Projection Writ Large in American Politics.....

 

Recent events lead me to the conclusion that I should comment on them with the hope of breaking up the current pattern.  I see a lot of “hopes and prayers” commentary and “we need to unite like we did after 911” – but I don’t think that gets us very far.  What might help is recognizing the pattern, what it means, and using that knowledge to move ahead.    

Let’s start with the pattern.  To me it looks something like this. 

1:  Gun extremism for the past 20 years (as previously defined).  This results in no adaptive solutions for the problem for one of the major parties.

2:  Normalization of name-calling, blame, and rage by the President.  I don’t think any footnotes or references are needed at this point.  He posts something on almost a daily basis on his social media platform consistent with these activities. As Robert Jay Lifton said in 2017 commenting on the Trump Presidency as a descent into darkness “With Trump of course malignant normality becomes the rule because he’s President and what a President does tends to normalize potentially bad, evil, or destructive behavior.”

3:  Secondary spread of these patterns of behavior to everyone in his party – reinforced by mandatory compliance with his wishes using direct threats.

4:  Attributing all of the bad behavior to other people and another political party and acting as if that is true. 

In psychiatric parlance, 1 -> 4 above is referred to as projection.  I notice today that it is also used by commentators who are not psychiatric professionals.  A basic definition of projection is: ‘’Feelings and desires are not seen and admitted in oneself, but excluded from one’s experience and attributed to another.” (1)  In dealing with a person who uses that defense – it is common to feel like you are being blamed for something you are not responsible for and experience the associated anger.

But it can get even more complicated.  Kernberg writes:  “In contrast to higher levels of projection characterized by the patient’s attributing to the other an impulse he has repressed in himself, primitive forms of projection, particularly projective identification are characterized by: 1) the tendency to continue to experience the impulse that is simultaneously being projected onto the other person, 2) fear of the other person under that projected impulse, and 3) the need to control the other person under the influence of this mechanism.” (2)  In other words, the accuser in this case may be doing the same behaviors that he is accusing the other person of doing. In the cases I am referring to another party or member of another party is being accussed of radical politics that leads to political violence by a party or member of a party that has advocated and conducted radical and violent politics for years.

Before anyone invokes the Goldwater Rule here – let me say that I am not making any diagnosis of any individual.  I am simply observing patterns.  Observing patterns at a macro level is different from observing them in an individual patient in an intersubjective setting.  That field is profiling and it was invented by Jerrold Post, MD.  Post observes that in the case of paranoia projection distorts reality (3).  More specifically:  “Attempting to discredit Clinton’s popular victory in the 2016 election, he claimed massive voter fraud by illegal aliens.  As the 2018 midterms approached Trump expressed his concerns that the ‘Russians would be fighting very hard for a Clinton victory’.  So in his fevered imagination, there was a real basis for voter fraud.  And this suggests, given his reliance on the defense mechanism of projection that he would consider voter fraud.”  He subsequently refused to consider any polls that did not show him leading and called them fake news. (4).  Given his role in concessions to Putin and uniting China, Russia, and North Korea – the original suggestion of voter fraud was not consistent with reality.           

Sure you can say it’s just entertainment.  You can say like a recent District Court Judge that it is just rhetorical hyperbole that no reasonable person should take seriously.  You can say that Trump is “just joking” and that nobody takes him seriously but that misses two critical points.  First, this pattern of thought had to start somewhere.  Most of us are familiar with it from early to mid-adolescence when it is a developmental stage.  We can recall when it ended and we made a conscious decision to take responsibility rather than blaming other people for our problems.  Second, there are obviously many people who take this pattern of thought seriously and who can blame them?  I have seen trained mental health professionals fooled and reacting to it.

It is at the point where it cannot be ignored.  If you “do your own research” all the facts are out there. The current situation is the result of a decades long process that values gun extremism and political divisiveness – all leveraged by one party.  As long as you are caught up in that process – things will only get worse.  The results of future violence will be predictable and the soonest anyone can hope for change is 3 more years.  Stop the problem now by seeing this for what it is – a pattern of thought and behavior that most people grow out of.

