JAMA Summit on Reducing Firearm Violence

 

One of my frequent topics on this blog is firearm violence, the likely causes, and ways to prevent it.    When I saw this topic in my most recent edition of the Journal of the American Medical Association (JAMA) – I could not wait to read it.  Now that I have - it is a different story.  

The paper begins by posting some astonishing numbers of gun violence in the United States.  Since the year 2000, there have been 800,000 firearm deaths and 2 million firearm injuries in the US.  Firearms are the leading cause of death in children in the United States.  There were no references to school or mass shootings even though the United States is the only high-income country with this problem.  No other country comes close.

There is a description of the group who produced this paper.  We learn that it consisted of a multidisciplinary group of 60 thought leaders and they were charged with producing an innovation roadmap to decrease firearms harms by 2040. Their recommendations are summarized in this 12-page document and I do not think it will prove very useful. 

The best part of the document is the table Evidence Base for Interventions That Demonstrate Significant Reductions in Firearm Violence.  For 20 years, the Dickey Amendment restricted research on firearm violence and the prevention of firearm violence largely done by the CDC and NIH.  Starting in 2020 funding for research on firearm violence was resumed at both agencies.  This July, the Trump administration cut $158M in gun violence prevention grants (69 of 145 community violence intervention (CVI) grants.   In October, the Trump administration fired key personnel in the CDC violence prevention program that collected data and produced dashboards based on that data.   They also closed the White House Office of Gun Violence Prevention that had been initiated under the Biden administration.  Despite that active suppression of gun violence research except for the last few years – several effective interventions have been discovered and they are included in the table.  They cut across areas involving licensing, violence prevention programs, disarming potentially violent offenders, changing the violence ecosystem, improving the socioeconomic environment, decreasing the availability of alcohol, and an increased police presence and more efficient and targeted policing.

When I think about the people who told me they were saved by their inability to purchase firearms it generally came down to legal waiting periods and federal firearms checks.  They were people considering firearm violence directed at themselves or another person and the only reason it did not happen was that they were prohibited from purchasing a gun at that instant.  In retrospect they were universally thankful that they could not get the gun and when the impulse passed, they did not purchase one later.  This document does not specially mention either of those interventions.

Despite the table, the document focused on a lot of speculative interventions looking at reducing community violence, improving the socioeconomic status, and changing the ecology of neighborhoods where these kinds of crimes occur.  I have no doubt these strategies will be useful to some degree but cannot help but see that most people in these communities are law abiding and are an unlikely source of gun violence.  That does not mean they are immune to the effects of gun violence because just having a gun in the house increases the chances of gun violence death by suicide or accident.

Treating guns as a commercial product is a suggested strategy.  The argument suggests that manufacturers and sellers assume product liability.  When that happens liability suits or the threat of these suits will change gun manufacturers to make safer products.  They provide examples of successful lawsuits.  We should all take a lesson from mental health care in considering a strategy that depends on civil liability.  The Mental Health Parity and Addiction Equity Act (MHPAEA) of 2008 was supposed to lead to equal treatment of mental illnesses.  It treats insurance coverage as a commercial product.  It has led to lawsuits that (while successful) have had absolutely no impact on the insurance industry.  Their attitude is “if you think you are being treated unfairly – you will have to sue us and win.”   Their basic rationing practices remain unchanged.

There are frequent mentions of technology and artificial intelligence (AI) in the report.  Smart guns that can only be fired by the owner have been talked about for quite some time – but there are not a lot of products. Analyzing data by AI, even if it appropriately designed to incorporate racial diversity and equity does not seem to be a major innovation. The current data being collected lacks the granularity (see below) to properly study the decision making involved.

The authors make the argument that people seem to ignore the fact that violent crime is significantly decreased over the past decades.  They do not describe how this happens but suggest that countering this fallacy is important. It is a difficult fallacy to counter when a major political party uses this narrative daily to rationalize laws that promote gun extremism and gun permissiveness.  Politics is not mentioned at all in the document even though one political party would find it difficult to function without repeated references to gun access and promoting gun extremism.

What is missing?  Just about everything I have written about on this blog.  First, guns are a problem and there is no way around it.  I was concerned to see the following sentence in this paper:

“Firearms are not a cause of violence but, because of their high lethality and ability to injure large numbers of people, result in serious harm when combined with violent acts.”

It contrasts with:

“Primordial prevention addresses the most upstream, root-level causes of adverse outcomes—well before they take shape—by changing the structures and systems that give rise to them. This means transforming the fundamental social, environmental, and economic contexts that foster violence. This upstream approach is relevant to all types of firearm harms and applies across urban and rural settings. The current moment demands bold, systems-level interventions that prioritize housing stability, economic opportunity, environmental improvement, and equitable policies.”

In biological systems theory, a firearm is not conceptualized in isolation as an inert object.  Firing a gun is seen as an emergent property of the interaction of multiple subsystems in the individual, the task, the implement used, and the environment.  There are many examples.  You are not brushing your teeth without a toothbrush or walking with a cane without the cane.  The firearm is an integrated component of that system.  To prevent adverse outcomes from that system, all the components including the gun need to be addressed.  It is guns and people that account for the outcome not either in isolation.

Second, there is not a single mention of culture as a significant factor. There is discussion of changing narratives and all the various groups involved but not a single mention of the cultural aspects of gun violence. More specifically there is no mention of how the US has gone from a culture of firearms for hunting and target shooting in the mid-20^th century to the current culture of carrying firearms with minimal regulation like what existed in the mid-19^th century.  That was before towns in the Old West passed ordinances about not carrying firearms in town.  There is clear current evidence that lax firearm regulation correlates with firearm casualties and deaths.

Third, there is a clear gun extremism culture that I have elucidated in this past post.  The elements are clear and this level of gun extremism correlates with increases in mass shootings and school shootings.  Gun extremists typically take and expansionist view of the Second Amendment while ignoring the preamble.  Many are also strict constructionists who ignore gun restrictions that were in place when it was written. 

Politics is a clear factor in gun extremism since it is promoted by the politicians, judges, and operatives of one political party.  It is really a combination of gun extremism and inaction. After every mass or school shooting – nothing ever gets done.  School shooters are a subset of the gun extremist culture and a clear example of how cultural effects can spread to other people.  At the broader political level gun extremism is heritable and passed on from generation to generation.

Fourth, the neuroscience of human decision making and development is ignored, especially the emotional component.  It has been known for some time that human decision making is more than a purely rational process and that an emotional component is essential (5-8).  Since then, the neurobiological substrate has been partially elucidated but research continues to find new components (9).  The basic observation seen on any true crime TV show – the relationship of anger and gun availability to gun violence has not been adequately investigated.  The epidemiological methods use to examine gun violence gather adequate contextual details for accidental injury and death but not homicide (10).  One of the gun extremist myths is that gun owners and carriers have superior ability to control themselves and avoid making mistakes. There is no reason to expect that is true.  Just having more people carrying lethal weapons in public will increase the chances of a violent confrontation.      

