The Real Lesson of January 6th – How Fascism Works

 

Yesterday was the third anniversary of the Insurrection at the Capitol.  This event remains prominent in the news due to ongoing civil and criminal litigation and the overall meaning to culture and politics in the United States.  At the level of accountability there are striking discrepancies between those who were physically at the Capitol and many who orchestrated the event. The most striking discrepancy and controversy is former President Trump. He has currently been removed from the ballots in 2 states pending what will likely be Supreme Court decisions.  The Supreme Court is clearly stacked in his favor and one of his attorneys stated an explicit quid pro quo this week as in “this President appointed you - better get him back on the ballot.”  There have also been threats that Republicans would remove Biden from the ballot to compensate for Trump being removed from ballots as a 14^th Amendment insurrectionist.

There is striking video footage of Republican legislators calling the initial event an insurrection and clearly stating that Trump was responsible – but years later walking all of that back and saying the Insurrection was just a protest – nothing to see here.

Former President Trump continues to promote The Big Lie whenever he has access to an open microphone despite overwhelming evidence being frequently recited that it is a lie. He continues to portray himself as a victim of politics even when partisans from his own party and administration recite why it is a good idea that he never be elected again. Since I ascribe to the Goldwater Rule, I will avoid any psychiatric speculation.  At an overt level, it is obvious he can keep going and continue to attack and alienate people even when it is not in his best interest. Many of his interviewed followers describe this as his best trait.

I happened to be watching a popular television show the other night and they put up a recent poll about the Insurrection and whether it was initiated by the FBI. Quite surprisingly 25% of the respondents were convinced the FBI initiated it and 26% were unsure or did not comment. So even though at this point 1200 people have been charged and 890 convicted of federal crimes associated with the Insurrection – over half of Americans are either certain that this was an FBI conspiracy or uncertain that it was not.  What is happening here?

Although much of politics is an irrational appeal to emotion – it is clearly at an all time high in the United States.  A recent Foreign Affairs article describes this trend as coinciding with the US now being a major exporter of white supremacist terrorism. Most Americans probably do not know that President Grant created the Department of Justice to counter white supremacist terrorism by the Ku Klux Klan in 1870.  A group who spread recruiting literature across Twin Cities suburbs in 2022 also promoted antisemitism.  Just the act of dispersing that literature is a clear sign that something in the US has gone horribly wrong.  What is the problem?

Listening to many of the supporters of these processes it is easy to attribute the support for autocracy, the Insurrection, and the MAGA movement to ignorance.  They see the former President as a strong man who speaks his mind and that is all that they are interested in. They do not care about the book length criticisms of people with worked closely with him during his Presidency.  Many of those criticisms have been severe – questioning his depth of knowledge and decision-making ability. They don’t care about public remarks he has made that were basically false or dog whistles.  They say they care about the economy but the Biden economy is clearly superior to the Trump economy and easily exceeded any warnings Trump had about not re-electing him.  They don't care about the fact that Trump does not campaign on relevant domestic or foreign policy issues.  

The lack of a rational basis for supporting Trump and MAGA suggest that other factors are at play. First and foremost is partisan politics.  Practically all the Republicans that were skeptical or critical of Trump have fallen in behind him – not wanting to provoke the ire of his MAGA loyalists.  Their affiliation is with a seriously compromised Republican party rather than the republic itself.  Better to have a good career and government job and let the Insurrection cards fall where they may.  The Republicans walking away rather than make that compromise are a small minority and deserve our gratitude.

Nihilism is a significant factor.  Nihilism is a vague term, I am using the existential meaning.  In other words, meaninglessness is pervasive both in terms of the truth being relative rather than absolute and the same is true for institutions. This is a large part of what Trump does on almost a daily basis.   Using a shotgun approach he has attacked just about every aspect of the government, military, public health, educational, and judicial systems and continues to do so.  Many of the attacks have been personal and directed at people who have distinguished government service. These attacks are unprecedented by any American president and unquestionably erode the authority of these agencies – not just with his followers but in general.  Some have endangered the people attacked and their families.  Many of his supporters clearly want to burn “the system” down and not replace it. Nihilism also reinforces many right-wing conspiracy theories like the secret Deep State or the FBI orchestrating the Insurrection.

The symbols of nihilism were prominent at the January 6 Insurrection and included a Confederate flag, a gallows and a noose, militia gear and paramilitary tactics.  Since then, at least one Republican candidate offered support for Lost Cause rhetoric that revises history to suggest that aggressive northern states fought the Civil War to suppress states’ rights in the south rather than end slavery. The idea of a rebellion is also suggested rather than an insurrection and an attack on the legitimate government of the United States.  The Civil War was really a war between the Confederacy and the United States rather than the North versus the South. All that rhetoric is designed to render the real history of the Civil War meaningless.  It was no accident that the Confederate flag appeared in the Capitol carried by insurrectionists.  There is nothing more nihilistic than vigilante law as evidenced by the threat of hanging rationalized as “so the traitors know the stakes” initially and then a site where insurrectionists chanted to “Hang Mike Pence!” while searching for him in the Capitol Building.

“Nihilistic hooliganism” or “striving to create the atmosphere of a street battle or barroom brawl” was a tactic used by Goebbels in the Nazi propaganda paper Der Angriff because at the time he knew it appealed to supporters (2). It seems obvious that several individuals and factions in the Republican party are intent creating this kind of atmosphere.  Late in 2023 it extended into Congress with threat of physical violence against a witness in a hearing and alleged physical contact between Republican members of Congress in the hallways.

