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

Supplementary 1:  Unfortunately I have to keep adding boxes.  The latest is a direct comment form former President Trump.  Before anyone suggests he was just "joking" or "nobody takes him seriously" or tires 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 form 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.  

It’s Not The Heat – It’s The Wet Bulb Global Temperature (WBGT)!

Despite the current election cycle and massive denial of climate change by the MAGA party – the average temperature of the Earth is getting much higher. The ten warmest years on record are the last 10 years (see graph above).  That is corresponding with the expected melting of glacial ice, increasing sea surface temperatures, and higher sea levels. It is equally obvious that the necessary measures to reduce carbon dioxide in the atmosphere are not being taken.  We can therefore expect future generations to experience the burden of excessive heat, unstable weather patterns, flooding, crop shortages, and all of the economic and international instability that will occur.  I don’t think it is a stretch to see this as potentially catastrophic to civilization.

Of all those weather related phenomena – extreme heat and humidity are the number one cause of death.  Mortality due to heat stroke is increasing every year. This was the first year that I heard frequent stories about hikers perishing from the heat.  The CDC estimates that about 1200 people a year die from extreme heat and they have a web page dedicated to providing resources about this public health threat. The EPA has a site that looks at heat related deaths over the past 20 years and although they are higher – they discuss the issue of variable reporting, largely due to inconsistent criteria about what is called a heat related death.  There is a good chance that heat related deaths are underreported and attributed to other causes.

Modern reviews of heat stroke and heat related illnesses (1-3) suggest that there are two conditions that are clear emergencies and varieties of heat stroke – classic heat stroke and exertional heat stroke. Classic heat stroke develops in people exposed to heat who may be predisposed because of chronic illness, medications, and an environment that is excessively hot.  These patients are typically elderly.  Exertional heat stroke occurs when heat is generated by muscle exertion in hot weather and that leads to excessive body temperature. In both cases emergency cooling is a critical treatment along with fluid volume replacement if that is an issue.  Heat stroke is a multisystem inflammatory disease that leads to a combination of autonomic, cardiovascular, and metabolic responses that can lead to organ failure and death.  Mortality is high - 80% in classic heat stroke and 33% in exertional heat stroke (3) if there is no immediate treatment.  The issue of immediate treatment is problematic because heat stroke can cause compromised mental status including loss of consciousness – further exposing the person to prolonged heat exposure.  Preexisting cognitive compromise complicates both recognition of heat related illness and getting timely care.      

The issue of heat, humidity, and heat dissipation from the human body is an exercise in physical chemistry.  Evaporative cooling is one of the ways that mammals cool their bodies to maintain a stable body temperature.  In humans the other way is skin surface vasodilatation and heat transfer from blood.  Every time water changes phase (solid -> liquid -> gas) there is an energy requirement that is termed enthalpy in physical chemistry. The enthalpy or heat of transition from liquid to gas is 40.67 kJ/mol.  That means that we can calculate the amount of water necessary to maintain cooling at an amount of energy production. The relevant variables include how much energy the person is expending, ambient air temperature, and the relative humidity since the last two affect the amount of water that can transition to the gaseous phase.

All these variables can be considered form a meteorological viewpoint using the concepts of heat index and wet bulb global temperature. On this prototype site you can chose either value, click on your location on the map (it scrolls), and get the heat index or WBGT.  As an example, two days ago the temperature at my location went firmly into the danger zone as indicated by this tracing that I downloaded at the time. Suggested activity levels and precautions are available on the site for the WBGT values on the curve over the course of the day.  Another way to look at WBGT is that it is the temperature where evaporative cooling starts to fail and that is the measure of danger.

WBGT was recently assessed looking at wet-bulb temperature adaptability thresholds in health young research subjects (4).  Under experimental conditions they looked at subjects under moderate metabolic load and determined the critical wet-bulb temp beyond which the heat stress could no longer be compensated for.  The researchers looked at the proposed critical wet bulb temp of 35ºC (95 Fº)(threshold wet bulb temp) and discovered that it could be considerably lower and that it was unlikely that a single critical temperature for all conditions could be found.

Irrespective of the reporting issue, public health officials are concerned about ambient temperatures and the heat island effect of concrete in large cities where emitting energy can raise the ambient temperature up to 7 degrees hotter than the surrounding area.  They have identified high risk populations including the elderly, people with inadequate housing, and people with no air conditioning. That last category can rapidly expand whenever weather conditions effect power transmission and cut electrical power to large populations.  We just experienced those conditions in Minnesota shortly after a burst of peak temperature and humidity conditions.