Fifth, the authors recommend strategies to decrease alcohol consumption and there is some evidence that younger generations are consuming less alcohol.  At the same time, we have increased cultural permissiveness for other intoxicants that are as likely to be associated (directly or indirectly) with aggression and violence – specifically stimulants, cannabis and cannabis derivatives, synthetic cannabinoids, and opioids.

Sixth, homicide prevention needs to have a similar path toward resolution that suicide prevention currently has.   To put things into perspective, many people with either problem end up on psychiatric units in hospitals.  Most of them are there because of stated suicidal ideation or making a suicide attempt.  The violent people are typically there because of police calls where they had to contain an aggressive person who has a mental illness.  There are no hot lines comparable to suicide hot lines.  There are no homicide prevention programs for the acutely homicidal person. As far as I know there has been no research in this area.  Aggressive and homicidal behavior needs to be identified as a clinical and public health problem that needs to be addressed in a timely manner. 

These are some obvious unaddressed factors in this report.  It is probably easier to consider general solutions than more specific cultural and political ones.  But we can no longer pretend that maintaining and ignoring these cultural factors will lead to any effective changes.  It also requires adequate expertise in data collection, sociocultural changes, and in clinical settings. More discussion in this area will result in people who are more comfortable talking about the problem.   This is a complex problem but it does have solutions.  Considering the biological and sociocultural factors described – it should be apparent that the sociocultural factors are primary. The current administration is doing nothing to address childhood adversity.  The logical place for intervention is changing the sociocultural environment with legal and public health interventions.  It will take more than what is  suggested in this review.   

George Dawson, MD, DFAPA

 

References:

1:  Rivara FP, Richmond TS, Hargarten S, Branas CC, Rowhani-Rahbar A, Webster D, Richardson J Jr, Ayanian JZ, Boggan D, Braga AA, Buggs SAL, Cerdá M, Chen F, Chitkara A, Christakis DA, Crifasi C, Dawson L, deRoon-Cassini TA, Dicker R, Erete S, Galea S, Hemenway D, La Vigne N, Levine AS, Ludwig J, Maani N, McCarthy RL, Patton DU, Quick JD, Ranney ML, Rimanyi E, Ross JS, Sakran JV, Sampson RJ, Song Z, Tucker J, Ulrich MR, Vargas L, Wilcox RB Jr, Wilson N, Zimmerman MA; JAMA Summit on Reducing Firearm Violence and Harms. Toward a Safer World by 2040: The JAMA Summit Report on Reducing Firearm Violence and Harms. JAMA. 2025 Nov 3. doi: 10.1001/jama.2025.18076. Epub ahead of print. PMID: 41182880.

2:  Rostron A. The Dickey Amendment on Federal Funding for Research on Gun Violence: A Legal Dissection. Am J Public Health. 2018 Jul;108(7):865-867. doi: 10.2105/AJPH.2018.304450.

3:  Lin JC, Chang C, McCarthy MS, Baker-Butler A, Tong G, Ranney ML. Trends in Firearm Injury Prevention Research Funding, Clinical Trials, and Publications in the US, 1985-2022. JAMA Surg. 2024;159(4):461–463. doi:10.1001/jamasurg.2023.7461

4:  Zaller N, Brown J, Fischer K, Abaya R, Cardoso LF, Dreier FL. The Critical Role Of Federal Funding In Combating Firearm Violence. Health Affairs Forefront. 2025.  Accessed on November 8, 2025) https://www.healthaffairs.org/content/forefront/critical-role-federal-funding-combating-firearm-violence-public-health-perspective

5:  Bechara A, Damasio H, Damasio AR. Emotion, decision making and the orbitofrontal cortex. Cereb Cortex. 2000 Mar;10(3):295-307. doi: 10.1093/cercor/10.3.295. PMID: 10731224.

6:  Bechara A. The role of emotion in decision-making: evidence from neurological patients with orbitofrontal damage. Brain Cogn. 2004 Jun;55(1):30-40. doi: 10.1016/j.bandc.2003.04.001. PMID: 15134841.

7:  Sanchez EO, Bangasser DA. The effects of early life stress on impulsivity. Neurosci Biobehav Rev. 2022 Jun;137:104638. doi: 10.1016/j.neubiorev.2022.104638. Epub 2022 Mar 24. PMID: 35341796; PMCID: PMC9119952.

8:  Potegal M, Stemmler G. Constructing a neurology of anger. In International handbook of anger: Constituent and concomitant biological, psychological, and social processes 2009 Dec 21 (pp. 39-59). New York, NY: Springer New York.

9: Jung J, You IJ, Shin S. Thalamo-hippocampal pathway determines aggression and self-harm. Sci Adv. 2025 Nov 7;11(45):eady5540. doi: 10.1126/sciadv.ady5540. Epub 2025 Nov 5. PMID: 41191756; PMCID: PMC12588284.

10:  Forsberg K. Surveillance for Violent Deaths—National Violent Death Reporting System, 50 States, the District of Columbia, and Puerto Rico, 2022. MMWR. Surveillance Summaries. 2025;74. https://www.cdc.gov/mmwr/volumes/74/ss/pdfs/ss7405a1-H.pdf

Graphic:  The graphic above is a line drawing of my MRI.  I intend to place it in a larger drawing of all the relevant factors to consider when it comes to gun violence. That is a work in progress and it is an extremely complex drawing.  When I complete it – I will replace the graphic at the top of this post.

Social Media Discovers Managed Care and Rages - Or Not?

I watched TMZ last night and they were fascinated about the homicide of Brian Thompson the CEO of United Healthcare in New York City the night before.  The hosts could not approach that topic directly so they brought on Taylor Lorenz who they described as a social media expert.  She made some posts about healthcare companies.  She claims that the “entire internet left and right” was united in celebrating the death of this CEO because “Somebody stood up to this barbaric, evil, cruel violent system.”  Her rational is that if you see a loved one die because an insurance company denied care it is natural to want to see that person dead and this is not advocating homicide. It is a justice fantasy.  She went on to say that United Healthcare has murdered tens of thousands of Americans by denying healthcare.  She sees this as a revolution and it is a problem that should be addressed without violence.  She suggests letter writing and possibly politicians and journalists getting a clue and seeking to correct this imbalance. 

I have been aware of United Healthcare for at least 30 years.  They are renowned in Minnesota for their initial emphasis on not funding psychiatric care and moving on from there.  Physicians like me have been railing against United Healthcare and other managed care companies for decades.  And nobody - and I mean nobody cares. No politicians, nobody in the media, and nobody in physician professional organizations.  There has been an occasional activist state Attorney General suing these companies into a temporary correction that they can easily wait out.   The American Medical Association just recently came out against prior authorization one of the main forms of managed care denial – just a few years ago.  It has been in place along with utilization review – the other main form of denial for at least 40 years.

These business practices have transformed the practice of medicine into a high productivity and low-quality enterprise where medical judgment is replaced by the judgment of middle managers with no medical training and company profit in mind. Physicians have been displaced in their roles in managing the treatment environment and now it is staffed by business people concerned only about the bottom line. If a company decides it is not going to cover a medication or a procedure or a hospitalization – the general message to the patient is “you are out of luck.”  I worked at the same hospital for 22 years and during that time we went from providing care to anyone who walked in the door to care based on businesses telling us what to do.  At one point to make things less contentious (and after we were bought out by a managed care company) – the external review was replaced by the same kind of decisions made by internal staff.  Some physicians became "managed care friendly" in order to move up the corporate ladder.

