A Troubled Leaders case study by Dr. Marsha Peterson.
I have been a psychologist for twenty-three years. In that time, I have sat across from men and women who controlled billions in capital, who shaped legislation, who built and dismantled companies the way my father used to build shelving units in our Kansas City hardware store—with the quiet certainty that they knew where every nail should go. I have learned to listen not for what these people say, but for the words they circle around without landing on. The vocabulary of avoidance is more revealing than any confession.
I am writing this account because I believe it matters. Not as gossip, not as judgment, but as a clinical observation about what happens when a certain kind of mind meets a certain kind of consequence. My patient has not authorized this reflection, but I have changed enough details of our therapeutic interactions to protect confidentiality while preserving the psychological truth. The public facts I reference are public. The private moments are reconstructed, as all memory is, imperfectly.
He arrived seven minutes early on a Tuesday in February 2026. I noticed this because my previous session had run long, and when I opened the waiting room door, I found him standing by the magazine rack. He had rearranged the magazines. They were sorted by height, tallest on the left, shortest on the right, their spines aligned with the precision of a factory floor.
“Physical media is extraordinarily wasteful,” he said, not as a greeting but as a continuation of some internal monologue I’d interrupted. “The carbon footprint of a single magazine issue, from pulp to recycling bin—it’s absurd when you consider the alternative.”
“Good morning, Mr. Musk.”
He looked at me then. The photographs don’t capture something essential about his presence. He is tall, broader than you expect, and he vibrates with a kind of coiled frequency that suggests a machine idling too high. But his eyes, that morning, were tired in a way that no amount of energy could disguise. The skin beneath them was bruised with sleeplessness.
He sat on the edge of my leather chair, not in it. His knees were apart, his hands clasped between them. He scanned my office the way I imagine he scans a factory—looking for inefficiency, for wasted space, for something to fix.
“I have fifty-five minutes,” he said. “Let’s be efficient about this.”
I sat down across from him and crossed my legs. I let a beat pass. Two.
“That’s an interesting word to lead with,” I said, “given why you’re here.”
Something flickered behind his eyes. Not anger exactly. Recognition, maybe. The look of a man who has just realized the person across from him is paying closer attention than he’d like.
The Architecture of Justification
His attorneys had recommended therapy. This is more common than people think. When a client faces deposition, particularly in matters involving potential government liability, legal teams want to demonstrate good faith. They want their client composed, reflective, capable of the kind of measured self-awareness that plays well in a recorded session. I am not naive about my role in this ecosystem. But I have also been doing this long enough to know that a door opened for the wrong reasons can still lead somewhere real.
The Department of Government Efficiency had been established by executive order on January 20, 2025. Musk had taken the role with the fervor of a man who believed, genuinely believed, that government was a machine running badly and that he was the mechanic it had been waiting for. In the months that followed, he led what the press called the “chainsaw era”—a phrase he seemed to relish. At CPAC, he had brandished an actual chainsaw on stage to applause. The federal workforce was reduced by roughly nine percent, the largest peacetime reduction in modern history.
And government spending did not go down.
The Cato Institute, hardly a bastion of big-government sympathizers, confirmed what the budget numbers already showed: DOGE had produced “no noticeable effect” on federal expenditure. But by then, the foreign aid cuts had begun their quiet, catastrophic work overseas. Public health researchers would later estimate that more than seven hundred thousand deaths could be attributed to the dismantling of programs that provided vaccines, water purification, and maternal care in sub-Saharan Africa and Southeast Asia. By the time Musk departed DOGE in May 2025, citing “mission accomplished” while his legal team quietly settled three separate lawsuits, he had described the experience as “a little bit successful.” In a podcast interview, he added that he “wouldn’t do it again.”
I asked him to walk me through the timeline. He was fluent in the language of systems. He described organizational charts, redundancy coefficients, approval bottlenecks. He could tell you how many layers of bureaucratic review stood between a policy proposal and its implementation. He had the numbers memorized the way some people memorize poetry.
“The federal hiring process alone,” he said, leaning forward now, fully animated. “Eighty-seven days average time-to-hire. Eighty-seven. At SpaceX, we onboard in eleven. The waste is staggering.”
“And the people in those positions,” I said. “The ones who were let go. What happened to them?”
He paused. Not long. Just long enough.
“There were transition packages. Generous ones.”
“I’m not asking about the packages. I’m asking about the people.”
“The numbers don’t support the narrative that this was some kind of catastrophe. Government employment has fluctuated for decades. We accelerated a trend that was already–“
“Mr. Musk.”
He stopped.
“I’m not a congressional committee,” I said. “You don’t need to convince me of anything. I’m asking what you know about the individuals whose positions were eliminated.”
He looked at the window. “I didn’t memorize their names, if that’s what you’re asking.”
It wasn’t what I was asking. But it was an answer.
