Human Behavior

Walking corpse syndrome: The long-term impact of repeated trauma and identifying with death

Michael Sefton, Ph.D. Human Behavior , , ,

Preamble: The Boston Globe published a Spotlight Series called The Taking of Cell 15 alleging how dysfunctional and secretive the Department of Corrections here in Massachusetts has become. The story was reported by Mark Arsenault, Matt Rocheleau, and Spotlight editor Patricia Wen. The piece published on August 14 2022 in the Boston Globe Spotlight Series shines a light on the perceived secrecy that exists within the Department of Corrections and illustrates just how difficult it is for inmates to get fair treatment and defense against correctional department abuse and supposed secrecy in its methods. But I am not writing about the current day Department of Corrections and have great respect for anyone who walks the walk. According to Boston Globe reporting, “between Jan. 10 and March 1, 2020, men incarcerated at Souza lodged 118 allegations of excessive force by officers, according to Prisoners’ Legal Services of Massachusetts, a nonprofit organization that aids and advocates for incarcerated people.” Many of these have not been adjudicated by the DOR and many have been unfounded.

This post is all about Cotard’s Syndrome first identified in 1880 in a female patient. It is a distinct delusional disorder that is manifest by a fixed belief that one has died or has organs in her body that are rotting or have been removed. The walking corpse named for Jules Cotard who first described this delirium of negation. I am working with a retired correction officer (called ‘CO’) who was a supervisor. He has PTSD that was diagnosed in 2020. It is quite poorly controlled and he receives no therapy or medication for its management. CO was admitted to our hospital after becoming debilitated by kidney disease. He receives hemodialysis (HD) three times weekly. He sometimes falls asleep during HD and has flashback images of people being beheaded. Part of his delusion is a belief that he has been “embalmed”. His 21 years as a correction officer and supervisor are firmly embedded in his psyche and this has left him estranged from his wife and 3 of his 4 children. The flashbacks manifest as tortured sleep and daytime trance-like visions. All triggering his fight-flight response and memories of bearing witness to dozens traumatic events while serving the people of Massachusetts. He sometimes fights violently upon awakening. These experiences still linger now 9 years after his retirement from a maximum security prison. Almost every correctional officer experiences similar traumatic events during their career, but many never get psychological help to deal with PTSD.

CO has very unusual thinking when particularly tired or stressed. These come to him during sleep in the first half of the night. He was diagnosed only 2 years ago, even though he has not been on the inside for 9 years. There has been no consistent therapy offered CO since his diagnosis from what I learned. He has dozens of traumatic experiences most of which have gone untreated. The description of his experience is similar to those recently reported by the Globe in the Spotlight Series, particularly chaotic and violent. As we became more acquainted his war stories streamed from one ghastly story to the next until he gradually grew fatigued and sometimes tearful. He was never disrespectful when speaking about the inmates he watched and shared some regret he could not help them.

He told me the story of a member of his team who killed himself with a shotgun at the start of his shift. He was in his prized Camaro that he had rebuilt. “He loved that car,” CO added, now entranced. In most cases, law enforcement and correction officers alike would undergo debriefing when officers are exposed to a particularly gruesome death scene. Debriefing was rare following inmate deaths years ago. Officers were expected to handle it and move on. But after an officer killed himself in the parking lot men were given the chance to talk. CO was on the front line of this incident and saw the aftermath. The victim was a friend. Members could not comprehend his reason for shooting himself, where as he loved that car so much. “There were a lot of tears after that one” said CO. This may have been a trigger for CO developing a rare psychiatric disorder that would follow him into retirement.

Slowly, under watchful eyes, the victim was taken from the car and brought back into the facility until the Commonwealth medical examiner could get there from Worcester to retrieve the remains. Members gave a salute as he moved to the medical facility as we have seen with other first responders after the death of one of their own. Meanwhile, life went on inside the prison. No time for whining about losing a friend – it did not matter that he was in his buffed out Camaro. He loved that car and it would be part of his final plan.

Cotard’s Delusion is a rare condition marked by the false belief that you are walking dead or your body parts are dead, dying, or don’t exist. It is rare and not even listed among the common ICD-10 psychiatric conditions. The Cotard’s idiosyncratic beliefs often evolve from existing obsessive compulsive (OCD) thinking on steroids. It also may occur with severe depression and some psychotic disorders. I was trained to think that walking corpse was usually associated with borderline personality disorder, hypochondriasis, or somatization disorder. You might also hear it referred to as walking corpse syndrome, Cotard’s syndrome, or nihilistic delusions.

In the case of CO, a 57-year-old male has a history of unstable PTSD as a result of his 21 years of service at a maximum security prison here in Massachusetts. He is cooperative and likable in a slow matter-of-fact kind of way. His speech is slow and thoughtful. During this time he experienced physical attacks over 5 times – one of which kept him out of work for 10 months. He witnessed over 100 prisoner hangings – deaths by suicide that required a special team response. He was a supervisor and was responsible for the extraction teams comprised of officers who deal with the most violent offenders. He admitted with pride that he was always the first man at the scene. He witnessed men who had cut their own throats and watched them die before the entry team could assemble and make the save. He witnessed vicious fights among competing prison factions that were sometimes merciless and deadly.

These experiences followed him into retirement and invade his sleep regularly even now. He says poor sleep is his primary problem. He seems tired whenever we speak. He is careful to warn me about waking him up. Sometimes when awakened he experiences a threat as if someone was trying to hurt or kill him. He even warned our nursing staff and me to be careful when awakening him. CO sometimes awakens trying to kick out or defend himself as if he was under attack. His level of arousal was trigger sharp and he once almost pushed his granddaughter out a window when she tried to get him up. He is ashamed that his wife is afraid of him and lives out of state. They talk on the phone daily while he is in our hospital. He does not get many visitors.

That is CO’s cross to bear. In fact, he sleeps only 2 hours at a time, awakened by dark and scary images of his own death and his embalming. He dreams of people being decapitated and of planes crashing. When awake, he walks the house checking doors – just as he did on the block during his time on the job. For his part, he is strongly conflicted about his role in the prison. As a Christian, he believes in his heart, that he could help many inmates – some of whom went on to take their own lives. He was trained in peer support and crisis intervention skills he often could not utilize. As a supervisor CO could not turn the other cheek when inmate brutality threatened officer safety. Correction officers are often seen as the last first-responders and are rarely debriefed following inmate deaths, personal attacks, or violence toward officers.