How did these organizations get so much power over healthcare?  A lot of it depended on lying to gullible politicians.  The original sales job was that physicians were just too expensive.  They order too many tests.  They were going to close down or buy out the expensive specialists and greatly expand primary care.  That primary care expansion would lead to more prevention and reduce the overall costs of medicine. But once these organizations were granted all the power they wanted, they began acquiring specialists and providing their own specialty care.  They also greatly expanded middle management to micromanage staff and basically tell them to work harder.  The result is a system that is much more expensive rather than more cost effective.  Shareholder profits and CEO salaries require a lot of denied care to fund.  This article about the company is an indication of the amount of money that we are discussing. We are talking about executives that are making tens of millions of dollars in an organization that rations health care.

Of course, people are angry about the situation of rationed health care. But it is more about how things are organized and all the associated politics. I think we can all agree that there do not seem to be many bright politicians out there and that low bar took an even more precipitous drop in the last election. Even managed care companies know more than to ration vaccines or give everyone hydroxychloroquine for COVID.

 Politicians have invented this system at every step of the way and made it impossible for the average citizen to get any satisfaction when their health care is denied. Federal and state governments both side with healthcare companies to support the denial of care and (incredibly) indemnify them from liability when their denials result in bad outcomes.  Death is just one of many bad outcomes. 

The press does not get it. I am tired of writing about it for physicians.  The only bright idea that group seems to have come up with is not contracting with these companies and either charging cash or asking the patient to seek their own insurance reimbursement after paying their bill. This obviously has limited application and doesn't work if the patient needs more resources like operating rooms or rehab facilities.  So - Ms. Lorenz’s solution of writing letters certainly will not work.

Some news services seemed to connect a policy reversal by Anthem Blue Cross/Blue Shield (ABCBS) to the homicide. Some of the original stories claimed that anesthesia time per procedure would be limited and the patient might need to pay the balance. Subsequent stories state that the insurance company planned to pay the time allotment indicated in the estimated relative value units (RVUs) for the surgery.  They claim their reversal was based on misinformation. RVUs are another form of rationing – paying only a set amount irrespective of the complexity of the case.  It is another way that psychiatric services were also rationed by reduced reimbursement.  In some cases, it leads clinics to stop seeing all the patients from a particular insurer based on low reimbursement to the physicians and providers.  Lorenz posted a caption of the ABBCBS story with the additional line:  ‘And people wonder why we want these execs dead.'     

This is the state of medicine in the US today. We have just had an election that puts the most rational parts of the fragmented healthcare system (the ACA or Obamacare, Medicare, and Medicaid) at risk.  The party in power espouses gun extremism and uses political tactics that direct violence and aggression toward specific individuals or groups. The party in power favors the top wage earners rather than production or knowledge workers. That includes large healthcare conglomerates that all function by rationing care and access to medications and procedures. And in that context, we have a social media expert claiming that we now have bipartisan rage against these health care companies who have murdered tens of thousands of people by denying their care.  I certainly know many people who have been harmed by the denial of care.  In some cases, I spent hours advocating for them and trying to get the care they needed but I was simply ignored.   

At this point, the crime is being analyzed like it is just another true crime TV show. Endless analysis about the perpetrator’s behavior and possible motivations.  It is all highly speculative but made as controversial as possible.  All the analyses I have seen so far seem way off the mark – but I am not going to add mine at this point.  I am more than a little suspect about all the social media rage. Is it real or just generated by a few provocative trolls?  Will it lead to a typical Congressional show hearing where members manufacture outrage and nothing changes. One thing is for sure – the current state of events is not a good sign.  It is a sign of just how corrupt, ignorant, and not self-correcting the American political system is - and just how much those politicians collude with businesses.

In the end, Americans end up paying top dollar for a healthcare system that may refuse to treat them, an airline system that may refuse to fly them, a financial system with excessive charges and minimal interest payments on savings, and a system for workers that disproportionately pays the people who do not do any of the brain or physical work.  Is it any wonder that 4 people in the US possess more wealth than 50% and that 50% are essentially left hoping for changes that never come.

 

George Dawson, MD, DFAPA

References:

Jeremy Olsen.  Shooting of UnitedHealthcare CEO revives criticism of company’s medical claim denials.  Some mourn the shooting of chief executive but still have scorn for the insurance company he ran.  StarTribune.  December 5, 2024.  https://www.startribune.com/why-unitedhealthcare-is-a-four-letter-word-to-critics/601191492

 

Addendum:

As any reader of this blog can attest – I do not consider homicide as a solution to any problem.  The two main features of homicide that I consistently observe on this blog is homicide as a primitive value and a primitive solution.  It has no place in civil society.  In the anthropological literature homicide as a solution dates to prehistoric times when minor conflicts escalated from individuals to entire villages.  Modern man has not uniformly progressed very far as evidenced by every active war in the world right now and ever.  The shooting of Brian Thompson is no exception. Given everything, I have listed in the above post – it changes nothing.  It was a cowardly, immoral act, and unlawful act. I hope that the perpetrator is caught and punished.  I hope that the privacy of Brian Thompson’s family is respected.  

Lessons In Political Violence

 

I got tired of waiting for the American free press to provide an analysis of political violence in the country.  It is a huge omission in day-to-day discussions of the coarsening of American politics.  I was prompted to think about it as I was out driving around today listening to stories of election officials being threatened and manipulated as the federal election approaches, some to the point that they will no longer do the work that they have been doing for years. In a long-standing democracy why is this not front-page news?  Where is the analysis of the problem?  Who has an interest in suppressing the vote and why are they continuing to do this?  At the same time, I heard about a poll today saying that most Americans will not trust the election results – even though they are the most secure at any time in history and there is no evidence of suspicious activity.

Elections are not the only places where political violence is acted out in the US.  Abortion clinics – even during the days of Roe were places where women were harassed and doctors were shot and killed. Schools, teachers, librarians, and school board members are targets for similar politics with threats, work exhaustion, and ultimately moral injury when they are shouted down and threatened for doing the work that they are trained and licensed to do.  Public health officials are attacked for providing the best possible public health advice just because some politicians don’t like it or need to cover their own incompetence.  Since when is it acceptable for politicians to be inciting this level of violence against competent citizens with high levels of competence – who are just doing their jobs?   

Before proceeding I will define what I mean about violence.  The same people who incite it frequently minimize it after the fact using the rhetorical sleight of hand: “It is free speech and I can say whatever I want to say.”  Without invoking the famous Supreme Court quote – let me provide a little detail about definitions.  First, violence or aggression does not require physical act.  Aggression has components that occur on a strictly verbal level and aggression toward property or inanimate objects as well as self (2).  If you have ever witnessed any of those forms of aggression, you know why it is important.  It has a direct impact on you that can be long-lasting. Threats alone can significantly affect your sense of physical and mental well-being. Many states have terroristic threat statutes that can result in legal action before any physical contact occurs (see Minnesota statute below). Threats alone are a signal that physical aggression may occur and in many states it can result in visits from the police, orders for protection, and in the case of mental illness – involuntary holds and civil commitment. Interestingly, the political violence I described typically results in the victims trying to protect themselves.

