If one of my patients frequently said one thing and did another, I would want to know why. If I found that he often used words that hid their true meaning, and affected a persona that obscured the nature of his actions, I would grow more concerned. If he presented an inflexible worldview characterized by an oversimplified distinction between right and wrong, good and evil, allies and enemies, I would question his ability to grasp reality. And if his actions revealed an unacknowledged – even sadistic – indifference to human suffering, wrapped in pious claims of compassion, I would worry about the safety of the people whose lives he touched.

For the last three years, I have observed with increasing alarm the inconsistencies and denials of such an individual. But he is not one of my patients. He is our President. He wants to remain our President for four more years, and he intends to do so on his own terms. On August 27, the eve of the Republican Convention, Bush said to New York Times reporters Sanger and Bumiller that “he would resist going ‘on the couch’ to rethink decisions.”

Since the Swift Boat controversy hit center stage in mid-August – both the ads and Bush’s refusal to take responsibility for them – we again see his reluctance to examine his conscience. Instead he remains mired in his long-standing pattern of denial and blame. Responsibility is something this president flees at all costs. It is a behavior pattern that began long before Bush became president, governor, or even a college student. It even began before Bush had become an alcoholic (he finally stopped drinking at age forty, with the help of his religion), though his response to criticism is typical of untreated alcoholics.

Bush was the first born child to a family that had long and moneyed traditions on both sides. When he was three and a half his sister Robin was born. It has been said that the nursery rhyme “Humpty Dumpty” was written with the first-born child in mind. It seems to capture perfectly the irrevocable trauma felt with the second child is born: Nothing can put the first-born back together again. Of course, first-born offspring find different ways to manage this insult. Some can be suspicious and overly competitive; others can be overtly nice while covertly furious; still others always keep an eye on the second child, making sure he doesn’t get too much. First-born children keep careful track of how much food mother gives to their siblings.

But if the second-born dies, as Robin did when George was seven, then an entirely new and complex dynamic is set in motion. The first-born often has to disown his destructive fantasies and banish them into his unconscious. But such fantasies threaten his mental equilibrium and he has to do something with them. One solution is to project them outward, thereby experiencing people around him as destructive or a source of danger.

By the time Robin died Bush already had a mother who was emotionally elsewhere. Children resent it when the mother is absent, and Bush’s resentment would have grown stronger in the face of his mother’s grief after Robin’s death. If George’s feelings were never addressed – and it is clear from numerous family accounts that the parents didn’t have a funeral and never talked to George about the loss – his natural animosity toward his sister would have remained unresolved; he would have been left with a host of forbidden feelings that were too threatening to acknowledge, only furthering the process of having to disavow these unwanted aspects of himself. He was deprived of the opportunity to learn to mourn, to heal. In that deprivation lays the kernel of what has by now become Bush’s knee-jerk reaction of denying responsibility for anything that goes wrong. He can’t allow it to be his fault.

It is true that blame and denial are arguably as typical of politicians as of alcoholics, though the latter are generally more likely to involve family members in the process. But blame is also a reminder of one’s destructive impulse; the individual who hasn’t resolved his anxieties surrounding that impulse is particularly motivated to avoid confronting those anxieties, which he can accomplish by shifting responsibility to someone else, or denying it outright. Drinkers turn to alcohol to suppress anxiety.

The untreated alcoholic who has simply stopped drinking treats anxiety as an enemy, and with good reason: He is often more challenged by anxiety because he has lost his time-tested means of numbing its sting. He knows that anxiety is a threat to his abstinence – he fears anything that might lead him back to the bottle – but his years of drinking get in the way of learning other methods to manage uncomfortable feelings. Bush manages his anxiety through his inflexible daily routines – the famously short meetings, sacrosanct exercise schedule, daily Bible readings, and limited office hours. All public appearances are controlled and staged – even the ones that appear to be spontaneous. They have to be.