Cotard’s syndrome is characterized by nihilistic delusions focused on the individual’s body including loss of body parts, being dead, or not existing at all. Cotard’s is neither mentioned in DSM-V nor in ICD-10 – both diagnostic tools made for identifying nervous and mental disorders. There is growing unanimity that Cotard’s syndrome with its typical nihilistic delusions represents some underlying behavioral health disorder. Organic causes should be ruled out as an etiology before attribution of Cotard’s syndrome as a fully psychological problem. Some papers are cited in the literature that suggest several typologies may underlie the outward presentation of walking corpse. The most common is a syndrome associated with major depression and its symptomatology including: melancholia, nihilism, and psychotic features. There is a literature suggesting a preference for ECT when treating walking corpse. A slightly different nosology abnegates depression and aligns it more closely with delusional thinking and not primarily associated with affective disorder. There is some association with on-going hemodialysis as a source of the unique delusions due to its associated similarity with blood being removed form the body. CO was discharged to a lower level facility because he lived alone and still needed help. He called me once after discharge to cancel out follow-up. I know he was looking forward to the wedding of his daughter, the youngest of 4 children. He smiled as he imagined them dancing together at her wedding. She seemed to be his favorite.

Debruyne, Hans & Portzky, Michael & Peremans, Kathelijne & Audenaert, Kurt. (2011). Cotard’s syndrome. Mind & Brain, The Journal of Psychiatry. 2. 67-72.

Fabrazzano, M, et al. (2020) A hypothesis on Cotard’s syndrome as an evolution of obsessive-compulsive disorder, Oct, International Review of Psychiatry 33(2):1-6 DOI:  10.1080/09540261.2020.1810425

Debruyen, H, et al. (2011) Cotard Syndrome.

Good stress – Bad stress: Don’t let holiday season bring you down

Michael Sefton, Ph.D. Bullying, Health Psychology, Human Behavior

The Whittier Health Network is happy to offer this on-line presentation entitled: Stress and Holiday Blues: Learn ways to lower the dread too many feel during the holiday season. Take steps to reduce stress and its impact. Learn to be resilient and do not dread the holiday season. Be a part of this zoom continuing education presentation and learn the steps you need to reduce the powerful impact of stress. “Learned resilience can be taught and leads to reduced stress and psychological hardiness rather than psychological weariness.” according to Leo Polizoti, Ph.D. Psychological weariness is a drain on personal coping and adaptation to situational stress. Contact Joanne Swidersky at 508-871-2134 to reserve a place at the holiday table.

Finding purpose for career success

Michael Sefton, Ph.D. Human Behavior , , , ,

As a member of the Direct Decision Institute, Inc in Worcester, Massachusetts, my colleague Dr. Leo Polizoti, the Institutes senior lead psychologist, are charged with doing pre-employment psychological screening for all officers heading to a regional police academy across New England. There are details about the pre-employment process at the institute website: drdecision.org. One question I usually ask is: “Why do you want to be a police officer?” As you might expect, the answers are all well rehearsed and touch on: inspiring, decorated family members who were police officers, the personal desire to help people, or a memorable encounter with a member of law enforcement early in life. There are always others too.

A more curious inquiry might sound like this: “why would you want to be exposed to fatal car crashes, domestic violence, including intimate partner homicide, completed suicide and suicidal persons, sudden infant death, violent, intoxicated subjects, random citizen complaints, professional jealousy, long hours, and sometimes decrepit leadership?” I might even add: “if you want to help people why not become a nurse or high school teacher?”

As a police consulting psychologist my goal is to offer my best judgment about candidates for police officer. I offer my two cents worth of resiliency advice by painting a portrait of how they see themselves five years in the future. When asked what they expected in the pre-employment psychological interview one or two have said it was a “waste of time.” Now these men and women are in the minority, only 1 in 15 has said that in my last round of interviews. But just as importantly, going forward, these new officers are going to represent law enforcement and should be better prepared to embrace mental health awareness and the reduced stigma associated with behavioral health and human resilience. Most cops are starting to understand this. To say that a one hour meeting with the police psychologist was a “waste of time” reflects both the lack of understanding of personal well being and a blind spot in progressive policing. Mental health is everywhere in law enforcement on both sides of the badge.

Finally, the families of LEO’s and first responders who die by suicide are being afforded line of duty death status and the dignity they deserve

Michael Sefton, Ph.D. Human Behavior , , , ,

First, New Hampshire, and now on July 16, 2022 the City of Chicago, IL has agreed to pay line of duty death (LODD) benefits to officers who die by suicide. Each of these cases are complex and I am sure some form of assessment of the individual officer’s case will be carefully chronicled. I can imagine this is going to be slow going as I am not sure whether there are some strings attached to the individual suicide. 

The denial of this LODD recognition diminishes the honor of one man’s service and by doing so, fails every man or woman who puts on a uniform by saying “your experience is yours alone”. And even worse, it amplifies the stigma attached to law enforcement deaths at a time when all else has failed them and their families. Michael Sefton, 2019

“Chicago is kind of like ground zero with the number of suicides that are happening on a monthly basis now at this point,” said Daniel Hollar, who chairs the department of behavior and social science studies at Bethune-Cookman University in Florida. Dr Holler hosted Dr Doug Joiner to Chicago for a symposium on 2019. Dr Joiner taught us much of why officers kill themselves. He says they become embittered, they feel a deep sense of thwarted belongingness and grow increasingly detached with and higher  risk. “These are people who are answering calls of duty to protect lives. We (need to) do our job to make their jobs safer.” After an officer suicide, personnel try to reconstruct what was going on in the person’s mind by systematically asking a set of questions, in a consistent format, to the people with the greatest insights into the person’s life and mind—family, co-workers, and friends.” This is known as a psychological autopsy. I have been writing about this for 9 years in these pages. This must include a 3 month list of calls the decedent answered including those for which he or she were given debriefing, defusing, or time off for respite from the job. I would want to understand how the call volume may have triggered underlying acute stress of were there calls that triggered new trauma?

NH Governor Sununu signed House Bill 91 on July 8, and it goes into effect Sept. 6. Sponsored by N.H. Rep. Daryl Abbas, R-Salem, it drew bipartisan support. He is the Link:

The New Hampshire law will go into effect on September 1, 2022 and allow officers to feel that their families are secure with benefits of They should die in the line of duty which now include dying by suicide.

