American Democracy is at Best A Semi-Rational Process

 

“Political language … is designed to make lies sound truthful and murder respectable, and to give an appearance of solidity to pure wind.”  George Orwell in Politics and the English Language, 1946.

 

In the closing month of the federal election for President, I think it is useful to consider my previous comments on the Goldwater Rule and Does the Insurrection End The Debate on the Goldwater Rule.  The rule was promulgated by the American Psychiatric Association to prevent casual comments about psychiatric diagnoses of candidates when they had not been examined and given permission for those diagnostic evaluations.

I have always been in favor of this rule largely because it is outside the scope of psychiatric practice and like many forensic settings there can be a prominent conflict of interest based on political affiliations.  It also turns the diagnostic process on its head in that it is no longer used for the benefit of the patient, but the benefit or lack of benefit falls to third parties.  And finally, whenever psychiatric diagnosis is used in the press or other forms of common usage they lose their real meaning. They are no longer useful observations but, in many cases, become ad hominem attacks.

I have not counted the number of comments about narcissistic personality disorder, but it has grown significantly since the 2020 Presidential election and several commentaries that Trump had that disorder.  Antisocial personality disorder and psychopathy (a trait rather than a formal disorder) have also been used to describe him.  Since the terms became more visible, they have been widely applied.  You Tube and TikTok videos suggest how to make the diagnosis yourself or at least recognize it.  They describe typical speech patterns and how you should respond.  Many describe the red flags.  After watching this material none of it seems useful to a psychiatrist who makes the diagnosis and provides treatment. 

There seems to be a significant overlap with people who are difficult to get along with – often in asymmetrical roles like employer-employee.  Do the conflicts that typically happen in these situations rise to the level of a psychiatric diagnosis?  Do conflicts and misunderstanding that occur in other interpersonal relationships rise to that level? Probably not.  But there is a whole lot of videos encouraging people to make that diagnosis.   

The original arguments for making a psychiatric diagnosis on former President Trump were basically threefold.  First, that it was a professional obligation.  Psychiatrists were obliged to warn the American people about the dangers of any diagnosis basically as a public service.  There are several problems with that approach – the most significant being that diagnoses are associated with a wide range of behavior of varying severity and not predictive of anything specific.  It is unlikely that any diagnosis would have predicted the wide variety of significant problems that Trump exhibited following the election. The other problem of course is that it removes the Constitutional threshold for action by the Cabinet and replaces it with a much lower threshold – the psychiatric diagnosis.  It is basically the reason why people do not undergo civil commitment or guardianship proceedings based on a diagnosis.  The law requires obvious behavior that can be observed by any lay person. The 25^th Amendment standard is “ a written declaration that the President is unable to discharge the powers and duties of his office” from either the President himself or a “majority of either the principal officers of the executive department or of such other body as Congress…”  The determination is strictly based on lay observation and not medical or psychiatric evaluations.  Second that it provided additional information for voters that they could use in making their decision.  And finally, the somewhat grandiose assumption that it may be a superior method than the judgment of officials mentioned in the 25^th Amendment. All of those assumptions have failed at multiple levels.

Rather than be concerned about Trump’s diagnosis this may be a question of voter capacity or competence.  In other words, is the voter using available information to make a rational choice?  And can the available information be analyzed rationally?  That requires more than just stating a preference.  It requires a rationale for casting the vote. This is also a difficult measure because there is a value system baked in to some of these decisions.  For example, some votes are based on single issues or traditions like always voting for members of a certain party. Some votes are based on issues like abortion, guns, and censorship even when it is clear the results have been worsening medical care for women, gun extremism, and book banning that includes shutting down some school libraries. The value system can also include extremism like guns, racism and antisemitism.  Even though most reasonable people would agree those values have no place in modern society – they do not disqualify people who value those ideas and vote on that basis.  All of this illustrates why voting is a semi-rational process. On that basis you can also ignore all the negatives that members of the same party or Cabinet say about a candidate’s intellect and character.

