Ignoring Joe Biden’s Unassailable Fact: A Serious Deficiency of the Debate Analysis

 

The Debate uproar continues largely at a very superficial level.  That level is basically that Joe Biden is too old and feeble to be President and therefore he needs to step down and the Democrats need to run another candidate for the sake of “not losing the office.”  This is being spun at multiple levels.  We are hearing stories about White House Staff being conflicted, the President offering cookies to members of Congress, the plausibility of sleep deprivation as an explanation, and even provided with a list of 10 possible Democratic candidates. Whenever supporters of the President come forward the wisdom of loyalists is being questioned rather than what they describe.  The actual content of the debate continues to be ignored as if Joe Biden did not provide any. 

I came up with the following diagram to put things into perspective.  It consists of Trump’s hyperbole about Joe Biden and the single Biden response that effectively cancels that hyperbole across multiple dimensions.  Instead of hearing anything about that response the news media continues the endless speculation about Biden’s Presidency and who should replace him.  The excerpts in the table below are taken directly from the CNN transcript that is easily accessible.  For the sake of simplicity – I eliminated Biden’s point-by-point responses to the Trump hyperbole that were more than adequate and included only the responses that included his reference to the Presidential Greatness survey.

Trump	Biden
“He also said he inherited 9 percent inflation. No, he inherited almost no inflation, and it stayed that way for 14 months. And then it blew up under his leadership because they spent money like a bunch of people that didn’t know what they were doing. And they don’t know what they were doing. It was the worst – probably the worst administration in history. There’s never been.”
“But look, we had the safest border in history. Now we have the worst border in history. There’s never been anything like it. And people are dying all over the place, including the people that are coming up in caravans.”
“Nobody had been worse. I had the highest approval rating for veterans, taking care of the V.A. He has the worst. He’s gotten rid of all the things that I approved – Choice, that I got through Congress. All of the different things I approved, they abandoned.”
“First of all, our veterans and our soldiers can’t stand this guy. They can’t stand him. They think he’s the worst commander in chief, if that’s what you call him, that we’ve ever had. They can’t stand him. So let’s get that straight. And they like me more than just about any of them. And that’s based on every single bit of information.”
“His presidency, his – without question, the worst president, the worst presidency in the history of our country. We shouldn’t be having a debate about it. There’s nothing to debate.”	“The idea that veterans are not being taken care of, I told you before – and, by the way, when I said “suckers and losers,” he said – he acknowledged after it that he fired that general. That general got fired because he’s the one that acknowledged that that’s what he said. He was the one standing with Trump when he said it, number one.   Number two, the idea that we’re going to be in a situation where all these millions and millions, the way he talks about it, illegal aliens are coming into the country and taking away our jobs, there’s a reason why we have the fastest-growing economy in the world, a reason why we have the most successful economy in the world. We’re doing better than any other nation in the world.   And, by the way, those 15 Nobel laureates, economists, they all said that if Trump is re-elected, we’re likely to have a recession, and inflation is going to increasingly go up.   And by the way, worst president in history. 159 presidential scholars voted him the worst president in the history of the United States of America.”
“He caused inflation. As sure as you’re sitting there, the fact is that his big kill on the black people is the millions of people that he’s allowed to come in through the border. They’re taking black jobs now and it could be 18. It could be 19 and even 20 million people. They’re taking black jobs and they’re taking Hispanic jobs and you haven’t seen it yet, but you’re going to see something that’s going to be the worst in our history.”
“Did you fire anybody? Did you fire anybody that’s on the border, that’s allowed us to have the worst border in the history of the world? Did anybody get fired for allowing 18 million people, many from prisons, many from mental institutions? Did you fire anybody that allowed our country to be destroyed? Joe, our country is being destroyed as you and I sit up here and waste a lot of time on this debate. This shouldn’t be a debate.”   “He is the worst president. He just said it about me because I said it. But look, he’s the worst president in the history of our country. He’s destroyed our country. Now, all of a sudden, he’s trying to get a little tough on the border. He come out – came out with a nothing deal, and it reduced it a little bit. A little bit, like this much. It’s insignificant.”   “He wants open borders. He wants our country to either be destroyed or he wants to pick up those people as voters. And I don’t think – we just can’t let it happen. If he wins this election, our country doesn’t have a chance. Not even a chance of coming out of this rut. We probably won’t have a country left anymore. That’s how bad it is. He is the worst in history by far.”	“Number two, the idea that we’re talking about worst presidents. I wasn’t joking. Look it up. Go online. 159 or 58, don’t hold me the exact number, presidential historians. They’ve had meetings and they voted who’s the worst president in American history. One through best to worst. They said he was the worst in all of American history. That’s a fact. That’s not conjecture. He can argue the wrong, but that’s what they voted.”
“Just you understand, we have polling. We have other things that do – they rate him the worst because what he’s done is so bad. And they rate me – yes, I’ll show you. I will show you. And they rate me one of the best. OK.”
“All my life I’d grow up and I’d see politicians talking about cutting taxes. When we cut taxes, as I said, we did more business. Apple and all these companies, they were bringing money back into our country. The worst president in history by far, and everybody knows it.”
“But he hasn’t cut the tariffs because he can’t, because it’s too much money. But he’s got the largest deficit in the history of our country and he’s got the worst situation with China. China is going to own us if you keep allowing them to do what they’re doing to us as a country. They are killing us as a country, Joe, and you can’t let that happen. You’re destroying our country.”
“Then he came along. The numbers – have you seen the numbers now? It’s not only the 18 million people that I believe is even low, because the gotaways, they don’t even talk about gotaways. But the numbers of – the amount of drugs and human trafficking in women coming across our border, the worst thing I’ve ever seen at numbers – nobody’s ever seen under him because the border is so bad. But the number of drugs coming across our border now is the largest we’ve ever had by far.”