Many people with chronic mental illnesses are in the high-risk category.  Compromised judgment whether due to effects on cognition or more focal problems with judgment and problem solving can lead to potentially fatal situations at either end of the temperature spectrum. During the recent heat emergency, I witnessed several people wearing excessive clothing and at the same time expending a lot of calories.  They were in a weather zone where the National Weather Service (NWS) suggested minimal activity. Chronic mental illness also creates the risk of no housing or inadequate housing. In extreme heat – the lack of air conditioning can create an emergency situation for many people.  

At the policy level (5) there have been some approaches to try to assure the safety of people that might experience exertional health stroke.  They are in the form of mandated breaks, access to water, and access to air conditioning.  They are far from universal and in some cases there has been political opposition based primarily on anti-science (climate change, human physiology) ideology and ignorance. It is a reckless approach to humanity but consistent with gun extremism views held by the same groups. 

At the individual level, psychiatrists need to be aware of their patients’ living conditions and their theoretical susceptibility to heat related illnesses.  That requires an integrated view of their current health status, medications, cognitive status, functional capacity, physical activity level, and specific access to air conditioning. Assertive Community Treatment (ACT) teams will have an advantage is knowing first hand what the living conditions are. In the past I have worked out a plan for people to go to an air-conditioned shopping mall depending on the weather conditions. Some people will find this difficult and could benefit from a visit and prompts from a case manager. A call list of people who may be at risk could be useful for case management teams.  As more municipal areas develop cooling shelters – a more formal referral process might be possible.

In the short term, a focus on the medical and social aspects of patient care will be necessary to mitigate the potential lethal risks of heat related illness. It is a necessary role for all physicians as the climate disaster unfolds.

 

George Dawson, MD, DFAPA

 

1:  Savioli G, Zanza C, Longhitano Y, Nardone A, Varesi A, Ceresa IF, Manetti AC, Volonnino G, Maiese A, La Russa R. Heat-Related Illness in Emergency and Critical Care: Recommendations for Recognition and Management with Medico-Legal Considerations. Biomedicines. 2022 Oct 12;10(10):2542. doi: 10.3390/biomedicines10102542. PMID: 36289804; PMCID: PMC9599879.

2:  Epstein Y, Yanovich R. Heatstroke. N Engl J Med. 2019 Jun 20;380(25):2449-2459. doi: 10.1056/NEJMra1810762. PMID: 31216400.

3:  Sorensen C, Hess J. Treatment and Prevention of Heat-Related Illness. N Engl J Med. 2022 Oct 13;387(15):1404-1413. doi: 10.1056/NEJMcp2210623. Epub 2022 Sep 28. PMID: 36170473.

4:  Vecellio DJ, Wolf ST, Cottle RM, Kenney WL. Evaluating the 35°C wet-bulb temperature adaptability threshold for young, healthy subjects (PSU HEAT Project). J Appl Physiol (1985). 2022 Feb 1;132(2):340-345. doi: 10.1152/japplphysiol.00738.2021. Epub 2021 Dec 16. PMID: 34913738; PMCID: PMC8799385.

5:  Burton A.  Energy justice for all: keeping disadvantaged populations cool in a heating world.  Federation of American Scientists: https://fas.org/publication/energy-justice-keeping-cool/

6:  Knochel JP. Heat stroke and related heat stress disorders. Dis Mon. 1989 May;35(5):301-77. PMID: 2653754.

This was the first comprehensive review I read on the topic.  I was a subscriber to Disease-a-Month and the Medical Clinics of North America early in my career - based on recommendations from an Internal Medicine resident who I worked with.  This remains an excellent review of the topic.  

Graphics Credit:

National weather Service (weather.gov) for all except for the North Carolina High School Athletics Association as noted. 

 

 

 

Mass Shooters - The American Gun Extremist Superman

I had dinner the other night with a long-time friend and psychiatric colleague.  She and I ran an acute care unit for many years where we were charged with assessing and treating some of the most difficult problems in psychiatry. By definition, that also means the associated social problems.  That work included a significant number of civil commitments and in Minnesota associated hearings about medications.  The conversation turned to politics and then the recent attempted assassination of Trump.  Before I could say anything, she commented about how absurd it was that there was endless speculation in the media about “motive” and the fact that there was no motive. I agreed with her completely on that point.  What motive can you have for picking up a high-capacity military weapon and deciding to shoot and kill someone and anyone else who happens to be around?  And of course – why does it predominately happen in the US? 