The only inconsistency in the law that occurs is that capacity to vote is considered in guardianship and conservatorship decisions by the court.  In my experience I have seen the county forms, but in the hundreds of assessments that I have done – capacity or competency to vote was never a dimension that I commented on.  Associated capacities for entering marriage and contracts were also typically listed but not commented on.  In practice it may be that people who are under guardianship or conservatorship are not offered a trip to the polls or a contract but I cannot say for sure.

The polls themselves handle the issue like everything else in the law and politics as a contentious issue.  For example, these are direct quotes from Minnesota Statutes regarding election procedures:

“Mental capacity is a question of fact for judges of election.” Op. 82, Atty. Gen. Rep. 1942, October 22, 1942.  p. 26

and

“Provision of Minnesota Constitution prohibiting a person under guardianship from voting at any election in the state did not violate the Equal Protection

Clauses of the U.S. and Minnesota Constitutions, since pursuant to Minnesota statute, persons under guardianship were presumed to retain the right to vote, and the constitutional prohibition against voting based on guardianship status applied only when there had been an individualized judicial finding of incapacity to vote. Minnesota Voters Alliance v. Ritchie, 890 F. Supp.2d 1106 (D. Minn. 2012).”  p. 43

The county auditor shall mail a notice indicating the person's name, address, precinct, and polling place to any registered voter whose civil rights have been restored after a felony conviction; who has been removed from under a guardianship of the person under which the person did not retain the right to vote; or who has been restored to capacity by the court after being ineligible to vote. The notice must require that it be returned if not deliverable”.  P. 386

I have never heard of a single situation where an election judge challenged a voter based on their mental capacity and do not understand how that would happen unless they were exhibiting signs of severe mental illness and were disruptive.

All these considerations point to the fact that voting and politics in the United States and elsewhere is a semi-rational process.  It was designed that way by the founders.  There are minimal qualifications to run for office - basically age, citizenship, and in some cases residency requirements. It is interesting that you cannot vote in many states if you are convicted of a felony but that does not disqualify you from running for President.  The top issues for most voters are not rational decisions.  I wrote a recent post on the fact that the President has little to do with the economy and an academic analysis showing Democrats were much better for the economy could not be explained rationally. That type of analysis can be applied to any of the top issues that voters are considering. There is one candidate who has been severely criticized for intellectual and character defects that include ignoring an attempt to overthrow the US government, lying for 4 years about an election outcome, lying more recently about disaster relief, and being convicted of multiple felonies. A significant number of voters and politicians in his own party elect to ignore these facts.  On the other hand members of his own party have endorsed the opposition candidate and actively campaigned for her. Forty of 44 cabinet and staff members of his own administration have said he should never be in the White House again.

This election exposes all the ugliness of American democracy that was previously not discussed.  All it took was a candidate who was more focused on himself and a few people at the highest income levels, disingenuous antiestablishment rhetoric, a lot of name calling, and some active obstructionism to real solutions.

My guess is the Founders of the Republic – did not see that coming.   

 

George Dawson, MD, DFAPA

 

References:

1:  2024 MINNESOTA ELECTION LAWS Office of the Minnesota Secretary of State, Elections Division. Annotations provided by Minnesota Attorney General.  Accessed on October 11, 2024.  https://www.sos.state.mn.us/media/5067/minnesota-election-laws-statutes-and-rules.pdf

 

Graphics Credit:

1:  Trump Photo:  Gage Skidmore from Surprise, AZ, United States of America, CC BY-SA 2.0 <https://creativecommons.org/licenses/by-sa/2.0>, via Wikimedia Commons" https://commons.wikimedia.org/wiki/File:Donald_Trump_(52250930172)_(cropped).jpg

2:  Harris Photo:  Lawrence Jackson, Kamala Harris Vice Presidential Portrait.  Public domain, via Wikimedia Commons" https://commons.wikimedia.org/wiki/File:Kamala_Harris_Vice_Presidential_Portrait.jpg

 

The American Gun Protection Fantasy and the Secret Service....