 

What do I conclude from this analysis?  Far from being feeble – Joe Biden presented solid information that (as far as I can tell) was ignored by all the talking heads.  Trump’s characterizations of Biden as the worst President are strictly hyperbole. Biden’s response points out that according to a survey of 154 Presidential scholars Biden is ranked #14 and Trump is dead last at #45.  Beyond that obvious fact – Biden is ranked higher than Reagan (#16), George HW Bush (#19), and George W Bush (#32).  In a follow up article it was noted that Trump ranks lower than William Henry Harrison (#41) who died 31 days after taking office.  There seems to be no doubt about where Presidential scholars rank Trump.

The implications of this transcript are clear.  There is always the possibility that Biden has suddenly developed severe problems by per my previous post – but I doubt it. Anyone should be very skeptical about the stories coming out of the press at this time.  Ageist bias is so prevalent that it affects all these stories.  The associated lack of criticism of Trump by comparison is telling. There have been stories suggesting that Trump “lied” anywhere from 30 to 50 times.  I checked these lies against the transcript and they are there. The problem with that analysis is that Trump gets a pass by the MAGA crowd and most of the media whenever he does lie.  The best example is the stolen election lie. Any interview about this typically results in Trump repeating the statement until the journalists stops asking the question.  That strategy is obvious even in the debate transcript.

Another consideration is misinformation and how that affects the ongoing debate spin. The standard MAGA misinformation channels should be ignored.  There is undoubtedly a more insidious effort by enemies of the United States to create additional misinformation on social media.  It is obvious that Russia and Putin see the election of Trump as more consistent with their interests because of Trump’s lack of support for Ukraine and NATO.  Russia clearly supports groups hacking and extorting American businesses.  Threat analysis suggests that Russia, China, and Iran are actively interfering with US elections by misinformation that includes generative AI based approaches.  It should be clear that these countries would prefer a President who is isolationist, does not back Ukraine or NATO, and one who they believe they can manipulate.  Trump’s former National Security Advisor John Bolton believes that Putin knows he can easily manipulate Trump.

All of this information is being ignored in the face of the Presidential debate and the fact that Biden basically looked bad even though he easily produced content that countered Trump’s hyperbole and advanced his own case.  This is not the first-time appearances at a debate were considered a deciding factor.  As I have written in the past, I don’t generally consider the economy to be determined by Presidents – they either take credit or get blamed even though most of the economy is outside of their sphere of influence.  There is plenty of misinformation out there about the economy and the fact it is a motivating factor for people to vote for Trump. There is no doubt that the Biden economy is better and his policies will strengthen the economy in the future.

