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.

The Real Lesson of January 6th – How Fascism Works

 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 

George Dawson, MD, DFAPA

 

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

The actual story:

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

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

References:

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

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

 

Graphics Credit:

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

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

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

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

 

 

 

Brandolini’s Law

There was an informative editorial in Nature this week by Phil Williamson - a scientific expert on ocean acidification.  I like the concept of bullshit and have referred to Professor Harry Frankfurt's classic essay on it many times.  I was not familiar with Brandolini's Law until I read the essay.  Simply stated:

Brandolini’s Law: “The amount of energy needed to refute bullshit is an order of magnitude bigger than to produce it.”

It is also more simply known as the The Bullshit Asymmetry Principle.

Williamson uses a political example from a libertarian web site.  The central piece of that article was that ocean pH was not decreasing and that climate change would lead to reduced carbon dioxide in the oceans.   Because the climate is not changing there is no worry that the ocean pH would change.  The original publication denied Williamson's rebuttal.  An opinion piece in a professional journal led the author of libertarian piece to write online that his work should be "squashed like a slug".  Nothing like elite scientific dialogue is there?

In the UK there is apparently a press watchdog called UK Independent Press Standards Organization (IPSO).  Williamson filed a complaint with them about the factual accuracy of the piece and is awaiting their verdict.  He goes on to illustrate how Brandolini's Law comes in to play in this situation.  The original author these days can essentially be anyone from a journalist to a blogger.  He points out that online journalism "seems to be subject to few if any rules."  That leaves anyone in the position of responding to a factually inaccurate claim at a distinct disadvantage.  There may not be any formal complaint procedure and there is probably no editorial hierarchy.  Many web sites count on bloggers and writers to produce content that they can attach advertising to and this content seem to have very little oversight in terms of accuracy.  Much of this content on social web sites makes up what has been referred to as fake news.

Williamson's position is very clear.  He thinks that these inaccuracies need to be responded to and corrected.  He accurately points out that the audience for the correction is not the authors, but readers who are interested in accuracy and science.  I don't think that the division is that clear for a number of reasons.  A large number of people really don't care.  They are involved in the emotion generated by the issue and don't make decisions based on facts.  That general attitude is promulgated by the political process in most countries.  This is rarely a rational discussion of the main issues of the day.  I think this goes a lot deeper than generating rebuttals.  There needs to be education on the difference between science and everything else.  A good example is Creationist based rhetoric and the denial of evolution.  Creationist advocates do not seem to recognize that they are engaged in a process that is nothing like science and therefore cannot scientifically prove anything.  They fail to recognize the basic issue that science is a process and not an immutable collection of writings written by ancient prophets and subject to many interpretations.  That failure of recognition also leads to a failure to recognize that they are  completely outside the field of science. They fail to recognize where they are and that the best critics of a scientific theory are the scientists in the field.

This failure of recognition is much wider than Creationists.  Journalists produce many examples, not the least of which is a consistent bias against psychiatry.  That bias is present whether or not there is editorial oversight.  A great example is the journalistic tendency to propose what psychiatry is and then proceed to attack that straw man.  And interestingly these outsiders with no training in medicine or psychiatry are often joined by insiders pushing the same arguments.  In one case a prominent journal editor came out and endorsed an anti-psychiatry book, proclaiming legitimate criticism when in fact the book was rhetorical.  I would not presume that medical editors are without common biases.  There are many forces producing misinformation.

I diverge a bit with Williamson's approach on refuting the misinformation and hoping for the best.  I think that there are additional considerations.  One thing is very clear - the head-in-the-sand approach taken by physician professional organizations in response to misinformation is clearly not a good idea and is sure to lose in the current propaganda war of misinformation and political corruption.  If there is a lesson with the current Presidential campaign it is that there is a very small margin between a typical fact less campaign and one where anything at all can be said whether it is true of not - and nobody seems to care about it.

That is foreboding for all levels of public policy, especially when the political spoils includes being able to appoint agency heads with not only a lack of basic footing in science but also a lack of knowledge about what constitutes science.  For the country to run and maintain some standards in science, technology, and engineering there needs to be a basic understanding of these fields in all branches of government and at the highest levels.  There is currently no better example of what happens when the unscientific manage the store than what has happened to American medicine.  We are not only cursed by work rules that are made up as we go and have little to do with the practice of medicine, but we we have to live with pseudo-scientific management practices that affect our work flow and and detract from the lifelong task of learning the science of medicine.  A few strategies I can offer as a blogger follow.  I also have additional strategies that I am going to keep to myself until just the right time.