As I pondered our conversation over the past couple of days and what I have written here about it – I came up with the idea of the American Gun Extremist Superman. This is not a traditional superman role or even the antihero role.  It is a superman role that can occur only in a culture of gun extremism.  I have written in the past about how this is quite definitely a cultural problem and the people who have been the source of the culture – extremist politicians, judges, and other gun extremist advocates largely blame everything else.  Incredibly they blame the lack of an armed staff in schools, a shortage of firearms in the most heavily armed country in the world, and more recently law enforcement and parents. They never examine the fall out of gun extremist policies that have been accumulating over the past 40 years.

Here are the features of the gun extremist superman that I have so far.  They are not diagnostic criteria by any means.  This is a societal and cultural problem more than anything.  It obviously exists only in the US.  There are undoubtedly people with psychiatric disorders who acquire these traits – just like people with psychiatric disorders assimilate other social and cultural traits.  But a psychiatric disorder does not explain most of these shootings.  I am using the pronoun he in these cases for the obvious reason that practically all of the shooters are men and boys.   

He is disgruntled and dissatisfied:  This is a common nonexplanation for mass homicide. It is basically a marker for what causes an unexplainable behavior.  When you study human behavior, these changes can occur from internally driven psychological states, external states, and all points in between.  To what extent is their insight, judgment, and decision making affected? To what extent does their moral decision making have an impact on what is occurring?  It is complicated by what is known about a person’s baseline.  For example, are they quiet and non-disclosing about their internal states or are they more demonstrative?

He has no problem at all attributing his state to the actions of others even when that is completely displaced.  In other words, displaced onto completely innocent coworkers, bystanders, school children, etc.  In psychiatry we call this projection and historically it is listed as a defense mechanism.  It is typically seen in persons with psychotic disorders and moderate to severe personality disorders.  It is a common experience to feel like you are being unjustly blamed during interactions with people using this mechanism or in the extreme case where that person is reacting to you as though their accusations are true.  Even though it is difficult to research this mechanism in mass murders – it seems intuitive that it has to exist at some level given the discrepancy between their real victims and the purported abusers (if any).

He knows that there is a burst of fame associated with each shooting and endless speculation about his motivations.  Although there is little information about the Trump shooter – it is known that he had details about a previous mass shooter on his electronic devices and this has also occurred with previous mass shooters. Anybody experiencing the news cycle in the US following a mass shooting notices a flood of information and speculation about that shooter that can go on for weeks followed by other bursts from associated court cases, documents, computers, web sites documenting mass shootings, legislation, and scientific literature.  Mass shooters seem to be guaranteed immediate and sustained notoriety – despite some concerns expressed in the literature that this is reinforcing the behavior.  The psychology of mass shooters is difficult to investigate, but I would not be shocked to learn that revenge fantasies go hand-in-hand with the expectation of notoriety from the act. 

He feels some justification by identification with previous mass shooters and cultural revenge themes.  As noted above many aspiring mass shooters have immediate access to the mass shooter literature as well as a wealth of revenge-based video games and movies.  The preponderance of this information depicts the shooter as the good guy meting out justice and revenging either his own victimhood (real or imagined) or that of his loved ones.  A secondary theme is that the usual channels of justice – law enforcement and the courts are too weak, do not apply to him, are too slow, or too negligent to be useful.

He sees it as a singularly masculine activity – especially with the use of firearms.

Most of the cultural figures engaged in this activity are men.  Armed men are typically the graphic elements of disaffected groups of society but their rhetoric has creeped into the political mainstream.  You don’t have to look too hard to find opinion that in the battle over “gun rights” – the correct interpretation of the Second Amendment will go to the winners of an armed insurrection or that the more heavily armed political party will “win.”  In that atmosphere was it an accident that we witnessed an insurrection on January 6^th?  Nobody steps back to point out that gun rights are there in the Second Amendment and the real battle is between gun extremism and common-sense guns laws.  In the common discussion nobody has advocated to take guns away from law abiding and responsible citizens.  At this point the US is awash in guns to the point that collecting all of those guns or buying them back is impractical.

Societal reinforcement of the Gun Extremist Superman. 