In the vacuum of nihilism, the right does not hesitate to dictate how people should think on culture war or hot button issues like guns, abortion, LGBT issues, separation of church and state, control over education, climate change denial, and pandemic denial.   They cast attempts to remove overt misinformation as censorship and a return to rational gun control as a denial of Second Amendment rights.  In many cases there is a “doubling down” on any political gains made in these areas.  This level of cynicism and disingenuousness keeps the threat of gun violence very real for most Americans and has had a clear negative impact on women’s health where abortion access is considered essential health care by experts. This doubling down to the point of criminalization is characteristic of autocracies that consider winning cultural issues crucial for the survival of their ideology.

Trump and his supporters are using very well-known propaganda techniques.  The first is to establish Trump as a cult of personality. He has certainly done this himself by marketing himself as a superhero. Any search on superhero Trump merchandise brings up pages of this stuff.  He also markets himself as being a genius and being tough and ruthless if necessary. Practically all the drama surrounding the current court cases, including sustained attacks on court officials is all part of that image. An average citizen watching this unfold can only wonder why he can get away with behavior that would cause anyone else to get contempt charges and incarceration. Since this is also unprecedented behavior it is reminiscent of other negatively charismatic leaders like Hitler who cultivated mythical images:

“Hard, ruthless, resolute, uncompromising, and radical, he would destroy the old privilege - and class-ridden society and bring about a new beginning, uniting the people in an ethnically pure and socially harmonious 'national community'.” (1)

The entire MAGA movement and its associated “drain the swamp” mottos are consistent with Trump’s cultivated image that has successfully obliterated the fact that he has had far more privilege than practically any other person in the MAGA movement.

As in the case of Hitler, it takes more than a self-cultivated mythical image to establish a following that will ignore obvious deficits and vote for you no matter what. In the case of Republican politicians – self-interest is the obvious motivation.  If any other candidate has a chance in the national elections, they would not all be in lock step behind Trump. The fall out from that process has been astounding including continuing to support the Big Lie strategies and making the original January 6^th Insurrection out to be a picnic.

A pillar of the autocrat playbook is to attack everything in the existing government and suggest all these problems will be solved when the superior human being is elected.  That involves significant distortion at three levels.  First – it devalues clear accomplishments of the existing government.  Most serious students of government would describe the Biden administration as one of the most successful in modern history.  Some of that success depended on correcting the damage done by the last Trump administration.  Second - direct attacks on the opposition, unfounded accusations, and name calling.   Third – it depends on a distortion of the abilities of their ideal candidate.  In the case of Trump there is a long list of deficiencies provided by members of his own party and people who were in his own cabinet. Many of them are clear that he should never be re-elected.  That stands in sharp contrast to the hyperbole candidate Trump and his dedicated followers.   

The real lesson of January 6, 2021 is that American democracy is under attack from one of the major parties and a former President who is combative to the point of alienating members of his own party, never admits he is wrong, is hypersensitive to criticism, and is not honest with the American people.  A significant part of the electorate finds that attractive even though it is not clear what would happen if their candidate is reelected.  His stated first order of business is to get revenge on those who he feels have slighted him. That image should give any rational voter pause.  The only thing scarier is what happens when autocrats implode (and they all do).  It is typically as a colossal failure – negatively impacting the entire country for years.  In the United States there is a good chance that fall will be far greater than any other country.

That is why the lessons of January 6 at the Capitol should never be forgotten.

 

George Dawson, MD, DFAPA

 

Supplementary 1:  How the FBI started the Insurrection Conspiracy Theory got started was discovered and debunked in January 2022.  An Arizona man named Ray Epps was filming the insurrection and apparently encouraging people to enter the Capitol.  Assuming he was an FBI agent provided the basis for the conspiracy theory.  When he was questioned by the January 6 Committee – Epps stated he was not working for law enforcement or a member of the FBI.  As the linked article states prominent Republicans including Sen. Ted Cruz promoted this theory. 

The actual story:

".....Fox News Channel and other right-wing media outlets amplified conspiracy theories that Epps, 62, was an undercover government agent who helped incite the Capitol attack to entrap Trump supporters. Epps filed a defamation lawsuit against Fox News last year, saying the network was to blame for spreading baseless claims about him...."

Kunzelman M.   Ray Epps, a target of Jan. 6 conspiracy theories, gets a year of probation for his Capitol riot role.  Associated Press January 9, 2024.  https://www.yahoo.com/news/ray-epps-target-jan-6-164800399.html

References:

1:  Kershaw I.  The Hitler Myth.  History Today. 1985; 35(11): 23-29.  https://www.historytoday.com/archive/hitler-myth

2:  Lemmons R.  Goebbels and Der Angriff.  1994.  University of Kentucky Press. Lexington, Kentucky. p. 128-131.

 

Graphics Credit:

1:  Main Graphic is: DC Capitol Storming by TapTheForwardAssist, CC BY-SA 4.0 <https://creativecommons.org/licenses/by-sa/4.0>, via Wikimedia Commons. 

https://commons.wikimedia.org/wiki/File:DC_Capitol_Storming_IMG_7947.jpg

Note the original was altered by me with the superimposed transparency.

2:  Transparency is:  WWII, Europe, Germany, "Nazi Hierarchy, Hitler, Goering, Goebbels, Hess", The Desperate Years p143 – NARA by National Archives and Records Administration, Public domain, via Wikimedia Commons https://commons.wikimedia.org/wiki/File:WWII,_Europe,_Germany,_%22Nazi_Hierarchy,_Hitler,_Goering,_Goebbels,_Hess%22,_The_Desperate_Years_p143_-_NARA_-_196509.jpg

 

 

 

Does the Insurrection End the Debate on the Goldwater Rule?

 

I think it does and both sides lose.