 

Ten days ago, a lone shooter attempted to kill former President Trump at a rally in Pennsylvania. About 6 minutes after he began speaking, Trump is noticed to turn his head to the right and then grab his right ear and drop to the ground. He is swarmed by Secret Service agents and after a period that seems too long is escorted off the stage and taken to a local hospital for assessment and treatment.  Three people in the audience are shot – one dead and two seriously wounded.  They were all in the line of fire seated behind Trump.  About one minute later the Secret Services Counter Assault team returns fire fatally wounding the shooter.  Weeks later it is learned that the shooter may have fired as many as 8 rounds based on shell casings found near his body on the roof.

There is immediate speculation and controversy about the incident. Quite incredibly several members of the Republican party blame the incident on Democrats even though they are the party that has been espousing political violence and gun extremism. Preliminary reports suggest that although the shooter is a registered Republican – he donated $15 to a liberal cause a few years earlier.  The shooter was using an AR-15 rifle that he borrowed from his father and he had purchased 50 rounds of ammunition.  At the time of this post there is no information on whether he was using a high-capacity magazine or not.  The state of Pennsylvania has no prohibition on assault rifles or high-capacity magazines.

We subsequently learn that the shooter did not make the cut for his high school shooting team, but did belong to a local shooting club.  He was described as a loner who was bullied in school. Some people described him as bright and eccentric.  All agreed that there was no suggestion that he was a potentially violent individual and nobody ever heard him make any threats. It was later learned that he did some drone surveillance of the site and had saved materials on several people from both parties.  To at least one analyst this data suggested that his goal was a mass shooting rather than an assassination.  Others speculated that it may have been a “suicide by cop” scenario.  Some information leaked from the preliminary investigation suggested he was searching “major depression” on the Internet. 

We also learn that the shooter had a picture of a recent mass school shooter whose parents were also convicted for allowing him access to firearms.  The shooter in this case places his father in the same predicament, although there have not been any statements from the parents.

At this point there are signs that there were significant security lapses.  That led to Congressional testimony by the Director of the Secret Service on July 22.  Several members of Congress demanded an immediate resignation and she subsequently resigned on July 23. She did accept full responsibility for the security lapse, an administrative maneuver that is apparently expected only in the government.  She resigned at a time when the results of the investigation of the incident are still pending.

The public has been presented with interviews of people who saw the shooter on the roof and tried to get the attention of law enforcement including the counter assault team without success.  The shooter was approached on the roof by a police officer who apparently had to back down because the rifle was pointed at him and he was not able to draw his weapon in defense.  There was a story today that Secret Service agents were located at the roof level on the interior of the same building that the shooter was on but did not see him.  The shooter was identified as a “suspicious person” but not a threat because his rifle was not seen initially. If he had been identified as a threat – Trump would have been sequestered in a safe area until the threat was neutralized.

I have not heard any information about the perimeters established for security.  I heard initially that there was a Secret Service perimeter closest to Trump and extending out for 200 yards.  The meant that Secret Service was responsible for anything inside that perimeter and local law enforcement was responsible for the next tier beyond 200 yards.  That may explain the aborted attempt by the police officer to intervene moments before the shots were fired at Trump. 

Most significant to me as a psychiatrist is the continued “search for a motive” or that “no motive has been found.”  That is a routine finding in these events.  There really are no rational motives for picking up a gun and trying to kill the former President or anyone else.  There is no motive for essentially firing into the crowd beyond Trump and killing a spectator and seriously injuring two more.  Most firearm related homicides are irrational acts – related to angry disagreements and firearm accessibility.  The fact that motives are lacking is probably the reason mental illness is often considered to be a factor in firearm homicides. 

That takes me back to my hypothesis of mass shooters that can probably also be related to lone shooters in this case.  The United States has a long history of cultural memes related to firearms.  Film and television is a rich source of revenge stories where the hero/antihero is wronged and proceeds over the next 90 minutes to kill everyone who wronged him.  That has extended in the media to include mass shooters and school shooters. Many are described as “bullied”, loners, or mentally ill.  The overriding story is the revenge meme – whether it is accurate or not.  For several decades the meme involved postal workers "going postal" due to workplace stress and mismanagement although a subsequent investigation showed the incidence of post office violence was not greater than other workplaces.   All it takes is a marginal person without self-control ability to decide to project their problems onto an available individual or group and extract their revenge.  The method of choice in the US is a firearm.