Dr Hollar is organizing the forum in Chicago the first of these I participated in with my colleague Dr Leo Polizoti from the Direct Decision Institute, Inc. in Worcester, MA. Among the issues up for discussion is what role Chicago’s relentless violence problem plays in officer suicide. Hollar said they will also talk about other factors, including whether familiarity with death makes suicidal officers more likely to follow through with their plans as reported in the March 2022 Chicago Tribune.

“What we see in this career, the calls that we get, can take a toll on somebody’s mental health and wellness,” he said Monday. “When we go to a death of a child by the hands of a parent, or a pretty nasty accident scene, these things will add up.” Cheshire, NH Sheriff Eli Rivera

Sometimes a law-enforcement officer will begin to question whether they may have arrived at the scene earlier by driving faster, or whether there was something else they could have done to prevent a loss of life, said Rivera. This can add up to behavior that may place an officer at risk if he decides he needs to get on scene faster the next time around. Some begin to believe that the world may be better if without them. Many are angry and become hopeless and embittered for a variety of reasons, like feelings of resentment and misunderstanding.

Roadside memorials and people who maintain the shrines we see on roads everywhere

Michael Sefton, Ph.D. Human Behavior, Stress , , ,
Roadside memorial

I am always in awe when I drive past roadside memorials. They commemorate the place where someone was killed in a motor vehicle crash. They grew in popularity following the of MADD, Mother’s Against Drunk Driving first in the 1980’s in Austin, Texas. These are usually a white cross along with trinkets, toys, and photos that memorialize them life or lives that were lost at the location. Many are painted with the names of people who have lost their lives too. What strikes me is who maintains the site? Is there any sort of memorial at a internment site? Do the same people who maintain the shrines also maintain a grave site?

There is a psychology to the roadside memorials that are dotted across our country’s roadways commemorating the lives of people who have perished. Usually these are simple crosses sometimes emboldened by the name or names of people who may have been in fatal accidents at the location. Others grow to become memorials to a lost love one and are maintained by grieving family members. I seem to see them everywhere and wonder about the survivors. Do they visit the site? It is different then a cemetery in that this is not the place where they were laid after death, but this is the last place on earth their loved one was alive. 

I am reading a couple of books about roadside memorials with interest. One is a thesis from a Canadian university, authored by Holly Everett from Memorial University in Newfoundland. These sites are also known as the “spontaneous shrines” that result from a public outpouring of grief according Everett who studied the shrines in Texas as part of her graduate work. It makes me sad when someone builds a spontaneous shrine to honor the loss of someone. On my way to work a few months go, I noticed that 2 crosses were erected in a tree near my home. A spontaneous shrine.

While working as a police officer I noticed these spontaneous shrines popping up in our town usually after a fatal accident. Fortunately, we had very few fatal crashes in the 12 years I worked. Towns everywhere, including the one in which I patrolled, were discussing regulations about the roadside crosses and all the stuff that accumulated along with them. Our chief was sympathetic but the one or two shrines in our town became a traffic hazard in his mind. Cars (I assume family members or friends) would slow or stop for a short visit. We always worried about someone getting injured or killed on the site of one of the crosses. And we had a call to the cross on Rt 67. The boyfriend of one of the victims was sleeping at the cross site. Upon further investigation we learned that he was so grieved that he wanted to stay with the girlfriend’s cross one last time. Sadly, we had to send him along because having a sleeping person on a busy road caused too much public concern. Communities are needing to regulate these sites because the grieving public tends to add more and more to them. Some family members even mow grass or shovel snow keeping the site looking prosperous. According to the draft policy posted on the BBC site, “locations and content of roadside memorials will be vetted for safety and messages that can be considered “offensive” will be banned, as will any sort of illumination or materials that can shatter, such as glass” January, 2022

It struck me that the first names were imprinted on white crosses leaving off the last names of the two boys who died at the site. I would have liked to know the last names. I wanted offer my condolences in some way. Maybe I had seen them riding bikes in the neighborhood just recently, at least until one of them earned his driver’s license.

Treatment Resistant Depression and it’s impact on life: looking toward more contemporary options in 2022

Michael Sefton, Ph.D. Human Behavior , ,
Intractable depression now has multiple options and hope for its resolution – read on

Intractable depression is something that occurs in 20-30 percent of patients with major depression. It is called treatment resistant depression or TRD according to Zhadanava M, Oilon, D,Ghelerter I, et al. (2021). There are more medications than ever and a range of programs for treatment resistant depression that some may not have heard about. For that reason this review will be useful.

As the name implies, treatment resistant depression is highly refractory to the typical treatments that generally include psychopharmacology and psychotherapy. I have had the clinical opportunity to meet with men and women in psychotherapy who are diagnosed with major depression but for some of them, nothing has helped. They have had multiple trials on numerous medications and psychotherapy with little to no relief of symptoms. Some describe a worsening of symptoms after beginning treatment and some claim this to be signs of an allergic reaction to the medication. The British Journal of General Practice has published a list of the first line antidepressants in 2019, Kendrick,Taylor, and Johnson. The meta analysis is conducted in 2019 revealed 21 medication’s that showed efficacy and tolerability in patients with it it may be depression. They found agomelatine, (Valdoxan), amitriptyline – a tricyclic antidepressant but is prescribed for various nerve, arthritis, and muscle pain, escitalopram (Lexapro) – may treat generalized anxiety as well as depression, mirtazapine (Remeron), used for poor sleep hygiene, failure to thrive, and major depression, paroxetine, (Paxil), venlafaxine, (Effexor) may help with GAD and panic anxiety, and vortioxetine (Trintellix) more effective than others.

These patients are intractable in their sadness and become resolute that nothing will help them. Most have been talkative, intellectually curious, but deeply sad in my presence. They are often hopeless that they may never feel a few moments of joy each day, no matter what they do. Many feel embarrassed for being so overwhelmed with life and barely hold on from week to week. Others take life with little hope that things will ever change and, for them, suicide is always on the drawing board. These few patients sometimes need a more structured living arrangement, usually a hospital.  Many patients with intractable depression live life with their final exit all cued up and ready to roll. Some plan to move west to states like Oregon that has physician assisted suicide – saved for when they can no longer live with themselves. For these people, I work with them to find a greater purpose upon which to focus and measure success – often one day at a time. In addition to psychotherapy it is important to get these folks moving with rigorous exercise and activities to find greater purpose. Some patients decide to return to school, work or start attending church again. This programs not only enhance dopamine transport but they also result in social interpersonal contact, something many are missing as they grow older.