Are there concrete steps you can take?  I suggest the following.  First, recognize what is going on. I am an old man and I have never seen a President behave like Donald Trump before.  All the projection going on needs to be ignored.  When you see news stations and social media sites trying to amplify his rage and name calling – just shut them off or ignore them.  You will not be missing a thing.  Think of the good old days when we had Presidents from both parties that did not demand our constant attention and outrage.  Presidents that acted in good faith for all of the people.  Presidents you could criticize and it would be taken seriously.  The government ran quietly in the background.  It was never perfect but it was a lot better than what we currently have.  Second, recognize that one of the provocative strategies associated with projection is to devalue some and overidealize others.  Civil servants, scientists, military officers, veterans, women, the disabled, low income people, and minorities have all been devalued while Confederate Generals, dictators, and white supremacists and neo-Nazis are praised and idealized.  It is a consistent dynamic over time.  Third, projection is a mechanism for producing bogeymen. One good example is the alleged left-wing organization Antifa.  Whenever I encounter that trope, I typically ask for evidence the organization exists and find none.  The Wikipedia page suggests there have been more hoaxes than action. For comparison, I was in college during the time of the Weather Underground and a collection of other radical underground left wing organizations were responsible for 2,500 domestic bombings in 1971 and 1972 (5).  That included attacks on universities and munitions plants. There is no possible way that any organizations like those exist today.  Fourth, recognize that the mechanisms I am referring to are intertwined with rhetoric and a distorted sense of reality. The best example I can think of is the constant accusation that you must hate a politician because you disagree with them. That is a recent development in the political landscape and it is a direct product of projection. You attribute hate to someone else if you really hate them and (per Kernberg) may experience it at the same time, fear the person you are projecting onto, and feel the need to control that person.  You also don’t have to think about it too long to see that the person(s) doing this has to see themselves as being extraordinarily important in your life.  That is also not consistent with reality.

There has never been a time in my life when ignoring rhetoric and focusing on reality has been more important.  I hope that I have provided a few pointers on how to get there and am confident that most mature adults in the country can do this.  When that happens it will be the unifying factor we are all looking for.  

 

George Dawson, MD, DFAPA

 

 

 

References:

1:  PDM Task Force.  Psychodynamic Diagnostic Manual.  Silver Springs, MD.  Alliance of Psychoanalytic Organizations. 1980:  p. 643.

2:  Kernberg OF.  Severe Personality Disorders: Psychotherapeutic Strategies. Yale University Press, New Haven.  1984: p. 16-17. 

3:  Post JM.  The Psychological Assessment of Political Leaders. University of Michigan Press.  Ann Arbor, MI. 2003: p. 96.

4:  Post JM, Douchette SR.  Dangerous Charisma: The Political Psychology of Donald Trump and His Followers.  Pegasus Books, New York. 2019: p. 222.

5:  Burrough B.  Days of Rage: America’s Radical Underground, The FBI, and the Forgotten Age of revolutionary Violence.  Penguin Press, New York. 2015

6:  Lifton RJ.  The Nazi Doctors.  Basic Books, New York.  1986.

Letter to Gov. Walz About Guns

 

Dear Governor Walz,

 I am a psychiatrist and have practiced for most of my career in Minnesota. Much of that time was spent running an acute care unit at St. Paul-Ramsey and then Regions Hospital.  In acute care psychiatry we spend most of our time addressing psychiatric emergencies involving violence and aggression directed at self and others. The goal is to prevent injuries including suicide and homicide and we do a good job with that.  Addressing any associated firearms is part of that job.

I was driving around yesterday and heard on MPR that you may be planning to introduce legislature to toughen gun laws based on the recent tragic events.  I encourage you to do this and have written extensively about this issue and the surrounding politics.  It is quite unbelievable that nothing is ever done to address the problem solely because we have a political party that supports gun extremism.  I offer some posts off my blog to give you necessary data if you need it.

The first looks at the issue of permissive gun laws and how they affect the gun death rate of children and adolescents.  Firearm deaths are the number one cause of preventable deaths in this age group and the United States is the only high-income country where this is true.  In the study I reviewed, Minnesota is classified as a state with intermediate permissiveness in terms of gun laws.  In states in this category there were 1,424 excess firearm deaths.  States in the most permissive category had 6,029 excess firearm deaths.  I have a table in this post that compares Illinois, Minnesota, and Wisconsin as examples of strict, permissive, and most permissive gun law states:

https://real-psychiatry.blogspot.com/2025/06/pediatric-deaths-from-firearms.html

In a second post I address the issue of likely and unlikely causes of mass shootings.  There is always a lot of excuse making by gun extremists when these events occur.  Recently that has included blaming mental illnesses and even psychiatric treatments.  As an expert in treating aggression and violence I can attest to the fact that psychiatric treatment does not cause aggression.  Beyond that I would invite you to look at the data in this post clearly illustrating that the major variable in mass shootings is gun density.  Countries using the same number of antidepressants or more bracket the US in the first table and neither country has mass shootings and nowhere near the number of gun suicides or homicides. Even considering mental illness as a risk factor, people with that problem do worse in the US due to firearm availability.

 https://real-psychiatry.blogspot.com/2023/03/likely-and-unlikely-causes-of-mass.html

And finally, I have a few posts about gun extremism in the US and how it has evolved over the years.  We have gone from 19^th century local ordinances that require checking your firearms at the city limits to permitless concealed carry of much more deadly modern firearms.  And all of that is since the party pushing this agenda has no functional policies that would appeal to the electorate.  In fact, in one of my posts I point out that the same party that pushes gun extremism has pushed political violence.