There is a big interview between Biden and George Stephanopoulos coming up this evening.  We will see if Biden can present in a way to reassure the voters – but all things equal they are still going to hold his age against him.  It is unfortunate that there is little rational discussion of the issue at this point – including the points that Biden made in the debate.   

 

George Dawson, MD, DFAPA

 

Addendum:

The Joe Biden - George Stephanopoulos Interview:

I watched the entire brief interview this evening.  I thought it was an exercise in gotcha journalism.  Biden responded with reasonable answers to why he wants to continue to run and why he is the best person for the job.  His response about whether or not he would take a "cognitive exam" was also reasonable - basically that his job is a cognitive exam every day.  Stephanopoulos' interview technique was controlling and trying to get Biden to respond to hypotheticals that he eventually stated he would not respond to.  He also asked Biden to respond to uncorroborated speculation.  I thought that overall it was a very poor interview and Biden handled it as well as anyone could.  In many ways it was an interrogation rather than an interview. Another disappointing aspect of the interview was the additional four journalists that Stephanopoulos discussed the current situation with. They all clearly had a fixed agenda that Biden should withdraw for various reasons and seemed to be trying to create news rather than report it.  That seems to be the basic problem for Biden at this point.  The news media is more critical of him than Trump - despite Trump's massive deficiencies. As an expert on cognitive testing of the elderly I can add that the "cognitive test" that Trump brags about - is really a screening test that is not sensitive enough to pick up anything short of a moderate to severe problem.  They are easy for anyone who is not cognitively impaired.  Trump has also been noted to brag about his results on this screening test as well as inaccurately describing the test - specifically the naming tasks and word recall task.  All of those details as well as this quote are from reference 1:

"It's a very, very low bar for somebody who carries the nuclear launch codes in their pocket to pass and certainly nothing to brag about," said Jonathan Reiner, a cardiologist and professor of medicine and surgery at the George Washington School of Medicine &Health Sciences.

If there is a cognitive contest between Biden and Trump - and I am sure that will never happen - testing should occur in the same manner, given by the same examiner and it should be recorded for outside validation purposes.  It should also be a more rigorous screen - like the test battery given to physicians in some centers if they want to practice past the age of 75.

But at this point Biden's fate appears to be predetermined by a media bias against him that does not exist for his opponent.

References:

1:    Parker A, Diamond D.  A ‘whale’ of a tale: Trump continues to distort cognitive test he took.  Washington Post Jan 19, 2024.

Graphic Reference:

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

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

Supplementary 1: 

The following Tweet today from Norman Ornstein:

He does a good job capturing the media bias against Biden.  There is also more than a little conflict of interest at the NYT - since their editorial board has already said that Biden should step down.  Practically every journalist I see - even after the Stephanopoulos interview is either explicitly or implicitly suggesting that Biden should step down, that Democrats will tell him to step down, or that he will lose the election if he doesn't.  That kind of stacks the deck against you in polls - especially when almost all of the polls quoted are poorly characterized to the point that they may lack validity.   There have been comparisons with Supreme Court Justice Ruth Bader Ginsburg who is often faulted by the left for not stepping down in time for President Obama to appoint a successor.  She is an easy scapegoat for a party who failed to win the Senate or maintain any countermeasures for right wing activism that seeks to appoint as many federal judges as possible.  Comparing a life long appointment in the case of Ginsburg to being elected President and according to experts doing a better than average job lacks equivalency.  There is also a clear asymmetry in the criticism with Trump getting a complete pass despite his abysmal rating as a President.  Instead of even mild criticism in Trump's direction - I expect the press to continue to portray Biden's presidential bid as a scandal and look for any evidence to back that opinion up.  

Supplementary 2: 

Conclusory language is discouraged in many formats in psychiatry like evaluations for civil commitment, guardianship, and conservatorship.  The idea is that conclusory language short circuits uncertainty and statutory requirements and can prematurely lead to a wrong conclusion.  Even routine psychiatric evaluations should avoid conclusory language in favor of probability statements or statements about the inherent uncertainty in medical evaluations.   

