The eyes have it: The intersection point of physicians and gun violence

WALTHAM, MA April 5, 2016 As an audience participant at the Firearm Violence: Policy, Prevention, and Public Health – described as the 12th Annual Public Health Leadership Forum that features state Attorney General Maura Healey who discussed reducing gun violence in the Commonwealth of Massachusetts. I was interested in what AG Healey might suggest as the linchpins for reducing gun violence.  As the highest ranking law enforcement officer in the Commonwealth, Healey is an advocate for people in Massachusetts in all health-related domains.

Major public health issue in Massachusetts according to Dennis Dimitri, M.D. president of the Massachusetts Medical Society.  85 people are killed by firearms on a daily basis across the country. “Physicians must discuss gun safety and have the continued right to do so that is an issue physicians feel quite strongly about” according to Dimitri.  Physicians need to ask about access to guns because the likelihood of death by firearm in the homes where domestic violence and suicidal depression exists may occur if a gun is present.  Physicians have been seen as “the trusted source of information for patients and their families” according to Steve Ringer, M.D. suggesting a need for education and leadership.

George Benjamin, M.D., “If it hurts people or kills people it is ours” referring to the responsibility of physicians to take an open and direct approach to reduce gun violence, injury and death due to firearms.  Public health responsibility to overcome the fear of gun violence yet a paradox exists in that society normalizes violence in society.  Game systems today have celebrated gun-related violence that has become part of the culture.  The protective safety of guns is overstated.  Arguably, the view that a gun protects us against violence but far too often a toll is taken in increased the presence of a gun suicide, homicide, and accidental death due to the presence of a gun. Intimate partner violence takes the lives of 51 partners a month. More days with mass shooting than days without.  “A persistent drumbeat of gun violence approximately 91 daily – 33,000 annually” according to Benjamin.  What are we doing about suicide?  “It is an impulsive action that one cannot re-think when a firearm is used.”  Gun ownership is declining and fewer people are owning guns in 2016 although there are more guns than people in America.

  • Make guns safer – using technology, i.e. password or fingerprint
  • Make people safer with their guns, annual firearms safety class
  • Make people safer in an environment with guns in it, gun storage, background checks, create youth safety education, sensible gun laws

Maura Healey became AG in 2015 – formerly an assistant D.A. in Middlesex County has been dealing with heroine crisis and improving criminal justice system.  “We in law enforcement deal with this on a daily basis here in Massachusetts” according to Healy.  We aren’t able to prosecute away all of these individual incidents there are too many. It is not about the right to bear arms it is about future generations of people and the health of people across the Commonwealth. This is a crisis that requires renewed focus and a persistent approach as a public health and civil rights issue that needs to be addressed from a broad underpinning of disciplines including physicians. Gun dealers need to follow the rules when it comes to gun sales.  “Trauma may beget trauma and violence may beget violence” according to Healey. Empowering young girls to be aware of their rights against being victimized. Healey cited the violence intervention program at BMC that has intervened with families for 10 years.  Healey is committed to increasing access to mental health services for those most at risk. Opportunity to conduct research to deliver and make a difference in the crisis of gun violence. Healey talked about intersection points where frontline personnel interact with those at most risk of death. Physicians are at a precious spot to intervene.  Healey’s mother is a school nurse and her father is a teacher and coach – also at the intersection point for youth safety and support.

Rep David Linsky and gun legislation.

In the state of Florida it is not allowed for physicians to ask their patients about gun ownership – a case currently being challenged in the state’s court system.

National violent death reporting system identify unintentional deaths are greater than what is reported in death reports.  Children are killed by someone else – usually a friend showing the gun.  Suicide prevention without changing laws. Focus should be on how suicide takes place rather than why a suicide takes place.  The acute phase of a suicidal urge is often short lived.  Keep highly lethal means away from those who are suicidal – for those who cut themselves or use poison to kill themselves the lethality is reduced greatly.  Rates of suicide are explained by the presence of a gun in the home. Suicide prevention plan includes getting gun out of the house for a period of time.  Friends need to help get guns out of the house during periods of crisis.  Gun sales need to be aware of those who might buy a gun in order to kill themselves.  3 suicide deaths in one week from a NH gun store.