At first that seems like an extreme idea.  How can American culture and society reinforce this behavior? I have touched on the very real aspects of gun extremism and the cultural aspects that are reinforcing but there are others. Whenever mass shootings occur – politicians show up make the typical statements about “sick individuals”, offer “hopes and prayers”, and in some extreme cases have encouraged the affected communities to “move on.”  Mental health becomes a distraction, when politicians use it as a cause for the incident but never do anything constructive to address it.   The condemnation of the shooter is trivial compared with what has occurred. And no effective measures are ever suggested or accomplished. If anything, many politicians come up with a series of rationalizations about why the shooter was not stopped – the teachers were not armed, law enforcement response was inadequate, the only way to stop a bad man with a gun is a good guy with a gun, etc. Specifically, no measures to counter gun extremist laws are ever suggested and we are supposed to pretend that getting as many guns out on the street is a remote problem from the problem of mass shootings.  The real message to mass shooters is that “we are not going to do anything to stop or interfere with you.”

There is an additional message that is the direct result of gun extremism and that is – shoot first and ask questions later. Stand your ground and castle doctrines or statutes are a relatively recent development in the gun extremism landscape.  Stand your ground statutes basically say that there is no duty to retreat before using deadly force. Before these laws self-defense laws included the provision that the person who is unlawfully attacked needs to exercise judgment to try to avoid the use of deadly force by retreating if necessary.  Stand your ground laws were passed initially in 2005 in Florida and since then these laws exist in 38 states. The details are available at this site, including references to the fact that it probably increases the crime and homicide rate.  Although these laws were passed primarily in the past 20 years, they are the culmination of gun extremist rhetoric that has emphasized the need for people to be armed and dispense justice with firearms.  My conceptualization of the mass shooter is that he likely believes he is dispensing justice, even though nobody would agree with that premise.

The additional cultural change that preceded stand your ground was the idea of the armed citizen.  In the 1960s, the people who owned guns were predominately hunters.  The focus of the National Rifle Association (NRA) was hunter safety. When I took that course one of the mainstays was never pointing a gun at a person and always assuming a gun was loaded.  As firearms become more important as political rhetoric there was a sudden shift to the idea that there needed to be more guns out there for personal protection.  Since then there has been a steady escalation in gun extremist rhetoric and the idea that there are defined preconditions for shooting someone.

Psychosis is not an exclusion from societal or cultural factors:  Although the majority of these shooters are not mentally ill there is a lot of confusion over whether mental illness excludes the person from societal and cultural factors - making the psychosis in itself an explanation for the behavior.  It does not.  Just as computer chips, microwaves, and surveillance satellites were incorporated into delusions as they became incorporated into society - gun extremism has the same effects.  There is no reason that they and the folklore of mass shooters cannot be incorporated into a delusional system of thinking and acted upon.  In other words - there is no de novo psychosis of mass shooting - it happens in a gun extremist society.

All of the above elements are more important to him than self-preservation.  Many mass shooter incidents occur with the death of the shooter by homicide or suicide.  The high mortality rate suggests that mass shooters are unconcerned about their own life in carrying out their actions. This information is readily available to potential mass shooters and I would argue is part of the Gun Extremist Superman stereotype.  

He has easy access to high-capacity firearms – both handguns and rifles. Easy access to legally purchased firearms is well documented in many of these cases.  In some cases the firearms are borrowed and in other cases they are purchased from licensed firearms dealers.  One of the common gun extremist slogans is “if guns are criminalized only the criminals will have them.”  It is obvious that firearms are legally available at this point to anyone who wants to commit a serious crime like a mass shooting. It is also obvious that there are loopholes that allow gun purchasers to bypass existing laws.

What I have described here is a Nietzschean superman who clearly rejects traditional moral values of society and adopts his own – even though they are morally reprehensible to almost everyone else.  There are currently numerous patterns in American culture and society that reinforce this pattern of activity.  We are on a course for that to continue unabated.  It may worsen as the pattern of gun extremism worsens.  There are two potential solutions as far as I can see.  Reverse gun extremism back to the gun rights laws of the 1960s or preferably the 19^th century.  If the 19th century seems  too radical - see the Tombstone ordinance at the bottom of this post.  A second more public health focused measure would be on mass homicide prevention – by identifying the problem and trying to intervene while researching it.  

At the time I am writing this - neither intervention seems likely.

 

George Dawson, MD, DFAPA  

Supplementary:  If you have any doubt about the lack of motive for most firearm related homicides - I suggest watching crime TV like The First 48.  These shows typically have investigations by experienced homicide detectives that include interrogations of  suspects, witnesses, and family members.  In some cases court proceedings are included. The majority of cases are attributed to senseless violence and that typically means somebody got angry, there was a firearm available, and it was used to commit homicide.  Mass homicides can be viewed as taking the senseless violence theme to the next level.  Senseless violence is a predictable outcome of widespread gun availability and gun extremism. 

