Flashbacks on Election Night...

 

Well – the 2024 election is over and I thought I would bring it to a close with this final post on the issue.  As previously stated, I am a small “I” independent and have never registered as a Democrat or a Republican.  Except for Barack Obama and Joe Biden - I have voted for Ralph Nader in nearly every other Presidential election that I have voted in.  As you can see from recent posts, I absolutely did not want Trump or his minions anywhere near the White House again.  It is astounding that it has happened.  To make sense of it – sometime last night the media started to spin it as Trump being some kind of genius or popular hero.  That lacks any real explanatory power. The media has done an incredible job during this election making Trump seem to be a normal Presidential candidate when he is far from it. It was quite a spectacle this morning watching the morning TV gang falling all over themselves making this seem like a miracle – when they essentially staged it.

You do not have to be a psychiatrist to see the obvious problems here but apparently it helps. I have listened to Trump voters interviewed and during those interviews they can provide no rationale for their vote.   I have listened to young voters interviewed and it was not clear that they knew anything about how voting works in the United States.  Young voters are criticized for being ideologically self-centered as if older voters are not.  The only voters that made sense were self-identified Republicans who could not vote for Trump based on his attempt to overthrow the elected government of the United States.  You would think that would be a hard stop for any law-abiding citizen.  Back in the day when I took civics, I think it was referred to as treason.  Beyond that small problem, nobody seems to recall all of the other the legal problems that would keep the average person from getting an interview just a few years ago.  Somebody posted that Americans need to stop pretending that they are superior to everyone else when they put a guy like Trump in the White House.  Trump could not get a job at Piggly Wiggly and he is now President of the United States.  That personifies everything that is currently wrong with the United States.

There has been no discussion of the rhetoric used in this campaign particularly Trump's.  To cite one example, in a previous post about the initial debate with Biden - Trump suggested Biden had “destroyed” the country (he used the word destroy 22 times) and he is the “worst” President – (he used the word worst 22 times). All that despite the fact that Trump produced no useful content on policy and did not respond to Biden's comment that in a scholarly ranking of presidential achievement - Trump was dead last (Biden was 14 out of 45 and that has probably improved).  This has been Trump's strategy in every speech.  No content and irrational personal attacks.  He attacked Harris' ethnicity and called her a "bitch" several times (2-4) as well as many other derogatory names and insults.  And there was no criticism of this by anyone apart from Biden in the debate, who was characterized instead as old and feeble by the press.

Of course, Trump opponents are also issuing conciliatory statements acknowledging the win and wishing him the best.  They are doing everything he would not do and ignoring all his vicious name calling along the way. I have not heard the usual platitudes about how he is the President for all Americans yet – but it will be coming.  Let’s face it – he is not the President for all Americans.  He is the President for the powerful and the gullible.  OK - I will acknowledge that maybe there are still a few loyal Republicans caught in the headlights who don't realize the party of Reagan has been transformed into a cult. 

He was described as a transactional President by the BBC today (3).  In other words what does he get out of what he gives in negotiations?  It came up in a conversation with a Ukrainian Prime Minister Kira Rudik reminding everyone that Trump said he would solve the war in Ukraine in one day.  And later that he would solve the war in Ukraine before he was in office.  Those are the first of many failures that I will be looking for and pointing out.  Trump is completely disingenuous and I expect to see a long list of failures.

One major point that seems to be missed about this election outcome is that it is a textbook example of how rhetoric alone can carry the day – even when there is a complete lack of substance.  This is a critical point that I have not seen analyzed by anyone. If anything – the press is still reacting to Trump’s rhetoric as though it is true. The economy is a clear example.  Trump has described it as a disastrous failed economy due to Biden and Harris. The press still accepts that despite the recent edition of the Economist pointing out it is an outstanding economy as far as economies go.  There is the other reality piece that Presidents don’t have that much of an effect on the economy anyway – but the economy persists as a top explanation why Trump won.  It really wasn’t the economy – it was false rhetorical ideas about the economy. 