There is another group and cultural factor that may be important in these cases and that is the American sniper.  There are thousands of snipers in the US military.  They typically operate at a range of 600-1200 meters, although several shots have occurred at much greater distances. The IMDB database lists 18 sniper movies dating back to 1963. Just inspecting that list suggests to me that there are many more. And of course there are constant real-life stories about mass shooters.

My point about snipers is fourfold.  First, it reinforces the shooter meme in that a sniper is generally seen as a very competent person who is shooting people for the right reason.  Even the cinematic revenge version often has the audience primed to see the shooter's viewpoint.  Second, snipers are generally portrayed as cool and professional.  Third, there are any number of weapons that can be used to become a self-styled sniper.  The first mass shooting I became aware of was the Texas Tower mass shooting of 1966.  The incident occurred at the University of Texas and the shooter fired from the same clock tower position.    Snipers are generally portrayed as possessing some special talent to shoot well – but the reality is that anyone can shoot well – even at a distance if they have enough practice. Fourth, gun access in the US is easy.  The problem of how long mass shooters experience thoughts about shooting people is unknown and probably an impossible study.  That leads to a certain politics of explaining the motives.  To gun extremists the shooter is just “a bad guy with a gun.” who needs to be stopped by a “good guy with a gun.”  Many of these same gun extremists tend to blame the behavior either on mental illness or the treatment of mental illness even though most incidents are not related to either.  This group rigidly avoids acknowledging their possible role due to cultural changes and the widespread availability of guns.  They are joined by some mental illness advocates for not treating mental illness who suggest the behavior is due to medical treatment.  In the past, I have suggested going after the problem directly and approaching it as a public health problem.  That is – if you have homicidal thinking call an emergency number for intervention.  Acute care psychiatrists intervene in the problem when it is precipitated by severe psychopathology, but in most cases that is not the issue.  It is safe to say, the problem and successful interventions cannot be well studied in the current landscape.

Getting back to the shots fired at the Trump rally, Trump was speaking 430 ft away from the shooter or about 131 meters.  That is well within typical sniper range.  Further – given the military sniper range suggests that the Secret Service would need to secure the entire area out to 10 times the distance to that rooftop and even then, that may not be far enough.  If there are two important lessons from this event it should be that guns are inadequate protection from a shooter with an element of surprise and a long-range weapon.  You can make the argument that the Secret Service snipers may have stopped a mass shooting event, but at this point that seems to be highly speculative.  Secondly, the perimeter is very significant.  If the initial descriptions of a 200-yard perimeter are accurate – new strategies are required and even then, I would question the likelihood of stopping catastrophic results from single shot fired by a sniper who was trained in evasive action.  These are important considerations when the political solution at this point appears to be an investigation focused on who to blame for security lapses.  Members of Congress are saying all that is needed is a thorough and transparent investigation.  So far – very few details of the investigation are available.

It is doubtful that the obvious cultural factors like gun extremism, widespread availability of weapons and military style weapons, and the cultural phenomena of the lone wolf shooter will be addressed. It is doubtful that public health approaches to the problem will be discussed. I expect a final report several hundred pages long focused on what law enforcement and the Secret Service should have done.  I look forward to reading that report to see what perimeters and measures are considered and anticipate that they will be woefully inadequate compared with any determined shooter from a long range. 

And then there are the legal considerations. After the Reagan assassination attempt, the Brady Bill – a modest modification of existing gun control laws was eventually passed 12 years later.  Since that time there have been decades of gun extremism put into the law, basically because one of the major parties needs the issue for political purposes.  This has made the United States less safe for everyone including Presidential candidates.  The most striking example is that the city of Milwaukee was not able to ban firearms outside of the hard security perimeter at the Republican National Convention that occurred 2 days after Trump was shot at.  Wisconsin law prohibits local municipalities from banning firearms.

Over the past 30 years we have gone from a nation of common-sense gun laws – to a nation of gun extremism.  That is almost entirely due to the actions of the Republican party and its politicians.  There has been a clear association with increased firearm deaths and there has been no resulting retracing of the path to gun extremism.  Gun extremism puts everyone at risk including Presidential candidates. I will refrain from the usual political platitudes about how I hope everyone will be safe out there. Hopes and prayers for the victims of firearm violence have not changed anything so far and I expect more of the same until the party of gun extremism decides to change their mind or they are voted out. 