As a refresher take a look at my earlier comments on the Goldwater Rule at this link.  More briefly, the Goldwater Rule was implemented by the American Psychiatric Association (APA) as ethical guidance to its members following an incident where a 1964 magazine survey of psychiatrists concluded that the Republican candidate Barry Goldwater was “psychologically unfit” to be President of the United States.  As you can see from the ad in this previous post, there was a strong implication by the Lyndon Johnson campaign that a Goldwater presidency would put the country on a path to nuclear war.  Goldwater subsequently sued the magazine and was awarded damages – three years after he lost the election.

In the meantime, the APA included the following section in the Principles of Medical Ethics with Annotations Especially Applicable to Psychiatry.

Section 7.3

On occasion psychiatrists are asked for an opinion about an individual who is in the light of public attention or who has disclosed information about himself/herself through public media. In such circumstances, a psychiatrist may share with the public his or her expertise about psychiatric issues in general. However, it is unethical for a psychiatrist to offer a professional opinion unless he or she has conducted an examination and has been granted proper authorization for such a statement.

Since I wrote the original post, I have queried many colleagues who are also APA members and as far as I know no member has ever been sanctioned by the APA or any of its district branches for violating the Goldwater Rule.  There has been a lot of intense debate about it and that debate has never been as intense as during the recent Trump administration.  Beyond the debate there are unequivocal examples of psychiatrists ignoring the Goldwater Rule and, in some cases, criticizing the APA about it. The rhetoric extends to the point that the APA invented the rule because it was embarrassed about the original Goldwater incident and it was suppressing the free speech rights of its members who felt an ethical duty to use their skills to either warn or protect the United States from President Trump.  While some have found that rhetoric to be admirable, I do not. First, APA membership is completely voluntary and the obvious way to escape its long reach into First Amendment rights is to not be a member.  The predictable response to that suggestion is that all of the benefits of membership will be not be available and that might put non-members at a disadvantage.  Having been an APA member for over 30 years, I can attest to the fact that there are minimal advantages to being a member primarily as discounts to publications by the organization.  Even then, the American Medical Association (AMA) membership fee is much lower and includes free access to many more publications.

A second consideration is the context of what is happening.  In my previous post, I pointed out that psychiatrists are trained to assess problems in a particular context.  During years of training that comes down to a face-to-face discussion with the patient about problems that were either identified by the patient or someone else.  Collateral information is considered and that can be exhaustive. A diagnosis and problem formulation follows. Until the profiling of political leaders, criminals, and historical figures came into the scene in the past few decades there was no suggestion that psychiatrists could assess people at distance with any degree of accuracy. In fact, criminal profiling is generally done these days by trained law enforcement personnel suggesting that no psychiatric qualifications are necessary at all.  It all seems predicated on a folk psychology model that personality features and patterns of behavior are constant over time and dependent on past behavior. Some of the commentators on this issue have identified themselves as forensic psychiatrists. Forensic psychiatrists are paid to do even more exhaustive interviews and review of collateral information than clinical psychiatrists. They may take 15-20 hours to do an assessment compared with a clinical psychiatrist who probably has 60-90 minutes at the most. The idea that forensic psychiatrists endorse assessments at a distance seems even more incongruous to me.

Focusing only on the conclusory article (1) post insurrection it is clear why psychiatric opinion adds nothing to the political mix.  In the first paragraph, the authors conclude that Trump is “clearly mentally unbalanced and unable to grapple with a reality that threatens his inflated and fragile ego.”  They suggest that only reason that people would not believe their statement is that they ascribe his behavior to “puckish idiosyncrasy or creative disruption”.  That gives their statement way too much explanatory power. How about the obvious political considerations and Trump’s previous behavior as a businessman?  He is clearly a guy who is used to steamrolling over people and often uses the legal system to do it.  He demonstrated that in the primary and the debates.  He demonstrates it on a weekly basis toward anyone who he thinks is being disloyal – irrespective of their track record. He threw his Vice President under the bus for adhering to the Constitution that he was sworn to uphold. Who would describe that behavior as puckish?  Any objective observer would see that President Trump is a negative force and somebody that you do not want to deal with and hopefully would never be employed by. In political terms, he is an autocrat that deals in propaganda and he knows the power of propaganda. By definition, that is dangerous to any democratic republic but once again – it has nothing to do with psychiatry or the special training of psychiatrists.

The preamble in that conclusion: “clearly mentally unbalanced” is also rhetorical.  He has tens of millions of followers who all believe the propaganda. The authors themselves acknowledge that if Trump was a private citizen they would not be concerned and that their concern is only based on the fact that he was the President. This would be the first case of mental illness based on the condition of Presidency. The additional evidence in this article that Trump was “delusional”, “impulsive”, vengeance seeking, or “deranged” is non-existent and it can easily be argued that deficiency occurs as a direct result of not having personally examined him to ask him for direct explanations.   All of the examples cited are consistent with the behavior of a highly self-interested politician or businessman who will do anything to win. In the event that the authors have not noticed there are tens of thousands of these people walking around in American society. Possibly hundreds of thousands and none of them are being treated by psychiatrists.

The authors previous argument that they have an ethical responsibility to warn the public about Trump’s dangerousness based on a presumptive personality disorder falls apart under that scrutiny.  If there is no clear evidence of a diagnosis there seems to be no basis for the authors to base their actions on. Further Trump’s recent statement on the day of the insurrection and even since are no more radical than many of his colleagues or followers. Why are psychiatrists needed when there is nothing to base a professional opinion upon?

