Thursday, August 27, 2015

Anger and Projection Are Not Political, Racial Or Gun Control Problems

Anger and projection are mental and public health problems.

The homicides of two young broadcast journalists yesterday continues to stimulate the same media response that it always does - mourning the victims, discussing the tragic aspects of the event, and doing a media profile of the perpetrator.  Anyone who has read this blog over the last three years knows my positions on this.  Lengthy posts and academic references don't seem to matter so I thought that I would keep this brief and reiterate the main points before it becomes the usual media circus about gun control and speculating about the perpetrator's mental state.   The most rational analysis considers the following points:

1.  This is first and foremost about the mental state of the perpetrator:

Without the perpetrator there is no tragedy.  Preliminary descriptions in his own words that he was a powder keg that was waiting to go off.  He had a pattern of angry conflicts with coworkers that severely complicated his life, led to job loss, and ongoing conflicts.  I heard a detailed analysis of an alleged pattern of behavior that results in this kind of homicide on the morning news today and it was too pat.   It sounded like the old "stages of grief" model that people used to adhere to.  I think there is a lot of confusion out there about what is normal anger and what kind of anger is pathological.  Anger is a socially and culturally difficult construct.  In many places like my home state of Minnesota it is generally unacceptable.  It is difficult to recognize when anger becomes a problem, if your reality excludes it as a possibility.

Anger is a problem when it is persistent and pervasive.  Normal anger is transient and does not persist for days, weeks or longer.  It is necessarily transient because it can activate physiological processes like hypertension that are not conducive to the health of the individual.  Persistent anger also gets in the way of normal social interactions that all people need in order to function properly.  Human beings are undeniably social animals and we do not function well if we are isolated or cut off from one another.  Anger tends to automatically focus people on an outside source for their problems and frustration while minimizing their own potential role in the process.  Persistent anger does not allow for the necessary productive interactions with family members, coworkers, or in many cases casual contacts in everyday life.

Projection is the attribution of a feeling state or problem to another person.  It is commonly experienced when observing a person blame other people or circumstances for problems they are having in life.  How rational that level of blame seems may be an indication of the severity of the problem.  In my years of treating people in inpatient psychiatric units, it was rare to encounter a person who did not see me as the root of their problem, even though I had barely met them, had nothing to do with why they were in the hospital, and was the person charged with helping them get out.  Some might think that was just a part of me representing an institution, but that goes out the window when the reasoning being given is that I am white or jewish or racist or I am physically attracted to the patient.  Those were typically the mildest accusations.  In many cases, this anger and projection was obvious to family members and coworkers for months or even years before the person was admitted to my unit.  Threats of physical violence or actual physical violence in these situations was common.

2.  This is a public health problem:

People with anger control problems and projection generally do not do well in life.  At the minimum these problems are significant obstacles to a successful career and social life.  One public mental health focus should be on optimizing the function of the population and preventing this social morbidity that is also associated with somatic morbidity and mortality.  In some cases, these mental states are also precursors to violence including suicide and homicide.  In some cases they have led to mass shootings.

There are very few people who talk about this kind of violence and the associated mental state as a preventable or treatable problem.  Part of the issue is that anger is socially unacceptable and it seems like a moral issue.  We should all learn how to control our tempers and keep ourselves in check.  If we don't, well that's on us and we should be punished for it.  Another part of the problem is that some people want to see it as a strictly mental health problem and turn it into a problem of prediction.  The argument then becomes the inability to predict who will "go off" and harm someone.  The additional issue that will heat up at some point is the gun control issue.  Any reasonable person will conclude that gun access in the US is too easy and the amount of firearm injuries and deaths are absurdly high for a sophisticated country.  That said, there appears to be no practical way to alter this problem within our current legislative system.  Even if all guns were removed, it would not stop the problem of people with anger control problems and projection from not doing well in life or harming innocent victims.

