will do what I can but I have to be able to make an independent assessment in order to do that….”

Patient: “Look – I don’t care about that.  You have no right to hold me here.  I want to go home right now and you are in my way.”

MD: “OK – this is the first time I am seeing you. None of the people who brought you to the hospital or admitted you to my unit have been in touch with me.  I have nothing to do with who is admitted to my unit and in fact have been told that I am supposed to discharge people as soon as possible.  But I can’t do that unless I am fairly certain that they will be safe….”

Patient: “So you’re just covering your ass doc?  Really?  You are just worried about getting sued?”

MD: “I am not worried about getting sued, but I do worry about not getting people the assessments and treatment they might need.  The way this is supposed to work is that you and I talk about what happened and try to determine if you have any problems that I can help you with. It is not me against you or you against me.  It is you and I working on an agreed upon set of problems.  Do you think we can do that?”

Patient: “I suppose…”

MD: “OK let’s give it a try.”

This is an example of a situation that many physicians find impossible to approach because their authority is questioned and the potential for escalation.  That escalation depends largely on the physician not taking the critical comments as a personal attack but rather as a process issue.  It requires the ability to remain neutral in addition to confronting the dilemma and establishing a middle ground to proceed on. This skill is critical in acute care psychiatry as well as in crisis outpatient situations.  And before I get too grandiose like all things in medicine there are no guarantees – only probabilities.  There are situations that will rapidly escalate out of control despite your best efforts – but in my experience they are rare.    

There are many other dilemmas facing therapists during assessments and in ongoing therapy.  More common examples arise from the situation where the patient is reluctant to disclose the details of certain events or has expectations of the therapist that are not consistent with the reality of the therapy situation.  The standard cinematic approach of reflecting the problem back to the patient (“well how do you feel about that?”) is generally not an optimal response and it is one that most people see as cliché these days.  Clarifying what is going on in the room and in the therapy is probably a better strategy.

I have written about the therapeutic alliance in several areas on this blog. Here is a post from 2012 and 2017.  I also posted diagrams of the therapeutic alliance in those posts and include my most recent modification below.  In the diagram I am using MD as the therapist since almost all the therapists I interact with are psychiatrists or psychiatric residents, but it also applies to non-physician therapists.

 

I use a tripartite diagram to highlight the problem space as being a specific focus of patient and therapist since it is the combined process of what is happening in the therapy rather than the isolated process of either person.  Some authors write about this as intersubjectivity (2) or the result of the interaction between two unique conscious states.  Most physicians are taught to observe and record findings from an objective third person position.  The exception is psychiatry where subjectivity has recognized value and the importance of the physician-patient relationship is emphasized.  

Intersubjectivity provides a more comprehensive look at what happens in the therapeutic alliance than seeing the interaction as orchestrated solely by an objective therapist.  The therapist and patient have complementary roles.  For example, empathy is a critical dimension of the therapeutic alliance and a critical skill for the therapist.  Empathy is also required on the part of the patient and its presence can be palpable to varying degrees.  Does the patient really understand what the therapist is trying to do?  Does the patient experience the therapist as a person who is trying to be helpful?  Intersubjectivity does not reduce the value of traditional concepts like transference and countertransference.  Both can exist in this intersubjective space.  It provides a more comprehensive framework for understanding.   

Intersubjectivity has developmental origins, is considered adaptive from an evolutionary perspective, and therefore most people have it to one degree or another. An exception might be autism where the absence of an intersubjective process has been considered as a deficit or a defense.  Along the same lines varying degrees of severe mental illness can impact it.   

In a therapy session, the process and content of the session are co-created rather than being dependent on the therapist.  As the therapy progresses the process may be more important than the content.  This is an obvious departure from criteria based diagnoses and highlights the social determinants of the problem. The underlying assumption of how the mind operates on an intersubjective basis is that the primary goal is to form object relations or real relationships and their internalized representations. That differs from some other assumptions of mind goals such as discharge for pleasure.  Like many technical terms used in therapy there is often confusion based on how they are used by different authors.  For example, when I have written about empathy on this blog I have used Sims very precise definition (par. 10). In the chapter I have referenced here, Stern suggests that intersubjectivity subsumes many dimensions including all the imprecise definitions of empathy, sympathy, and mind reading as ways to appreciate the subjective experience of another.  To further complicate matters, there are other descriptions of this phenomenon that are difficult to separate.  One is folk psychology which is defined as the intuitive way people understand and predict the behavior of others. Folk psychology (3) could be seen as the result of a long series of intersubjective encounters – the success of which will depend on both the quality of the interactions and the inherent properties of the subjects.