What does interpersonal violence look like?  On a verbal basis it can be angry shouting like we have seen many times in televised school board meetings.  That can include name calling, personal insults, and profanities.  As the verbal aggression increases the insults gets worse to the point of threatening physical violence. That is evident in routinely televised road and customer rage incidents.  Whether it culminates in physical violence or not is not the point. For years the police tended to ignore verbal aggression and operated on the basis that the only type of aggression that counts is physical aggression.  Over the past 20 years there has been a more enlightened approach since verbal aggression is harmful and predicts physical aggression.  That has been associated with domestic violence and terroristic threat statutes.  In the main areas I have discussed the violence has increased to the point that the Department of Justice is aware of it and successfully prosecutes cases (3,4,5).

Social media has become another source of aggression and interpersonal violence. The popular press documents an explosion of hate speech on X (formerly known as Twitter) while the new owner Elon Musk denies it and claims to have reinstated both right wing and left wing posters as a "centrist".  In the meantime academics debate the definition of hate speech (6) but were still able to find 91 papers written about it on Twitter alone.  Violence and hate speech are probably best analyzed on a case by case basis and in my estimation there is no better example than the last two chapters of Anthony Fauci's book On Call (7).  In it, Fauci clearly describes how providing the best possible public health advice to the White House angered President Trump and the non-experts he hired to manage the pandemic. Fauci was politically scapegoated, derided by other Republicans and MAGA, terrorized at work and home, and ultimately threatened with incarceration for providing historically outstanding public health service to the American people.  MAGA politicians are still threatening to incarcerate him even though he is retired.  I encounter people to this day who "hate" Dr. Fauci - not based on any semblance of reality but the gross misinformation provided to them by MAGA.  That entire sequence of events flowed from Trump's anger that the scientific facts (masking, herd immunity, immunization) did not fit with what he wanted to tell the public.  This is exactly how political violence occurs.  

From a political standpoint, this violence and aggression is often rationalized as “free speech” and it is not.  Violence is often rationalized as the absence of physical contact.  That really minimizes the impact of significant unprovoked threats that can include threats to bodily integrity.   The current elimination of gun laws makes some of these situations even more dangerous.  To cite one example, there was an armed protest in front of a director of public health’s home and in this case the police did nothing.  How would anyone feel about have a group armed with assault rifles outside of your home saying there will be no violence “for now” because you are doing your legal job.

What I find missing from most of these discussions is the overall cause.  I do not think there is any doubt that it originates with one party or more specifically movement and their aggressive rhetoric essentially because they have no useful policy. That is as obvious as the continued denials of the 2020 Presidential election results and the high percentages of people polled within that party (88%) that have doubts about the current election.  We have seen the effects of their propaganda, repeated lies, and political violence on these systems and it is completely unnecessary.  It also causes significant degradation of these systems when long time competent professionals leave because of the threats and harassment.  

Political violence in the US is quite literally the elephant in the room.  And it is time to start talking about it that way. Where is the press with this analysis?

 George Dawson, MD, DFAPA

Supplementary 1:

I decided to include the current Minnesota terroristic threat statute as an example. Note that physical violence is not necessary.  I am no attorney but carrying assault rifle and saying that you are not going to commit violence "yet" would seem to be an indirect threat of violence.  

Supplementary 2:  My wife and I voted at City Hall today.  It was technically an "in-person absentee" ballot.  The process was identical to the one 4 years ago.  We provided several levels of ID including - Driver's License number, address, phone numbers, email address, and Social Security Number. The election official was separated from us in a separate room and all discussion occurred through a heavy glass window with a portal.  We presented an identification form.  When that information was confirmed the election official printed a label with verification that was affixed to the top of our ballots. We were advised to complete the ballot - seal it inside 2 envelopes using tape provided at the voting stations and then return it to her.  When we returned the ballot she personally signed each ballot with her name and address.  There was no public access to a ballot box or voting machine and the entire process was airtight.  I did notice that Robert F. Kennedy, Jr. is still on the Minnesota ballot along with several other third party candidates.

Supplementary 3:  Former President Trump's ad in 1989 directed at the Central Park 5 is another good example of political rhetoric obscuring the facts.   In this ad he discusses hating the suspects and wanting them executed.  They were subsequently exonerated based on DNA evidence and won a $41 M lawsuit against the city of New York for malicious prosecution.  

https://www.documentcloud.org/documents/6131533-trumpdeathpenaltyad05011989

Supplementary 4:  Updated graphic to include a number of false attacks on the Biden Harris administration and their handling of hurricane emergencies.   Many were ultimately refuted by Republicans including Republican Governors.  First responders and aid workers were described as demoralized.  This occurs two weeks after Elon Musk commented that  "no one is even trying to assassinate Biden/Kamala"  Musk subsequently said he was joking and removed the comment from Twitter but said he would not retract it.  The White House condemned it for condoning political violence.  In an age where you can not joke about bombs or terrorists on airplanes "jokes" about assassination should obviously be out of bounds.  I have seen people interrogated by the Secret Service for similar comments.   

  

Addendum:  There are so many of these incidents of violence out there I decided not to try to reference them all.  They can easily be found by Google searching the main heading like "election worker violence" and secondary elements.  You will get a lot of references and very little attribution to the political cause other than "divisiveness".   That word in itself should be telling because it is one of the main strategies of one party. 

References:

1:  Meghna Chakrabarti.  On Point.  "Elections officials endure protests, death threats. Here are their stories."  https://www.npr.org/podcasts/510053/on-point

This is the radio program I heard this afternoon.

2:  Yudofsky SC, Silver JM, Jackson W, Endicott J, Williams D. The Overt Aggression Scale for the objective rating of verbal and physical aggression. Am J Psychiatry. 1986 Jan;143(1):35-9

3:  USDOJ Election Threats Task Force:  https://www.justice.gov/voting/election-threats

4:  USDOJ.  Justice Department Addresses Violent Threats Against School Officials and Teachers

https://www.justice.gov/opa/pr/justice-department-addresses-violent-threats-against-school-officials-and-teachers

5:  Fraser MR. Harassment of Health Officials: A Significant Threat to the Public's Health. Am J Public Health. 2022 May;112(5):728-730. doi: 10.2105/AJPH.2022.306797

6:  Mansur Z, Omar N, Tiun S. Twitter hate speech detection: A systematic review of methods, taxonomy analysis, challenges, and opportunities. IEEE Access. 2023 Jan 25;11:16226-49.

7:  Fauci A.  On Call: A Doctor's Journey in Public Service.  New York, New York: Viking, 2024: 374-455.

We Need A Model Terroristic Threat Statute

 

Over the past ten years of writing this blog, I hope that I have been clear about a few things. First, violence and aggression are complicated problems. Most of the political arguments out there today focus on peripheral issues like gun violence. In a country of gun extremists – there will always be excuses for why there is so much gun violence.  A common one is that there are mentally ill people with guns.  Some of the gun extremists have gone so far recently to suggest this is due to a crisis of untreated mental illness. Nothing is further from the truth.

