The Psychological Impact of Pandemic: The best and worst of human behavior

On November 11, 2020, I presented a program on the Psychological Impact of Pandemic sponsored by Whittier Rehabilitation Hospital.  It was well attended with a mix of nurses, midlevel practitioners, social workers, and nonclinical participants. The program was presented on the zoom platform. I am now going to put to paper my perspective narrative espoused in my 90 minute presentation.  I had also invited members of law enforcement with whom I have regular contact as the information was drawn from the growing literature on mental resilience and its positive impact on coping with exposure to trauma.

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According to the PEW Research Group, 4 in 10 Americans know someone who has either been afflicted with Coronavirus or someone who has died from the virus. My mother was infected with the Coronavirus in mid April in the same nursing facility where I lost my 93-year old aunt in the first wave of the virus in May, 2020. My mother survived the virus but it has taken a significant toll on her physical and cognitive well-being. We were not permitted to see my mother during her illness and my aunt was alone on May 1 when she succumbed to the virus. Both living on a nursing unit that was doing its best to render compassionate care under extraordinary conditions, in some cases with nurses, aides, and therapists working round the clock. Both of these loved ones received extraordinary care. Nursing units across the country suffered unimaginable loss of life including over 70 elderly veterans at the Soldier’s Home in Holyoke, Massachusetts.  We all saw the images of refrigerated trucks holding victims in expiated purgatory hidden behind hospitals. It may bring horror to those who lost loved ones and never saw them again.

I saw my mother on November 12. She looked frail and disheveled.  The nurse practitioner had ordered a blood draw out of concern for her physical well-being. She is 92 and may have a blood disorder. They had three staff people hold her in place to obtain the small sample of blood which took over and hour.  She has always had difficulty having her blood drawn and this has gotten worse as she has gotten older. She fought and screamed from pain, and fear, I was told. It was torture for all those involved, including me.

Little did anyone realize the extent of disease, contagion, and trauma this pandemic would bring to the United States and the world. We waited in February and March with curiosity and vague forewarning from our leadership. We were led to believe the virus would dissipate once the weather became warm and it would essentially vanish in the heat of summer. This did not happen and public health officials at CDC and WHO were spot-on in terms of the contagious spread of covid-19 and the deaths it would bring.  Now with the approach of winter our fear borders on panic.

This virus poses significant stress and emotional challenges to us all. It raises the specter of both an overwhelmed medical system as well as increasing co-occurring emotional crisis and a collapse in adaptive coping, for many. Sales of alcohol went up 55 percent in the week of March 21 and were up over 400 percent for alcohol delivery services. Americans were in lock-down and many made poor choices. The link between stress and physical health and well-being is well documented and will be a factor as American’s find their way free from the grip of Covid-19. 

“The human mind is automatically attracted to the worst possible case, often very inaccurately in what is called learned helplessness”

Martin Seligman

Whenever human beings are under stress they are going to utilize skills they have learned from other times when they felt under threat. Chronic stress has been shown to have negative effects on health including autoimmune functions, hypertension, inflammatory conditions like IBS, and pain syndromes. Many find it impossible to think about anything but the worst case scenario. Marty Seligman described the concept of “catastrophizing” that is an evolutionarily adaptive frame of mind, but it is usually unrealistically negative.” This leads to a condition known as learned helplessness. In another book, Dr. Seligman writes about learned optimism published in 1990. His cognitive strategies hold true today.

So many use the same coping mechanisms over and over, whether they are effective or not like drinking or gambling to let off steam. These things may help in the short term but can cause further health and social problems later on. They are not adaptive strategies. Stress is unavoidable and the best thing we can do is to understand its physical impact on us and adapt to it in healthy, adaptive ways. Stress raises the amount of cortisol and adrenaline in the body activating the fight-flight response. For many, that meant an uptick in the procurement of spirits in late March to help bring it down. Others think differently. Many began a routine of walking or running or cycling. Regular exercise contributes to reducing stress and when kept in perspective, is an adaptive response to the threat of coronavirus.