These are my observations about this Trump rally. It was a shocking event, but probably not shocking enough to change any gun laws or the steady march towards gun extremism that is oddly enough in the hands of the party whose candidate was targeted. 

George Dawson, MD, DFAPA

References:

1:  Update on the FBI Investigation of the Attempted Assassination of Former President Donald Trump Update: July 15, 2024, 3:05 p.m. EDT:

https://www.fbi.gov/news/press-releases/update-on-the-fbi-investigation-of-the-attempted-assassination-of-former-president-donald-trump

2:  Neuman S, Westervelt E.  Trump's close call: A detailed time line.  NPR:  https://www.npr.org/2024/07/19/nx-s1-5041734/trump-shooting-assassination-crooks-bulter-secret-service 

 

Supplementary 1:

I decided to write this essay ahead of any investigation results because it appears that will be a very slow process. I will read those reports as they become available.

Supplementary 2:  This article became available after I completed the above post.  It is based on testimony by the FBI Director Christopher Wray.  He states the AR-15 used by the shooter had a collapsible stock and therefore was easier to conceal.  He also said the shooter flew a drone for 11 minutes over the site about 2 hours before the event.  And in terms of the motivation:   

"Wray said investigators haven’t found a manifesto or obvious motive for the shooting. He said pictures were saved in the cache of Crooks' electronics from news searches, rather than necessarily because of a specific search for a public official."

https://www.yahoo.com/news/fbi-director-wray-set-house-143641332.html

Supplementary 3:  Additional fragments of information today in the news. There were 8 expended cartridges next to the shooter's body.  No word on the location of the other 42 rounds or whether there was a high capacity magazine.  Some data from the shooters laptop showed that he did a Google search on the JFK assassination searching on both Kennedy and Lee Harvey Oswald. 

Graphics Credit:

Click on graphic to get full information and CC license on Wikimedia Commons.

 

 

 

 

The Irrational American Voter – Arrogance, Ignorance, or Both?

 

 “Critics are men who watch a battle from a high place then come down and shoot the survivors."  -  Ernest Hemingway

Let me preface this essay by saying that I am an expert in assessing cognition and cognitive disorders  based on my 35 years as a psychiatrist doing that specific job in acute care settings, outpatient clinics, nursing homes and other healthcare centers, guardianship and conservatorship proceedings, and contested hearings about decisional capacity.  For 15 years I ran a Geriatric Psychiatry and Memory Disorders Clinic.  I have made positive diagnoses of the various forms of dementia, detected and treated reversible forms of cognitive impairment, and corrected misdiagnoses of dementia. So, I was more than slightly taken back by all the armchair diagnosing of President Biden during the debate last Thursday. The press got (at least) – 3 days of sensational and speculative headlines. I just saw a poll today that showed an increase in the number of Americans who think “President Biden has a cognitive problem” from 35% prior to the debate to 70% after the debate.  As an expert – with no special knowledge of the President’s health status I can tell you why there is no sufficient information to make that determination.  I also have doubts about what “cognitive problem” means to the average American based on the hundreds of family conferences I have had to explain that concept.  

Just based on the debate, the President’s responses and overall presentation were suboptimal - but there are many untouched explanations.  I would describe the resulting press as excessive and discriminatory against Biden. Here are a few possible explanations:

My first thought was he was over preprepared and probably angry about having to confront a liar and a propagandist.  Let’s face it – this is the first time any Presidential debater has been forced to do this.  Trump is the first convicted felon and repetitive liar in any presidential debate.  He is good at it.  Recall how Trump made his fellow Republican primary candidates look in those debates.  Many of them were speechless and ineffective.  Trump’s propaganda style clearly makes it difficult for the media to criticize him.  He effectively neutralized the moderators who were unable to get him to answer questions.  Some in the press described him as a “ball of energy” rather than a “ball of lies”. They know that no matter what they say – Trump is repetitive and successful in wearing them down.  The best example is “The Big Lie” about how the election was stolen but there are more. He maintains lies in the face of solid evidence and even the press does not know how to handle it. They eventually acquiesce and start to treat the propaganda as fact.  During the debate he was able to not provide responses to questions while repeating his own brand of propaganda.  