Early in the course of the Trump presidency, the issues arising with the Goldwater Rule were analyzed by Kroll and Pouncey (2).  After considering all of the variations their conclusion was that the Goldwater Rule was based on the need of the APA to prevent embarrassment to the profession by making statements similar to the statements made by psychiatrists during the original Goldwater controversy. That assumes that the APA as a guild is successful in preserving and promoting the interests of psychiatrists in the USA.  The track record there is very sketchy.  The APA and medicine in general has been completely unsuccessful in preserving a practice environment conducive to quality care.  At many levels it has facilitated that transition most notably by a near complete lack of opposition to managed care tactics and legislation and more recently collaborative care initiatives.  The APA has not been successful in advocating for patients with the most severe forms of mental illness. There has also not been any success in advocating for reasonable infrastructure to help the severely mentally ill avoid homelessness and incarceration. That string of failures is potentially more embarrassing than whether or not a few psychiatrists look foolish on the evening news.  I think there is an ethical basis for the Goldwater Rule that extends far beyond embarrassing the many by the few.

One of the key dimensions that I have not seen anyone comment one is that most psychiatrists are liberal Democrats. Psychiatry is the only medical specialty where that is true.  That is a clear bias when assessing a President from the opposite political party.

The insurrection itself clearly illustrates that psychiatric intervention in a Constitutional crisis is not possible or advisable.  I am basing that on the fact that for 25 years I participated in thousands of civil commitments, guardianships, and conservatorships.  I know all the legal requirements for these proceedings in both Minnesota and Wisconsin.  There is no court in any county in either state that would accept a legal proceeding against the President based on his current public behavior.  A typical argument against my position would say it is a utilitarian argument and therefore limited on those philosophical grounds. I don’t think it is at all.  If you are arguing that psychiatrists need to be involved, the question needs to be asked: “What for?”  The psychiatrists who have been the most vocal that President Trump is dangerous or irrational and, in some cases, claim that they are being stifled by the APA and the Goldwater Rule need to have an endpoint.  Every day psychiatric practice dictates that if you are seeing a dangerous individual you have to enact a plan to protect the patient and others. I don’t think that level of evidence exists – it certainly does not rise to the level of court intervention. The next step would be approaching members of Congress and asking for Impeachment or invoking the 25^th Amendment. They don’t need psychiatrists for that.  So what mysterious psychiatric intervention do the Goldwater Rule deniers want to see happen?  Should psychiatrists sitting in arm chairs call someone in the White House and tell them to remove the President based on his most recent outrageous statements?  That clearly would not work.  The concern that he has access to the nuclear briefcase also does not work. The evidence at this point is very clear, his cabinet had the opportunity to enact the 25^th Amendment and they declined.  Vice President Pence declined even after he was publicly berated by the President. Limits were set by the Department of Justice, the Joint Chiefs of Staff, social media companies, the National Guard and law enforcement on the ground.  President Trump had an unorthodox exit from the White House but he did leave.  Several days later the public was informed that he left a letter for President Biden.

The Republic survived without psychiatric intervention and none was indicated. The Goldwater Rule did not prevent some psychiatrists from making rhetorical statements from both the right and the left.  Nobody was sanctioned because from a practical standpoint it is ethical guidance – and I think it is good ethical guidance.

Is there a role for psychiatrists in these situations apart from making a speculative guess about the mental status of the Commander-in-Chief?  I think there is and that is in an advisory capacity about some of the group dynamics and containment of violence that occurred. It is absolutely critical to notice when propaganda is being used to incite violence or in this case an insurrection. Propaganda is not a “shared delusion” it is emotionally charged speech that can lead to fixed irrational positions.  It has to be recognized and countered in order to prevent the mass level of dysfunction associated with the denial of systemic racism, pandemic denial, mask denial, climate change denial, and the denial that the Presidential election was free and fair.  All of those levels of denial associated with the Trump administration occur in the context of longstanding denial that there is a serious problem with firearms in this country.  If psychiatrists want to be politically involved – those are the hard problems that need to be addressed.

There is much to be said for psychiatrists’ experience with containing violence and aggression.  When I witnessed what happened on January 6, I had many concerns about Inauguration Day.  My primary concerns were whether there would be adequate force to stop a similar attack and minimize the risk of injury to the police or demonstrators.  As I saw the barriers erected my concern was whether they was a plan in place to keep large groups away from the fences and avoid a violent confrontation.  Was there intelligence about the possibility of foreign actors taking advantage of the situation? And most of all – did the police and National Guard have clear rules of engagement to contain escalating violence and aggression and avoid serious injuries.  It turns out that everything except the rules of engagement were handled well. 

My advice about the Goldwater Rule either way is straightforward.  Forget about debating the President’s mental status in public.  The standard for Presidential capacity is a lay standard and not specified by any statute.  Psychiatric opinion is and will be remain unnecessary.  And if an APA member decides they want to bring an ethics complaint based on a violation of the Goldwater Rule – that is a waste of time as well. Stay focused on your own medical professionalism and remember that being a psychiatrist does not necessarily make you immune to emotional reasoning, political rhetoric, or propaganda. There are probably many more friends, neighbors, and relatives that need to get back on track to carry on the more mundane work of democracy.  

 

George Dawson, MD, DFAPA

 

References:

1:  Leonard L. Glass,  Edwin B. Fisher, Bandy X. Lee.  Trump’s Danger is now Undeniable.  He is clearly mentally unbalanced and unable to grapple with a reality that threatens his inflated and fragile ego.  Boston Globe January 7, 2021.

2:  Kroll J, Pouncey C. The Ethics of APA's Goldwater Rule. J Am Acad Psychiatry Law. 2016 Jun;44(2):226-35. PMID: 27236179.

Graphics Credit:

1:  Donald J Trump official portrait By Shealah Craighead - White House, Public Domain, https://commons.wikimedia.org/w/index.php?curid=63769676  Downloaded from Wikimedia Commons on 1/29/2021

2:  Barry Goldwater 1960 portrait By United States Senate - https://www.senate.gov/artandhistory/history/common/generic/Featured_Bio_GoldwaterBarry.htm  Public Domain, https://commons.wikimedia.org/w/index.php?curid=79152516

Downloaded from Wikimedia Commons on 1/29/2021

 

Disclosure 1:

Jerome Kroll, MD was one of my professors when I was a resident at the University of Minnesota.  He is a brilliant psychiatrist and wrote one of the best books ever The Challenge of the Borderline Patient.  He was also one of many professors who taught me that you can argue with colleagues and nobody has to take it personally - a good lesson in politics as well. 