Many people in our hospital were afflicted with the virus or some other health concern and became immersed in loneliness and isolation that can lead to disconsolate sadness. It is hard not to be affected by this suffering. Most reviewed studies reported negative psychological effects including depression, anxiety, post-traumatic stress symptoms, confusion, and anger, according to Brooks, et.al. Lancet 2020. At Whittier, we had many cases of ICU delirium where patients became confused and frightened by healthcare providers wearing PPE including face shields, masks, and oxygen hoods. Many thought they were being kidnapped or that the staff were actually posing as astronauts. This made it hard to help them feel safe and to trust the core staff including doctors, nurses, and rehabilitation therapists.

Michael Sefton

We have had some very difficult cases including a man who found his wife on the floor without signs of life. He fell trying to get to her and both lay there for over 2 days. He was unable to attend her funeral because of his broken hip. We had another man who pushed us to be released from the hospital. He worried about his wife who needed him to assist in her care at home. She has Parkinson’s disease. He was discharged and died shortly after going home. His wife fell while getting ready for his funeral and is now in our hospital undergoing physical rehabilitation and receiving support from our psychology service. The table below is a list of observations from recent admissions:

  • Anxiety – what will my family do while I am here?
  • Deep felt sense of loneliness
  • Depression – loss of support; loss of control 
  • Exacerbation of pre-existing conditions i.e. sleep disturbance, asthma, uncontrolled diabetes, hypertension
  • Slower trajectory toward discharge
  • Debility greater than one might anticipate to diagnosis
  • Subtle triggers to prior trauma – changes in coping, regression, agitation, sleep and mood

What is left for us to do? Have a discussion about what it means to be vulnerable – talk about family members who have been sick with non-covid conditions like pneumonia or chronic heart disease, COPD, etc. It is important to be ready to work from home again such as when schools switched to remote learning this spring and when governors’ call for closing things down. Consider the return of college kids as campus dorms everywhere are likely to close this winter.

The 1918 Spanish Flu pandemic killed 50 million people worldwide. 500 million people were infected with the virus that lasted 2 years. The virus was said to have been spread by the movement of troops in WW I. The website Live Science reported that there may have been a Chinese link to the Spanish flu as well due to the use of migrant workers and their transportation in crowded containers leading to what we now call a super spread event. We know a lot more about this virus than we did in March 2020 when it first took hold but we need to understand the eradication will be a herculean task driven by science.

“The coronavirus has profound impact on the emotional stability of people around the world because of its unpredictability and lethality. It evokes fear, and uncertainty as it spreads unchecked. Later, the virus can serve to trigger long hidden memories in a way that can sabotage healthy human development leading to vague anxiety, physical symptoms, loss, and deep despair” said Michael Sefton, Ph.D. during a recent Veteran’s Day presentation. People must have resilient behaviors that foster “purpose in life, to help them survive and thrive” through the dark times now and ahead, according to police consulting psychologist Leo Polizoti, Ph.D. at Direct Decision Institute in Worcester, MA.

 

What is involved in CIT and Jail Diversion?

“The important part of crisis intervention training comes in the interdisciplinary relationships that are forged by this methodology. Trust and respect between the police and its citizens builds slowly one person at a time. “

Michael Sefton, 2017

Police officers have historically been ill prepared to deal with people exhibiting signs of mental illness or severe emotional disturbance. Many were thought to be unpredictable and therefore resistant to the typical verbal judo officer’s are trained to use. The CIT programs provided training to police officers in an attempt to bridge the gap between myths about mental illness passed down from one generation of LEO’s to the next and actual training and experience in talking with citizens experiencing a crisis in their life, learning about techniques to manage a chaotic scene, strategies for enhanced listening, understanding the most commonly encountered disorders and role playing. For one thing some person’s afflicted with mental illness have difficulty following directions such as those suspected of hearing voices, paranoia or command hallucinations but this is not always the case. Many individuals CIT trained officers will encounter are normal human beings who are experiencing a high stress, crisis such as the death of a loved one, financial loss, failed marriage or relationship, or major medical illness. This adds a layer of complexity to the CIT model that officers soon experience.