There are now new and controversial treatments for treatment resistant depression that are being reported in the psychiatric literature bringing hope to families everywhere. Treatment like transcranial magnetic stimulation, ketamine treatment, stellate ganglion block, deep brain stimulation (requires a surgical procedure to set a deep brain stimuator in the area of the brain that subserves the aura of well-being, and even psilocybin, a powerful psychedelic. Family members sometimes ask why can’t we do something less invasive? The transcranial magnestic procedure is non invasive and uses strong magnetic fields to stimulate neurons within the brain in the area that underlies mood regulation. Treatment requires 15-30 sessions. Readers may have heard little about these treatments, but for families who have watched their loved ones languish, they offer a modest hope that life for their loved ones now has options and promise. These are the cases that you worry about at the end of the day. These are the cases that may not buy what you are selling when it comes to a therapeutic modality or trial of medication that they have already tried and failed. The handoff to one of theses specialty options including ECT – electroconvulsive therapy needs to be a careful one and deep brain stimulation requires sensitivity and cautious optimism about the likelihood of success. A little halo affect can go a long way in getting a good first impression, and a good start to a new treatment modality. A careful history about what medications have been tried and failed is important to document including the length of time they took the drug.

Still newer is the return of hypnotic and synthetic therapy. Scientists are using psilocybin to bring patients through their depression in one of two treatments. Reader may understand that psilocybin are the main ingredients in LSD. There is a growing literature on the use of psilocybin to improve depression resistant cases. Those participating in psychedelic studies often say the experience was among the most meaningful of their lives, on a par with the birth of a child or death of a parent. Many report feeling a sense of connectedness with the universe. “This psilocybin journey was the single most transformative experience of my life,” Mr.Fernandez wrote in a medium post in 2018 reported in a recent NY Times opinion piece by Dana Smith, Ph.D (taken 7-16-2022).

I saw the 60 minutes story on SGB a year or two ago as a possible treatment for refractory PTSD. Many patients now matter how many medications the the and even combined with hours of individual psychotherapy still have reactive symptoms of the condition. SGB stands for Stellate Ganglion Block. Ganglion simply means a bundle of nerve fibers. We have numerous ganglia in our bodies. The Stellate ganglion is different and offers a potentially serendipitous treatment option for posttraumatic stress disorder (PTSD) that heretofore has been refractory to conventional psychiatric therapy. It may hold promise for co-occurring depression as well. It involves a neurochemical blockade of the stellate ganglion. The use of a small amount of anesthesia provides a risk free blockade of the autonomic nervous system overflow that contributes to the toxic levels stress hormones like adrenaline and cortisol that directly add to feelings of anxiety and hyperarousal among people with PTSD. This elevated arousal puts them on high alert night and day. This is not sustainable. 

Here in Massachusetts, the MGH has a Stereotactic Functional Neurosurgery Program that among other things does SGB for medically intractable Obsessive-compulsive disorder and Major depression under a current protocol at MGH. Surgical options are not considered until when medical options are no longer effective or side effects may be severe (Functional Neurosurgery Program, Massachusetts General Hospital website, taken August 22, 2022. DBS has been utilized for Parkinson’s disorder for many years. For people who suffer with major depression many are hopeless and believe the world may be better without them in it. These alternative treatments like: ECT, TMS, Ketamine, stellate ganglion block, and DBS afford greater options at some personal cost. While they are intensive and in some cases invasive there is a trade off in terms of quality of life. The tipping point in my view, when people are isolated, hopeless, and their depression becomes a barrier to functional living, like failure to thrive, the cost of not taking a broad approach to treatment is too great. Human suffering can sometimes be so silent that no one takes notice. The treatment resistant are sometimes elderly and often alone. It is these people that I worry about in my practice as a clinician here in Massachusetts.

REFERENCES

Zhadanava M, Oilon, D,Ghelerter I, et al. (2021). The prevalence and national burden of treatment-resistant depression and major depressive disorder in the United States. Journal of Clinical Psychiatry; 82(2):20m13699

Kendrick, T, Taylor D, Johnson, C. (2019). Which first-line antidepressant? British Journal of General Practice; 69 (680): 114-115.

Smith, Dana (2022) Taking the Magic Out of Magic Mushrooms, Opinion, NY Times, July 16, 2022

Agin-Liebes GI, Malone T, Yalch MM, Mennenga SE, Ponté KL, Guss J, Bossis AP, Grigsby J, Fischer S, Ross S. (2020). Long-term follow-up of psilocybin-assisted psychotherapy for psychiatric and existential distress in patients with life-threatening cancer. J Psychopharmacol.Feb;34(2):155-166. doi: 10.1177/0269881119897615. Epub 2020 Jan 9. PMID: 31916890.

MGH (2022) Stereotactic Functional Neurosurgery Program, Website taken 8-22-2022.

There is no repository for red flags: The ongoing argument for containment

Michael Sefton, Ph.D. Human Behavior

Despite the public outcry for red flag warnings as a method of mitigating gun violence and high lethality shooting incidents there is no single repository for cataloging red flag behavior when red flags are observed. In some cases, red flags are ever present in a one-sided, authoritarian relationship slug fest. One man we investigated posed with a Remington shotgun in his high school year book. A real gun guy.

Think about how difficult it would be to track and classify all the red flags we see in people all the time. As psychologists, it is something we do regularly. A dangerousness assessment is a component of every exam I do. If someone gives off signs that they may become violent, psychologists have a duty to warn potential victims and the local police. Who does the public call? Concerned citizens call police to do well-being checks almost daily – sometimes more than once. These are usually benign calls for service but domestic violence and dangerousness require greater understanding of the risks of harm to LEO’s and innocent family members. It is a fact, that someone usually knows that there is imminent risk of violence – even mass murder, and does nothing.