Gun Extremism Not Mental Illness:  https://real-psychiatry.blogspot.com/2022/05/gun-extremism-not-mental-illness.html

Mass Shooters - The American Gun Extremist Superman:  https://real-psychiatry.blogspot.com/2024/08/mass-shooters-american-gun-extremist.html

Another Note on Gun Extremism - An Appeal to Grandparents:  https://real-psychiatry.blogspot.com/2023/01/another-note-on-gun-extremism-appeal-to.html

Current Political Violence In The USA:  https://real-psychiatry.blogspot.com/2024/10/current-political-violence-in-usa.html

You can find more posts on my blog by searching guns, firearms, or gun extremism. Good luck with your efforts to make Minnesota a safer place for all of us.

Sincerely,

George Dawson, MD, DFAPA

Additional Information:  I sent similar notes to both US Senators from Minnesota.

Photo Credit:  I took this shot of the crowd at the Minnesota State Fair on August 26, 2025. 

Pediatric Deaths From Firearms

 

If American society every becomes rational for any sustained period in the future – everyone living in the current epoch will be mocked.  We will be mocked for the absurd and obvious inconsistencies in society almost entirely driven by politics.  Guns, abortion, the discrimination and scapegoating of small segments of society, persistent racism, misogyny, a lack of concern for the disabled and disadvantaged, and a total lack of concern for the planet.  Sometime in the very near past – we stepped into a fantasy world where politicians could say anything – no matter how absurd, be believed, and get elected.

The lesson today is firearms and gun laws.  Over the course of writing this blog I have written about this many times. How the gun issue has been co-opted by one party and their judges.  That party has extremist views about gun laws and the Second Amendment.  Those extremist views endanger all of us and make the likelihood of ending school and other mass shootings impossible.

About a week ago, a paper came out in JAMA Pediatrics (1) that looked at the issue of permissive gun laws and pediatric mortality.  Guns in the United States are the number one cause of pediatric deaths in the country.  There are no other countries in the world where that is the case.  It speaks to these unique aspects of gun extremism in American culture and the degree to which people will rationalize gun access and laws that enable rapid deployment of guns with very little rationale.  Children and young men are dying in that crossfire and they have been for some time.

The research design of this paper was very interesting. It looks at the change in pediatric gun mortality over time stratifying states by their degree of gun permissiveness before and after the 2010 Supreme Court decision McDonald v. City of Chicago. In that case, a retiree and two additional plaintiffs brought action against the city of Chicago because they wanted to purchase handguns – but were not able to due to a citywide ban on issuing permits that began in 1982.  Details of the decision are included at the above link and my assessment is that the decision against the Chicago law was based on technical interpretations about whether gun ownership is a fundamental right. 

The overall effect of this decision was that many states changed their gun laws to make them much more permissive. Permissive gun laws are what I have been calling gun extremism.  Examples include mandatory issuance of gun permits and carry permits,  permitless carry laws, open carry laws (with or without permits including all types of firearms), stand your ground  or castle laws that say if you are armed you have no duty to retreat in certain environments, no bans on assault weapons, high-capacity magazine, or bump stocks, no red flag laws that remove weapons from individuals considered to be high risk, and no local laws that override state laws.  There is action in some cases to remove the ban on returning firearms to people convicted of domestic violence or drug charges.

The authors found that gun permissiveness correlated with excess pediatric mortality - and there was an increasing effect depending on the degree of gun permissiveness.  In the states with the most gun law permissiveness 6029 excess pediatric deaths and in the permissive category there were 1424 excess pediatric deaths.    