All of the press that I have seen comment on the debate or the Stephanopoulos interview have been using conclusory language or suggesting that they have a source who will provide that language.  Needless to say that is all highly prejudicial against Biden.

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 Insurrection

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Let that sink in……

 

 George Dawson, MD, DFAPA

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

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

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

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

References:

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

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

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

Anti-ECT Rhetoric ........

There is probably no clearer example of the pernicious effect of rhetoric in psychiatry than what has happened with electroconvulsive therapy or ECT.  ECT has a demonstrated therapeutic and life saving effect for decades and yet it is a flashpoint for antipsychiatry groups.  I had the experience of being attacked for pointing this out and the people attacking me posted references from a book that was published in 1980 and it was debunked at the time of publication in a book report in the New England Journal of Medicine.  Ignoring what the facts are - often for decades is one of the rhetorical techniques. Interestingly that technique was pointed out in the book report.

There is no doubt that ECT is a very safe and effective treatment. The onset of action is also much faster than can be expected from medications of psychotherapy. But the most important aspect of the ECT recommendation is way it is recommended by clinical psychiatrists.  It is not recommended for everyone just because it is highly effective.  Clinical psychiatrists recommend ECT for treatment resistant depression. By definition, that means various treatment modalities have been tried and found to be ineffective.   That may have included many antidepressant trials. It is often forgotten these days that psychiatrists are seeing patients who have been treated for decades with antidepressants.  I often see people who have been taking the same antidepressant with dose modifications for 10-15 years or people who have been taking 5-9 different antidepressants over the same period of time.  Those antidepressants have been prescribed by various non-psychiatrists.  The majority of these patients have also seen psychotherapists and list the acronyms (CBT, DBT, IPT, ACT, REBT, etc) and specifics about the therapy. They are also clear that they were not helped by psychotherapy.

The process of being stuck in that situation by itself can lead to increasing hopelessness associated with the thought: "Am I always going to be depressed? Is there anything that can be done to get rid of this depression. Would it be better for myself and anyone else if I was just dead rather than hanging on like this?" In the case of more dangerous forms of depression, delusional thinking presents a greater level of danger in the form of suicide attempts and completions.  One of the ironies of depression is that the public perceives it as a minor condition that is easily treated.  That ignores the fact that most people that die from suicide are depressed.  Severe depression is a lethal condition and not a minor one. Ignoring severe depression and not treating it is an option only by denying that it exists.

A second group of people who need ECT as a life saving treatment are people with catatonia.  Catatonia is a potentially lethal condition that develops in association with other severe mental conditions - especially mood disorders.  Malignant or delirious catatonia had an extremely high mortality rate (80%) prior to use of ECT.  Death from catatonia typically occurred from severe food and water refusal, agitation leading to congestive heart failure, injuries from severe agitation, and in some cases autonomic dysregulation often seen as elevated body temperature with no evidence of infection.  This group of patients is hospitalized and cannot function outside of a hospital setting. Even inside a hospital they need very intensive monitoring to protect them from injury.  The fastest way to treat these patients, keep them safe, and help them to get out of the hospital is ECT.  In fact, it may be the only consistently effective therapy.   

People with severe medical problems who cannot tolerate antidepressant or antipsychotic medical constitute another group who can benefit immensely from ECT.  In many cases these patients are disabled by depression and do not appear to be recovering form their associated medical illness.  They may be in a coronary care unit and taking in inadequate amounts of food and fluids due to depression.  At the same time they may not be able to take medications due to an acute cardiac condition.   They can generally be safely treated with ECT.

A final important group of people are those with experience with ECT.  They typically have a form of disabling depression, know that most of the usual medications either do not work or cause unacceptable side effects.  They are also typically very functional people and know that they need to get back to work as soon as possible.  They request elective ECT for treatment.

Why should anyone want to deny ECT to people in the above groups when it is safe and effective?  Here is some of the rhetoric evident in any Internet discussion. 