Second, people with mental illness can be violent and aggressive. In political arguments where violence and aggression is being attributed to mental illness it is common to deny it. In a Community Psychiatry seminar 40 years ago – my position was “people with mental illness are no more violent than anyone else.”  My 40 years in the field has taught me that looking at violence across large groups is meaningless. In the acute care setting where I worked many if not most of the patients I treated were there for violence against others or self-directed violence.  Some were aggressive toward me and the staff I worked with – with some threats that persisted well after any hospitalization.

Third, violence and aggression can clearly be treated in many if not most cases, especially if it is a manifestation of acute psychiatric illness. Despite that being common knowledge in acute care settings – there is no effort to characterize it as a public health problem like suicide. There are no public service announcements about what to do if you have violent or aggressive thoughts. No hopeful messages that you do not have to act on any of those thoughts and that you can get help to restore your baseline thought patterns.

Fourth, violence and aggression are stigmatized in society. Most people at some point in their lives have been bullied or traumatized by other forms of aggression. In the US, incidents of extreme violence and aggression are commonplace in the daily news. There is a fascination with true crime television and documentaries about serial killers. The media seems preoccupied with discovering a “motive” for these crimes.  Apart from the usual sociopathic motives of intimidating and injuring people to get what one wants – motives are generally lacking. In fact, I would go so far to say that in the homicide cases broadcast on television the limiting factor was the availability of a firearm. In other words – no homicide would have occurred if a firearm was not present. The resulting stigma toward aggression, leads to biases toward patients with psychiatric illnesses who are violent because of those illnesses.

Fifth, there is a limited rational response to violence and aggression even if a public health response is ruled out. This occurs daily. There has been no clinic or hospital where I have worked where I have observed a well thought out plan to respond to these incidents even though aggression toward health care workers is a current epidemic. There are plenty of errors along the way whenever an incident occurs in the community. I have had patients who were in the cross hairs of a police sniper until somebody noticed they were pointing a toy gun at the police. Anyone in my field has had people who assaulted them, threatened them and their families, and in some cases that aggression has resulted in serious injury or death. The rate of intentional injury by another person is five times greater in the healthcare industry than all other industries and that rate is ten times greater in the psychiatric and substance use fields. With a healthcare system run by administrators rather than physicians – it is not clear why there are no functional approaches at the institutional level. In the case of the community and the hospital the usual approach is to send the person to the emergency department to see what they can do and if necessary, hospitalize them on a psychiatric unit.  By that time, it is common to see people who have been escalating for days or weeks and the necessary interventions are riskier than they would have been at an earlier point.

In thinking about a more functional response there are two problems – epidemiology and existing laws.  From an epidemiological standpoint there are many studies documenting specific forms of violence and how that individual may have been victimized in the past.  A joint Department of Justice (DOJ) and Centers for Disease Control (CDC) report from 2000 estimated that physical assault and stalking affected roughly 2.9 million women and 3.5 million men every year.  Intimate partner violence affected 1.3 million women and 835,000 men. Getting to the earliest point in that cycle of violence from an epidemiological standpoint seems to be missing.  At least I cannot locate any data.

From a legal standpoint, intervening before there is any physical danger is a highly problematic threshold. And if the necessary statutes exist, there is wide latitude in their interpretation by law enforcement and the judicial system. There has been some progress over the past 40 years but not much.  For example, in the past if a person was threatened – it was common for law enforcement to say they could not do anything because the threat has not been acted upon. That was clearly a suboptimal approach because threats involving lethal force often result in the precipitous application of lethal force. In many cases the lack of a firm limit on threatening behavior encouraged more of it. Contingency based systems also have the tendency to put the responsibility for action on people who have no relationship to the person making the threats.  Even though there has been substantial progress in domestic violence scenarios, it is common for the person being threatened to need to seek a court order for protection and convince a judge that threats or actual violence have occurred. In the case of threats by patients with known psychiatric illnesses, the Tarasoff decision has placed the treating professionals in the position of law enforcement with a duty to inform the person who is being threatened. A clear terroristic threat statute could address all of these issues and provide a path for early intervention.

Since most of my career was in the State of Minnesota, I will be referring to their statutes.  Preparing for this piece, I also read a paper from the University of Pennsylvania Law Review (2) highlighting some of the confusion in this area.  Minnesota, if a health care professional is threatened it is a good idea to inform the police about the threats and present them with any hard evidence (voice messages, emails, mailings, etc).  Laws enforcement who I have dealt with in these situations may refer to the threat as a “terroristic threat”. That is defined in Minnesota Statutes (3) as:

“Threaten violence; intent to terrorize. Whoever threatens, directly or indirectly, to commit any crime of violence with purpose to terrorize another or to cause evacuation of a building, place of assembly, vehicle or facility of public transportation or otherwise to cause serious public inconvenience, or in a reckless disregard of the risk of causing such terror or inconvenience may be sentenced to imprisonment for not more than five years or to payment of a fine of not more than $10,000, or both.”

I have highlighted the relevant section of the statute. Minnesota legislation appears to cover both the individual case as well as larger scale incidents that would typically be equated with terrorism.  This statute allows law enforcement to exercise some judgment in dealing with threatening individuals.  For example, they can go to that person and say that if they persist, they will be arrested and charged with making terroristic threats. No other action is required by the person being threatened. In many cases that is a definitive intervention and no further action is required.

The paper by Flanders, et al looks at various scenarios that have occurred in the context of the current COVID-19 pandemic.  Their basic argument is that much of the mayhem created during the pandemic would not reach the legal standard of terroristic threats and if charges were required – they could occur under other statutes such as disorderly conduct or harassment. They are using a standard suggested by the American Law Institute Model Penal Code that includes the following:

“A person is guilty of a terroristic threat if he threatens to commit any violent felony with the intent to cause evacuation of a building, place of assembly or facility of public transportation, or otherwise to cause serious public inconvenience, or in reckless disregard of the risk of causing such inconvenience.”  (2)

Note the difference with the Minnesota Statute – there is nothing about threatening with intent to terrorize another.  It is more about violent felonies that disrupt the public.  The authors in this case go on to specify the elements of terroristic threats in their “core case” model as consisting of a credible threat, use of a dangerous weapon, targeting the public or government, and the intention to create a panic or forced evacuation (p. 68).  They illustrate how this model statute has been modified and adapted in other states. I am not a legal scholar but to me – the model statute is missing one of the prime elements of terrorism – the intent to kill and injure people. The way it is written seems to make this implicit and secondary to disrupting the public. The public is disrupted because of their fear of being killed or injured. The Minnesota statute covers both cases by including the element of the individual being threatened.

Whether you are a health care professional or a member of the public, this is the level of protection from threats that is needed. Even then there is no guarantee that there will be a successful intervention by law enforcement. The person making the threats needs to be identified and the police need probable cause to intervene.  I have seen it work well even if no arrests or emergency holds are placed. Most importantly it creates clear boundaries between the police, the person being threatened, and the person who is threatening. The responsibility for action is no longer on the person being threatened.