You do not have to be a public health researcher to figure out what is wrong with these laws.  They basically return us to the days of the Wild West, where it took the local sheriff to come up with laws that guns needed to be checked at the city limits.  People roaming the streets carrying high-capacity automatic weapons is a recipe for disaster.  The current televised real crime genre – is an endless source of stories about gun homicides that occurred because somebody was angry, had access to a firearm, and impulsively shot somebody.  In the case of children and adolescents there is the additional risk of accidental shootings, suicide, and in some well publicized cases holding parents responsible for giving their child access to a gun that is subsequently used in the commission of a crime by that same child. When guns are everywhere – gun tragedies follow.

In this paper the researchers group states into 3 categories based on how permissive their gun laws have become since the MacDonald decision.   The categories were strict, permissive, and most permissive based on a classification protocol available in this supplement.    States rated as strict (total of 9) include:  California, Connecticut, Hawaii, Illinois, Maryland, Massachusetts, New Jersey, New York, and Rhode Island.  States rated as permissive (total of 11) include:  Colorado, Delaware, Michigan. Minnesota, Nevada, New Mexico, Oregon, Pennsylvania, Vermont, Virginia, and Washington.  The remaining states were rated most permissive (total of 30) and include:  Alabama, Alaska, Arizona, Arkansas, Florida, Georgia, Idaho, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maine, Mississippi, Missouri, Montana, Nebraska, New Hampshire, North Carolina, North Dakota, Ohio, Oklahoma, South Carolina, South Dakota, Tennessee, Texas, Utah, West Virginia, Wisconsin, and Wyoming.

What might a head-to-head comparison of states from each category look like.  Here are three states from the upper Midwest – one from each category (taken from supplementary data from reference 1).

Illinois (strict)	Minnesota (permissive)	Wisconsin (most permissive)
2013: Concealed Carry Act - Allowed concealed carry of firearms. 2013: Firearm Concealed Carry Act - strict requirements for obtaining a concealed carry license. 2014: Private Sale Background Check Law - Required private sellers to verify buyer's FOID card with state police. 2018: 72-Hour Waiting Period Law - Enacted a 72-hour waiting period for all firearm purchases. 2019: Firearm Dealer License Certification Act - Required gun dealers to obtain a state license in addition to federal license. 2019: Red Flag Law - Allowed family or law enforcement to petition for temporary firearm removal from at-risk individuals. 2021: Universal Background Check Expansion - Extended background check requirements to all private firearm transfers. 2022: Ghost Gun Ban - Prohibited the sale and manufacture of unserialized and untraceable firearms. 2023: Protect Illinois Communities Act - Banned sale, manufacture, and possession of assault weapons and high-capacity magazines. 2024: FOID Fingerprint Requirement - Mandated fingerprint submission for FOID card applicants   FOID = Firearm Owner Identification Card	2003: Minnesota Citizens' Personal Protection Act - Established a "shall-issue" system for concealed carry permits. 2005: Stand Your Ground Law - Expanded self-defense rights, removing the duty to retreat in certain situations. 2014: Domestic Violence Gun Ban - Prohibited individuals convicted of domestic violence or subject to protective orders from possessing firearms. 2015: Suppressor Legalization - Legalized the ownership and use of firearm suppressors. 2019: Gun Violence Protective Order Law - Allowed family members and law enforcement to petition courts for temporary removal of firearms from individuals deemed a risk. 2021: Capitol Carry Notification Law - Required the Department of Public Safety to notify permit holders about their right to carry in the State Capitol complex. 2023: Universal Background Check Law - Required background checks for private firearm transfers, with some exceptions. 2023: Red Flag Law - Implemented an Extreme Risk Protection Order system, allowing courts to temporarily remove firearms from individuals deemed a significant danger. 2023: Safe Storage Law - Required firearms to be securely stored to prevent unauthorized access, especially by minors. 2024: Ghost Gun Regulation - Restricted the sale and possession of unserialized firearms and unfinished frames or receivers.	2011: Concealed Carry - Legalized concealed carry of firearms with a permit. 2011: Castle Doctrine - Expanded self-defense rights in one's home, vehicle, and place of business. 2015: Waiting Period Repeal - Eliminated the 48-hour waiting period for handgun purchases. 2015: Switchblade Legalization - Legalized the possession and carry of switchblade knives. 2017: Constitutional Carry for Knives - Removed restrictions on carrying knives, including in a vehicle. 2018: Extreme Risk Protection Orders - Implemented "red flag" law allowing temporary removal of firearms from individuals deemed a risk (Note: This may have faced legal challenges or implementation delays). 2021: Second Amendment Sanctuary - Some counties declared themselves Second Amendment sanctuaries, though not at the state level. 2022 (L): Campus Carry Proposal - Significant discussions about allowing concealed carry on college campuses, though it may not have been enacted. 2023: Universal Background Checks - Implemented background checks for private gun sales (Note: If not enacted, this was a significant proposal during this period).