The Chainsaw and the Silence
In my practice, I work frequently with a concept borrowed from military psychology: moral injury. It is distinct from post-traumatic stress, though they often travel together. PTSD is the wound left by what happened to you. Moral injury is the wound left by what you did, or failed to do, or allowed to happen. It is the damage sustained when your actions violate your own moral code—sometimes a code you didn’t know you held until you broke it.
I have seen moral injury in a retired general who authorized a drone strike on faulty intelligence. In a pharmaceutical executive who delayed a safety recall by six weeks to protect quarterly earnings. In an engineer—a brilliant, principled engineer—who designed cost-reduction protocols for a hospital chain that resulted, eighteen months later, in the deaths of four patients. The engineer sits in a chair much like the one Musk was perched on, and she tells me that the math was sound. The models were correct. The implementation was within parameters. And people died anyway.
The optimizer’s dilemma. The numbers are right and the outcome is wrong, and there is no formula for reconciling the two.
I introduced the concept to Musk obliquely, as I do with most patients who are allergic to vulnerability. I talked about veterans. About the specific grief of having done something you believed was necessary and discovering, after the fact, that the necessity was an illusion or that the cost was real in ways your models never captured.
He listened. He is a better listener than his public persona suggests.
“You brought a chainsaw on stage,” I said. “At CPAC. You were smiling. What was that moment like?”
Silence.
I have learned to measure silence the way a cardiologist measures heartbeats. There are silences that are empty, the patient simply gathering their thoughts. And there are silences that are full—pressurized, loaded, the sound of something being held down. This was the second kind.
Six seconds. Eight. Twelve.
“It played well,” he said finally.
“That’s what it was like? It played well?”
“The audience responded. It communicated something clearly. That we were serious about cutting.”
“And now? When you see that footage?”
He shifted in the chair. For the first time, he sat back. “I don’t watch old footage of myself.”
“Why not?”
“Because it’s not useful. The past is fixed. I focus on what’s ahead.”
This is a defense mechanism called intellectualization-the retreat into abstraction when emotion becomes dangerous. It is the mind’s emergency exit, and Musk had clearly used it so often that the hinges were worn smooth. What I found more telling was what he didn’t say. He didn’t defend the chainsaw moment. He didn’t explain it. He filed it under “played well” and moved on, the way you might file a receipt you’d rather not look at again.
The Wound He Won’t Name
Midway through our session, something unexpected happened. We were discussing the public reaction to DOGE, the protests, the editorial boards, the lawsuits, and Musk was in full defensive mode. His critics were ideologically motivated. The media was hostile. The bureaucracy had fought back because bureaucracies always fight back. Standard fare. I’d heard variations of this speech from a dozen executives.
Then he said, almost as an aside: “My older kids saw some of the coverage.”
He stopped. Redirected. Started talking about Tesla’s stock price.
I let him talk about Tesla for exactly ninety seconds. Then I brought him back.
“You mentioned your children seeing the coverage. What did they see?”
“It doesn’t matter. Kids don’t understand policy.”
“I’m not asking about policy. I’m asking about your children.”
“They’re fine. They have their own lives.”
The deflection was immediate and total. But I had seen the wound. It opened and closed in less than two seconds, the way a fault line shifts—barely visible on the surface, seismic below. Whatever his children had said, or not said, or communicated through the particular silence that children deploy when they are disappointed in a parent, it had landed.
I chose not to press. Not yet. Some wounds need to be circled before they can be approached. You don’t walk straight at a frightened animal.
Instead, I returned to the phrase that had brought him to my office in the first place.
“You said you wouldn’t do it again. In the podcast. Help me understand what, specifically, you wouldn’t do.”
He was ready for this. “I’d focus on my companies. Tesla lost two hundred billion in market cap during the DOGE period. SpaceX had three launch delays because I wasn’t paying attention. The opportunity cost was enormous.”
“So the regret is economic.”
“The regret is practical. I took my eye off the ball.”
“You’ve described the cost to your companies. I notice you haven’t mentioned the seven hundred thousand figure.”
His jaw tightened. “Those numbers are disputed. The methodology–“
“I’m not asking about the methodology,” I said. “I’m asking about the silence.”
“What silence?”
“The silence around those numbers in your answer. You described what DOGE cost you in market cap, in launch schedules, in personal bandwidth. You haven’t described what it cost anyone else.”
He stared at me. I held his gaze. This is the moment in therapy where the patient decides whether to go deeper or to leave. I have had patients stand up and walk out at this exact juncture. I have had patients burst into tears. Musk did neither. He sat perfectly still, and I watched something behind his eyes rearrange itself, like tectonic plates finding a new configuration.
“The aid programs were going to be restructured anyway,” he said. But the conviction was gone. It was a sentence running on fumes.
The Scalpel and the Food Bank
I have a metaphor I use with patients who are, by nature, builders. Engineers, architects, surgeons. People who understand tools, who define themselves by their ability to solve problems with precision instruments.