Before I get too far afield, I will add a brief comment about confusion over the objective and subjective in psychiatry. When physicians start out, the objective is highly valued.  What are the reproducible elements of diseases and treatments? Physicians leave medical school with a sense of medical science being like any other science until they start practicing and realize they are seeing hundreds of conditions that defy description and standard treatments.  In psychiatry there has been an historic move from an attempt at the highly objective approaches of the late 19^th century to the subjective wave of psychoanalytical dominance and back to the attempted objectivity of brain-based precision psychiatry.  That pendulum swing is more rhetoric than reality.  The reality is that in psychiatry we are privileged to work with the most complex organ in the body.  The brain has an obvious complex physical basis and an equally complex psychological basis.  Both must be understood as completely as possible.  That is difficult in that it takes a lot of time and effort – but that is the job.

On a practical note, what about the rest of the book and should you buy it?  I was pleasantly surprised to find what I have done for decades was recommended by an academic psychiatrist who is an expert in the field.  I am certain that most people who have been engaged in providing psychotherapy will find the same thing.  The overall advantage in this book is that it is an information dense text of 115 pages with additional pages for 84 references, an index, and a glossary.  It is set in what appears to be 10-point font and you can read it in one long sitting.  There is no elaboration on the history and technical details of schools of psychotherapy.  The chapters are matter-of-fact and straightforward. Every concept has a concise definition and definitions are added as needed as footnotes on the respective pages.  Since the author is a psychotherapy researcher there are some unique conceptualizations and jargon contained in the book.  There were well explained and not an impediment to understanding.  

The model of therapy described is described as an integrative cognitive-psychodynamic approach that consider both conscious and unconscious elements.  He takes the secret handshake elements out of psychotherapy by clearly stating what he is doing and providing many clinical examples.  When therapists are starting out especially in psychodynamic therapy – the goal of therapy is often not very clear.  It can seem like therapy hinges on definitive interpretations of unconscious wishes and the residuals of past interactions.  Even when a therapist gets to the point where they feel more competent to make those interpretations, they may be skeptical of their accuracy and concerned that they be trying to convince the patient to accept an inaccurate interpretation.  Dr. Horowitz is very clear that interpretations are not necessary for change and reviews several cognitive and behavioral interventions that can be useful. I counted about 39 of these interventions in the obvious places, but there are probably more.  In some spots it assumes that the reader has working knowledge of basic behavioral interventions (breathing techniques, relaxation, etc) for application in the early stages.   

This method of therapy – supportive interventions used initially and intermittently in association with more interpretive therapy is often not explicit in therapy texts, but I am convinced that it is the norm for people who learn psychodynamic therapy and apply it outside the context of psychoanalysis.  There are clearly times when people being seen strictly for therapy or psychiatric treatment are in crisis and need supportive interventions for stabilization or to assist them toward an intersubjective state consistent with more exploration and interpretation.

 The book benefits therapists at both ends of the training and practice spectrum.  If you are starting out – it is a good overview of the topics and skills that you need to provide psychotherapy.  If you have been working in the field for years or decades, it leads to reflection on what you have been doing, whether there is potential for improvement, and how what you are doing fits into the general scheme of things.

Either way Dr. Horowitz does not disappoint.     

 

George Dawson, MD, DFAPA

 

References:

1:  Horowitz MJ.  Clinician Technique in Personalized Psychotherapy.  American Psychiatric Publishing, Inc, Arlington, VA, 2025.

2:  Stern D.  Intersubjectivity.  In: Person ES, Cooper AM, Gabbard GO. The American Psychiatric Publishing Textbook of Psychoanalysis.  American Psychiatric Publishing, Inc, Arlington, VA, 2005, 77-92.

3:  Hutto, Daniel and Ian Ravenscroft, "Folk Psychology as a Theory", The Stanford Encyclopedia of Philosophy (Fall 2021 Edition), Edward N. Zalta (ed.), https://plato.stanford.edu/archives/fall2021/entries/folkpsych-theory