Acuity increases with encounters of mentally ill who are both substance dependent and have some co-occurring psychiatric condition. The alcohol or drugs are often veiled in the underlying “mental illness” but in truth they are not mutually exclusive. The importance of treatment for substance dependence and mental illness cannot be understated as violent encounters between law enforcement and the mentally ill have been regularly sensationalized. The general public is looking for greater public safety while at the same time M.H. advocates insist that with the proper treatment violent police encounters may be reduced and jail diversion may be achieved. 

5 Stages of Police Crisis Intervention

  1. Scene safety – Assess for presence of firearms – obtain history of address from dispatch – have back-up ready
  2. Make contact with complainant & subject – express a desire to help; listen to explanation of the problem – ascertain what is precipitating factor?
  3. Establish direct communication with subject – attempt to establish trust; support for taking steps toward change; “why now?”; identify any immediate threats – sobriety, weapons
  4. Pros and Cons for change – ascertain how willing  is subject to begin change process, i.e. sobriety, counseling, detoxification
  5. Positive expectations for change = direct movement toward change – hospital program; rewards that will come with positive change

“A crisis event can provide an opportunity, a challenge to life goals, a rapid deterioration of functioning, or a positive turning point in the quality of one’s life”

(Roberts & Dziegielewski, 1995)

There is a high degree of stress in any call involving a person in crisis. Repeated exposure to trauma is known to change the fight/flight balance we seek for emotional stability. Excessive autonomic arousal poses a threat to cardiac functioning and damaging hypertension. After high intensity/high lethality calls I suggest a defusing session take place immediately after the shift or as soon as possible. Excess adrenaline from an abnormal stress response can have significant health effects on LEO’s. Defusing or debriefing sessions can help reduce the impact of these types of calls. Full critical incident debriefing should wait until the normal effects of such calls wear off.

Sefton, M. (2017) Human Behavior Blogpost: https://msefton.wordpress.com/2017/03/30/police-are-building-bridges-and-throwing-life-savers/ taken December 10, 2017

What is driving the killing: Update on the Myth of Mental Illness

After a spate of bomb threats and mass shootings there are still many myths about the attribution of these events and the underpinnings of violence.  The knee jerk reaction is to attribute the recent Thousand Oaks, CA nightclub shooting to a “crazed gunman” but that would unfairly place the blame on the mentally ill.  12 people were left dead in a despicable sequence of events during which the shooter Ian David Long posted that he had no reason for doing it except boredom.  In truth, most people with mental illness are not dangerous, and most dangerous people are not mentally ill.” Liza Gold, 2013. But Long had a history of violence and aggressive behavior that may have been linked to his service as a decorated US Marine. Published information suggests Long’s mother was terrified of making him angry out of fear that he would harm or kill her. Was Long’s terminal behavior attributable to mental illness or the result of traumatic events he experienced in the service of his country?
“Fact is I had no reason to do it, and I just thought….(expletive), life is boring so why not?”  Ian David Long via social media post (now removed)
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.  “Doctors and scientists know that the perpetrators of such violent behavior including incidence mass shooting events are frequently angry young men, who feel they have been mistreated by society and therefore seek to exact revenge” described in a BBC the report Criminal Myths published in November.
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“Confounding variables such as a history of childhood abuse or use of alcohol or drugs can increase the odds of violence.” according to a BBC report debunking the belief that people who commit mass murder are mentally ill  by Rachel Newer in November, 2018.  The vast majority of cases are committed by a person or persons without mental illness.  In fact, people with mental illness are more likely to be victims of crime and are not prone to violent behavior. The Thousand Oaks killer refused any mental health support and was not driven by demons
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.  This is essential and will help to reduce officer involved use of force against the mentally ill substantially.  What to do?

Red flag indicators are often demonstrated in behaviors that are observable and measurable sometimes for weeks and months before the terminal event according to Michael Sefton, 2015.

The incidence of mental illness leading to mass shooting may be illustrated in the 2007 Virginia Tech shootings.  The Virginia Tech shooter Seung-Hui Cho had been treated for depression and was hospitalized on an involuntary basis prior to the rampage in 2007. Cho exhibited a life-long pattern of withdrawal from interpersonal relationships. He was often nonverbal and did not respond to people who reached out to him including direct family members.  His mother prayed for God to transform her son.