“I thought he might do something, like kill himself or something, but I never thought he’d take the kids”

Sister of a Maine man who killed his family and then himself in 2011

As yet, there is no repository of “red flags”. People wrongly believe there is a single place where violent intentions are stored. Yet no. There is seemingly no red line, that if crossed, someone would be deemed too dangerous to own a weapon or perhaps be brought for early dangerousness assessment. The quotation above is from the psychological autopsy conducted after Steven Lake murdered his wife Amy and their two children in Dexter, Maine. Red flags are the antemortem behaviors that indicate growing affective instability. These are suggestive of an increased level of risk to intimate partners and often the general public. They are the clues that behavioral scientists hand out whenever the topic of dangerousness is brought up – we are reminded of all the red flags. I think the American public is tired of hearing about red flags because so often they are present in the retrospective after the murder victims have been laid to rest. The prior depression, suicidal behavior, various forms of interpersonal violence, availability of firearms, forced sex, choking, pathological jealousy, violation of restraining order, and threats of death are a few red flag warnings often overlooked. We will speak about the Uvalde killer and a couple others in the next few paragraphs. But bear in mind, the best predictor of future behavior is past behavior.

Just as violent spouses manifest a behavioral purulence, mass shooters often display a similarly angry predilection that is posted on the their chosen social media platform in the form of a host of  miserable, cantankerous resentments. This resentment can take many forms and is often the road map into the underpinning of their anger and growing desire for violent recompense. These are not monitored by the dangerousness police, in fact, red flags are not collected, tallied, or catalogued at all. If the ad hoc red flags are laid out and the subject suddenly comes into contact with law enforcement and all the planets align, then a high lethality event may be averted serendipitously one day. But derailing a mass casualty event on the front end has been an inauspicious foist at best. These shooters inevitably fall through the cracks and very few have been stopped in their tracks because of red flags that rose to the level of containment. How is that possible?

In 2016, the knee jerk reaction is to attribute the recent Thousand Oaks, CA nightclub shooting to a “crazed gunman” that would unfairly place the blame on the mentally ill. Psychological experts believe mentally ill persons lack the higher order planning to execute the complex steps necessary for anything more than petty crime – more often associated with co-morbid substance abuse.  It is the co-occuring illness of drug or alcohol addiction that is a confounding variable in all police-mental health encounters. The interaction of substance abuse disease, like alcoholism or opioid abuse and mental illness is complex.  Persons with drug and alcohol addiction must be expected to become sober with the help of substance abuse treatment and family support. The risk of violence and suicide declines when sobriety can be maintained. It goes up when depressed and angry men drink more than they should.

Some social media platforms use algorithms to predict when someone may use violence based upon target words, internet search terms, and photos that may be posted. So far, none of these have helped to intercept a shooter from his intended targets. In the aftermath of high profile mass shooting, law enforcement and the FBI uncover pages and pages of antisocial ranting, hostile embitterment, ethnic hatred, and angry beliefs along with veiled threats. These often are directed at one person or group of people who are perceived to have wronged the shooter. Virginia Tech killer Seung-Hui Cho send his diatribe to the media in 2007. In the case of Steven Lake, his daily online diatribe about the unfairness of the court order protection always drew dozens of ‘likes‘ and comments that he was a good father and should “fight for his children”. The fast action by the victim’s employer and the Dexter police on the morning of the murders is likely what prevented a rampage. It is believed that Lake had an intended list of people he planned to murder.

Some mass shooters are engaged in group chat rooms where messages of violence and hatred are shared, bringing their fetid ideas to the drawing board. In these chat rooms, like-minded antisocial men and women hoard their reactionary fantasies decayed by the never ending bluster and beset in a de facto life filled with anger and decreased empathy. Video games contribute to aggressive thoughts, feelings, and behavior in the laboratory and in life (Boffey, Dana Foundation). So among the cartoon characters in the chat rooms are young men who are searching for meaning behind the call to war or other video games. They collectively create a sense of having been the victim of injustices and being driven to seek vengeance against anyone he believed had wronged them” assuming no responsibility whatsoever, according to Peter Langman, 2017.

Each time a person strikes out in a mass shooting the people who are tasked with understanding and identifying red flags that were present signaling the impending violent combustion. These are often easy to spot by those closest to the shooter. The possibility of mandating the report red flags is being debated. Like child and elder abuse, proponents of red flag warnings want mandated reporting laws for persons with direct knowledge of violent intensions when it becomes known. “And when it comes to mass shootings, those with mental illness account for “less than 1 % of all yearly gun-related homicides” a 2016 study found. Other studies indicate that people with mental disorders account for just 3-5 % of overall violence in the US”  – Paul Appelbaum, M.D. taken from BBC by Rachel Newer 11-1-2018.

In May, 2014, Elliot Rodger, 22, posted a YouTube video declaring his intention to slaughter “those with a good life”. Elliot felt like girls he had dated were unkind to him. He wrote a manifesto over over 100 pages. These pages detailed his childhood, family problems, his inability to get a girlfriend, and his hatred of women, ethnic minorities and interracial couples. And it contained his plans for a massacre according to Andrew Springer, journalist who interviewed Peter Rodger, Elliot’s father. This occurred in Santa Barbara, CA, where his murderous rampage was posted using social media sites as a prequel to the killing of 6 college students including his two room mates – one of whom he stabbed 94 times. His therapist made a valiant effort to warn the possible victims of his violent intentions as the law requires.

In a case of nihilistic violence, Vester Flanagan, a television news reportely killed a female colleague and her cameraman while live on the air. “Like dozens of mass killers before him, the shooter embodied a deadly mix of resentment, delusion, and thwarted aspiration” according to Sarah Kaplan (Washington Post, August 27, 2015). The live twitter posts, videotaping the shooting, and horrific execution of the victims by Vester Flanagan on live television will be a specter for years to come in Virginia’s Roanoke market. Just as important may be the analysis of Flangan’s devolving mental status in the months and days leading up to the terminal event.

The case in Uvalde, TX is similar in that the shooter set his sites on children and teachers. Ostensibly, selecting a soft target to amplify his intent on bringing forth chaos, pain, and historic violence, like the Sandy Hook, CT killings in 2012 and Stoneham Douglas High School in Florida. Much of the aftermath scrutiny of the event will catalogue his social media presence and its potential for understanding what triggered the despicable attack and may have informed law enforcement about potential for exploding embitterment through violence. And the police response in this event remains under investigation because of the poorly executed breach and termination of the event. No one knows how long James Ramos may have exuded his intention when he purchased two AR-15 style rifles just days after he turned 18. One could infer that his plan was hatched months before given the timing of his gun purchases. Dr. Peter Langman described an accumulation of real or imagined injustices among the causal attributes of such gun violence as Uvalde, Sandy Hook, and so many others. Shooters are deeply driven to seek vengeance against anyone they believed had “wronged” them according to Langman in 2017. Interestingly, video game violence has not risen to the top of the list as a leading cause of mass killing although, “Violent video games provide a forum for learning and practicing aggressive solutions to conflict situations,” Anderson 2000.