The second most common narrative to explain the results is that Trump sold himself to the commoners as someone who would attack the “elites” and either burn the system down or take them all down a notch. I heard Mark Cuban on Sam Harris’s podcast describing the elites as basically anyone Trump wanted to criticize – generals, doctors, etc. So the elites are basically the rhetorical targets of Trump. They don’t really meet any unique definition of elites.  And the definition of elites is quite wide ranging from people with special abilities to the wealthy class. Is a general concerned about Trump’s treatment of military veterans and war casualties an elitist?  What about the billionaires all circling around Trump and Trump himself?  What about the richest man in the world giving over $100M and intensive media coverage on his social media site to the Trump campaign and other MAGA candidates?  What about people who are clearly above the law compared with the rest of us? Any application of the elitist explanation must leave out the fact that Trump is one of the biggest elites of them all.   

The failure to see Trump as the character and intellectual failure that he is seems matched by rationalizations that equate him to your eccentric old uncle who shows up once a year at the family gatherings.  During the past months where his style was equated to autocracy (which it is) and Naziism (which it is not) – several excuse makers came out and said that Trump could not possibly be a Nazi because he is only interested in himself and not promoting any long-lasting ideology. So, if he moves on the dark cloud will go with him.  In another case, the Wall Street Journal stated: 

“We don't buy the fascism fears, and we doubt Democrats really do either. Our own concern is whether he can successfully address the country's urgent problems. Most second presidential terms are disappointing, or worse, and Mr. Trump hasn't mapped out a clear agenda beyond controlling the border and unleashing U.S. energy production.”

And

“The authoritarian rule that Democrats and the press predicted never appeared. Mr. Trump was too undisciplined, and his attention span too short, to stay on one message much less stage a coup. America's checks and balances held, and Democrats benefited from the political backlash.”

Yes – they really are suggesting that we can rest reassured that their candidate's cognitive limitations and complete lack of an agenda should be reassuring that he can sit in the White House and not try to fashion an autocracy with staying power when he has a raft of Mini-Mes at his disposal.  He has after all demolished the Party of Lincoln to the point where it is no longer recognizable as a legitimate political party and rendered it into a cult.

The other problem with all of this is that there is an expectation somewhere that all Americans will accept this atrocious set of affairs, reconcile with the people who voted for this man, and we will all be one big happy family.  That is very unlikely to happen.  What is likely to happens is that Trump and his cronies are likely to “double down” on all their intrusions into private life, functional government, and public safety.  Even today we are hearing about how Kennedy wants to eliminate FDA departments and Musk wants to impose a new austerity standard on all Americans. The Rolling Stone quoted several proponents of Project 2025 saying that they no longer must pretend that there is distance from Trump and they can now own the connection.  All of that translates to direct harm to the people who voted for Trump thinking that he is somehow interested in them.

There needs to be resistance to this at every level.  When the harm occurs it needs to be documented whether that is maternal mortality because some politician thinks they know how to manage pregnancy or increased infant mortality due to vaccination limitations or worsening asthma as a direct result of lax air quality standards.  I think that violence, gun violence, and violent crime will increase just because it is part of the MAGA culture.  Their standard response that they are the law-and-order party no longer applies – because they are not.  There is a long list that I will record over time.  Expect a PowerPoint.

As all of this was churning in my brain last night – I realized that Trump getting elected was just like me working on my acute care unit just before I quit.  I was lying in bed wide awake and feeling like an electric current was running through my body. It was impossible to relax.  My heart rate was elevated. It reminded me of why I can never go back to that kind of work again. Although I did it for 22 years, at the end it was intolerable.  I did not mind when the stress was due to trying to help people resolve severe psychiatric problems.  It was very problematic when the environment became politicized and I was one of the targets.  It also reminded me of the current danger, a dangerous man, and a dangerous party and why it is more important to be loyal and true to the idea of a country than a candidate.  Stay vigilant and don’t let this extremely bad turn of events get you down.

In the most basic final analysis – a vote for Trump was a vote for lawlessness, resentment, dishonesty, greed, corruption, and disrespect. It was a vote for big business managers and CEOs, misinformation, income inequality, climate change, pollution, government intrusion in your personal health care, and autocrats worldwide. 

How can that possibly end well?  