 

Note that there is significant overlap in terms of gun permissiveness.  For example, all states now have concealed carry laws.  Illinois was the last state to legalize this but all 50 states legalized concealed carry within a period of 10 years.  The creates the obvious question of how we all survived without concealed carry for a period of 222 years after the Second Amendment was ratified?  Minnesota and Wisconsin both have stand your ground laws.  Stand your ground and castle laws are euphemisms for shoot first and ask questions later.  All 3 states have red flag laws that allow for gun removal from high risk individuals but only one state mentions domestic violence as a condition.  Illinois has a FOID (Firearm Owner Identification Card) requirement.  Minnesota used to have one in order to purchase firearms but currently the concealed carry permit serves that purpose. Minnesota also allows businesses to post whether firearms can be carried on their campuses – but there is no enforcement.  Any way you look at these comparisons – the last 20 years has resulted in an unprecedented growth in firearm access.

The study period was 1999-2023 and during that time there were 41,012 pediatric firearm deaths accounting for about 4% of the total mortality.  Expected mortality calculations were done comparing the pre-decision period (199-2010) to the post decision period (2011-2023) and excess mortality was determined.  Incident rates as deaths per million were calculated based on the populations in each study period.  The firearm mortality crude rate increased in 33 states (see Table. Incident Rates Pre– and Post–McDonald v Chicago With Incident Rate Ratios).  Suicide and homicide by firearms both increased.  The most permissive states had the greatest number of deaths due to firearm suicide and homicide..

That authors list three minor limitations to their study, but seem to omit a major one and that is a control or no-gun category.  That may seem like a truism – how can you have gun related suicides and homicides if you have no guns?  One estimate is to compare firearm mortality to peer countries like the graphic from the Kaiser Family foundation at the top of this post.  The US child and teen firearm mortality rate is 10 to 200 times that in peer countries. The same is true for adult gun homicides and suicides.  All of those thousands of excess child deaths are due to easy gun availability in the US that is getting even easier.

We have a grim reality of a country that is chock full of guns to the point that we are trying to establish a dose-response curve. We are doing that exercise in a landscape that is still driven by gun extremists wanting even more permissive gun laws. Common sense has clearly been suspended in favor of political convenience in the US when it comes to guns.  Until it returns America’s children will pay the price in the form of completely unnecessary deaths and the ruined lives and families of the both the victims and perpetrators.

 

George Dawson, MD, DFAPA

 

References:

1:  Faust JS, Chen J, Bhat S, Otugo O, Yaver M, Renton B, Chen AJ, Lin Z, Krumholz HM. Firearm Laws and Pediatric Mortality in the US. JAMA Pediatr. 2025 Jun 9:e251363. doi: 10.1001/jamapediatrics.2025.1363. Epub ahead of print. PMID: 40489107; PMCID: PMC12150223.  

Graphics Credit:

Excellent analysis of child firearm death rates compared to peer countries is from the Kaiser Family Foundation at this link:  https://www.kff.org/mental-health/issue-brief/child-and-teen-firearm-mortality-in-the-u-s-and-peer-countries/

Use here is per the CC BY-NC-ND 4.0 license:  https://creativecommons.org/licenses/by-nc-nd/4.0/

No changes were made to this graphic downloaded on June 16, 2025.

Social Media Discovers Managed Care and Rages - Or Not?

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

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

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

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

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

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

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

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

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

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

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

 

George Dawson, MD, DFAPA

References:

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

 

Addendum:

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

Current Political Violence In The USA

 

One last political post before the election.  I have been working on a graphic on the political violence scenario and how it has drastically changed in the past 8 years. Part of the issue with aggression and violence is that it is generally very difficult for most people to talk about. They lack the vocabulary and for a long time there was the suggestion that it may have been the fault of the victim.  It took far too long to recognize that this was a dynamic in domestic violence situations and modernize those laws to set limits on the violence and ultimately prevent homicides. Another factor that recently came to light was the issue of firearm access by perpetrators of domestic violence. A recent court case challenged the ban on firearms possession by these men and contrary to the general trend of increasing gun extremism that ban was upheld (United States v. Rahimi).

I do not intend to elaborate on what is contained in the table. I encourage any reader to do your own research on what I have posted.  I have extensive references, but with these political posts – most people do not seem to be interested, especially when they run counter to the conventional wisdom or prevailing political rhetoric. Instead I will make some general comments on aggression, violence, and its effects.