Disclosure 2:

In my previous post I pointed out that for the past several decades I have been a small "i" independent.  That has changed with recent events.  I would find it very difficult to vote for a Republican based on their collective behavior and inability to respond to President Trump for the good of the American people.  But I still  do not think that psychiatrists have anything to offer in that area.

Supplementary:

I decided to attach the next several paragraphs based on what I have encountered over the Goldwater Rule into arguments I have heard from deniers and supporters of the rule. The last section are my personal observations (from above) - admittedly not independent of the others

Goldwater Rule Deniers:

1: Psychiatric or mental health experience is necessary in the case where a President may be incapacitated and unable to perform their duties.

2: Psychiatrists are ethically bound to publicly speak out if the President is incapacitated and a potential danger to the country.

3: The only reason the Goldwater Rule exists is to prevent embarrassment of the psychiatric profession.

4:  There may be an element of financial conflict of interest if the Goldwater Rule was recently modified over concerns that the APA may receive less money/tax benefit because of criticism of the President.

4: The APA suppresses the free speech rights of psychiatrists who speak out on the basis of their public assessment of the President.

5.  At least some deniers of the Rule believe that there should be a lower standard for capacity or mental illness if it is applied to the President. In other words, psychiatric opinion is conditional on whether or not the person being observed is the elected President at the time.

6.  The personal interview is not reliable and all of the information necessary to make a diagnosis is already out there in the public domain.

7.  The President's personality or alleged mental illness is the primary problem in what appear to be poorly thought out decisions.

 

Goldwater Rule Supporters:

1:  The Rule is the rule and direct examination of the patient is required to get the assessment out of a purely speculative mode where observations potentially have multiple possible meanings.

2:  The politicization of psychiatry is inevitable with experts for either party.

3:  The politicization of psychiatry potentially impacts patients’ willingness to see psychiatrists for help.

4:  Competency versus capacity – competency requires legal definition, capacity may be informal but that is unlikely in a contested procedure.

5:  Scientific accuracy of predictions of dangerous behavior are not good (Estelle v. Barefoot and APA amicus brief)

6:  Psychiatrists are not immune to rhetoric, propaganda or emotionally charged speech. The original treatment of Goldwater is a good example.

7:  If the issue is dangerousness and we are talking about President Trump there were many more dangerous presidents based on total war casualties that occurred during their terms – including Lyndon Johnson who was elected in part on the alleged dangerousness of his opponent Barry Goldwater.

8:  The President's personality or alleged mental illness is difficult to separate from purely political tactics like intentional misinformation or propaganda that are designed to disrupt and manipulate the electorate. 

 

GD:

1:  The Rule is ethical guidance that has never been enforced.

2:   The Rule is obviously ignored – nobody has ever been sanctioned by the APA or a District Branch in the 50 years it has been in effect

3:   The Rule only applies to APA members so people outside of the APA should not be concerned about it.  If you are really concerned about it don’t be an APA member and comment as much as you like.

4:   Presidential capacity is a lay standard that is not specified in any legal statute. In other words, there are no judicial descriptions of a standard for Presidential incapacity, no standard of proof.

5:  There is no mechanism to remove the President from office based on psychiatric opinion.  There are however political and legal mechanisms (25^th Amendment, Impeachment) to remove the President based on the opinion of his cabinet and in the case of repeated impeachments disqualify from further election eligibility.  A non-psychiatric standard is defined in the 25^th Amendment.

6:  In retrospect, some of the original campaign against Goldwater was propaganda (see ad on nuclear war) and that was reflected in some of the psychiatric opinion at the time.

7:  Psychiatrists potentially have a more significant role at the level of the group dynamics of violence, aggression, misinformation, propaganda, and the containment of violence and aggression.

8:  Several polls have characterized psychiatry as the most liberal medical specialty and the only one where a majority of members are Democrats.  That conflict of interest should be disclosed when commenting on opposition party politicians.

 

The Insurrection

This has been an historic week in the United States. On January 6, 2021, President Donald Trump and several of his supporters incited a large group to attack and invade the Capitol Building as Congress was in the process of certifying the electoral college vote – the last official but routine step for Joe Biden to become the duly elected President of the United States.  During the riot, Capitol police were assaulted and one of them was killed. A rioter was shot and killed.  Three people died of medical emergencies due to poor access at the scene. There were scores of people injured, many serious.

Police and the National Guard eventually regained control and Congress was able to reconvene and certify the electoral college vote.  The challenges to the votes in several states were overwhelmingly rejected.  The President had also suggested that the Vice President Mike Pence could decide to not accept the votes and nullify the election, but the Vice President was very explicit about his Constitutional duties and knew that was outside of his scope of power. He kept the process going and brought it to appropriate closure declaring that Biden-Harris were the winners.

The aftermath of this event has produced a little certainty but not much.  As I write this late on a Saturday night, all that we know for sure is that Joe Biden is the certified winner of the election and that he will be inaugurated on January 20^th.  President Trump’s supporters from the recertification debacle are in disarray.  Press reports quote them as lashing out at the expected fall out from their efforts and the insurrection at the Capitol. At least one has lost a book deal and in other cases constituents are calling for their resignation.  Since the official vote was preceded by the insurrection and violence, some of the people who were expected to object to the certifications from specific states did not. Other Republicans were outspoken against the process from the outset since it was clear that the President had repeatedly lied about the election being stolen and there was no factual basis for any objections. Republicans adopting those positions were subjected to derision and threats from Republicans who supported Trump.