Let us look at the most recent event in July 2022 where Robert Crimo III, known as Bobby, climbed to the roof of a structure overlooking the start of the July 4 parade in Highland Park, IL. He had a semiautomatic AR-15 style rifle that he legally purchased himself. And yet, in November 2019, police were called to his home because he was threatening to “kill everyone in his family”. He had the means and the mindset for such a crime that the Highland Park police removed 16 knives and a sword from his home in his possession. These were returned to him sometime later. In 2021, they were called to the home once again for now-18-year old named Bobby, who wanted to kill himself. The same person. In the Chicago Post interview, the senior Crimo downplayed his son, Bobby’s threats in that incident as a “childish outburst.” Not quite right. The red flags were there and if a red flag repository existed, he should not have been allowed to purchase or poses firearms. Whether or not he should have been contained in a mental health treatment facility is not known.

Containment of violent offenders is an important component of the criminal justice system. But what about those who are exhibiting red flags? Containment of violent citizens is also something to consider before they act on violent impulses. How do we protect their individual right to privacy? Someone usually knows what is likely to happen if something isn’t done to break the cycle of coercion and violence. In the Dexter case the killer’s sister knew. 12 hours before the murders she told her brother to “go get help”. But he could not. He was a gun guy. The fact that so many mass shooters are killed by law enforcement or kill themselves prevents analysis of broad psychological factors that may have triggered the terminal rage such as early childhood instability, loss of a love object, hostile embitterment, or a desire for blazing masculinity. And those who are captured such as James Holmes who was convicted of the 2012 Aurora, Colorado theater shooting in 2015. There was nothing that could be cited that correlated with the extent of violence and victims from that night in Aurora – 12 fatal and over 40 with severe injuries. A quick review reminds us that Holmes was a bright doctoral candidate in neuroscience prior to the massacre. “Studies have shown study that exposure to violent video games is positively related to adolescent aggression; however, normative beliefs about aggression have a mediating effect on exposure to violent video games and adolescent aggression, while the family environment regulates the first part of the mediation process.” In general, the research has not consistently supported the notion that violent video games contribute to aggressive behavior or mass shootings but some have offered modest correlation without espousing causality. Massachusetts has recently enacted an emergency red flag for people who are exhibiting the most violent behavior. It allows police to remove firearms and revoke a person’s license to carry a firearm. Known as the Extreme Risk Protection Order (ERPO), also known as a red flag law, is an order from a judge that suspends a person’s license to possess or carry a gun. That said, greater emphasis on the assessment dangerousness, along with mandated reporting just like in suspected cases of child or elder abuse and a DV offender registry may be worth considering. It is not an exact science but in case after case there are undeniable red flags and someone who knows what is going to happen because of an intimate and shared relationship. Look at the red flags and make a determination of risk. Containment including: no bail holds, loss of second amendment privilege, and GPS monitoring will instill greater responsibility in both violent citizens and shared criminal responsibility with those keeping the dangerous secret.

Anderson, C, Dill, K, (2000), Video games and aggressive thoughts, feelings, and behavior in the laboratory and in life. Journal of Personality and Social Psychology, Vol. 78, No. 4.

Anderson, C. A., and Carnagey, N. L. (2014). “The role of theory in the study of media violence: the general aggression model” in Media violence and children. ed. Gentile, D. A. (Westport, CT: Praeger), 103–133.

Boffey, P (2019) Do Violent Video Games Lead to Violence? Dana Foundation, Neuroethics Viewpoint.

Only darkness for Uvalde

Michael Sefton, Ph.D. Childhood violence, Dangerousness assessment, Human Behavior, Leadership, psychological relevence, PTSD, retirement, terminal rage , , , , ,
Only blackness in Uvalde, Texas

The day started normally enough with a ceremony for children who had made the honor roll. The parents of these children had no idea that the ceremony would be the last bright moments of their young child’s life. Shortly after the end of the honor roll ceremony the proud 4th graders went back to their classrooms. When a few minutes later, the school was breached by a former student of a different variety. At 11:28 AM, Salvador Ramos entered the Robb elementary school through an open door. The 911 system had been activated. Law enforcement was in the building and took fire. Only months earlier, they had trained for this and learned they must quickly engage the shooter. For his part, Salvador Ramos would receive no awards on this day. He was no longer a student; he was a hunter. By all rights his rampage may have been cut short by an hour or so, had law enforcement brought the tip of the spear to him as shots first rang out. We know this from Columbine. His day would end in blackness, just like the front page of the Uvalde Leader-News.

The tactical training instructs officers to move to contact and bring the fight to the sound of the guns even when you must step around or over victims. In the Pulse Nightclub massacre in Orlando, FL, Sergeant Mark DeBona led a team of officers after a power outage darkened the club. He told us that had to ignore victims pleading for their lives as this small group of sheriff’s deputies chased the shooter in pitch darkness into a men’s room and neutralized the threat. We were taught that as few as three officers could bring an end to an active shooter incident by quickly entering a building and moving to the sound of the shooting and neutralizing the threat. 

We knew from Columbine, that the longer we waited the more children, teachers, and staff would be lost. There was no way a swat team could deploy in the time needed to move into the school and find the bad guy and put an end to the killing. We trained in neighboring schools too, so we might be familiar with the maze of corridors common in most school buildings for a time when we may become the tip of the spear. Our chief in New Braintree, MA vowed that he would drive his cruiser through the front doors of the school if needed, to gain immediate access in order to save lives. He believed this would cause a significant distraction to the gunman allowing the assault team to catch up. The New Braintree elementary school was much like the school in Uvalde with many doors and easy access to classrooms.