As an acute care psychiatrist, I was faced with the problem on a daily basis.  Aggressive and violent people brought to my care generally by the police or paramedics.  The people I saw were involved in fights, shootouts, violent confrontations with the police, homicides (real and attempted), vandalism, threatening behavior, and suicide attempts.  The behaviors were extreme enough to precipitate 911 calls and for emergency responders to bring them to my hospital.  Not all hospitals take these calls because not all hospitals are set up to deal with violence and aggression.  The staff and the physicians need to approach it as a treatable problem.  That is the first lesson. Violence and aggression – even when it is caused by psychiatric illness is not considered a medical problem.  It is considered a moral problem.  In other words – the person intended to commit violent acts because they are either morally deficient or simply have no moral code. The vast majority of people I treated in this situation had a severe psychiatric disorder and did not know what they were doing. They could not appreciate the wrongfulness of their act.

In order for the person with aggression to be admitted to my unit – they had to have a psychiatric diagnosis rather than just criminal behavior.  That is an imperfect triage criterion and in a few cases, people were admitted with either criminal behavior or aggressive behavior that was goal directed to get what they want. Common examples include intimidating people for money or sex or just disagreeing with them. The associated excuses would be: “Well he/she had it coming.”, “They were just there when I went off.”, or "They did not give me what I wanted.”  These are all attitudes that people use who see others as strictly a means to an end. Other people are just there to be manipulated to get what they want. They are not seen as people just struggling along like everyone else with important goals and relationships. Resentment is a common theme and many of the perpetrators see themselves as getting a bad deal in life, not getting what other people have, and that may include loyalty in relationships.

All of that is a backdrop to the actual aggression or violence.  No matter how egregious that violence and aggression is – it is very common to see it minimized after the fact. That minimization can take the form of complete denial “I wasn’t there” to partial denial “I did not mean to kill him.”

On the less obvious end – aggression can include threatening behavior that involves appearing to be very angry and using profanity in someone’s presence for no clear reason, throwing objects, destroying property, right up to specific threats to kill or injure a person.  There is some confusion over how well these behaviors predict actual violent acts that result in injury but there are two considerations.  The argument has been made that psychiatrists really can not predict violence very well and that may be true for routine evaluations of relatively stable people in outpatient setting.  The prevalence of violence in that population is so low that I would not anticipate being able to predict it.  That changes in an acute care setting where the transition from verbal aggression or aggression toward property to physical violence against people happens very quickly.  The goal is always to stop it before the physical phase.

 At the societal level, the laws have slowly been changing to catch up.  Domestic violence laws lagged for decades until many states adopted the law that if a call occurred, an arrest had to be made. The law about domestic violence convictions leading to no gun possession was a similar development.  Finally, terroristic threat laws made it illegal to threaten people before any physical violence occurred. These terroristic threats laws have developed over the past 30 years and are really a major development compared with the idea that the person making the threats hasn’t done anything yet and we can’t do anything unless they do something.  It is hard to imagine how many people were directly threatened and heard that response from law enforcement.

The driving force behind these legal changes was recognition of what the victims were going through. In some cases, years of harassment, needing to take extraordinary measures to assure their safety, and suffering the effects of this extreme stress in the form of chronic insomnia, anxiety, panic attacks, post-traumatic stress disorder, depression, and physical symptoms.  In many cases jobs and families were disrupted.

The groups I named in the above graphic have been through all of that and more.  In the Insurrection there were estimates of 140-170 officers injured and 5 dead – one from injuries sustained at the scene and 4 subsequently by suicide.  I have not seen any specific reports of the number of police affected by mental health symptoms but expect it is significant. Various efforts have been made to minimize the event and the media seems to go along with them. Even though the popular press does say that one party and one candidate has been lying continuously that the 2020 election had been “stolen” – very little is done on a day-by-day basis to confront this lie.   Nobody is saying that we have a Presidential candidate who attempted to overthrow the elected government of the United States and currently has operatives in place to disrupt the current election. That may be why 1 out of 3 election workers report being harassed often to the point that they quit volunteer jobs that they have been in for decades. 