1.  Don't feel compelled to engage - Twitter is an excellent example of how this principle is applied. Suddenly you are being given the third degree by some poster. That turns into misinterpretations of your statements and positions and before you know it personal attacks.  But it doesn't stop there. A new account pops up and mysteriously continues the attack.  Call them trolls or whatever you like but recognize the tactic. They don't really care what you have to say and are quite happy to waste your time.  Don't engage. Twitter gives you the option to block them and that works the best.

2.  Present the facts but counter the rhetoric - It is important to recognize the common forms of rhetoric without being pedantic.  The best way to do that is by pointing out the erroneous aspects of the argument and the overall form without naming the fallacy.  This sounds easy and it should be - but physicians and psychiatrists seem to be spellbound at times by the simplest arguments.  One common example is anytime a business executive shows up and talks about "cost effectiveness" - everybody shuts down.  Nobody seems to understand that this is just business rhetoric.  It should be as obvious as the fact that with 30 years of intensive management and "cost effectiveness" - per capita health care costs are 40% higher than the country with the next highest per capita expenditures and health care is certainly no better.  In the case of treating mental illnesses and substance use disorders it is much worse.  Somebody needs to stand up and say: "We are doing our part - when are you going to start to do yours." or "Get out of the way and let us do our work." or "Give us the resources to provide the adequate service or shut it down."   Rationing is clearly a very ineffective and costly way to provide health care services.

3.  Recognize bullshit no matter where it comes from -  Many of the arguments for health care reform are just plain erroneous.  And why wouldn't they be.  We now have a continuous supply of what are essentially blogposts on the front of our most respected medical journals.  How could anyone expect that 12 or 52 health care reform ideas each year for years would be worth anything?  All of the top posts that they have been implemented like the electronic health record, managed care as business intermediaries for government purchasers, pharmaceutical benefit managers, creating various financial incentives - have all been progressively worse ideas.  Sifting through the misinformation to correct what is false, what are lies, and what is bullshit is a tedious but necessary task.  As long as medical journals legitimize this constant stream of unscientific information - countering it will remain an onerous task.  The sources of bullshit go far beyond blogs and traditional journalism.

4.  Don't let anyone define you - A common strategy these days is that detractors tend to jump in and set the stage with false criticism.  It was easy to see this in political debates.  In medicine and psychiatry the same process happens and I have pointed out the dynamic on this blog.  I also posted a recent summary of how the release of the DSM-5 was a major source of misinformation, lies, and bullshit in 2015 but there are many more examples in psychiatry.

5.  Don't let the barbarians at the gate get you down - I tell aspiring physicians and aspiring psychiatrists the same thing - don't let the detractors or in these days trolls - get you down.  Psychiatry is a tough field because there will always be a lot of people blaming you for their problems.  This is where Brandolini's Law really applies.  There are numerous dialogues on web sites available where the game is to post as much misinformation, bullshit and lies about psychiatry in particular.  Entire web sites exist for that purpose.  Entering into that discussion and taking the opposite side of the argument can be more futile than the Law suggests.  It may take several orders of magnitude of effort and even then it may be futile.  The best approach is to just get the information out there in cyberspace in an independent forum where you know that it can be safely viewed.   That is one of the reasons that this  blog exists.

6.  The Internet is still the Wild West and that will probably never change in its current form - Williamson suggests that it may be possible to "harness the collective power of the Internet to improve its quality."  He suggests the global scientific community reviewing sites and rating them like film rating sites.  I am far less optimistic.  The first problem is the scope of that project.  The second would be consistency in ratings.  The third is that a rating in some sense is legitimizing.  It is a far better approach to ignore the ignorant.  The reality is that reputation protection web sites basically work by generating a lot of information designed to bury the obnoxious web site.  Most people find that if they contact a search engine about a web site that may be slandering them that they are met with a a relatively hostile response and a complete lack of interest in correcting anything.  That is true for even the largest search engines.  Google for example, clearly doesn't give a damn about your reputation.

7.  Brandolini's Law is a significant deterrent to keeping professionals engaged in educating the public - Physicians certainly find this out in a hurry if they decide to post a rebuttal in political or media forums that are populated by the ignorant, trolls, or those with a specific agenda.  That is more true of psychiatrists than any other specialty.  That has a dual effect of limiting feedback to those who might be interested and eliminating the most informed criticism.  It also has the added effect of adding professionals who may have legitimate criticism to antipsychiatry web sites where scientific criticism is clearly not the agenda.  It is a dangerous path of least resistance when legitimate professionals start posting on web sites dedicated to the destruction of the profession.

