crisis intervention

Police as therapist: the inherent risk of unconditional positive regard 

Michael Sefton, Ph.D. career criminal, Dangerousness assessment, Human Behavior, Police officer behavior, psychological relevence, Relationships, Suicide by cop , , , , ,

WESTBOROUGH, MA January 12, 2017 Changes in the responsibility for those afflicted with major mental illness must remain in the hands of medical and psychiatric providers who are trained in contemporary diagnosis and treatment models. Yet a growing mental health strategy has emerged to train and educate first responders – including the police to deescalate and divert those with mental illness from jails into treatment.  The problem with diversion here in Massachusetts and New England is that a continuum of care is lacking. Since the closure of the state hospital system here in Massachusetts the community-based treatment centers have been overwhelmed by the volume of cases they must see.  To say they have failed is shortsighted and disingenuous and behalf of the Globe Spotlight team.

Make no mistake about it, putting police officers in the place of psychotherapists and psychiatrists is not going to happen here or anywhere. But cops are being asked to act as mediators to diffuse encounters with persons with suspected mental illness. The intention is to reduce violent encounters between the police and those with mental health issues. “Most people with mental illness are not dangerous, and most dangerous people are not mentally ill” according to Liza Gold, 2013. Yet in the past several years there have been many high profile officer-involved shootings involving people afflicted with a variety of psychiatric conditions including major depression raising the specter of suicide by cop.

POLICE ACT AS CRISIS MEDIATORS WITH MENTALLY ILL

It is very risky putting the police in the role of crisis intervention specialists to manage those who may be emotionally distraught. For one thing the high incidence of drug and alcohol intoxication in these cases makes any negotiation or mediation almost impossible. I was always taught that until the patient is sober there is no meaningful assessment or interaction is possible.  Police are the front line responders to crises of all kinds. Asking them to serve in this new role presents a level of officer specialization like never before.  Some officers are being asked to offer unconditional positive regard to those encounters in an effort to slow the scene giving time for intervention to take hold.  In some places like San Antonio, TX and Vancouver, BC it works.  But it has taken a long time to gain traction. If the goal is to avoid incarcerating those with mental illness this is especially difficulty in the absence of a treatment continuum as I have said.  In the cities just mentioned there is a well established mental health infrastructure that affords the police various options for the unstable citizens they are asked to assist.

In most larger communities a dearth of mental health services exist resulting in a large number of mentally ill persons being held in custody – sometimes a county house of correction or any one of

Dr. Michael Sefton brought out myths of mental illness while serving as a police officer retiring in 2015

16 prisons in the Commonwealth of  Massachusetts. The Spotlight team at the Boston Globe has featured the plight of those who are sent to prison with comorbid mental illness and substance abuse. The fact is that criminality and mental health are often difficult to disentangle.

The National Alliance for the Mentally Ill believe as many as 20 to 40 percent of prison inmates may have severe mental illness and may not be receiving the needed treatment to allow them to rehabilitate.  Yet in the absence of the mental health infrastructure needed to provide treatment – including hospital care for those most unstable, few viable options were put forth.

The Boston Globe fails to inform readers that criminality and mental illness are not mutually exclusive.  Drug addicts break into homes to feed the hunger of their addiction.  In prototypic fashion, the Globe offers no alternative and no solution aside from casting blame on the Commonwealth of Massachusetts. Without a doubt the stories they report are heart wrenching and emotionally palpable for the readers. But not all those in custody who are suspected of preexisting mental illness are helplessly suffering without therapy.  Most are not.  In many cases being incarcerated allows an addict to become clean and sober and begin the first steps of recovery. Those who are most resistant to therapy and fail to attend psychotherapy, anger management, and medication monitoring have a higher risk of violence and substance abuse. This fact must be considered when responsibility for treatment failure is studied.  

Those relationships that suppress the normal, effusive, life force are detrimental to health much like a toxin said Sefton in 2013.