Second, the cognitive task was much more demanding for Biden.  In the news leading up to the debate there was clear messaging from both camps on how they were being prepared. Trumps preparation was clearly casual and not information intensive. That was reflected exactly in his ease with repeating his overlearned propaganda, dodging solid answers to questions, and ad hominem attacks on Biden.  The Biden camp reported an intensive schedule of fact-based mock debates and attempting to answer moderators’ questions based on much more factual content.  Clearly the Trump strategy presented a markedly lower cognitive load and practically no information content to memorize.

Third, a single debate is not a marker of much – recall Barack Obama’s problematic debate from 2012 when CNN stated that Mitt Romney “trounced” Barack Obama in a debate. That is one reason Obama came out two days ago with the statement that “bad debates happen”.

Fourth, choking in a presentation even substantially should be a common experience. Public speaking is an almost universal fear. It happened to me in a memorable incident where I found myself suddenly blank and thinking about driving across Montana – as I was presenting in a pharmacology seminar in medical school.  I was about 26 years old at the time. My professor snapped me out of it by reminding me where I was and what we were doing. I was intensely prepared and sleep deprived at the time. Since then, I have found that the ability to focus and pay attention to what is happening in a presentation is inversely related to preparation intensity.  In other words – if I overprepare, I am likely to get bored with the content and will find my mind wandering in the presentation even to the point that I do not want to be there. Now, once I have the content mastered – I stop studying it and my plan is to just free associate to the bullet points.  President Biden had no bullet points.

Fifth, the reaction of the pundits has bordered on mass hysteria. Their conclusions that Biden is acutely impaired and too “feeble” has very little basis in fact. Several people including some pundits have described talking to Biden and noticing that in his face-to-face conversations there is no doubt that he is capable and mentally competent.  The fact that he seemed like his old self immediately after the debate in a Waffle House and the next day in a rally also defies the common explanation of what happened in the debate – that he is somehow irreparably impaired. I also had some interesting reactions to this when I was contacted and asked about “what they gave Biden after the debate that brought him back to normal.”  To my knowledge there is nothing.  Memantine was suggested to me, but as a physician who has prescribed this medication for cognitive problems the results are far from impressive. The real question is whether he took anything for cold symptoms before the debate.  Typical medications used have clear cognitive side effects. 

Sixth, time of day – the debate started at 9 PM and went to 10:30 PM Eastern time.  Circadian rhythms are important.  Drawing on my own experience I would never schedule a presentation or a lecture in the morning.  I am not a morning person and that is probably the main reason I did not elect to go into a surgical specialty.  I could not imagine trying to concentrate intensely in the early morning hours. The later in the day the better. I don’t know Biden’s typical schedule but speculate it is loaded in the mornings rather than evenings.

Seventh, Biden’s longstanding articulation disorder.  He has never tried to cover it up. It is a life long problem with no cure, but he has discovered some management strategies. It is probably worsened by stress and changes in voice quality from a recent cold.

Eighth, the pervasive ageism bias has never been more real.  The next day Biden observed that he doesn’t walk, talk, or debate like he did when he was a young man but he is still competent to do the job. His record of accomplishments in the face of an obstructionist party and their Supreme Court - backs him up.

If anything, the debate has taken the focus off Trump’s severe deficiencies.  There were several attempts to fact check the candidates and it was clear Trump had 3 to 4 times as many inaccurate statements.  Some were obvious like the stolen election and infanticide propaganda.  Like all propagandists – repetition seems to work on an unknowing or willfully ignorant public. Apparently, Mussolini was such a skillful propagandist that some of what he said is still believed as accurate today.  In this case the focus on Biden has basically given Trump and the MAGA GOP a free pass and they have been emboldened to the point of suggesting the 25^th Amendment be invoked against Biden based on a 90-minute television broadcast.