 These are just a few ideas about Brandolini's Law.  I did not write the most important one down and that is you can always just go off the grid.  Even then there are problems.  I talked with a psychiatrist about 10 years ago who was asked to give presentations at local churches on depression.  He eventually gave up because there were people in the audience who for various reasons were so disruptive that it prevented him from giving the interested people the information that they wanted.  Only psychiatrists could end up being heckled in church.  Bullshit can be presented in person just as easily as is can by typed online.

Williamson refers to a "rising tide of populism threatens the future of evidence-based government."  I don't think that we have ever had evidence based government in the US.  I see it as mostly a power dynamic here - influencing people by emotional ideas and shouting them down.

The only reason why that Brandolini's Law doesn't work in reality in the case of psychiatry is that at the end of the day, there are still people with severe mental illness - no matter who tries to deny it and a group of people called psychiatrists who are interested in helping them.  That is not necessarily enough to prevent the widespread demoralization of a profession.        


George Dawson, MD, DFAPA

Reference:

1:  Phil Williamson.  Take the time and effort to correct misinformation.  Nature 8 December 2016; 540: 171.


Supplementary 1:

My brother saw this post and commented that Brandolini's Law has "never been more true."

I reflected on that true statement and the continued widespread ignorance of science and came up with the following observation that might have been made by Casey Stengel:

"Good science cancels out bullshit and vice versa."

That probably captures why misinformation grows as exponentially as scientific information in any society.  It levels the playing field (to some degree) between the informed and the uniformed.

The Fake News

I have been watching the controversy about "fake news"with amusement.  The clamor is a direct product of the unexpected results in the Presidential election.  In search of somebody to blame, the media is currently pointing fingers at Google and Facebook as incentivizing a process where any group of people can write fake news stories, have them published and generate ad revenue from both of those services.  An expert in Big Data pointed out (1) that this is a problem with algorithms and suggested hiring human judges of fake news.  That will help until we hit the artificial intelligence singularity - a point at which humans will have access only to the news that our machine overlords want us to have.  But isn't the fake news about a lot more than just software?

Looking at the literal definition. there are different types of fake news.  Satire is the best example.  It is a staple of late night television comedy and satirical publications.  Implicit in this comedy is the capacity of the viewer to recognize immediately that it is fake and "get" the associated irony.  For various sub-populations who have difficult with social cues that may not be possible.  There is what used to be called propaganda or fake news with an agenda to control access to what information people have access to or how they think about it.   The implicit aspects of current fake news is that it is there to intentionally deceive but also profit by the structure of social media sites.      

Like most news cycles, this is another story that strikes me as absurd at several levels.  First off, how hard is it to look at your Facebook feed and realize that some of the sources being posted by people with too much time on their hands are the equivalent of an e-mail attachment from an unknown source?  The Wild West nature of the Internet prevents me from making up websites for fake news.  The first 5 that I made up apparently exist.  Suffice it to say that even a slight amount of Internet common sense should preclude a lot of these stories from consideration.

Secondly, is the concept of fake news really news to anyone?  I can recall arguing with my late father back in the 1970s about a book that was basically a collection of conspiracy theories about how one party or the other lost due to groups of powerful Kingmakers who were manipulating the electorate (sound familiar?).  But nothing slows down the outrage crescendo like publishing detailed and tedious theories in a book.  Immediate viewing by thousands of the outraged and outrageous creates a much better mob atmosphere.  The theme of a clueless electorate being manipulated in one direction or the other is a historical theme in America and probably most legitimate elections in the world.  Don't like my candidate - you must be clueless.  My candidate loses - I am going to ignore confirmation bias (among others) and write obsessively about why I think that happened.  I won't let any facts get in my way.  That basic process occurs whether or not there in an Internet or a Facebook or a Google.  The indignant losing side will always try to tip the landscape to their advantage in the future.  It is how we ended up with left and right wing media outlets in the first place.  It is basically why the United States has no politically viable third parties.