There are also potential benefits in terms of earlier intervention in the case of psychiatric illnesses associated with threatening behavior.  There is a current awareness that crisis intervention services may be a better early option than the police and that may be a better early intervention.  The epidemiology of threats needs additional work.  My speculation is that there are tens of thousands of people who are trying to live every day with these kinds of threats.  They are a disenfranchised group whose needs have only partially been addressed by domestic violence and civil commitment laws.  A more functional terroristic threat statute like the one in Minnesota could result in early intervention and providing significant relief from that stress.

And finally early intervention can provide relief to many of the people I treated in inpatients settings for 22 years.  They were generally suffering from severe psychiatric disorders and substance use problems. I saw most of them recover to the point that they regretted the aggressive and violent behavior and were appreciative of the treatment they received to resolve that problem. It is easy in our society to view these folks as hopeless and as outcasts – but every acute care psychiatrist knows that is nonsense. The first step in making a societal change is to get the message out that violence and aggression can be treatable problems and earlier treatment generally leads to better outcomes.  More functional and comprehensive laws on aggressive behavior are a part of that.

 

George Dawson, MD, DFAPA

 

Supplementary 1:

A better terrorist threat standard also may also serve to improve the likelihood of early firearms interventions.  Just from news reports the main obstacles seem to be a combination of easy gun access, gun extremist rhetoric, the ability to avoid background checks, legal action to defeat any gun access legislation, and extraordinary efforts necessary by law enforcement to restrict gun access to individuals who are either at high risk or proven risk based on their recent behavior. If a person meets a statutory terroristic threat standard - that could trigger red flag laws or laws to block or remove gun access at the local level by statute.

References:

1:  Tjaden P, Thoennes N.  Prevalence, Incidence, and Consequences of Violence Against Women: Findings From the National Violence Against Women Survey, Research in Brief.  Washington, DC: U.S. Department of Justice, National Institute of Justice, 1998, NCJ 172837.

2:  Chad Flanders, Courtney Federico, Eric Harmon & Lucas

Klein, “Terroristic Threats” and COVID-19: A Guide for the Perplexed, 169 U. PA.

L. REV. ONLINE 63 (2020), http://www.pennlawreview.com/online/169-UPa-

L-Rev-Online-63.pdf

 

3:  Various MN Statutes:

 

609.713 THREATS OF VIOLENCE.

https://www.revisor.mn.gov/statutes/cite/609.713

 

609.79 OBSCENE OR HARASSING TELEPHONE CALLS

https://www.revisor.mn.gov/statutes/cite/609.79

 

609.795 LETTER, TELEGRAM, OR PACKAGE; OPENING; HARASSMENT

https://www.revisor.mn.gov/statutes/cite/609.795

 

609.749 HARASSMENT; STALKING; PENALTIES

https://www.revisor.mn.gov/statutes/2022/cite/609.749

 

Graphics Credit:  Tim McAteer, CC BY-SA 3.0 <https://creativecommons.org/licenses/by-sa/3.0>, via Wikimedia Commons.  Page URL:  https://commons.wikimedia.org/wiki/File:SWAT_team.jpg

A Psychiatric Perspective on Beatdowns

My opinion on this is probably long overdue.

A beatdown is popular vernacular for beating someone mercilessly - often into an unconscious state. From the video I have seen of these scenarios - it is at least implicit that the person had done something to "deserve" the beatdown.  The best source of this video materiel is TMZ.com that follows the hip hop culture more closely than most mainstream television.  In watching those videos it is apparent that even the wealthiest and most influential celebrities are not averse to being affiliated with these activities, encouraging them, or even commenting on them.  Any casual observation of what happens during a beatdown illustrates that it is a situation with a very high likelihood of serious injury or death to the person who is being assaulted.

Take for example this TMZ clip entitled Cardi B Security Accused of Post-Met Gala Beatdown.  You see two young men punching a man who is on his back on the ground.  They are punching him rapidly and repeatedly.  When they finish another man runs in and kicks the victim as hard as he can while the victim is still laying defenseless on the ground.  I listened to the TMZ pundits analyze the situation.  One of those pundits is Harvey Levin who is the co-host and is also an attorney.  The consensus seemed to be that nobody had any problem with this man being repeatedly punched by two men when he was paying defenseless on the ground.  Only Harvey Levin thought that the kick was a little extreme and could result in legal charges.

The very first assault case that I was involved in occurred at a University Hospital outpatient clinic.  I was on the consult team and the clinic called to say that they had detained an outpatient who assaulted one of their clerical staff.  When she wasn't looking the patient hit her over the head with a cane as hard as he could.  I went down to assess the patient.  He was very calm and had no evidence of major psychiatric disorder.  He explained that he got impatient because the receptionist was not working fast enough and that was why he struck her. He had absolutely no remorse for injuring her. He minimized the potential for injury by hitting someone over the head with a relatively heavy object when they were not expecting to be hit.  He used the familiar rationalization: "If she didn't want to get hit she should have worked a little faster."  He was not intoxicated at the time.  I discussed the case with my attending and we both agreed that there was no psychiatric disorder and no reason why he should not go to jail to be charged for assault.

My attending psychiatrists at the time always tended to analyze the aggression. Punching or kicking someone when they were unable to protect themselves was viewed as a particularly negative sign and an event more commonly seen in antisocial individuals.  It led me to reflect on people I had known in my peer group who had been killed in fights.  One guy I played sports with who went away to college and ended up getting in a brawl at a large college bar.  He was apparently kicked in the side when he was on the ground. He went back to his dorm room and died that night of a ruptured spleen.  In another fight resulting in a kick to the head - that student went home and expired from a cerebral hemorrhage.  Both students were very bright, full of promise, well-liked and had no history of aggressive behavior but they were killed by blows that are commonly observed in movies and television shows. There are thousands of men incarcerated in this country for punching or kicking someone in a fight and killing them.  I can almost guarantee that at some point in their court proceeding somebody said: "I did not believe that hitting him that way could kill him."

There are mitigating factors in some of these situations.  Psychiatric disorders usually are not.  Personality disorders and intoxicated states are but not from a legal standpoint. Being intoxicated or a sociopath is not a defense in the American legal system.  The best chance to beat the charge is to appeal to sub-cultural mores: "Boys will be boys - it was just a fight gone bad and somebody died.  Nobody is to blame here!"  Or claim it was an accident or there was no intent to do harm.  In both of the cases I was personally aware of there was no case in one and in the other charges were dismissed by the court even though the victim in the case never threw a punch or acted in an aggressive manner.  American law is highly subjective and it is not likely that these cases can be decided in a consistent or necessarily rational manner. 