I strongly believe that mental illness does not mitigate citizens from responsibility for crimes they commit. I agree that alternative sentencing may be a powerful tool to bring these individuals into treatment. The substantive goal of streamlining encounters between police officers and citizens who suffer with untreated emotional problems belies the mission of these gifted officers and can teach others the role of discretion in mental health encounters.

Ostensibly, building relationships with network psychotherapists, physicians, addiction specialists, court judges, and other support service like Child and Family Services is essential. This is the area of most vulnerability.  When LEO’s fully buy-in to the mental health – police intervention model including the use of de-escalation techniques there must be receiving facilities available to initiate treatment and keep patients and citizens safe. The development of a fully integrated infrastructure for jail diversion, intake, and providing for the needs of the mentally ill is certainly a work in progress.

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Washington POST photo

“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


Nuwer, Rachel (2018) http://www.bbc.com/future/story/20180509-is-there-a-link-between-mass-shooting-and-mental-illness taken 11-10-2018
Sefton, M. (2017) https://wordpress.com/post/msefton.wordpress.com/4561
Mentally ill American’s and their proclivity to act out against authority.
Washington Post (2007) Rescue and Recovery: A story of resilience that began with the scene in this photograph, Blog post: taken on April 16, 2007. https://www.washingtonpost.com/graphics/local/virginia-tech-five-years-later/?noredirect=on&utm_term=.cd170ba2ac09 taken 11-10-2018
Sefton, M (2017) Police as crisis interventionist: CIT as it is meant to be. Blog post: https://wordpress.com/post/msefton.wordpress.com/3653 Taken 11-10-2018
Sefton, M. (2015) Unappreciated Rage: The Dissembling Impact of those living in the Margins. Blog post: https://msefton.wordpress.com/2015/08/27/unappreciated-rage-the-dissembling-impact-of-those-living-in-the-margins/ Taken 11-10-2018

Predicting the next mass shooting: do people just “snap”?

bigstock-Mental-illness-in-word-collage-072313WESTBOROUGH, MA January 21, 2018  Do people just “snap”? Rarely according to most literature I have read and published. The expression of violence is elicited slowly following a prolonged period of marginalized aloneness along with underlying resentment and anger according to Michael Sefton, Ph.D. This takes a great toll on relationships, loss of trust and a growing persecutory narrative that may become delusional.  The gunman in the Las Vegas mass homicide was described as narcissistic – a personality disorder vulnerable perceived rejection or disrespect often resulting in sudden rage, denial, decreased rational thinking, accusatory blaming, and often marked denial of responsibility. In the Las Vegas shooting it has been learned that the gunman had recently sustained a significant financial loss although its link to the people he killed remains a mystery.  There is typically some specific event that may trigger a violent event that could have been planned over months or years and evolve like the expression of some genetic permutation.

“People do not just “snap.” When something horrible happens, like a murder or violent attack, we naturally look for a cause. “Snapping” is an easy way to describe what is actually a complex, yet understandable chain of events. Research into violent attacks and the behavior of the attackers can shed some light on how one moves down a pathway toward violence.” Swink, 2010

The capacity for behavioral science to predict when the next mass shooting will occur remains unrefined. Yet, by studying the cases of mass murder that have occurred in the past 5 years there are important pre-incident behaviors that may foreshadow a coming terminal event. Often there are people who know precisely what is going to happen.  In our study of a domestic violence homicide that took place in Maine, 2011 we were told by the aunt of the murderer that she expected her nephew to kill himself but expect that he would do it in front of his wife and children.  What ultimately happened was a murder suicide.  Steven Lake killed his wife and 2 children and made an attempt to incinerate their bodies before local police arrived.  At that point he made himself comfortable and ended his life and the Lake family timeline.