The remaining groups in the table are self-evident.  We have all seen people screaming and threatening in school board town hall meetings.  There are substantiated reports of severe threats to public health officials and disaster workers. This is all politically motivated aggression and violence that is precipitated by misinformation and political rhetoric. A good recent example was the attempt to connect anti-immigrant rhetoric to hurricane relief and suggest that funds were being diverted to undocumented immigrants. Gun extremism and abortion clinic violence predates the most recent cycle but are good examples of the process. Make emotional inaccurate claims, blame somebody for the problem even if they are law abiding, and let the chips fall where they may.  This process just keeps repeating itself with a party that always doubles down, never acknowledges they are wrong, and never acknowledges what they are really doing – dividing people and turning them against one another.   This line of rhetoric also distracts from the fact that the party in question really has no acceptable policy.  When their self-proclaimed genius economic policy was vetted by Nobel laureates in economics it was found to be seriously deficient.

When I posted this graphic on another site I was immediately confronted with the question about violence and crime created by undocumented immigrants.  I responded with a study done by the Department of Justice based on the arrest records of the most right wing state in the US – Texas. That study shows that these people are much less likely to be arrested for violent or property crimes than citizens born in the US.  Even without knowing about it – it makes sense. The people at the southern border are fleeing corrupt governments and criminals in South and Central America.  The last thing they want to see happen is to be deported back to their country of origin. Because they are undocumented, they need to maintain as low a profile as possible. That would include no encounters with law enforcement.

The idea that political violence could be compared to violence by undocumented immigrants is a feature of the rhetoric used to obscure the real problem. That real problem is that there should be no political violence at all in the United States.  Politics in this country is supposed to operate on the peaceful transfer of power and no party using its power to intimidate either the voters or the election process. We are way past that at this point and it is all on one party.  The political violence is a direct effect of dishonesty and manipulation.  There has not been an adequate effort by the opposition to push back in many of these areas and that leads me to have grave concerns about the upcoming election.

I am hoping that the vote rejects political violence and all that involves so that people can feel safe and we can start to focus on real problems instead of contrived political problems.  You can get rid of political violence by voting it out - at least in this election.  It will be a worse problem to get rid of if it becomes institutionalized.

 

George Dawson, MD, DFAPA

References:

1.  Hutzler A.  Trump takes dark rhetoric to new level in final weeks of 2024 campaign: ANALYSIS.  ABC News.  September 30, 2024.  Link

Supplementary 1:  Unfortunately I have to keep adding boxes.  The latest is a direct comment from former President Trump.  Before anyone suggests he was just "joking" or "nobody takes him seriously" or tries to explain it in any other way consider this.  This is unprecedented discourse in an American election.  It follows Trump threatening to use the military against his perceived "enemies from within."  It should be fairly clear that he considers political opponents or in many cases people who just disagree with him as enemies.  Violent rhetoric aside - this is not an attitude any reasonable politician can have when they are supposed to represent all of the American people.

American Democracy is at Best A Semi-Rational Process

 

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

 

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

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

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

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

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

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

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

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

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

and

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

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

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

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

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

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

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

 

George Dawson, MD, DFAPA

 

References:

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

 

Graphics Credit:

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

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

 

We Live in Different Realities….

 

 

“We don’t have to like the reality that we live in, but it is the reality we live in.”  JD Vance comment on Apalachee High School shooting in Georgia that left 4 dead and 9 injured.

 

The school year began with a school shooting and all the associated irrationality of mass shooting in the US.  One of the most irrational comments is posted above and was made by the MAGA party vice presidential candidate.  When I say irrational – I mean that what Vance refers to as “the reality we live in” was in fact created by his party, its judges, gun extremists (who are undoubtedly all from his party), and the gun lobby in Congress.  They have created a parallel universe where there are minimal to no gun regulations, people can openly carry weapons, people are encouraged to use firearms, the country is saturated with guns, and the expectation that there will be no problems.  If there are problems it is always due to somebody else – as further elaborated by Vance:

“I don’t like that this is a fact of life.  But if you’re—if you are a psycho, you want to make headlines, you realize that our schools are soft targets. And we have got to bolster security at our schools… We’ve got to bolster security so if a psycho wants to walk through the front door and kill a bunch of children, they’re not able to.”

As far as I can tell nobody has confronted his statement about bolstering security in schools.  We just witnessed former President Trump’s near miss as he was protected by a full contingent of secret Service Agents and snipers. Even that impractical level of protection at every school in the country is no assurance that children will be safe.  In the case of this incident, an armed security officer at the school engaged the shooter in about 120 seconds and forced him to surrender. By that time, he had already shot 7 people.  His other theory is that the increasing numbers of mass shootings are due to increasing numbers of "psychos".  That term really has no meaning other than a pejorative one.  If he is referring to mental illnesses there is no evidence that mental illnesses are causal in mass shootings.  He leaves out the most likely causes of gun extremism and a mass shooter culture as well as easy availability of guns.