What Do Readers of This Blog Want To See?

 

I thought I would ask basically to see if I can be more helpful.  My interest in writing this blog came about because I had many people ask me what I was reading.  They seemed to find my information sources to be interesting. A secondary interest of mine is making sure that the best possible information is available to clinicians who are on the front lines making decisions each day.  Thirdly, the analysis of research whether it is basic science or clinical research is also an interest - both the scientific measures but also the rhetorical aspects.  Many people don't think that rhetoric enters into medicine and science. If you are a psychiatrist we have been contending with rhetoric for decades whether we want to or not and it has extended into literature that most would consider to be scientific.  There are a lot of posts about that rhetoric on this blog.  Fourth - I post about society, culture, and politics and how that impacts us.  I have frequent posts on the cultural effects on behavior - with many posts on my hypotheses about how gun extremism affects us all and is associated with the American mass shooter phenomenon.  Fifth - I have posts on diagnostic reasoning and taught a course to medical students about this for a decade in the past.  I try to tie in diagnostic thinking in psychiatry as a comparison.  Sixth - I have done book reviews on poetry with psychiatric themes and consciousness  and am currently reviewing another poetry book, Keith Rasmussen's book on ketamine, and a book on spirituality where I hope to illustrate a path to connecting that to psychiatry.

My most viewed page recently has been the updated review of systems for psychiatrists.  This is actually a tool I use in clinical practice and there are several other pages like it.  It has recently been viewed over 31,000 times - but I think at some point Blogger (the Google interface that this is published in) - stopped counting page views from virtual private networks (VPNs) by the page and only counts them in aggregate - where there are about 2.1 million views.   Additional highly viewed pages about clinical psychiatry include 2000 Words About the Last Ten Minutes of a Psychiatric Evaluation and Additional Work on the Review of Systems for Psychiatrists.  

Posts that are currently pending include:

1:  Updated post on Neanderthals and why they disappeared.  Paleogenetics is a fascinating read and it has implications for human illnesses, evolutionary aspects of psychiatry, and the evolution of man. 

2:  Review of the poetry book Coming to Love My Darkest Places by Jennifer Kelly. 

3:  Review of The Varieties of Spiritual Experience by David B. Yaden and Andrew B. Newberg.

4:  Review of Ketamine: The Story of Modern Psychiatry's Most Fascinating Molecule by Keith Rasmussen.

5:  Continued posts on the rhetoric of medicine and psychiatry including the theory of that rhetoric.

6:  Continued posts on the importance of biological theory to psychiatry.  I am referring to theory that originates in biology rather than the usual biological hypotheses in psychiatry although they are not mutually exclusive. I hope that I give the impression that I am not very impressed with the proliferation of purely philosophical ideas about the field, especially from people who have never been trained in psychiatry or medicine.  

7:  A musculoskeletal case including images (CT, MRI, bone) with a discussion of complex misdiagnosis and how all of that applies to psychiatry.  

I will avoid a top ten list of what is coming, but that is what is percolating right now. I tend to work better when I am thinking (and writing) about many things at once.  My motivation for this brief post is too see if there are any topics that readers would either like to see or like to see elaborated on.  They can be clinical or theoretical - medical or psychiatric. Feel free to send me your ideas either posted here or to my direct email address. 

I would also like to address two related topics.  The first is the use of these blog posts.  I think most people read them for their own interest, but some have been incorporated into books.  Everything on this blog is Creative Commons licensed.  That means it can be shared for no charge in just about any medium that you want it to be.  The only stipulation is that you cite me and this blog as a source.  I have found myself in the awkward situation of being at a conference and seeing my blog pages projected by a prominent researcher without referencing my work. I do not make any money writing this blog.  I have no paid subscribers or advertisers and pay all of the expenses out of my own pocket.  I think one line of 12 point font referencing my work in the bottom corner of a PowerPoint slide is not too much to ask. 

Even better, I am happy to collaborate.  I am willing to research, cowrite, or make graphics for your project for co-authorship credit and nothing else.  In fact, I recently offered to analyze the utilization of psychiatric medications for a large healthcare plan for free.  They declined the offered but I remain very interested in the analysis of real world data in health care setting.  Send me an email if you are interested.