 

George Dawson, MD, DFAPA

References:

1:  Bensinger K, Yourish K, Gold, M.  Failing to Provoke Harris, Trump Turns to Tried and True: Vulgarity.  New York Times.  August 31, 2024.  https://www.nytimes.com/2024/08/29/us/politics/trump-crass-imagery.html

2:  Haberman M, Swan J.  Inside the Worst Three Weeks of Donald Trump’s 2024 Campaign.  New York Times.  August 10, 2024.  https://www.nytimes.com/2024/08/10/us/politics/trump-campaign-election.html

3:  BBC News Hour November 6, 2024:  Interview of Ukrainian PM Kira Rudik (starts at 19 min 27 second mark): https://www.bbc.co.uk/sounds/play/w172zb96nbcppzq

4:  Lu C.  Trump Wields Sexist Insults at Final Campaign Rally. The Republican nominee has a long history of misogynistic rhetoric.  Foreign Policy November 5, 2024.  https://foreignpolicy.com/2024/11/05/trump-sexist-insults-remarks-pelosi-harris-gender/

And all of the post-election spin claims Trump is not a misogynist.

Graphics Credit:  Thanks to Tyler Black @tylerblack32 for allowing me the use of one of his election graphics from X(formerly Twitter).   See the entire sequence for his statistical commentary on the election dynamics. 

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.

Why A Diagnosis Is Not Stigmatizing and What Is...

 

 

The topic came up last week and it happens on a recurrent basis – diagnoses especially psychiatric diagnoses are not good because they are stigmatizing.  I addressed this fairly comprehensively in a post on this blog 10 years ago, but the persistent antipsychiatry rhetoric out there keeps repeating inaccuracies.  Since then there has been a comprehensive academic definition of stigma that makes things clearer.

Before that academic definition the standard dictionary definition was “a stain or reproach, as on one’s reputation” (1).  There is also a medical definition that is used to designate obvious pathognomonic findings: “visible evidence of disease” (2) and a long list of signs that apply.  There are additional definitions that do not apply to the specific situation of how mental illness is stigmatizing. The American Psychiatric Association has a web page on stigma and the adverse effects.  The web page does a good job of breaking it down to the public, personal, and structural levels.  Specific evidence-based interventions are suggested. They typically involve first-hand experience of persons with mental illnesses.

More sophisticated definitions of stigma are available today.  For the purpose of this post I am using one by Andersen, et al (3) that modifies previous work done by Link and Phelan (4).  According to the authors, stigma is a social process that involves “labelling, negative stereotyping, separation, and power asymmetry.” (p. 852).  They state further that stigma is not present unless all these criteria are met – specifically stigma exists “if and only if” all these criteria are present. 

Labelling in this case is defined as “social selection of human differences”.  The authors give an example of associating alcohol use with homelessness and whether it is a matter of “cognitive efficiency” based on personal experience and probabilities. The labelling that occurs is a result of these socially observed differences. Although these labelled associations can be positive, for the definition of stigma only negative associations are relevant for stigma.  That results in the negative stereotyping.

Separation creates a false barrier between the negatively stereotyped and everyone else.   It suggests that there cannot possibly be any overlap between the characteristics of the stereotyped and everyone else.  Earlier in their paper, the authors use the example of obesity, where it is obvious that there are several almost universal stereotypical qualities and overt discrimination. The same thing is true of ageism, where it is often assumed that elderly people are universally frail, cognitively impaired, and have negative personality traits. It is an us versus them mentality that is currently popular in right wing politics in the US.

Power asymmetry is attributed to the fact that is takes social, economic, and political power to label and negatively stereotype. This is inconsistent with the idea that it happens at an individual level and those individuals together can form a power structure. 

The authors cite an example from Link and Phelan: “They notice that mentally ill patients might label clinicians as e.g. “pill pushers” and link them to the stereotypes of being cold, paternalistic, and arrogant. But the clinicians will not, therefore, be a stigmatized group, because this group of patients simply do not possess the sufficient power to “(…) imbue their cognitions about staff with serious discriminatory consequences.”   