Guns have not fundamentally changed in the way they have been designed since 1916.  Stephen Teret, Ph.D. talked about changing the vehicle or vector of gun violence as a method of harm reduction.  He cited the science of changing the mosquito to reduce the incidence of the Zika virus or yellow fever by genetic alteration and likened this to changing guns in the manufacture of a “smart” gun that will recognize its owner.

Reverend Jeffrey Brown, a Boston area Baptist minister cited a Community-based collaborative for crime reduction in cities. Violence changed the city.  Conducted over 1000 funerals at his church and in the greater Boston area before coming to the conclusion that “something needed to be done and he was the one to do it”.  He and  colleague members of clergy walked the streets in Dorchester in an effort to understand the life after 9:00 PM in the neighborhoods.  The effort did not go unnoticed by members of the police department.  This cast the seeds of the 10-point plan in collaboration with the Boston police department by brokering a community-police collaborative.

David Rosmarin, M.D. at McLean Hospital – Rampage violence or spree violence is rare but always sensational- “violence is the currency of what we do” so MDs need to become comfortable with the conversation of violent intensions. The serious mentally ill account for only 3-5 % of all US violence – substance abuse a big factor in violence according to Rosmarin.  Violent intention is frequently communicated in advance.  “There were signs along the way that were ignored” according to Rosmarin.

What does our system have for those who are making threats of violence?  This is a question especially when police and first responders are called at times of crisis.

Divorce, loss of employment, substance abuse. Nihilism – fatalism.

Preparation in advance – no single typology.  In NY, MH professionals, RN’s, MDs are mandated reporters to Division of Criminal Justice patients “if they are likely to engage in conduct that would result in serious harm to self or other.”

Risk Assessment – Structured Professional Judgment – dynamic factors, static factors

  • Magnitude: verbal, shove, strike, shoot
  • Likelihood: low, medium, high
  • Imminence: immediate, short-term, chronic
  • Frequency: one-time, repeated
  • For each and overall: low, medium or high

Be humble, tolerate uncertainty, and try to articulate the valence given each factor. • Someone may be low imminence, moderate likelihood, chronic risk, and high potential magnitude—high magnitude always the case with guns

Slide presented by Dr. Rosmarin 2016

Deadly force continuum changing officer safety

The use of force is a fluid decision tree that requires instant recognition of threat often in response to another’s intention to do bodily harm and cause mayhem – Sefton 2016

WESTBOROUGH, MA March 23, 2016 Police agencies across the country are changing their use of force policies because of the hue and cry of constituents everywhere over police shootings. Some wrongly believe that street cops should use counseling techniques first to reduce the need for lethal force and – in their view – reduce officer involved shootings.

The clamor for the change in this policy is placing greater onus for limiting lethal force on the street officer. In effect, this is pushing him or her to be an armchair psychologist in addition to the ultimate defender of human rights when life is on the line. There is a growing expectation that crisis intervention, de-escalation techniques will be inserted into the use of force continuum in the officer’s armamentarium.  This adds to the officer’s conundrum on whether to shoot or not to shoot.  In the instant he thinks ‘can this situation be eliminated through dialogue and de-escalation tools?’ he may be killed or maimed. Police Commissioners in Los Angeles are considering a revamping of the use of lethal force by adding de-escalation language that officers might use to reduce the need for lethal force (LA Times, K. Mather).  The policy in Los Angeles dictates that officers be guided by “a reverence for human life” as the critical underpinning for the avoidance of using force.