On the night of the insurrection, there were rumors that Trump’s cabinet may be considering invoking the 25^th Amendment and removing the President from power based on his incapacity to do the job. Inciting an insurrection against the government and Constitution that he was sworn to uphold would seem like a sure way to get anyone fired.  The other logical question is, if a person can make such a drastic error in judgment – does it imply that they will continue to make further drastic errors?  In other words is their judgment compromised even beyond the crisis they have created?  I am not talking about a diagnosis of mental illness. I am an adherent of the Goldwater Rule and don’t believe that psychiatrists should speculate about the mental health of a public figure without doing a thorough personal assessment and then disclosing the result of that assessment only with the consent of that individual.

That does not mean that professional organizations should abdicate their roles in advocating for science, social justice and correcting disparities related issues, and most of all advocating for a practice environment that allows physicians to provide high quality health care to our patients who need it the most. Health care professional organizations have not done a very good job on these issues largely because they have been completely ineffective against the business takeover of health care. 

With the recent events the American Psychiatric Association came out with a statement on January 7, 2021 entitled: APA Statement on Yesterday’s Violence in Washington.  It seemed to be overly reactive to me and it carried the usual generic conclusions – if you are having problems see someone. It would have more authority if there had been statements at every stage of the President’s escalating rhetoric.  Where was the APA for example when the President attacked science, the CDC and its scientists, and Dr. Fauci?  Where was the APA when the President attacked Black Lives Matter and showed support for white supremacists? Where was the APA when the President trivialized the COVID-19 epidemic, politicized the treatment and endangered lives, and spread misinformation about the origins of the virus and how it spreads. There is no authority when you sweep in at the very end when conditions are dire and seek to correct what you did not comment on in the previous 10 months. Real time commentary on political action that is detrimental to the social fabric of the country is necessary from professional organizations, especially one whose members assess the impact of that social fabric on every patient they see.

But there is more blame to go around – especially when it comes to social media companies.  Facebook, Twitter, and Google all seem to be very confused about how they are used for propaganda purposes. Misinformation is a euphemism for propaganda these days and there has never been a more powerful amplifier of propaganda than American social media. To be clear, propaganda is an intentional lie that is repeated over and over again until a certain segment believes it to be true and starts to react emotionally to it. This behavior was clearly visible from people at the Trump rally and people who invaded the Capitol building. People clearly agitated about the election being “stolen”, socialists taking over, the country turning to socialism, personal freedoms being impinged upon.  Image after image of people in the media who were obvious Trump supporters who were agitated about what are essentially non-issues. The clearest non-issue was the election being stolen.  Trump himself keeps repeating this despite the clear facts that the elections are much more well run that when Al Gore was defeated by hanging cardboard chads in the 2000 election that was decided by a Supreme Court decision and a 271 to 267 electoral college vote. In fact, the score card about election fraud shows that there is a complete lack of evidence of significant “fraud” or stolen elections.  The major social media players finally came around and banned Trump and his accounts, but even as I type this he is vowing to get more media access and continue his divisive propaganda campaign.

In the big picture, the Trump propaganda is much more than a curiosity at this point.  In addition to the insurrection at the Capitol, Trump followers have threatened violence against the families of both Democrat and Republican elected officials largely as a way to support Trump.  These coercive tactics have no place in a functional democracy and at the individual level should be considered terroristic threats by local police. The insurrection has provided a blueprint for both foreign and domestic enemies of the United States who seek to disrupt the functions of our government and the security of our citizens. The disruptive effect that the Trump administration has had on our military, intelligence community, allies and leadership role in the world adds greatly to the insecurity of the republic. President Trump and his administration should be considered a case study of incompetent leadership and suggest pathways to competency that future leaders should be assessed by.

I started to write this with some suggestions about what needs to happen over the next 10 days to get the country back on track and correct some of the current glaring deficits:

1:  President Trump: the people on the ground specifically his Cabinet and leaders in Congress need to make an assessment acutely about whether he lacks the current capacity to function in his role as President. The insurrection is strong evidence.  His lack of commentary of a major Russian government hack that has been occurring for months (the extent of which is not currently known) is another.  There is speculation that some of his cabinet members are contemplating this but there have been resignations and temporary appointments.  There is a question about how fragmented the Cabinet is and whether that would hinder the process.  Members of Congress are apparently considering impeachment, but that is a long process.  There are platitudes about how impeachment would not “heal the divisiveness” that are more than a little ironic considering the people making these statements. I have heard that two impeachments of any President rules out any future candidacy and if that is true – it is a very good reason for proceeding with impeachment.

There are still some mental health professionals out there who think a psychiatric emergency is a better response. I routinely did psychiatric emergencies for 22 years and I can say without a doubt that there is no court judge that I know of who would detain President Trump on an emergency basis for hearing or schedule a hearing for guardianship or conservatorship on the basis of a mental illness. Media reports are full armchair diagnoses of narcissistic personality disorder or malignant narcissism (not an actual diagnosis) and even if these diagnoses were accurate – they are not diagnoses that result in court action.  Those diagnoses are typically statutorily defined severe mental illness.  The legal criteria in the 25th Amendment is much clearer: unable to discharge the powers and duties of his office. The only problem is that it is interpreted by lawyers and politicians and not everyone will agree with that interpretation.

Another feature of the legal versus psychiatric intervention is that the decisions can be made right now, by people who have been working with the President in some cases for 4 years.  That constitutes a larger amount of information and a much shorter timeline for action than is possible in any psychiatric scenario. 

2:  The security issue:  The Capitol and any place there are elected officials doing the work of the US Government needs to be very secure. That means there needs to be an adequate force and clear rules of engagement.  Right now there are people threatening the inauguration process and there must be very thorough plans to prevent that from happening.  The FBI is apparently trying to identify as many people as possible from the original insurrection and the message is out there that they will be prosecuted.