To address the problem, we need to take an approach that is similar to suicide prevention.  I am not talking about screening.  I am talking about identifying people at risk.  The best way to do that is to develop strategies to help them self-identify and request help or to help people in their lives assist them in getting help.  Typical ways this works in suicide prevention is public service announcements, volunteer hotlines, referrals through law enforcement and the court system, and referrals through the schools.  Suicide is also identified as a major public health issue and as such it is a focus of many organizations that do advocacy and intervention work in the area of mental health.  There are no similar resources for anger and violence prevention.

That is my basic message involving the most recent incident of preventable homicide in the United States.   I wanted to get this out after seeing just one broadcast on the issue and before I saw too many stories politicizing the incident.  I think that the factors that have resulted in lack of action in this area are obvious and several of them will be on display over the next few days.

As a psychiatrist who has worked in this area for nearly 30 years, I can say without a doubt that this unnecessary loss of life can be prevented and preventing it does not require psychiatric services, but it does require people who are willing and able to address the problem.

We just have to stop pretending that it can't be stopped.

George Dawson, MD, DFAPA


1.  Previous violence prevention posts here.

2.  Previous homicide prevention posts here.



  1. I would add that the station strongly urged him to get counseling and he rejected the idea, which is not uncommon in people with this kind of psychological profile, because they don't see the problem being internal.

    This isn't an easy one. Apparently he was never able to be legally committed and he waited two years after termination to do this.

    Maybe people who are identified with this type of problem after a few frivolous lawsuits ought to be placed on the federal registry. Not just felons and people who have been psychiatrically committed. There has to be a cost and consequence to this kind of acting out and misuse of the civil legal system. This kind of law would have to be drafted carefully, for example, I think New York's law goes too far.

  2. Dr. Dawson,
    Very thought provoking post! Looking at this as a "public health" issue is an interesting, and perhaps helpful way to begin to try to reduce the likelihood of future horrific episodes. I would suspect very few of the individuals with this degree of "pathological" intense chronic anger will be willing (or able) to step forward and say "I need help" on their own volition. Most will lack the insight into their own condition, and many will feel "justified" in carrying out their fantasy of homicide. Therefore, for a public health approach to have any effect, it would need to raise the awareness of "close others", such as spouses, family members, friends, colleagues at work, etc. and therein lies a problem, in that they would feel "guilty" for "ratting out" their friend, family member, etc.
    You raise a very interesting and potentially helpful way of approaching this, but it will be a very "tough sell" to get the general public to be willing to step forward and say "I'm worried about my friend (family member, etc.) becoming a mass murderer" beofore they display this type of behavior.

    1. Dr. Green,

      Many thanks for your response.

      I am hopeful based on some of my experiences. The commonest one is finding out how surprised some of these people are once their thought patterns are confronted. That leads me to think that being able to explain this phenomenon in simple language in public service type announcements will be useful. I think the recent use of cognitive behavioral therapy in severe psychiatric disorders is also reason for hope. Many of us have been doing this for decades under another name like supportive psychotherapy or the psychotherapy of psychosis, but it involves the same methods. Central to those methods is assisting the person to recognize some of these patterns of thinking. Societal biases also come into play. I agree that society needs to play a part in recognizing that violence ands aggression can be a sign of problems other than sociopathy or evil and that is can be treated rather than punished. During my years of inpatient work and in my personal life, friends and family members are always involved in situations like this – either as victims or concerned bystanders.

  3. Very well stated Dr Dawson! I have over 20 years experience in the legal system, working at the State Attorney's Office, 9th Judicial Circuit, and I have seen many defendants sentenced to Anger Management court ordered classes So I wonder, since this is already in place, why couldn't it be extended into the public mainstream for awareness purposes? These classes help people to recognize their anger issues so much so, it caused a criminal case to come about. These situations almost always involve family members and friends.

    1. Thanks for your comment. That was also my experience in a community mental health center. Our social workers ran those groups. They initially started out as court mandated programs but eventually became a resource for people who self identified as having anger control problems. I think that there is a palpable bias against considering these problems as treatable. Even within the mental health community depression and anxiety are more acceptable than anger control or violence. Advocacy groups take pains to point out that most people with mental illness are not violent and in the process stigmatize those with that problem and create a barrier to acceptance and treatment.