George Dawson, MD, DFAPA

Supplementary 1:  Requests for topics:

 The request for topics has gone well so far.  The following is a list by topic and/or specific question.  If this leads to any other ideas – feel free to send them to me.  I am also interested in learning about any graphics that people would find useful. 

 

1:  ADHD – rates of diagnosis, how people present for assessment, missed diagnoses and other associated problems, diagnosing adults, and neurodevelopmental diagnoses in general.  (see comment below).

2:  ADHD – stimulant treatment and cannabis use.

3:  Antidepressant withdrawal with a focus on gastrointestinal symptoms.

4:  The models of mental functioning that are helpful in psychiatry.

5:  Indications/guidelines for antipsychotic use in children and teenagers.  Data on long term use.

6:  Memory and cognitive problems associated with POTS (Postural orthostatic tachycardia syndrome) – and recommended medical treatment.

7:  How psychiatry was practiced and the current transition – implications for the future of the field.

8:  Dementias associated with Lyme Disease and other infectious diseases

9:  More biological psychiatry!

10: Pharmacology and psychiatric applications of alpha-1 and alpha-2 adrenergic receptor agonists and antagonists.

11:  Pharmacology and psychiatric applications of beta adrenergic antagonists in psychiatry.

12:  What are inverse agonists in 10 and 11 above?

13:  Post Finasteride Syndrome (PFS) – I continue to get treatment requests for this syndrome.  Some of the people sending me emails explain that I am listed on web sites as a treatment resource, even though I have never personally assessed or treated the disorder.  I will probably post a review on PFS in the next year.

14:  Post SSRI Sexual Dysfunction (PSSD)/Persistent Genital Arousal Disorder (PGAD) – I have posted a review of this disorder and I am listed on web sites as a treatment resource. I have also had at least one person try to convince me to remove my post or modify it to their liking.

https://real-psychiatry.blogspot.com/2023/07/post-ssri-sexual-dysfunction-pssd.html

15:  Antidepressant withdrawal/discontinuation:  I have posted on this and my opinions are all consistent with a recent major review.  I am always interested in medication side effects – no matter the medication and how they can be mitigated. I have also had treatment requests to assist with this problem. I will probably add a post on the major review and also continue to comment on the politicization and the associated rhetoric. As well as placebo/nocebo responses.   

https://real-psychiatry.blogspot.com/2018/06/the-problem-of-antidepressant.html

16:  Supportive psychotherapy:  Throughout my career I practiced supportive psychotherapy in practically every clinical encounter and across every diagnostic category.  I consider it to be a necessary skill for psychiatrists – but it is difficult to write about in terms of both observations and techniques.  At some point I will be posting about this.

17:  How to walk down stairs and minimize the risk of falling:  That's right - I am a psychiatrist and old speedskater with an interest in biomechanics. I will post this as soon as I can figure out how to draw stick figures walking up and down stairs.  Let me know if there is software out there that might help with this type of drawing. 

That should keep me going for a while.  Do not hesitate to send more ideas or questions.

A final note on treatment requests.  I have received these requests as noted on #13, #14, and #15 above from many different states.  My response is always that I am retired from clinical practice and no longer provide active treatment since 1/19/2021.  That also means that I do not have access to what is required to provide medical care and meet licensing requirements (records, malpractice insurance, support staff, etc.).  And even if I did – treating people across state lines remains somewhat of a logistic nightmare.  As a result, I cannot provide telepsychiatry services or casual advice.  What I write on the blog has always been educational and for a large part directed at physicians and more specifically psychiatrists.  It is not medical advice and I hope I have always emphasized that the best treatment with continuity is available from your local physicians and specialists.  Proper medical care requires a formal doctor-patient relationship and that cannot be casual advice.  And for the physicians out there I hope I come across as an interested colleague.  Another intent in writing this blog is not to suggest that my knowledge or practice is superior to anyone else.  Life, biology, and medicine are too complicated for that.

Supplementary 2:

Elements of a dynamic textbook:  In my spare time I will be arranging my blog posts from the past 12 years in the general form of a book.   The intention is not to create a book but an outline for a book.  Not all of the posts will translate well but most will.  I would like it to be dynamic - not psychodynamic but useful to all psychiatrists.  Typical texts waste too much space on just technical details and I would prefer to focus on key concepts and approaches including how that evolves. I will post the outline here when I have it - in the meantime feel free to suggest chapters. 

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

 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

George Dawson, MD, DFAPA

References:

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

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

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

 

Supplementary 1:

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

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

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

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

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

Graphics Credit:

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