Thirdly, most of what passes for credible scientific news is in a way fake news.  Ioannidis has famously stated that most published research is false due to the inherent practical limitations of research scale and confirmation bias (3).  His observation matches my experience over the past thirty years and I have posted some famous examples on this blog.  A lot of this information is vetted more rigorously than anything that you will find in the popular press and of course the researchers are generally not conscious of the falseness of their research.  It turns out that is even true for the hallowed meta-analyses and what has become the cottage industry of statistics (4).  That same study estimates that only 3% of these studies are useful and there is a very large non-publication bias.

Fourthly, a lot of psychiatric fake news involves government spin to make the government and policy makers look good.  It coincidentally maintains a business structure that adds no value but extracts a lot of revenue from the system for "managing" care.  I have many posts that illustrate this fact.  Most recently, the Surgeon General's report would have you believe that the sad state of addiction treatment in this country had something to do with the fact that medical providers were ill equipped to treat addicts and they were just shuffled off to other community agencies.  That is very positive spin considering long standing policies by governments and their proxies to not pay for addiction treatment or in some cases the physical trauma effects of acute alcohol or drug intoxication.  That has been 30 years of rationing policies that were supposed to be stopped by parity legislation.  But that did not happen.

Fifthly, does it make sense to separate bullshit from lies in the fake news category?  Harry Frankfurt's essay on the matter ads some perspective.  Are the producers of what people consider to be fake news - liars or bullshit artists or both?  A relevant question from a technical perspective.  Is fake news just part of the abundant bullshit that Frankfurt suggests is "one of the most salient features of our culture."  Are the people who want to stomp out fake news just deniers of the level of bullshit that we each have to negotiate every day?  Frankfurt's observation, that I happen to totally agree with - is given below:

"The realms of advertising and of public relations, and the nowadays closely related realm of politics are replete with instances of bullshit so unmitigated that they can serve among the most indisputable and classic paradigms of the concept." (p. 22)

It may be that the indignant are just angry that somebody has found another way to make money off of bullshit that they did not think of or have access to.

Sixthly, psychiatry gets more than its fair share of fake news and again - a lot of that has been posted here.  I can say without a doubt that one of the largest fake news stories of 2015 was all of the fake news about the DSM-5.  Apocalyptic visions of what would happen when that book was released.  The horror of grieving patients being treated with antidepressants like they have been for decades by their primary care doctors.  The horrors of "medicalization" and "diagnostic proliferation".  The horrors of clueless psychiatrists and family physicians as helpless as Manchurian candidates against the hegemony of the DSM-5.  The philosophical horror of a manual with an implicit moral agenda about how people should live.  And it is written by (gasp) psychiatrists.  We cannot allow that to happen!   And of course the vast profits to be made on the diagnostic manual.  What really happened is best captured by a brief conversation I had with another specialist just  yesterday.

MD:  "Is there a reference that explains what happened to the personality disorders in DSM-5"
Me:  "Yeah there is a reference or two.  The organization is different but there is still a categorical approach to the major ones.  You don't really read the DSM-5 do you?'
MD:  "No - the codes are basically the same.."
Me:   "More importantly when you type "depression" into your EHR don't you get about 240 diagnostic codes..."
MD:  "At least - it depends what the default is set at."  
Me:  "That's my point.  Any general psychiatric diagnostic category in an EHR generates more diagnoses than are included in the DSM, even though the recent edition had fewer codes than the last edition.  And the only thing that counts are the ICD codes that phrase is attached to."

That is the reality of the fake DSM-5 news.  Just to be clear - no cataclysmic events. No moral collapse.  No willy nilly assigning diagnoses to people randomly on the street.  No primary care physicians changing what they do or even reading the new manual.  Pretty much the same unimpressive tome that should really be of interest only to psychiatrists and then briefly.  There are more exciting things to read about psychiatry.

Fake psychiatric news is some of the most abundant fake news in medicine.  It is a prime example of the types of fake news that exists out there and what some of the motivations are.  The number one read post of all time on this blog focuses on a Washington Post article, basically correcting what was said about the DSM-5, conflict of interest, primary care, and psychiatry.  Should that level of correction render it into the fake news category?  The fake news in psychiatry is so pervasive there are entire web sites dedicated to it.  Some of these web sites have an air of legitimacy until you read what is actually being said.  Some even attract psychiatrists who are apparently confused about the content or tenor of the site and don't seem to understand rhetoric.

Just a few things to consider about the current fake news category - especially as it applies to psychiatry.  Fake news is here to stay - it is not some new problem introduced by Google or Facebook.  It is all a part of how society works, with a person or group of people seeking advantages over others.  In the USA we like to fool ourselves into thinking that we live in a fair society where everyone is equal.  We like to think that conflict-of-interest can be eliminated or at least managed.