The use of force continuum requires that officers may only use force when force is being introduced against them. The expectation that the average citizen is going to comply with police officer directives is no longer the case.  People of all sizes and shapes become violent often with little or no provocation. Passive resistance may not be met with a baton strike or taser.  Where as the baton strike and taser may be deployed when active resistance and an aggressive posture are demonstrated or directly administered against a police officer.  The increase in force against police takes just an instant and police officers train for this “oh shit” moment of attack. Too often an officer is caught off guard resulting in injury or death.  As a police officer, we practiced for these moments when on the range or during our night shoot twice a year.  Our range instructor had a special device that measured the time from when you drew your firearm until the first shot was recorded.  The fastest draw each year won a prize like a new knife or a light for your your pistol. Something as routine as a traffic stop can leave an officer dead when the operator may be in hiding or attempting a getaway unbeknownst to the officer.

The need for verbal dialogue is already part of officer training.  It is called “giving commands” and officers-in-training practice it for hours in all academy classes.  It becomes part of the daily behavioral vernacular of most citizen contacts – especially those with noncompliant, resistant or agitated subjects.  Adding verbal de-escalation commands to the use of force protocol will create a greater lag time when that moment of attack occurs or is about to occur.  I understand the need for sensitive dialogue in all potentially violent police-citizen encounters.  I believe it is a safe bet that all police officers are guided by the reverence for human life as the LAPD edict would espouse.

Counseling is not appropriate when the bad guy escalates to a lethal force moment such as when he draws a gun unexpectedly, or is fighting for an officers firearm or when he rushes an officer with a knife attempting to do grave bodily harm.

America’s moral failure: Veteran health and the slide into oblivion

WESTBOROUGH, MA December 26, 2015 The topic of suicide among America’s war veterans comes up over and over when morbid stories become known – generally after the death of a former soldier, marine, or airman. This must raise the consciousness of each of us and greater attention to the health of our veterans is our moral duty. So far, the incidence of suicide among America’s war heroes seems not to have diminished in 2014.  22 veterans are said to commit suicide daily – more than are killed fighting in war. How is it possible that more is not being done for these men and women and their families?  A society unmoved by these facts is a moral failure.

Amy Miner now speaks out on PTSD (AP PHOTO – Holly Ramer

No greater failure comes to mind but the case of Kryn Miner, a Vermont veteran of 11 wartime deployments who was killed by his son in 2014 after threatening his family with a firearm. Miner was seriously injured in 2010 sustaining a TBI after a roadside blast threw him into a concrete wall. But it was not his first exposure to trauma. He returned to his home with a brain injury and PTSD and was unable to receive the treatment he needed to release his demons.  His wife Amy was quoted as saying “the truth of the matter is if we can’t take care of our veterans we shouldn’t be sending them off to war.”  Miner’s mental health slowly languished as he fought the fight to gain access for veteran’s health benefits.

America failed to provide for access to meet his basic needs causing both he and his family to suffer immeasurably.  Some might argue that Kryn Miner and his family represent the unconscionable and symbolic misfortune of  America’s war heroes. Ironically, it was Kryn Miner who strove to gain access to benefits for many of his fellow Iran and Afghanistan war veterans via the Lone Survivor’s Foundation.  Eventually, he became a spokesman for the foundation.  But Miner struggled with his own demons that eventually cost him his life in a troubling case of patricide in rural Vermont.  Kryn Miner suffered with a traumatic brain injury and post-traumatic stress.  On the day he died, he had attended a wedding with his wife and arguably consumed too much alcohol.  He became angry and menacing ultimately threatening to kill his family.  In self defense, one of Miner’s children used a handgun to defend members of the family.  The state’s attorney general did not bring charges calling Miner’s death a justified homicide.

This family, like so many others has suffered immeasurably and will experience the pain of this death forever. It would be all too easy to point the finger at the Veteran’s Administration Healthcare System for having too few mental health clinicians or too long a waiting list. In fact as much of an advocate Kryn Miner was for his brother servicemen and women he did not help himself. He threatened his family with a firearm and may have killed them all were he not stopped by a courageous child in a unconscionable turn of events that no one could anticipate.

Are childhood sports becoming venues for expression of unencumbered anger?