A medical and psychiatric perspective allows a different analysis.  The human brain has a gel like consistency and it floats inside the skull in cerebrospinal fluid. Any sudden force applied to the skull leads to a shock wave that is initially dispersed as the brain impacts the inside of the skull where the forces was applied (coup injury)  and then when the brain rebounds and strikes the opposite inside area of the skull (contre coupe injury).  Which each violent movement thousands of axons are sheared off in the white matter adjacent to cortical areas.  Some forces shear veins and even arteries that can lead to very rapid death if not treated.  Treatment may consist of neurosurgery that requires opening the skull to remove large blood clots and repair blood vessels.  In extreme cases a piece of bone needs to be removed and stored to allow for the expansion of brain swelling to reduce the chances of death.   Lesser forces lead to more persistent cognitive, personality, and neurological changes.  From a strictly medical perspective - given the amount of damage, morbidity, and mortality that a beatdown can cause it is obviously not a good idea to engage in this kind of activity.  Even widely approved activities like football and boxing can lead to brain damage and death from severe brain  injuries.

I have seen plenty of the victims in clinical practice.  People whose lives has been altered by being exposed to this kind of violence.  Traumatic brain injuries, cognitive disabilities, and post traumatic stress disorder.  Careers and marriages lost from these effects. 

From a psychiatric standpoint, the only acceptable reasons for using force against another are self-defense and stepping in to assist a person who cannot defend themselves.  The latter situation can be difficult to assess and personal safety is always a priority. Those criteria rule out a lot of common altercations based on insults or taunts.  If that happens -  the safest solution is to walk away.  These criteria also rule out violence and aggression as a solution to problems.  If that is an issue, find help for anger control and problems with aggression.  The criteria rule out intoxicants as a reason for using physical force.  If that happened repeatedly with alcohol or drug induced intoxication states - get help with the drug or alcohol problem.  Even self defense may not be an adequate excuse for becoming aggressive and injuring or killing someone.  If you are bigger, stronger, a better fighter, or armed and you can easily handle the aggressor - killing or injuring them might make a self defense strategy less likely to succeed.  The initial example would appear to be a case in point.  Two men on top of the man vigorously punching him at the outset of this clip for pursuing an autograph would violate the acceptable reasons. The next man kicking him is far worse if these blows resulted in significant injury. It is tempting to put these situations in a legal framework - an individual's conscious state is probably more applicable. If you kill or permanently disable someone as the aggressor in one of these situations your conscious state is permanently altered.  You have become a person who is capable of excessive violence and that is remembered the rest of your life. Your entire moral development up until the time of that incident is called into question.  Guilt, shame, doubt, and regret become a major part of your life.

Age is certainly a factor in these situations. I have not seen any statistics but most of the protagonists seem to be in their 20s and 30s.  That is not universal.  I have seen many videos of older assailants beating the elderly or assaulting people randomly on the street.  The vigor, poor judgment, problematic peer pressure, and excessive use of intoxicants make this demographic group the likely perpetrators of beatdowns.

If you like my standard spread the word. There should be no beatdowns of any kind.  They endanger lives, lead to disability, and and can have far ranging effects for perpetrators and victim - both physically and  psychologically. They are unnecessary in what are typically nuisance situations where there are better ways to resolve the problem, including just walking away.

Beatdowns can kill people. They are a throwback to ancient civilizations when conflicts were resolved by violence and the object was to kill all of the adjacent tribes members.  The toll is great and the next time somebody asks you if someone "deserved a beatdown" - let them know that nobody does.

And let them know that two or three people hitting someone when they are down and vulnerable is unconscionable.       



George Dawson, MD, DFAPA

The Anarchist Cookbook

I am a child of the 1970s and I am still trying to figure out what happened back then.  Most people think that the history has already written, but that is not what generally happens in the USA.  The real history isn't typically written until after the major players are dead.  Usually until they are dead for a long time.  It was in that spirit that I watched a Netflix documentary about William Powell a few days ago.

William Powell wrote The Anarchist Cookbook in the 1970s when he was 19 years old.  In the documentary that single act was a thorn in his side for practically all of his adult life.  The documentary is set in the home of Powell and his wife Ochan Powell.  Ochan participated in the interviews.  They were living in France and Powell had no inclination to return to the USA but his wife did.  The interviewer asks Powell about his early life, the writing of the book, how his authorship had plagues him at times in his life, his knowledge about how it had been used and whether or not he had any regrets. Powell is introspective to a fault.  In many cases it is clear that he is trying to find the correct words and I think it is natural to speculate about whether or not he is being defensive.  He is confronted by the interviewer who is asking him tough questions about widely known incidents like terrorism and school shootings where someone happened to find a copy of the Cookbook in possession of the perpetrator(s).  The New York Times obituary is a summary of the Netflix documentary.  Please read that to determine if you want to see the film. I will focus on a few points in it that were under emphasized.

The depiction of his early life, emphasizes a pathway to alienation.  A Long Island born boy goes to England due to his father's occupation where he is viewed as an outsider.  The family then returns to the US where he is viewed again as an outsider and mocked for having a British accent.  He is sent to boarding school where he is molested by a teacher and at that point leaves and goes to New York City where he decides to write the Cookbook.  In journalistic (and documentary) style these conditions are all presented as sufficient for him to write this document.  I think an argument can easily be made that a large number of boys and men are alienated from society for various reasons and they eventually find a way to join the rest of the herd.  I would not find it too surprising that at some level it is related to brain maturation processes that we now know extend into the 20s.  There is another group of boys and men who are fascinated with weapons and explosives.  The vast majority of these boys are not dangerous in any way to other people.  Some of them are dangerous to themselves and end up getting killed or disabled by some of their experiments with explosives or setting up explosions.

Powell's description of how he wrote the Cookbook, by going to a public library and sitting in the military section that contained all of the material he needed is totally plausible.  I have some of these very books in my library and they were purchased off of Amazon.  As early as elementary school, I was being taught to use the Encyclopedia to write reports and a good deal of technical information was available in those general volumes.  You could find the general recipes for gunpowder, nitroglycerin, and even a detailed drawing of the inner workings of an atomic bomb.  All of this material was openly available in 1960s Encyclopedias.  Powell makes this argument a couple of times in the documentary as well as the disclaimer in the Cookbook that what he is presenting is general information.  At no point does he or the interviewer touch on the notion that putting generally available information into the political context of anarchism and revolution, although the interviewer does consistently push for some level of accountability.

At some point in his early life Powell found a calling - teaching emotionally and developmentally delayed children and teaching teachers about how to engage those children. There seemed to be a brief thread about how some of the school shooters may have had these problems.  In the course of his career he was boycotted for various positions when parents discovered that he had written the Cookbook.  He described a scenario where there was some initial concern and he e-mailed every parent to let them know that he had written the manual and was willing to answer any questions about it.  They did not have any additional questions.  During some of the interviews, his wife commented that he went through difficult times because of his association with the Cookbook.  Like most documentaries, editorial license is involved.  In the final shot Powell is asked a questions about some of the parallels between his life and some of the alienated people who read his book.  The scene fades at that point and we never hear his response.  I am sure that he had one.  The final announcement was that he died unexpectedly on July 11, 2016.