Rather than provide another point-by-point contrast between the candidates like I have done in the past there is a simple thought experiment that involves common sense thinking that can be applied. It is not based on wishful thinking or speculation.  It involves looking at the Presidency like a job application. Anyone who has ever applied for a job knows that you need to get recommendations from previous employers, supervisors, and in some cases co-workers.  The Presidency is interesting from this perspective because – all the coworkers are hand selected by the President himself.   Of the 15 cabinet level positions in the Trump administration only 6 people endorse him for re-election.  Eleven do not.  That number does not add up to 15 because of the turnover in the Trump administration and there are probably more people that I missed.  In addition, the most recent same party President George W. Bush and 2 of his 3 Chiefs of Staff, and a National Security Advisor do not endorse Trump in some cases criticizing him with the harshest possible language.  I am not aware of a single Biden staffer who has not endorsed him and President Obama came out with a statement of his support after the debate.

Although a direct comparison of Trump versus Biden is not possible on Cabinet level endorsements because of the lack of a survey of the Biden cabinet – the Trump results are striking based on the level of vehement criticism and what they say about the former President’s intelligence, inquisitiveness, and character.  A direct comparison across multiple dimensions is possible in the survey that President Biden described during the debate.  Presidential scholars rank Presidents across a number of dimensions and in that process, Biden ranks number 14 and Trump is dead last at number 45. Refer to the link for the specifics and outside validation.  The survey has received no coverage post debate relative to President Biden’s performance – even though it is an acknowledgement of his administrations’ accomplishments and a stark contrast to Trump’s rhetoric about how Biden has “destroyed” the country (he used the word destroy 22 times) and he is the “worst” President – (he used the word worst 22 times).  That contrast alone reveals Trump’s strategy.

That is my analysis of the debate from the perspective of a physician who has done thousands of cognitive and decisional capacity examinations.  To be clear, I have no way of knowing whether my suggestions are accurate.  I have not examined either candidate or their medical records. But I know that it takes a lot more to determine a person’s cognitive capacity than what we saw in that debate. The most straightforward solution would be to have each candidate take a standard assessment of their cognitive status and release the results to the public – but politics rarely takes a rational approach.  In the meantime, it is best to avoid the assessments of partisan politicians and party members, comedians, and gossip show pundits.  

This is not a laughing or pitiable matter.

 

George Dawson, MD, DFAPA

 

References:

1:  Nicholas P, Liebowitz M.  Dozens served in Trump’s Cabinet. Four say he should be re-elected.  NBC News July 30, 2023 https://www.nbcnews.com/politics/donald-trump/trump-cabinet-endorsements-rcna96648

2:  Joint Statement from Elections Infrastructure Government Coordinating Council & the Election Infrastructure Sector Coordinating Executive Committees.  November 12, 2020.  Accessed July 1, 2024  https://www.cisa.gov/news-events/news/joint-statement-elections-infrastructure-government-coordinating-council-election

This was known within days of the 2020 election. It is still not accepted by former President Trump and MAGA Republicans:

“The November 3rd election was the most secure in American history. Right now, across the country, election officials are reviewing and double checking the entire election process prior to finalizing the result.

“When states have close elections, many will recount ballots. All of the states with close results in the 2020 presidential race have paper records of each vote, allowing the ability to go back and count each ballot if necessary. This is an added benefit for security and resilience. This process allows for the identification and correction of any mistakes or errors. There is no evidence that any voting system deleted or lost votes, changed votes, or was in any way compromised."

3:  Presidential Greatness Project - see rankings at this site.  Biden #14  Trump #45   

No mention of this comment by Biden or the survey by any of the press.

Graphics Credit:  

Wikimedia Commons - click on photo for full credits and Creative Commons License

Disclaimer: 

As previously noted I am not now and have never been a member of any political party in the United States.  At the same time, it is clear to me that the Republican party, their Presidential candidate Donald Trump, and their partisan Supreme Court are an unprecedented danger to the United States that I have known all of my life and that they should be defeated. It is also clear that they have a level of organization that resulted in political advantages over the opposition and that their rhetorical strategy is to blame the opposition for what they in fact are doing.   

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.