1.  I don't like it and will never accept it!

You don't have to.  First it is only indicated for a limited number of severe conditions like treatment resistant depression, depression, catatonia, treatment refractory mania, psychosis, and high suicide risk. If you don't have any of those conditions no psychiatrist is going to recommend it to you.  But further - even if you have the conditions a psychiatrist may not recommend it because it is not available in the area.  Political rhetoric may have driven it out.  Other less effective treatments like ketamine infusions and transcranial magnetic stimulation (rTMS) may be recommended instead.

The second issue is informed consent.  You can decide you don't want it. Story over at that point.  I have no interest in talking anyone into it.  My job is to provide the latest information and the patient decides and consents or does not consent. 

2.  ECT causes brain damage!

Irrelevant based on the informed consent issue outlined above unless you are trying to make a political argument.  But more striking is the body of evidence that has accumulated that there is no evidence at all that ECT alters brain anatomy or leads to neuropathological changes. Denial or lack of scholarship are the most likely explanations of this problem.  Given the ease with which medical information can be accessed these days and the fact that many people making these arguments use antiquated and disproved data while ignoring the contradictory positive data - denial or intentional distortion of the data are the only obvious motives.

3.  There are important political and ethical considerations!  

Are there really?  Not when you look at the severity of the problem. Considering psychiatric illness and disease on par with other physical illnesses is difficult if you have never seen what happens on an acute care psychiatric setting where the most serious problems in psychiatry are treated.  In the current American healthcare system these patients are often committed and in some cases transferred to state hospitals if they do not get well.  In some cases, states have found it easier to close hospitals so that these extremely ill people are sent back to their families, to jail, or to the streets.  I routinely see patients who have had a severe psychiatric illness and were ill and unstable for decades.  In many cases they are chronically ill and never regain stability because of neglect or inability to treat them. All of those years of suffering and in many cases death could have been avoided with proper treatment early in the course. In many cases the proper treatment was ECT.

How does that compare with the rest of medicine? It does not. People with life threatening and/or disabling conditions are allowed access to high risk treatment options. A few examples can illustrate this point.  Cancer is a good example.  Chemotherapy agents are high risk medications that can lead to serious and in some cases lethal side effects. Giving informed consent for treatment with chemotherapy requires agreeing to accept the risk of congestive heart failure and many other serious and potential lethal side effects from those agents. The explosion of immunotherapy agents for autoimmune disorders provides similar risk.  Even more importantly, every patient consenting to the treatment are considered to be competent consentors.  In other words they are  considered able to understand the information, make rational decisions about it, and provide consent on that rational basis.  Patients consenting to ECT may not be competent cosentors based on vulnerability laws in states.  Consent is not considered to be competent necessarily based on status (on an inpatient psychiatric unit or outpatient clinic) or by specific statutes about diagnoses or recent behavior.  Those same rules do not apply to people giving consent for high risk medical or surgical treatments.  Keep in mind that ECT is portrayed as a high risk procedure - but in reality it is not.

4.  What about involuntary treatment with ECT?   

Some states have statutes that allow courts to decide on whether or not people who are civilly committed and have high risk psychiatric illness.  That is typically based on a hearing with opposing attorneys and a judge.  Unique state statutes provide the standards that must be met in those hearings.  The court typically hires examiners (psychologists, psychiatrists) to testify about diagnosis and recommendations.  Since ECT is a medical procedure psychiatrists may be required to examine the patient and testify about the recommendation.  These hearing may also be used because the patient is not competent to consent, but clinical competency is not a formal legal decision until it has been made by a court.  In these cases the state has an interest in preventing death and disability of its citizens. 

I have thought a long time about getting rid of involuntary treatment with ECT but how would that work?  The psychiatrist would be in a position that would be difficult to defend from a clinical standpoint.  Anyone with a severe disorder not responding to standard treatment needs to hear about ECT as an option.  Their treating psychiatrist needs to make sure that happens and that the discussion is documented as well as the patient's response. If involuntary treatment was not an option for severely ill people who were unable to consent, they would basically be maintained in a chronically disabled, high risk, or worsening course of illness. I don't think that is a decision that a psychiatrist can make because it is essentially one with a dubious basis.  At that level court intervention makes sense.