ALTERNATIVE SENTENCING

With so many incarcerated persons with suspected mental illness change must be initiated  by having services available to those on the front lines.  The criminal justice system and the department of mental health have an opportunity to work together now that the pendulum once again swings toward a treatment model. The police can be trained to control the scene through intervention and mediation strategies by slowing things down. When charges are brought alternative sentencing models may offer leverage that include mandated treatment in lieu of jail time.  Studies show that those who remain in treatment are less violent than those who fail or drop out of treatment, Torrey, et.al., 2008.

Mental health patient often rely on community services and social welfare including housing, disability payments, medical care and more.  Access to these services may be tied to participation in treatment including psychotherapy, medication, if prescribed, and substance abuse treatment.  Here is Massachusetts M.H. Advocates reject this notion as unfair a response that remains unique across the country.

The interaction of substance 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.  The 12-step programs have great success and are free to anyone willing to attend. Family members may attend Al-Anon or some drug-specific family support group.

Mental health infrastructure is necessary for the system to work.  In San Antonio it has taken 15 years to establish a system that works and saves lives.

Torrey, CF et. al. The MacArthur violence risk assessment study revisited: Two views ten years after its initial publication. Psychiatric Services, vol. 59, issue 2, February 2008, pp. 147-152.

Law Enforcement – Mental Health Collaboration

Michael Sefton, Ph.D. Health Psychology, Human Behavior, psychological relevence , ,

November 28, 2015 In a recent post the issue of mental illness and police use of force has been the subject of scrutiny.  The pairing of police officers and mental health counselors is becoming a compelling option in some departments.  In a previous blog post I published an essay ostensibly denouncing the utility of these patrols in part because it presents a greater level of risk to police officers, ride-along psychotherapists, and the community at large (Sefton, 2015)

Over 100 persons with known mental illness were the victim of lethal force following a suicide by cop scenario or some other violent encounter resulting in the rapid escalation of the use of force continuum. Police officers train for these situations and are expected to meet force with force.  These encounters sometimes end up in a lethal force standoff where split second decisions can wind up in a deadly outcome.  As quickly as encounters may escalate, police are trained to de-escalate their use of force as the situation dictates.  The use of force must be fluid and officers in the field are expected to modulate the force they apply to the demands of the situation and be ready to respond to changing threat levels.

The current population of jail inmates is said to have a higher percentage of people suffering with mental illness than ever before.  Since the early 1970’s an effort has been made to deinstitutionalize those with severe mental illness leaving many to flounder in the streets.  The National Alliance for the Mentally Ill believe as many as 20 to 40 percent of prison inmates may have severe mental illness and may not be receiving the needed treatment to allow them to rehabilitate.

Police are increasingly linking up with mental health agencies as a way of diverting mentally ill person’s from jails into treatment for their emotional affliction. This is necessary to free police to serve the public interest more efficiently and safely. Treatment options are quite limited especially in rural communities who may be underserved by specialists in psychiatric emergencies.

psychology2
British Psychological Society (BPS) photo

Police in Augusta, Maine have paired with crisis counselors two nights per week in order to provide support and expertise to police in the handling of mentally ill suspects with emphasis on de-escalating and diverting subjects from jail. Larger agencies routinely interface with mental health experts.  Courts across the country have in-house clinics that can provide up to date assessments of persons with suspected mental illness or risk for suicide and homicide.

In Massachusetts many smaller police agencies must pay overtime for police officers to sit in hospitals or outside of jail cells watching a mentally ill person who has been arrested.  Specifically, if a police officer arrests a person with a known history of suicidal ideation it has been policy among many agencies to provide an officer to monitor the prisoner to assure for a safe transfer to court. This is very expensive for small departments and takes a police officer off the road sometimes for 48 hours until the prisoner can be brought before a judge. Coupled with a high prevalence of cases of substance abuse and the growing menace of opioid addiction, police officers have their hands full with cases in which changes in mental status add to the complexity of decision-making and breadth of alternative dispositions.