But when routines fail, denial kicks in as the treatment of choice to manage the potential development of internal chaos. The habit of placing blame and denying responsibility is so prevalent in George W. Bush’s personal history that it is apparently triggered by even the mildest threat; when Jay Leno, on the eve of Bush’s DUI revelation (just a week before the 2000 election), asked him if he’d ever done anything he was ashamed of, he replied, “I didn’t” – and proceeded to tell a humiliating story of his brother Marvin urinating in the family steam iron. Fast forward to the Swift Boat ads, taking a brief stop at his denial that he knew Ken Lay (“Kenny who?”) of Enron who was in fact a friend and major contributor to his campaigns; then to his blaming 9-11 for the failing economy when the market actually began to crash after he announced his tax cut plans; then to his inability to admit to any mistake he made after 9-11 (in the April 2004 press conference he couldn’t bring himself to accept even a modicum of responsibility for either the intelligence failures before 9-11 or for the war in Iraq), to his denial in May of knowing Iraqi information source Chalabi despite having invited him to sit just behind the First Lady at his 2004 State of the Union Address. Putting it all together, we see a pattern that I call the KWD – the Kenny Who Defense. He employs it whenever and wherever he can, whenever he feels threatened.

All his disavowed destructiveness coalesces and requires management whenever anybody challenges him. He becomes instantly wary: Questions mobilize his anxiety and invite that exaggerated degree of rigidity he uses for self-protection. It is not a matter of intelligence per se, but a matter of paralysis when confronted with any question that requires thinking. When there is nobody in particular to blame he stumbles anyway, as he did at the Unity Conference on August 6 when asked to discuss the sovereignty of the Native American tribes. Mark Trahant, of the Seattle Post-Intelligencer, noted that children study city, county, state and federal government but that Indian government is not part of that structure. In noting Bush’s unique experience as governor and president, he asked about Bush’s understanding of sovereignty and how to think about tribal conflicts in the twenty-first century. Bush hesitated, and then said, “Sovereignty means [pause] that you’re a sovereign – that you’ve been given sovereignty and can be viewed as a sovereign entity. Therefore the relationship between Government and tribes is one between sovereign entities.”

His relationship to his father makes all the more sense in light of the anxieties I have described. First, his father cast a giant shadow: he was a good student, a fine athlete, a war hero, a successful businessman. One grows up in awe of such a father – and given this particular son’s need already to disown his own feelings of destructiveness, he imbues his father – partly by projecting his own aggression onto the father – as a man of enormous power, making him more of a threat. And young George W. had few of his father’s qualities with which to defend himself. Being a cheerleader and a big fraternity drinker are just not the same thing. This situation can make a son feel rage, frustration, and shame.

One way Bush managed his feelings was through his humor, his sarcasm (not unlike his mother), and his need to be in charge of any undertaking. At times, being in charge meant mocking his father’s power (being stick-ball commissioner while his father had been an All-American first baseman is a good example). One particular power that George Sr. did not express, however, was the important paternal responsibility to help a son separate from his mother. I doubt the success of that endeavor with George Jr., as his father was absent for most of Bush’s childhood. And when he was present, George Sr. was absently reading or distant.

This particular son is driven by the need to retaliate – against his father and against a world full of enemies. He does so in a variety of ways – though the underlying motives are the same. He tells Bob Woodward that he needn’t consult his father before invading Iraq because he consults a stronger higher father; he regularly introduces Vice President Cheney as the greatest vice president in history, without mentioning that his father was VP for eight years; he dismantles international coalitions once valued by his father; he practices what his father called “voodoo economics” by implementing massive tax cuts for the rich, maintaining that deficit spending will revive the economy; and at the Republican Convention in New York, he doesn’t make a place for his own father – an actual ex-president – to speak. Each event taken on its face value is but an incident. When they are linked together they reveal a distinct pattern.

His drive to manage anxiety is paramount. That requires him to shift responsibility whenever possible. He can consciously deny blaming his father for having failed him in his time of greatest need as a child – in helping him both stand up to his mother and to let go of his need to be her cheerleader rescuing her from her unspoken grief. But unconsciously, the blame persists – crippling his ability to think. He remains a cheerleader, not a leader. The inability to take responsibility makes Bush genuinely unable to lead: he can bully others and seem to act decisively, but he retreats from threatened confrontation (he says “bring em on” only when embedded behind the Secret Service thousands of miles away from the battle). His need to remain in control makes him unable to think things through in order to lead from strength. His is a stage-managed strength, something we saw all too clearly during the week of the Republican Convention.