“A surgeon’s scalpel is a magnificent instrument,” I said. “It saves lives every single day. The precision, the engineering, the design. Remarkable. But if you take that same scalpel to a food bank, you don’t get a better food bank. You get bleeding.”
He looked at me sharply. “That’s reductive.”
“Is it?”
“Government isn’t a food bank. It’s a system. Systems can be optimized.”
“Some systems can. Some systems exist precisely because they resist optimization. Because the inefficiency you see is actually a feature. The redundancy in foreign aid distribution, the multiple approval layers, the slow bureaucratic processes-some of those exist because the cost of moving too fast is measured in lives.”
“You’re saying I shouldn’t have tried.”
“I’m saying that the tool matters less than the understanding of what you’re cutting into. You are brilliant with machines. With rockets. With algorithms. You see waste the way a hawk sees movement. But government isn’t a machine, Mr. Musk. It’s an organism. And organisms bleed.”
He was quiet again. A different silence this time. Not pressurized. Hollow.
This is what cognitive dissonance sounds like when it finally becomes audible. The collision between two beliefs that cannot coexist: I am a force for good, and this thing I did caused harm. For months, perhaps years, he had managed the dissonance through compartmentalization. The numbers were disputed. The methodology was flawed. The critics were biased. His companies suffered, not other people. Every available buffer between himself and the consequence had been deployed. And here, in a quiet office on the Upper East Side, with fifty-five minutes and no audience, the buffers were thinning.
I thought of my father’s hardware store. On Saturday mornings, he would let me help stock the shelves. I was maybe ten, and I wanted to organize everything by color because it looked nicer. He let me try. Then he showed me why the experienced customers couldn’t find anything. “Pretty isn’t the same as useful, Marsha,” he told me. “And useful isn’t the same as right.”
It took me twenty years to understand what he meant. Some systems serve purposes that aren’t visible from the outside. The person who walks in and sees only disorder may be missing the logic entirely.
The Question at the Door
Our session was ending. Musk stood, buttoned his jacket. He moved toward the door with the purposeful stride of a man who has seventeen things scheduled after this and is already mentally in the next one.
Then he stopped. His hand was on the doorframe.
“Do you think they would have died anyway?” he asked. He wasn’t looking at me. “The aid recipients. Without the cuts. Given the political climate, the funding trajectory. Do you think it would have happened regardless?”
I recognized this question. I have heard versions of it from every patient who stands at the threshold of moral injury. It is the last defense, the final moat around the self. If the outcome was inevitable, then my actions didn’t matter. If my actions didn’t matter, then I am not responsible. If I am not responsible, then I can sleep.
“What do you think?” I said.
He stood there for three seconds. Four. His fingers tightened on the doorframe, and I saw something I rarely see in men who have built empires: uncertainty. Not the performative uncertainty of a press conference, where you hedge to manage liability. Real uncertainty. The kind that lives in your chest.
He left without answering.
What the Silence Contains
I sat in my office for a long time after he left. The magazines were still arranged by height. I considered putting them back the way they were, but I left them. They seemed like evidence of something.
In twenty-three years of practice, I have come to believe that power does not corrupt. It reveals. It strips away the social constraints that keep most of us from discovering what we’re actually willing to do. And then, if we’re lucky, it forces us to sit with that discovery.
Elon Musk is not a villain. I know that’s a dissatisfying thing to say in a culture that prefers its moral architecture clean. He is something more complicated and, I think, more instructive: a man whose greatest strength became the instrument of his greatest failure. The optimizer who met a problem that couldn’t be optimized. The engineer who discovered, too late, that some systems don’t have error codes—they have graves.
He already knows this. That’s what the question at the door told me. A man who genuinely believed the deaths were inevitable wouldn’t have asked. He asked because he knows the answer, and the answer is heavy, and he is trying to find a way to carry it that doesn’t require him to dismantle the version of himself that walked into DOGE with a chainsaw and a smile.
Whether he can do that—whether anyone can hold the full weight of that kind of knowledge and still function–is a question I cannot answer in one session. It may be the question of his remaining years.
I am publishing this reflection because I believe we are living through an era where the optimizer’s worldview has become our default setting. Efficiency as virtue. Disruption as progress. Speed as proof of competence. And I think we need to talk about what happens when that worldview meets human fragility, as it always, eventually, does.
My father would have put it more simply. He would have said: measure twice, cut once. And make sure you know what’s on the other side of the wall before you start swinging.
Elon Musk measured everything except what mattered most. I suspect he knows that now. The question is what he does with the knowing.
I left the magazines the way he arranged them. They stayed that way for three days, until my next patient knocked the smallest one onto the floor reaching for a tissue. Things return to disorder on their own schedule. That, too, is a kind of lesson.
This is a work of fiction. While inspired by real events and public information,
all characters, dialogue, and internal deliberations are entirely imagined.
Any resemblance to actual private conversations or decisions is coincidental.