The larger security issue is starting to counteract the propaganda about stolen elections, fake pandemics, fake news, and freedom being under attack. I am confident that clearer messaging from the White House and members of Congress will be useful as well as integration back into the international community.

3:  The potential for Civil War:  Not my idea.  About 3-4 months ago I was contacted by people who knew that I was a bit of a survivalist.  Their concerns ranged from civil unrest disrupting the food and power supply as well as access to medical treatment to outright armed conflict between warring factions  Their specific questions were about what they should acquire now to protect themselves and their family if the Trump induced negative reverberations through society continue and worsen.  I am not a historian and wonder if an attempted coup by an autocrat who refuses to accept or even acknowledge 200 years of democracy qualifies as a civil war?  The autocracies in my lifetime including Hitler, Stalin, Mussolini, Pol Pot and many others extending right up to modern times do not seem to be the products of civil war.  Many occurred as the result of internal political turmoil often fomented by propaganda.  Many of these propaganda techniques were codified by the Nazis such as the Big Lie propaganda technique.  

The transition from ordered to disordered society is never clear. No American anticipated the rise of a disruptive autocrat and the impact that he could have on ordinary citizens.  In many ways it reminds me of Robert J. Lifton's interviews in The Nazi Doctors and how the transition to state sanctioned medical killing occurred during the Holocaust.  On page 13 he quotes a French speaking eastern European physician on whether what happened can be understood from a psychology viewpoint:

"The professor would like to understand what is not understandable. We ourselves who were there, and who have always asked ourselves the question and will ask it to the end of our lives , we will never understand it because it cannot be understood."    

I think there may be some insights from the anthropology of warfare.  Keeley gathered anthropological evidence of ancient conflicts between tribes, towns, and eventually cities.  He concluded that there were no peaceful primitive people. The settlement of disputes between neighboring tribes or city states have always been violent with a significant toll on the losing population.  That theme is obviously extended to current times where there is an uneasy peace based on nuclear deterrence but a quarter million people lose their lives each year due to small arms fire.  Peace does not seem to be the interest of many nations even though there are clear cut advantages.  The human propensity for violent dispute resolution is not reassuring in a heavily armed nation and an angry faction who show up on government property holding assault rifles.  Interestingly one of the features of society that Keeley considered protective against war was an active trading and economic relationship with rivals.  That is another area where President Trump has not done well. 

4:  The propaganda at the individual level:  Many people ask me why so many people buy into obvious propaganda like the stolen election lie.  It turns out this recipe for influencing large groups of people politically has been around for decades.  The general message is to keep repeating the lie and at some point people start to emotionally react to it and that reinforces it.  From a neuroscience perspective there have been some imaging studies that claim to be able to detect Democrats from Republicans but I question those results.  Some suggest the problem is a lack of critical thinking, but I know a lot of professionals who have accepted Trump’s stolen election lie as a fact and their critical reasoning capabilities in all other areas seem to be intact.  One of my colleagues proposed an evolutionary social theory that seems to have some plausibility – as humans we are socialized to follow charismatic leaders whether they are right or wrong.  There seems to be a lot of historical data to back that up.

I would suggest a complementary hypothesis and that is the emotional inputs for day-today decision making.  Some time ago on this blog I discussed some of the groundbreaking work of Antoine Bechara, MD, PhD and his work on why emotional input is critical for human decision making. He demonstrated that without it – subjects with normal intelligence is unable to function.  We also know that an excess of emotion can adversely affect decision making and lead to errors both acutely and on an ongoing basis.

Propaganda has both a cognitive component (the lie) and a strong associated emotional component.  Supporters of the stolen election lie are clearly angry about getting a raw deal, about their rights being impinged up, about needing to take the law into their own hands, about someone treating them (or their candidate) unfairly, the list is quite lengthy but the emotion is always anger.

I don’t claim to know how to reverse that process.  I did take a course in how to deprogram cult members at one point and the main intervention was to get them away from the people influencing them.  Removing the continuous inaccurate social media messaging may be useful in that regard. An improvement in the general tone of the media may also be helpful.  Since the insurrection, the mainstream media seems a lot more willing to make determinations of what is accurate and what is a lie.  One lesson appears to be that even if the propaganda lie is labeled as misinformation that is probably not enough.  It will still be altered in a positive way and propagated for propaganda use.  Propaganda needs to be eliminated when there is obvious overwhelming evidence against it.

There also have to be organizations that are willing to step up and make a stand for accuracy to correct political misinformation.  Both Science and Nature the major general scientific publications have been doing that on an increasing basis.

And finally, there is the appeal to the individual. In some of my earlier writing on this blog about firearm violence I suggested that people self-monitor for violent or aggressive thinking and seek out help if they noticed this. My thoughts related this insurrection are no different.  Nobody should be thinking that American elections are rigged or that they need to take the country back from someone.  We all know how this democracy works and it has been working well for 200+ years.  It works well because of the concept of peaceful transfer of power and the associated traditions. In other words, it is about what is good for the country and its people and not an individual official.  The President is the President for all of the people and not half of the people and he or she serves at the will of the majority.

Let that sink in……

 

 George Dawson, MD, DFAPA

Supplementary 1:  A poster on Twitter pointed out the rationale for the suspension of Trump's account.  The rationale is listed in this blog post.  Pay particular attention to the last 5 bullet points, especially bullet point 5:

"Plans for future armed protests have already begun proliferating on and off-Twitter, including a proposed secondary attack on the US Capitol and state capitol buildings on January 17, 2021."