The other argument that seems to be gaining traction is blame the parents. As I predicted this is being sold as a solution to the problem rather than going directly at the culture of gun extremism. I heard several television commentators saying this was a “wake up call” to parents who allow their children to have access to guns.  I really doubt that it is.  The analysis will always be complicated by how the parents are portrayed in the media, but even without the parents in the picture we still have very easy gun access and a cultural basis for mass shootings that nobody ever addresses.  Having been a kid, I can’t think of a teenager who could not defeat their parents access prevention security measures – whether it was reading material, phone access, or weapons.

Many of the same commentators are also blaming smartphones. The context seems to be that parents are not able to deny their children access to smartphones anymore than they can deny their access to guns.  They cite as an example recent legislation that bans smartphones in schools.  Apparently it is much easier for politicians to limit smartphone access than it is to limit gun access.  Smartphones are not nearly as dangerous.

The blame the parent argument may have some application, especially in states where the gun laws specify that parents are responsible for their child’s use of a firearm. In many cases those laws are currently complicated by the fact that a child may possess a gun in certain circumstances – even if they are not eligible to purchase one. The smartphone argument is a weak one.  Banning smartphones in educational venues and where specific decorum is required – but smartphones clearly have nothing to do with mass shooting.  Not being able to say “No” to your kid doesn’t either. Gun extremists and the mass shooter culture has everything to do with it and it requires serious action.  It is time to get back to reality and acknowledge what we already know from American history.   Gun regulations save lives and lots of them.

I will cite what is known by most people in my generation and a frequent reference to the Old West that I have used before.  In the 1960s, 1970s and the years before – there was no mass shooting problem in the US and certainly no problem with children being shot in schools. Many middle school students took the National Rifle association Hunter Safety course.  In that course safe use of firearms was emphasized including treating every gun like it is loaded and never pointing a gun at anyone.  The middle schoolers in these courses were about the same age as the most recent shooter.  They had no access to high-capacity semiautomatic weapons or handguns.  The basic idea was – learn how to safely handle guns and use them for hunting and target shooting. There was no discussion of needing them for personal protection or needing to always carry them. There were no politicians promoting gun extremism.

There is evidence that the period of gun safety extended back to when frontier towns noticed that armed citizens were problematic and law enforcement started to insist on voluntary disarmament when people rode into town.  I have posted the Tombstone Arizona statute from 1881. There is also an article in the Smithsonian (1) that outlines some of the highlights of early gun control law including the association of the Gunfight at the OK Corral with Tombstone’s gun law.  Strict gun control laws existed in several other towns and the 1881 law in Tombstone is much stricter than the laws that exist today.  Today you can carry a gun without a license or permit in Tombstone. There was a contrast between frontier towns that had disarm laws and those that did not – with the latter having a higher gun homicide rate.  

A political gun extremist movement has endangered the lives of every American and made schools an unsafe place. We are well past the time to get rid of these extremists and their gun violence rhetoric.  The reality that most Americans want to get back to is to be able to walk down the street or go to school and not have to worry about getting shot.  That knowledge goes back to the Old West and it kept us in that reality right up until the 1970s.  The only strong message that needs to be sent here is that gun extremist politicians and excuse makers need to be voted out.  Even then there will be a lag time because of the gun extremist judges they have appointed.

Apart from gun extremism as a bizarre populist issue on its own – it also reinforces autocratic ideology.  The autocrat playbook reinforces political violence as a good idea.  That includes all the autocrats of the 20^th and 21^st century who typically target the “elites” in their population and encourage political violence against them.  The practical way it plays out today is self appointed militias showing up to intimidate elected officials,  self appointed law enforcement showing up to intimidate protestors, and verbal threats that the more heavily armed will prevail in any controversial elections.  

Never doubt that there is a gun extremist agenda in the United States.  I have pointed out the features in many posts on this blog. The gun extremist agenda is currently indistinguishable from the MAGA agenda.  It is more than a little ironic that the mass shooters it creates are labelled “monsters” and “psychos” by members of this political movement.  That is the reality that JD Vance is talking about and it will continue as long as these authoritarian politicians are elected and maintain that reality.    

 

George Dawson, MD, DFAPA

References:

 1:  Jancer M.  Gun control is as old as the Old West.  The Smithsonian Magazine.  https://www.smithsonianmag.com/history/gun-control-old-west-180968013/

 

 Graphics Credit:  Click directly on the photo - it is linked to Wikimedia Commons and all of the information about this phot and the CC license.