5.  What can be done to address ECT side effects if I get them?

First, like all medical procedures make sure the ECT is provided by an expert, working with an anesthesiologist who is used to providing general anesthesia for ECT.  Second, that expert needs to assess the results and side effects of those treatments on a treatment to treatment basis.  Modifications in techniques and side effect prevention need to occur on a regular basis if side effects are there.  In the case of voluntary ECT and significant side effects, stopping the treatment at any time is an option for the patient. In the case of involuntary treatment or substituted consent by a court involved family members or the patient can advocate for the same discontinuation.  The attending psychiatrist can also initiate discontinuing the treatment at any time based on side effects.

The perplexing issue is the number of people who write about numerous ECT side effects and that they have had a course of many treatments.  I ask myself, how does that happen?  Have they been told that they will get used to side effects?  Were the side effects ignored?  What happened?  Why didn't they just decide to stop? In those cases, the first step should always be to discuss the issues with the attending psychiatrist and psychiatrist performing the ECT.  If that is not effective, every state in the United States has multiple forums for investigation.  In the state of Minnesota, there is an Ombudsman for Mental Health and the Board of Medical Practice. Both of these agencies will exhaustively investigate any complaint brought to their attention. People are encouraged to complain about physicians and a national watchdog agency monitors how many complaints are made in each state and holds states with low complaint rates in a negative light.

More problematic is the political approach to ECT and how it has affected policy and has the potential to decrease the availability of this modality for very ill patients.  A recent editorial review pointed out how the process in the UK was factored into NICE guidelines that were restrictive and that those guidelines may adversely affect ECT practice in the US (1).  The restrictive nature of the NICE guidelines was apparently based in part on a flawed study suggesting more dissatisfaction and memory loss than expected.  A re-analysis of that data (3) describes the nature of those flaws that include in part:

"Two other studies selected individuals from user/advocacy groups generally biased against ECT and were probably overlapping. The significance of memory problems was not mentioned in any of the studies."

It is interesting that it took 9 years to reassess the original data and come to that conclusion and in the meantime it apparently was enough to alter ECT policy in the UK.

No other medical specialty allows political biases to affect practice standards, especially when it compromises the care of severely and potentially fatally ill patients. 

There is no reason why psychiatry should either.
 

George Dawson, MD, DFAPA 


 References:

1: McDonald WM, Weiner RD, Fochtmann LJ, McCall WV. The FDA and ECT. J ECT. 2016 Jun;32(2):75-7. doi: 10.1097/YCT.0000000000000326. PubMed PMID: 27191123

2: Rose D, Fleischmann P, Wykes T, Leese M, Bindman J. Patients' perspectives on electroconvulsive therapy: systematic review. BMJ. 2003 Jun 21;326(7403):1363. Review. PubMed PMID: 12816822.

3: Bergsholm P. Patients' perspectives on electroconvulsive therapy: a reevaluation of the review by Rose et al on memory loss after electroconvulsive therapy. J ECT. 2012 Mar;28(1):27-30. doi: 10.1097/YCT.0b013e31822d796c. Review. PubMed PMID: 22343578.

4:  FDA (Proposed Rule for reclassifying ECT devices):  Neurological Devices; Reclassification of Electroconvulsive Therapy Devices Intended for Use in Treating Severe Major Depressive Episode in Patients 18 Years of Age and Older Who Are Treatment Resistant or Require a Rapid Response; Effective Date of Requirement for Premarket Approval for Electroconvulsive Therapy for Certain Specified Intended Uses AGENCY: Food and Drug Administration, HHS. ACTION: Proposed order.

 https://www.gpo.gov/fdsys/pkg/FR-2015-12-29/pdf/2015-32592.pdf

5:  Electroconvulsive Therapy (ECT) Devices for Class II Intended Uses Draft Guidance for Industry, Clinicians and Food and Drug Administration Staff.  

https://www.fda.gov/downloads/MedicalDevices/DeviceRegulationandGuidance/GuidanceDocuments/UCM478942.pdf