That is just more fake news.


George Dawson, MD, DFAPA


References:

1:  Cathy O'Neil.  Social Media Companies Like Facebook Need To Hire Human Editors.  NYTimes Nov. 22, 2016

2:  New York Times Opinion Pages:  How To Stop The Spread of Fake News.  NYTimes Nov. 22. 2016.

3:  Ioannidis JP. Why most published research findings are false. PLoS Med. 2005 Aug;2(8):e124. PubMed PMID: 16060722.

4: Ioannidis JP. The Mass Production of Redundant, Misleading, and Conflicted Systematic Reviews and Meta-analyses. Milbank Q. 2016 Sep;94(3):485-514. doi: 10.1111/1468-0009.12210. PubMed PMID: 27620683.

Ioannidis concludes that despite the massive production of meta-analyses only 3% are "decent and clinically useful."

      

Prior Authorization - A Legal Document?

As part of the continuous harassment that is prior authorization, I recently received a form in the mail.  It was a repeat of one that I had already signed and faxed in. The only difference was this boilerplate attached to the bottom"

"I attest that the medication requested is medically necessary for this patient. I further attest that the information provided is accurate and true, and that documentation supporting this information is available for review if requested by the claims processor, the health plan sponsor, or, if applicable, a state or federal regulatory agency. I understand that any person who knowingly makes or causes to be made a false record or statement that is material to a claim ultimately paid by the United States government of any state government may be subject to civil penalties and treble damages under both the federal and state False Claims Acts. See, e.g., 31 U.S.C. §§ 3729-3733."

I suppose I should be grateful that the PBM in this case did not attach the 14 page federal statute. And that's right, this statute is a Civil War era statute that I am sure no legislator at the time or since then would have applied to the practice of medicine. What are the implications?

1. First is the clear alliance of PBMs with the federal government. There is no clear separation of where a private for profit business ends and the government begins. I have never sent out a form or a letter with a warning that governments at any level might enforce my recommendations or services. In fact, I have complained numerous times to government officials and agencies about managed care companies at several levels only to be politely told "We can't help you." Probably because they are tripping over one another to help out the managed care cartel.

2. Secondly (and this is a recurrent theme), we have the illusion that health care companies are policing doctors and holding them accountable. That's right - the same industry that is basically one of the largest taxes on most Americans and the same industry that has dismantled mental health care and transferred the mental health care of millions of Americans to correctional facilities. There is also an implicit threat very similar to the threat I wrote about during the billing and coding era.

3. The propaganda effect - practically all managed care intrusions into the practice of medicine are designed to shift financial and clinical risk to physicians. That would includes all of the other managed care schemes like report cards, capitation, pay-for-performance, utilization review, managed formularies and all other schemes to shift risk onto doctors. The net effect of this propaganda has been to adopt the propaganda as somehow being normative. The worst effect is that these insurance companies and MBAs push the propaganda as though it is scientific fact. It not only lacks scientific merit but they frequently do not know how to analyze the data. The best example I can think of is using the PHQ-9 to "measure" depression treatment in the state of Minnesota. This is not only an invalid application of the screening tool, but the state clearly does not have any way to analyze the longitudinal data in any scientific manner.

The blizzard of propaganda from the managed care industry has been a positive for them. It has such a deleterious effect on physician morale that nobody seems to be up for a fight. They have actually launched a new wave of propaganda that is very similar to the initial wave that was used to justify managed care in the first place. We are now seeing "collaborative care" studies that claim very positive results. Medicine and psychiatry in particular seem desperate in the face of managed care propaganda. One of the front page headlines in this month's Clinical Psychiatry News was:

Future of psychiatry may depend on integrated care.


I would submit that it does but not for the reasons claimed in the article. Integrated care will result in psychiatrists with considerable less knowledge than they currently have and they will be totally marginalized without a clear set of problems to treat. The only reason psychiatrists have not been put out of business so far is that we successfully treat a set of problems that nobody else does.

Standing around in a primary care clinic looking at PHQ-9 scores and monitoring the rapid and random prescription of antidepressants by nonpsychiatrists seems like a job for an MBA rather than an MD.

I am sure at the proper time, some business type will come to that conclusion and psychiatry in managed care systems will politely disappear.........

George Dawson, MD, DFAPA