WESTBOROUGH, MA January 20, 2016  “Childhood sport represents an opportunity for children to learn the value of teamwork, sensible competition, winning, and loosing. Some important lessons in life emerge from the spirit of youth competition,” according to Michael Sefton, Ph.D., Director of Psychology at Whittier Rehabilitation Hospital in Westborough.  “I have coached youth hockey up through high school-age boys and have found 99 percent of the families I worked with to be very reasonable and respectful,” remarked Sefton in preparation for the blog post.  Just as importantly the games must be fun or children will not want to play. In recent years there has been a growing notoriety of fan behavior while attending the sporting events of children.  It is almost a “mob mentality” as parents shout at referees over botched calls, yell at other players, and become obstreperous toward the opposing fans.  Sometimes this becomes violent as it did in Reading, MA in 2002 when two men squared off and fought over a youth ice hockey practice resulting in the death of one.  “The fight was less about hockey than about the loss of control and unencumbered anger” according to Sefton. For his part, Thomas Junta who outweighed the victim by over 100 pounds was sentenced to 8 years for manslaughter.  He was released from the state’s prison in Concord, MA in 2011.

Social scientists have been interested in mob behavior for years and when it comes down to what the underpinnings of fan behavior experts cite alcohol, adrenaline, and blind team loyalty as primary culprits. But as far as parent behavior at childhood sporting event goes some parents become delusional and behave out of some overdriven striving on behalf of their child. Some parents see scholarship money in a child as young as 5-years old when in actuality only 2 percent of athletes will ever receive scholarship funds for playing football for example, according 2008 NCAA published data – most receive only a partial scholarship package and not the coveted “full ride” – published in the NY Times.  As a parent I took my children to an NCAA ice hockey playoff event that was so much fun. The kids were given ice time to skate with coaches and players from the playoff teams.  During this time I attended a parent education seminar on scholarships and the lengths to which some parents will go to get their child athletes noticed.  How is it possible that an angry father might physically attack a volunteer referee over a missed call or become enraged at a youth coach over the amount of playing time a son or daughter receives?

According to Brooke De Lench, Mom’s Team executive director, parents lack the basic coping skills to respond to the ups and downs of their kid’s competition and are injured when their child does not succeed. De Lench seeks a shift from an adult-centered model to a child-centered philosophy as a way of eliminating unruly and sometimes outrageous fan behavior. When fans loose control the results can be deadly. “We lose ourselves when we watch our children play sports” said Sefton who regularly attends high school parents’ night in Massachusetts speaking on concussion.  But becoming lost as children play youth soccer or football must never include losing control as it sometimes does. Because for some parents, a child’s failure, or even the perception of failure may evoke strong emotions.

In 2002 during a youth hockey practice 2 children jostled and battled for the puck.  One parent, confronted the coach, whose son it was involved in the on ice scrap.  He objected to the rough play during the on ice scrimmage.  A shouting match ensued followed by the 270 pound Thomas Junta, 45, jumping the much smaller Michael Costin, 44, and punching him violently and killing him in front of his child and other players in the ice arena in Reading, MA.  Junta was charged and served 8-10 years in the state’s prison for manslaughter.  The lives of both families were destroyed by this event.  Both Junta’s and Costin’s boys have grown into troubled men and have themselves served time in prison.  This sensational story left quite an impression on me as an outrageous exemplar of state of the art parenting.

Most of us know there is much psychology in youth sports including developing core beliefs about winning and loosing, team cohesion, mastery of physical skills, and the growth of healthy competition. Balance is needed pushing children to become something for which they are may not be physically or emotionally equipped. Just as important parents must recognize their own feelings at their children’s games and accept that some things should not be worthy of the fight to end all fights.

Dr. Michael Sefton is a neuropsychologist and former police sergeant in Westborough, MA .  He along with 3 colleagues published a psychological autopsy on the Dexter, ME domestic violence homicide from 2011 and presented the research before the Domestic Violence Homicide Review Board at the state house in Augusta, Maine in November 2011.

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