I am hoping that there will be more than a few hundred National Guard troops present at the Inauguration and that Governors take these threats seriously, especially in states where gun advocates have succeeded in getting laws passed to carry firearms on state government property. I would suggest going as far as a temporary order to suspend firearms in proximity to the state capitols in addition to an adequate show of force to deter further antigovernment activity. 

Supplementary 2:  For anyone confused about what happened at the Capitol building it comes down to this:

References:

1:  Lawrence H. Keeley.  War Before Civilization. Oxford University Press, New York 1996.

2:  Robert Jay Lifton.  The Nazi Doctors. Basic Books, New York 1986: p 13.

Image Credit:  This is an image from the Capitol Building on Jan 6, 2021 from Shutterstock per their standard agreement.

Americans Can't Do The Basic Health Care Arithmetic

A minimum of $300 billion dollars saved.  That is what I thought could be achieved by eliminating insurance companies from the American health care system.  It turns out the savings are a lot bigger than that.  Just looking at countries where the per capita health care costs are at least $2500 and comparing the USA to Switzerland - the country with the next highest per capita health care costs we get the following equation:

$2640 (the difference) x 320 million (current population the the US) = $844.8 billion

That is what converting the US health care system to single payer would involve.  No more managed care companies (MCOs)  pretending to be efficient.  No more pharmaceutical benefit managers (PBMs) rationing medications in order to make profits.  No more outrageous Obamacare premiums that seem to be rising with no end in sight.  No more MCOs, and PBMs making your doctor's life miserable and burning him or her out.  The writing should be on the wall by now for all Americans.  The US Congress and their healthcare lobbyists fully intend to continue the unsustainable health care bureaucracy to every American until the last possible moment.  That is as true for Republicans as it was for Democrats.

What do I mean by unsustainable?  According to KFF.org in 2016 employer purchased health insurance policies averaged $18,142 per year ($12,865 paid by the employer and $5,277 paid by the employee).  For retirees the situation is even more stark.  I used the AARP calculator to look at estimated health care costs only in retirement for a theoretical couple retiring at 66.  The result was an estimated $225,463.  Of that total only $121,529 was covered by Medicare and that left a shortage of $103,934 in out of pocket costs.  To me that means the average Social Security dependent senior citizen in this country cannot cover their health care costs even with Medicare.  Some of them are telling me their supplemental policies are as high as $20,000 to $25,000/year.  For any couple trying to stay in their own home in retirement - health insurance premiums and property taxes will easily absorb most if not all Social Security income.  The gross estimate by this calculator varies from state to state but some sources have given the gross average amount for a retired couple to be about $260,000.

And where does all of that money go?  That is easy.  It goes to bad management.  In a country that has fewer doctors and fewer hospital beds than most countries in the above graph - it should be obvious that rationing medical care to make profits for Wall Street does not work.  Two recent experiences will illustrate the problem.  I heard a presentation given by a speaker from one of the major physician run medical clinics in the  US.  For some reason she started talking about the ratio of administrators to physicians in their organization.  The number given was 50 administrators to every physician.  That is an absolutely stunning number.  With that number of people in hospitals and clinics - it should raise the question "What are they doing there?" and "Why does it take this many people to administer the most accountable professionals in the US?" Not only that but what has all of this administrative oversight accomplished?  The answer is in the graph at the top of this page - the most expensive and most inefficient health care system in the world.  It is basically an expensive jobs program for managers and bureaucrats, and bad technology.

The second scenario was a physician talking with me about his speciality clinic of 5 physicians.  He recently learned that they were being administered by 15 mid level administrators reporting to a single higher level administrator.  When he questioned this practice, he was asked why he was concerned about the number of administrative staff.  I guess according to the previous estimate he was doing quite well with a ratio of 16 administrators for 5 medical staff.

The real impetus for this post occurred as I was doing some exercises at home before work this morning.  The Today show was playing in the background.  Matt Lauer and Katie Couric were interviewing Trump advisor Kellyanne Conway about a number of issues.  I heard the question: "Have they (Republicans) come up with something to replace Obamacare?"  Ms. Conway responded with the typical free market solutions - buying insurance across state lines, health savings accounts, etc, etc.  None of these are solutions to bad management and what is basically corporate welfare for the army of healthcare administrators in this country.  The only correct response to that question is:

Single-payer health insurance.

Get rid of the unnecessary managers and save a trillion dollars in mismanagement.



George Dawson, MD, DFAPA


Attribution:

The figure on per capita health care spending is from the Kaiser Family Foundation accessed on January 1, 2017 and this is their citation:

OECD (2016), Health spending (indicator). doi: 10.1787/8643de7e-en (Accessed on 01 January 2017).

 I have no affiliation with the Kaiser Family Foundation or the OECD and their graphic is used here per their terms of use for non-commercial, non-profit sites.


Supplementary 1:

I would be remiss in not pointing out the mountain of fake news that goes into getting Americans to believe that some kind of government led "reform" that concentrates market power into a few for-profit proxies is a good idea.  There is the associated fake news from both parties that just happens to leave the pricing power to private industries,  In that context the fake news by Ms. Conway this morning is all part of an unmistakable 30 years of nonsense stretching back to the Clinton administration and their idea about "managed competition".  We have had nothing but mismanaged competition ever since.  The dynamic in health care is an obvious parallel to the financial services industry and their guaranteed profits from the work of Congress.  In both cases, all Americans foot the bill.


Supplementary 2:

Let me remind the free market advocates that there is not now and there will never be a free market in health care or anything else in the USA.  It is (largely) a Republican fantasy.  The major markets in the US all depend on government intervention and the sector with the best lobbyists gets the most favorable deals.  It is the only way to explain a trillion in waste, just based on "free market management" not including other boondoggles like a highly regarded electronic health record that is less functional than 1990s database software and paying $300 for 29 cents worth of epinephrine.