Much of the aftermath scrutiny will catalog social media red flags that may have informed law enforcement of his embittered beliefs. The psychological autopsy will chronicle the facts of Ramos’ final weeks. Information about his state of mind will slowly emerge and the roadmap of his disaffected early beginning. No one knows how long Ramos may have been emotionally percolating when he purchased 2 high powered rifles after turning 18 in March. His mother, Adriana Martinez said he was angry for failing to graduate high school with his fellow classmates Friday, adding that “he was not a monster.” In an NBC News interview, Adriana Martinez’ boyfriend, Juan Alvarez, said that Ramos went to live with his grandmother after a fight with his mom over Wi-Fi. He said the relationship between Ramos and his mother was tumultuous and that the two often fought.” Since the pandemic quarantine Ramos’ mother described him as mean and police had been to the home more than once. His closest friend said that Ramos was bullied in middle school because of a stutter years later after posting a photo of himself wearing black eye liner. He grew distant from friends and sometimes used a BB gun to shoot people while driving around with friends. He had an online presence where his beliefs were broadcast and played violent video games with friends like Tour of Duty. These psychological underpinnings will be studied for years to come.

May 24, 2022 will forever be remembered as among the darkest in Texas history. It was an abject failure among contemporary law enforcement tactics and protocols for active school shooting. On this day, the wolf was camouflaged in sheep’s clothing, lurked on the periphery until he spoke, moving in, telling children “you are going to die”. The wolf gained access without so much as a growl from any sheep dog guarding the flock. And then he took 21 for his last supper, leaving the flock depleted of its young. Then Uvalde went into the darkness trying to understand what had happened “.

Above is the front page from the 5-26-22 Uvalde Leader-News that shows all that was left. Or perhaps, the sheep are forever in hiding in the darkness.

ADDENDUM on 7-17-2022: According to the report released 7-17-2002, 376 law enforcement officers massed at the school. The overwhelming majority of those who responded were federal and state law enforcement. That included nearly 150 U.S. Border Patrol agents and 91 state police officials.

DV homicide: When cities cut funding for domestic violence this can lead to increased risk of IPV and death

Michael Sefton, Ph.D. domestic violence, domestic violence homicide, DVH, Human Behavior , , , , ,

It is well known that law enforcement can be called to the homes of domestic violence victims only one in seven occurrences of abuse. That means there are possibly 6 times when victims are traumatized by intimate partners to which LEO’s are not privy. Why is this? In my experience, perpetrators of intimate partner abuse are secretive and forbid their partners to call police. They are manipulative and want to control the interview such as when first contacted by law enforcement. They frequently act surprised that police were called sometime saying “are you sure you are at the right place?” But in reality they silently simmer, waiting for police to take the bait and run. Often back on their spouse as soon as they are alone. The entire basis for the relationship is all about coercion and control of one spouse over another. It all starts as secret manipulation fueled by jealousy and insecurity.

Many victims of DV are coerced to feel afraid of calling for help. Police need to see all members of a household when called to a case of domestic assault. This bullying by perpetrators results in a pattern of threatening and control that is coercive to victims who learn to remain silent, in spite of fears of being killed. Red flags are often missed with the arrival of police officers as intimate partners pull it together trying to avoid angering their tormentors who control by making veiled threats. These investigations sometimes require more than one visit.

Follow-up intervention is recommended once the dust settles. This is sometimes hard to achieve. Whenever an aggressor is taken to jail, whether for the night or weekend, contingencies for his safe re-entry must be negotiated. When the risks to spouse or family members remains elevated, then an order of protection should come together based on the details of the call and written so as to bring to life all documented red flags. Either way, the investigation is not completed until there is an understanding of what happened (why the police were called) and what comes next for this couple? Specific issues like: threats of death, forced sexual contact, physical abuse leaving marks, any kind of strangulation, threats with a firearm or other deadly weapon, and threats of suicide are all the details written into a protective order. These are big ticket items and raise a victim’s level of risk substantially and usually become part of a stay away order. Each of these crimes are a red flag warning to cops looking at charges for domestic violence.

Larger departments across the United States have experienced greater numbers of domestic violence since the initial quarantine in 2020. As the months went on adaptive coping broke down resulting in larger numbers of domestic violence with maladaptive coping behaviors such as: excessive use of alcohol, threats of physical violence, frustration, and boredom increased greatly. Some, like Portland, OR actually saw a reduction in officers assigned to the DVERT – the multidisciplinary unit that investigates DV in Multnomah, County, Oregon in which Portland is the County seat.

The Portland (OR) Police Bureau’s Domestic Violence Enhanced Response Team (DVERT) and Domestic Violence Reduction Unit (DVRU) have been reduced in manpower according to information poached from their website. They now have about half the number of officers they did 10 years ago – five officers assigned to the DVRU and two officers plus a Multnomah County Sheriff Office detective assigned to DVERT according to a 2015 Blog post written by Emily Green. With this staffing level, they have the resources to investigate only about 7 percent of domestic violence reports received by the department each year. In 2013, out of a total of 8,179 domestic violence reports, only the 586 most serious cases were assigned to the domestic violence unit. DVERT strives for a “best practices” model of interagency collaboration by coordinating several forms of intervention for domestic violence victims and offenders as reported on the department website. As of this writing no more recent numbers are available.

Isolation of victims from family

Other cities struggle with DV and its social fallout. In 2017, San Diego law enforcement received 17,306 reports of domestic violence. This number was four percent higher than the previous year, according to the Criminal Justice Research Division. There were eight domestic violence-related homicides in 2017 that involved current or former intimate partners. Domestic violence incidents involved a death in four other instances. Five domestic violence offenders killed themselves according to a domestic violence blog maintained by a local attorney in San Diego.  Likewise, San Diego saw changes in the rate of DV during and after the pandemic. The Alliance for Hope in San Diego provides support for police investigating crimes such as strangulation with supportive end empathic care for victims of domestic assault.

I wrote about #24hourwindow project in my description of the Icelandic response to DV in Rejkavik and beyond. Police in Reykjavik, Iceland believe that detectives or senior police officers must intervene within the window – 24 hours from start of a call out, to put together a strong case and collect evidence. I agree with this approach and strongly urge local agencies use it as a model. They work in teams of 4 or 5 as described in a BBC story. The former protocol was often several days after the call and coincided with the honeymoon period where violent partners try and kiss and make-up. Bail conditions frequently fail DV victims as the abuser is often bailed out within 1-2 hours. Egregious cases of DV, those particularly life threatening should be held without bail until a dangerousness hearing may be initiated. 