This author was employed in an agency that generally deployed a single officer on duty.  When a mentally ill person was arrested the agency was forced to call in off duty personnel to transport and supervise the prisoner to assure for his or her safety.  This policy was implemented in any case of arrest whenever a person has ever had a documented history of depression with suicidal statements.  Across Massachusetts police dispatchers have access to a database of names of individuals with documented history of police interaction while mentally ill. This affords the police a heads up when a call goes out involving persons with a proclivity for suicidal behavior.  This protocol was not necessary and offered no help whatsoever to the person under arrest.  It resulted in emotionally vulnerable persons being held in custody longer than necessary out of fear that once released they would be at high risk of suicide and leave the police department liable and open to litigation.

The myths associated with mental illness – especially in the police service are abundant. For example, here in Massachusetts anyone arrested with a known history of suicidal threats needed to be watched while in custody – sometimes for one or two days until they could be brought before a judge. The question of suicidal risk should be made by psychologists and psychiatrists familiar with emergency mental health and crisis intervention.  Police officers are inherently apprehensive about legal action being brought against individual officers for decisions made because of a lack of understanding and training in dealing with those in crisis. District court judges have no greater training in suicide assessment and prevention than the cop on the beat and the decision about suicidal risk should not be left to them.  The police should turn to the experts whenever the question of risk for suicide arises and once evaluated the disposition may be straight forward gradually reducing the myths associated with this difficult population.

I agree with calls for added training for police officers in dealing with the mentally ill as a way of eliminating the myths that obfuscate decision-making and risk officer safety.  Agencies are making greater efforts to divert the mentally ill away from jails and the legal system whenever possible.  But for diversion to work well the city and county need to provide treatment programs at each point a mentally ill person comes into contact with the criminal justice system – from interactions with cops all the way through the courts, according to an NPR-Kaiser Health News report in July 2015. Our current system of liaison between mental health and law enforcement must be forged by greater cooperation and mutual understanding of the needs of those suffering from emotional illness such as depression, PTSD, and now a growing population of the addictions including alcohol and prescription pain killers.

Watch for the flying of the flags

Michael Sefton, Ph.D. Dangerousness assessment, Human Behavior, Relationships , ,

Terminal rage dissembled by increased red flag threats and violence

WESTBOROUGH, MA  November 2, 2014 A group of my colleagues and I were drawn into the chilling events of June 13, 2011 after Stephen Lake killed his family and then himself.  During the final moments of his life Lake laid out the death scene ostensibly to torture his spouse from whom he was estranged and ordered to stay away.  While police closed in, Lake killed and attempted to burn his victims in an act of emotional mayhem.

Arguably, the murderer in this case became blinded by anger and resentment at perceived disrespect and exclusion from the lives of his children. This anger had grown over the year since a protective order was issued following a violent episode in the family home. The perpetrator grew marginalized during the coming months becoming resentful and humiliated at missing key events like Christmas and an 8th grade commencement.  All the while he posted on social media sites his love for his family he grew depressed and disorganized.  12 hours before the violent ending he tearfully described feeling depressed to a family member and was advised to seek help.  Lake wrote 9 suicide notes that were found in the days after his death.

Renewed interest in retrospective study

The psychological autopsy revealed an increasing pattern of red flags in the weeks before the murder-suicide in Dexter, Maine. Greater awareness of these red flags may serve as a stopping and containment point for perpetrators of intimate partner violence.  In a sad retrospective, the Maine state Chief Medical Examiner cited that “in spite of some mental health treatment the extent of (the perpetrator’s) anger was not fully appreciated”. The research led to a call for no bail holds for some violent abusers and GPS monitoring for others.  After 3 years, these recommendations are finally beginning to emerge in the protection of victims of domestic violence in Maine. Mr. Lake was alleged to have violated the protective order more than twice.  His reported view of the “cost of divorce was the price of one bullet”.

Who can be expected to bear witness to red flags?