The central point of the documentary from the interviewer's standpoint was the effect that knowing the book was found in the possession of some infamous perpetrators of violence had on him and whether he felt he had any responsibility.  He was very clear that he was responsible for writing the book but not how people used it.  He acknowledged that he did feel badly about these associations and it did cause him to try to take action to get it removed from print.  On Amazon, he has published a detailed letter about how he came to write the book and the fact that he no longer believes that violence is an acceptable way to cause political change.  He refers to it as a "misguided and potentially dangerous publication which should be taken out of print" after discussing how he attempted to get his original publisher to take it out of print.  He also wrote a detailed letter to the Guardian on December 13, 2013 that was apologetic requested that the book go out of print and that is available on their web site.    

In the end I was left with the impression that William Powell had done something that he regretted at age 19 and spent the rest of his life trying to make up for it.  Unlike those of us who made similar mistakes, he was able to find a publisher that resulted in his big mistake being put into print.  If I look back on those times, revolutionary rhetoric was commonplace and only rarely acted upon.  Rebellious youth found no level of public support for a wide scale revolt.  Most Americans then as now just want to put in a day of work and go home to their families.  The other interesting aspect of trying to hold an adult man far removed from his rebellious teenage years accountable for that person is that it is developmentally incorrect.  At a wider philosophical level, much more dangerous information is now available both in books and over the Internet.  Anyone still reading the Anarchist Cookbook has not done much research.

For me the developmental questions always linger.  Why the fascination with explosives and violence?  It seems to be an area that is consistently ignored.



George Dawson, MD, DFAPA




References:

1:  American Anarchist. Netflix documentary: https://www.netflix.com/title/80143794

2:  Richard Sandomir.  William Powell "Anarchist Cookbook" Writer Dies at 66.  New York Times March 29, 2017.

Luncheon Consensus - Management Continues To Do Nothing About Hospital Violence

I had lunch last weekend with staff from several psychiatric facilities in the Twin Cities.  The group included nurses, nurse practitioners, and health unit coordinators.  Many of them were at the retirement party that I described a couple of years ago.  At one point in time we all worked on the same inpatient unit and that was the common bond.  Over the several hour long lunch the discussion gravitated to one of our favorite topics - violence and aggression in hospitals against medical and nursing staff.  There was the usual litany of injuries - concussions, a stabbing, beatings, and musculoskeletal injuries.  At one point I heard how a staff nurse in her fifties with knee replacement surgery and back problems had to interject herself between a patient she was admitting and a violent and aggressive person who walked in off the street.  In that situation she had to hope that security got there in time to protect her.  I listened to another nurse tell me how the assault charges were determined after she was assaulted - first degree assault only because she had a concussion.  The other forms of being punched and kicked that she sustained that day were all lesser forms of assault.  I also heard how some members of the hospital administration minimized the incident and how her assailant eventually was not charged with anything.

This is one of many areas where the army of health care administrators really don't seem to be able to do anything productive.  Every hospital in the country has posted non-discrimination policies.  They discuss how every patient will be treated respectfully.  These same rules do not apply to their own staff.  When staff are assaulted there is a common belief that it is an occupational hazard.  It is all part of the job.  The other crucial part of the problem occurs at the committee level in higher levels of administration.  When ever there is a potential problem resulting in injury, a standard administrative strategy is to move it to a committee or Task Force.  That is where real problems occur because there is no expertise on the committee in assessing and resolving problems with violence in medical settings.  That lack of expertise is common.  A corollary is that administrators are in the position that they do not believe that they can defer to clinical staff with much more expertise because of the chain of command.  That is a recipe for inaction and manipulation.  If a staff person brings up a concern that the administrators can't solve - the issue is tabled or the person is not asked to come back.  Even more problematic, some administrators embark on their own ideas about how to solve the problem.  I have listed some instances of this happening on this blog that have resulted in more staff injuries.  A final strategy is to bring in consultants.  I have seen situations where expensive business consultants are brought in to either tell the staff that their patients are not any more aggressive than the patients seen in other hospitals in the state.  If that doesn't work - bring in a consultant who will try to demonstrate that he or she knows more than the current staff.  Both administrative strategies fall flat when the staff is dealing with some of the more significant problems with aggression in the state and they have the most experienced clinicians.

No - the violent outbreaks that are described in most hospitals are the result of administrative failures at several levels.  A failure to recognize the issue exists.  A failure to recognize that your staff has the expertise to deal with it.  A failure to recognize that aggression toward the staff is not the result of staff failing to treat people in a particular way or due to a deficiency of the staff person.  And most of all - a failure to facilitate a team approach among the staff in the hospital or clinic with the most expertise.  It is really that easy.

In our discussion, several instances of these manipulative responses to hospital violence were noted.  Even very basic requests for additional security staff and to prevent aggressive people from walking in off the street are ignored.  There is no shortage of meetings and I have participated in many.  One of the administrative strategies is blaming physicians for the problem.  There is nothing like having a dedicated and skilled staff with as much expertise as can be found anywhere - suddenly being blamed for the problem.  In some of these situations the administrators bring in "consultants" to tell senior clinics who have been treating the problem for 20 years.  I am speculating that is right out of "Power Plays 101" in administrator school.  It is not difficult to see how all of this administrative drama and expense fails to solve the problem.  In most cases it ends up looking like nobody is even trying.  A scapegoat has been found - let's leave it at that.

There has been a laudable effort by nurses.  In my home state, the Minnesota Nurses Association (MNA) has been very vocal in terms of the number of aggressive incidents toward nurses in Minnesota hospitals very year.  A 2004 study showed that that nurses were physically assaulted at a rate of 13.2 assaults per 100 persons per year.  17% of nurses were threatened and 34% were verbally abused in the preceding 12 months of the study.  The MNA has also been active to get legislation to legally protect nurses from aggression and assault.  This link to their proposal does not indicate whether either of their proposals have been successful.  

It appears that there are no comparable efforts by the state psychiatric association or medical association.  I am sure that if this luncheon group meets again, there will be reports of further injuries and a continued lack of response to the violence and aggression toward health care workers.

It probably makes sense in terms of the American inertia in dealing with violence and aggression in general.  But it also makes sense because health care administrators really don't do anything to support clinicians or improve the environment where they work.

Replacing all of those administrators is the best place to start.



George Dawson, MD, DFAPA              


References:

1:  Phillips JP. Workplace Violence against Health Care Workers in the United States. N Engl J Med. 2016 Apr 28;374(17):1661-9. doi: 10.1056/NEJMra1501998. Review. PubMed PMID: 27119238.

2: Nachreiner NM, Gerberich SG, McGovern PM, Church TR, Hansen HE, Geisser MS,Ryan AD. Relation between policies and work related assault: Minnesota Nurses' Study. Occup Environ Med. 2005 Oct;62(10):675-81. PubMed PMID: 16169912; PubMed Central PMCID: PMC1740877.

3: Gerberich SG, Church TR, McGovern PM, Hansen HE, Nachreiner NM, Geisser MS, Ryan AD, Mongin SJ, Watt GD. An epidemiological study of the magnitude and consequences of work related violence: the Minnesota Nurses' Study. Occup Environ Med. 2004 Jun;61(6):495-503. PubMed PMID: 15150388; PubMed Central PMCID: PMC1763639



Supplemental:

Aggression and violence and their prevention is one of my interests on this blog.  A sampling of posts can be found at this link or by selecting any of the links from the right margin.