To the un-trauma-informed investigator, many behaviors exhibited by someone who’s just experienced a traumatic event double as signs of lying. Behaviors such as an inability to remember the chronological order of events, nervousness, avoiding eye contact or of recalling sounds and smells with more ease than physical details about his or her attacker, are all the result of effects trauma has on the brain.

Emily Green 2015

Specially trained Portland (OR) Police Officers review and follow up on reported incidents of domestic violence. Their responsibilities include reviewing reports from the initial responding officers, assessing each case in order to prioritize incidents requiring follow-up investigation, making attempts to contact the victims and witnesses to obtain additional information, providing referrals to victims for appropriate services, and attempting to contact and arrest perpetrators of domestic violence. This should be done during an 8-10 hour shift or by the next regular day shift by law enforcement who understand intimate partner abuse and its dysfunctional, cycling nature.

“In Iceland, twice as many women are reporting incidents of domestic violence to the police than they were two years ago. I wrote about this a couple months ago and had reached out to the #windowproject @IslForce and the #Rejkavikpolice commander without much fanfare. Like Portland Oregon, Iceland uses a multidisciplinary unit that enters the case in call-out fashion by each discipline rolling on scene called the 24 hour window project. This is due to an ongoing police initiative to provide women with better-timed and better-located assistance, which is bringing the problem out of the shadows” as reported in apolitical in 2017. I have called for regular aftermath follow-up in cases of domestic violence as a form of community policing. Officers work in pairs and stop during the next day to complete a check-in. Some victims are contacted by their abusers or family of the abuser and can be dissuaded or intimidated not to press charges. This resumes the honeymoon and cycle of violence is renewed.

REFERENCES

Green, E. (2015) How understanding the neurobiology of trauma helps Portland police work with domestic violence survivors. https://www.streetroots.org/news/2015/01/20/how-understanding-neurobiology-trauma-helps-portland-police-work-domestic-violence Taken 5-16-2022.

Stress and Burnout: Understanding the human stress response and its malignant power to impair

Michael Sefton, Ph.D. Alcoholism, crisis intervention, Health Psychology, Human Behavior, PTSD, Stress ,
The neurobiology of burnout starts with high levels of stress hormones coupled with perceived lack of efficacy and fatigue

Stress is well-known to the medical community and is treated with lifestyle adaptation and management of symptoms and disease. Once stress becomes too intense, it has a measurable impact on one’s own health.  I have posted blogs about a variety of stressful circumstances, some are associated with personal behavior and lifestyle choice; others are more in line with exposure to traumatic, stressful events experienced by first responders like members of law enforcement or front line healthcare providers. 

As well as impacting professional growth, research suggests that extreme stress levels can impair social skills, overwhelm cognitive ability, and eventually lead to changes in brain functioning. People who under constant stress pay a price in being unable to fully relax. They report feeling under constant threat from forces beyond their control and being stuck running in place. “In a recent study, job satisfaction, overall there were little differences between groups in ratings after a mindfulness program. The study looked at the impact on job satisfaction among members of a university faculty using weekly mindfulness meetings. Among those who participated, there was a significant link between feeling calm and relaxed, and greater workplace wellbeing, with those reporting less stress and anxiety also noting higher levels of job satisfaction according to Dr. B. Grace Bullock reporting on an Australian study in efficacy of mindfulness training.

Burnout can leave people exhausted, unmotivated, anxious and cynical – the consequences of which can be catastrophic to business and front line workers across all sectors of society. This is especially true among healthcare workers, where the stigma associated with mental illness still enables silence among those most in need. It is the real deal and probably underlies the recent exodus of nurses, doctors, police officers, and other front line professionals who have had enough and are moving on from their jobs. At our rehabilitation hospital more and more staff nurses are opting for a shorter commute by changing jobs. Some are leaving to become stay-at-home mothers after 18 months of fighting the fight with the virus, all the while their children were home in quarantine – going to school on their laptop computers.

“In a recent study, job satisfaction, overall there were little differences between groups in ratings after a mindfulness program but there was a significant link between feeling calm and relaxed, and greater workplace wellbeing, with those reporting less stress and anxiety also noting higher levels of job satisfaction. B. Grace Bullock 2017

Stress tends to create significant reactivity within the body. This brings forth rampant chemical flooding by the adrenal cortex and other stress hormones. These chemicals can add to a decline in physical well-being.  These over active hormones are lethal for the medically infirm and physically vulnerable. Yet, for some people, stress is like a drug and creates a circular pattern of sensation seeking as described in the prototypic type A personality.

 The neurobiology of stress and PTSD is being studied and may be linked to primitive brain circuits involved in the fear conditioning response and its eventual, sometimes refractory extinction or habituation of on-going perceived threat (Do Monte, Quirk, Li, and Penzo 2016). As an example, Police work carries with it a neurobiological underpinning that is well documented in terms of the impact of repeated stress and exposure to traumatic events. Chronic exposure to traumatic scenes and a host of other factors gradually elevate the hypothalamus-pituitary-adrenal (HPA) axis in the brain and body of typical career LEO’s. “The human brain, having evolved to seek safety in numbers, registers loneliness as a threat” as reported in a recent NY Times piece. 

Stress effects all aspects of how we feel. Most physicians know that mindfulness techniques lower subjective levels of stress. However, even though paced breathing puts the brakes on sympathetic overdrive, people do not use it long enough to create habits. “Meditating”, according to Dr. Woolery-Lloyd, initiates “the relaxation response,” which activates the body’s parasympathetic nervous system and decreases cortisol and inflammation.” Yet even our primary care physicians and physicians in emergency rooms across the country are at risk from frontline stress, burnout and area at higher risk of suicide. This taken from a story written by Jessica Defino about the impact of stress on human skin in NY Times on 12/08/2020. The point being that the stress response is pervasive in human functioning and can wreak havoc on physical health including the integumentary system – our largest organ – our skin.

“Why don’t we come up with a program before bad things happen?” asked Dr. Englert. “Bad things are going to happen. When they do, the person, the individual, and their family will be more resilient, more able to recover quickly from that event.” said Alexa Liacko, ABC News interview. It is in being vulnerable that we are able to stretch our emotional experience that brings forth growth and reduces stigma. You cannot expect frontline healthcare and first responders to walk through water and not get wet.

Lloyd, C et al. (2002) Journal of Mental Health 11, 3, 255–265