It is well documented that domestic violence is a secret happenstance that effects far too many families across the country.  Victims are expected to remain loyal servants of their spouses under the dissembling guise of love and devotion.  The findings published in the Dexter, Maine study reveal that people knew what to expect from Mr. Lake.  His unwinding was clear to some of his closest family members.  A paternal aunt was quoted as saying “I never thought he would take the kids” suggesting an awareness that Lake might kill his spouse and then himself – sparing the children.  Others believed Lake might commit suicide in front of his wife and children leaving them with the emotional specter of his violent death.  Instead, as the chief medical examiner cited the full extent of Lake’s anger was not appreciated.  In this case, as in many other retrospective studies of DVH red flags were not appreciated. Many believe that an order of protection is not effective in protecting victims from violent spouses who seem to ignore “stay away” orders seemingly at will and without consequence.  These are the red flags that require containment of the abuser and must serve as the frank evidence of elevated risk for domestic violence homicide.

The team of people helping 22-year old Elliot Rodger, a young man who went on a shooting rampage at the University of California at Santa Barbara in May 2014, all reached out to police and the media when they could not reach the estranged and overwrought man.  But they were too late as he had made his mark on history by then.  The the Virginia Tech shooting some red flags were missed.  Had the subtle clues the Rodger’s underlying mood been recognized the shooting may have been averted.  To read the blog from the UCSB shooting click here.

Mandated reporting for domestic violence 

As a civilized society there should be mandated reporting for those most at risk for domestic violence and the penultimate DVH as it becomes apparent.  Just as practitioners are mandated to report cases of suspected child abuse and elder abuse so too must we begin to take heed of the signs of domestic or intimate partner abuse and take action.  By doing this we may save the lives of those most effected by DV and arguably break the recurring cycle of domestic violence.  Some people wrongly believe there is nothing that can be done about domestic violence homicide. Others remark that “what happens behind the closed doors in a dysfunctional and violent household is no business of anyone else”.  To the extent that this draconian belief system prevails in the public understanding of DVH there is little chance of preventing this scourge.  As a result states are slowly changing their response protocols for DV and the police response to signs of abuse with mandated arrest for suspected perpetrators.

Risk assessment of those arrested for domestic violence is often overlooked.  However, police departments are teaming up with agencies serving the population of abuse victims like never before and are adopting tools to assess the likelihood of future violence when determining bail amounts. Bail commissioners must be educated about the cycle of abuse and domestic violence when assessing bail amounts.  The average abuse victim experiences 5-7 episodes of DV prior to calling the police. Police response to DV has slowly started to include a careful analysis of the history of aggressive events including the number and type of physical assaults that have taken place.  Some events are clearly more foreboding like choking to a point of unconsciousness, sexual aggression, threats of suicide, and the use of veiled threats of death if the spouse ever tries to leave. Other behaviors such as unrealistic jealousy may be the underpinning of current or domestic violence.  One victim told me that the abuse started as soon as she said “I do” 16 years earlier.

REFERENCES

Ronald Allanach et al., Psychological Autopsy of June 13, 2011, Dexter, Maine Domestic Violence Homicides and Suicide: Final Report 39 (Nov. 28, 2011), http://pinetreewatchdog.org/files/2011/12/Dexter-DVH-Psychological-Autopsy-Final-Report-112811-111.pdf.

Sefton, M. (2011) The Psychological Autopsy: Provides a host of pre-incident indicators. Blog:  http://www.enddvh.blogspot.com/2011/11/psychological-autopsy.htm, taken May 26, 2014.

“The underpinnings…

Quote Michael Sefton, Ph.D. Active shooter, Dangerousness assessment, Health Psychology, Human Behavior , , ,

“The underpinnings of violence are often present in some form or another and may be represented by marginalized demeanor and extremist views and often ignored by those in the cross hairs” according to Michael Sefton, Director of Psychological Services at Whittier Rehabilitation Hospital in Westborough, MA.

This quote represents a recurring belief about the evolving coping skill of an active shooter until the very end according to M Sefton.  The terminal event is often preceeded by growing fury and red flag signs of anger.  It suggests that greater awareness by outside observers of sudden changes in mental status should be recognized along with the utilization of stopping and containment protocols and coordination of care in or out of the state correctional system.