The social and pollical dimensions of the pill pusher characterization ignores history and the prevalence factor.  On a historical basis, Osler suggested that medications being used over a century ago were either worthless or cause more harm than good.  At the turn of the century "dope doctors" ran large practices by keeping people addicted to opiates. On the prevalence side, does the number of people with that characterization equal or exceed the number of people with other common important stigmatizing biases like obesity or ageism?  I doubt it. We do see an excessive amount of rhetoric directed at psychiatrists that is largely inaccurate and contrived and it is not without professional, social, and pollical fallout (5,6).  Very few reasonable people seem willing to discuss that.  The other reality that is rarely discussed is the fact that doctors are not powerful and certainly are not trained to use or exert power.  Today they are ordered around by middle level managers with no training in medicine exerting whatever form of administrative power that they choose.

There are much better examples of stigmatizing processes that are obvious but never discussed in today’s world.  I come back to the entertainment industry at the top of the list.  Apart from movie reviews psychiatrists have been curiously silent about this process that has gone on unabated for decades.  To cite a recent obvious example, I would refer anyone to the most recent episode of The Penguin an HBO series.  In season 1 Episode 4, we see one of the protagonists falsely diagnosed with mental illness to keep her from disclosing several homicides committed by her father.  She is placed in a medieval Arkham asylum where the patients are shackled by the neck and treated inhumanely.  She is eventually baited into committing a very violent homicide against another patient who is trying to befriend her.  The psychiatrists there are portrayed as indifferent at best and of course using electroconvulsive therapy as a punishment (there has not been any progress on that issue since One Flew Over the Cuckoo’s nest in 1975).  There may be people who argue these problems may have existed in 18^th and 19^th century asylums – but the problem is this is set in modern times.  The Penguin is driving a 2013 Maserati Quattroporte VI.  This episode plays the familiar stigma as the mentally ill being excessively violent and psychiatrists as agents of the state conspiring against people, using psychiatric treatments as punishments, and not caring at all about individual patients.

Right wing politics is a second source of stigmatization on almost a daily basis.  Trump and affiliated MAGA politicians routinely suggest that mass shooting and gun violence are attributable to mental illness – even though it clearly correlates with firearm availability and density.  In the case of undocumented immigrants, they are triply stigmatized as criminals, mentally ill, and invaders of the country when there is no evidence for it.

A final source is a carry over from my previous post.  Businesses and healthcare companies actively discriminate against mental illness despite parity legislation.  That should be obvious by the lack of resources that people face when trying to find treatment for a severe mental illness. It is easy to find state-of-the-art care and subspeciality care for any other bodily symptom – but not psychiatric care.  Getting an appointment to see a psychiatrist even in large metropolitan areas is often impossible.  Inpatient bed capacity in the United States is somewhere below the bed capacity of developing countries in the world. The majority of people with mental illnesses are not treated.

That is my update on stigma.  The only thing that has changed in the last 10 years is the current spin that a psychiatric diagnosis or treatment is stigma or stigmatizing and of course it is not at all.  As a reminder, a diagnosis is for the information of the patient and other treating professionals, it is confidential, and it is used by people who are professionally obligated to act in the best interest of the patient and incorporate that person's preferences.       

 

George Dawson, MD, DFAPA

 

1:  Random House.  Webster’s College Dictionary.  Random House, New York, 1996: p. 1314.

2:   Steadman’s Medical Dictionary.  The Williams and Wilkins Company, Baltimore1976: p.1338

3:  Andersen MM, Varga S, Folker AP. On the definition of stigma. J Eval Clin Pract. 2022 Oct;28(5):847-853. doi: 10.1111/jep.13684. Epub 2022 Apr 23. PMID: 35462457; PMCID: PMC9790447.

4:  Link BG, Phelan JC. Conceptualizing stigma. Annu Rev Sociol. 2001; 27(1):363‐385.

5:  Perlis RH, Jones DS. High-Impact Medical Journals Reflect Negative Sentiment Toward Psychiatry. NEJM AI. 2023 Dec 11;1(1):AIcs2300066.

6:  Bithell C. Why psychiatry should engage with the media. Advances in psychiatric treatment. 2011 Mar;17(2):82-4.

Photo Credit:

Click on photo to see Wikimedia Commons information about photo and photographer as well as CC license.

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