Swink, J (2010) The Pentagon Shooting: They Don’t “Just Snap” Posted Mar 06, 2010 Taken Jan 4, 2018

Co-occurring Illness: Effecting change at times of crisis

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WESTBOROUGH, MA  – April 24, 2017 There is no magic solution for de-escalating someone who is in “crisis” or emotionally distraught.  The loss of control may signal a failure of reality testing that can signal a diminished capacity to appreciate the consequence of their behavior.  This occurs frequently when people who have mental illness have co-occurring drug and alcohol addiction. It is true that the correctional system has more than its share of mentally ill prisoners but for many being in jail is the only way to stay sober.  The full capability to provide mental health services in the correctional system here in Massachusetts has not been realized.  The courts are reluctant to require that someone receive treatment for mental illness and/or substance abuse in lieu of going to jail.

Criminality and mental illness are not mutually exclusive so there will always be a high number of incarcerated persons with chronic underlying psychiatric diagnoses.  The prevalence of mental illness in the general population may range from 5-15 percent. The degree of mental illness in the correctional system may be as high as 40 percent by some accounting but the number is misleading. One needs to consider treating mental illness when it becomes a barrier to functioning such as in schizophrenia or bipolar depression where the symptom profile interferes with reality testing. Only then may a contract for treatment may be constructed to include medication and psychotherapy depending upon the diagnosis.  In cases where mental illness and co-occurring substance abuse exist a determination about primary diagnoses and treatment options must be considered.

“The consequences of dual diagnosis include poor medication compliance, physical comorbidities, poor health, poor self-care, increased risk of suicide or risky behavior, and even possible incarceration” according to Buckley and Brown, 2006

In many cases of emotional crisis those in need can be diffused with recognition of their struggle – such as death of family member or loss of employment.  By showing empathy for their emotional burden police officers and mental health providers can intervene and make a real difference.  But effecting change takes time and a consistent message that personal responsibility begins at home.  Instead of placing blame on a “system” that is filled with holes individuals need resilience and family support to get the help they require. teachinginprisonBefore I am criticized for being insensitive, I point to the 12-step programs in alcohol and drug recovery.  They are free and in many cases provide 24-hour support and mentoring at times of crisis. I strongly believe that if people can remain clean and sober than the need for crisis intervention will decrease.  Ostensibly, this is a perfect first step toward recovery and will bring forth a palpable reduction in emotion and reduce the potential for violence.  When substance abuse is stopped emotional growth is more able to take hold.  Healthy, more effective problem solving may result from prospering emotional maturity allowing for resilience and enhanced coping.

Stress can engulf individuals and families for a variety of reasons and should not be judged. People cope with stress differently and in many cases achieve emotional relief by having someone to talk to.  Some clinicians believe great personal change may be possible when coping skills are most frail.  But in too many instances, drug and alcohol abuse present a confounding variable when working with person’s diagnosed with mental illness. At the same time this raises the risk to law enforcement exponentially. Why?

One response to stress is the increase in substance use and with that increase there is often a worsening of any underlying mental health disorder such as depression and anxiety.  “There could be a common factor that accounts for both, primary psychiatric disorder causing secondary substance abuse, primary substance abuse causing secondary psychiatric disorder, or a bidirectional problem, where each contributes to the other.” (Buckley and Brown, 2006) Unemployment, early childhood trauma, financial burdens, and random emotional baggage result in a range of actions that foreshadow regression and failure of coping mechanisms that put us all at risk.  Some people are able to endure extreme levels of stress with little to no outward sign of distress while others boil over at the first sign of conflict or emotional ripple.

JAIL DIVERSION

There is a growing push toward alternative restitution and jail diversion for those with mental health and substance abuse problems.  In San Antonio, TX, the Bexar County jail had been filled to capacity for many years.  As a jail diversion and mental health program evolved the population dropped by 20-25 percent from 5000 inmates to 3800.  Data suggests that over one quarter of all prisoners may experience mental illness or substance dependence/abuse and are not receiving treatment.  But here in Massachusetts the systems are not available to make this innovation an effective reality in any scale.  Many departments are using jail diversion options such as drug treatment and counseling but here in Massachusetts psychiatric treatment cannot be court mandated. Arrest may not be indicated simply because a person is in crisis but those in crisis may be involved in some type of criminality such as assault, criminal threatening, domestic violence and property crimes. So what options are available? The drop out rate for patients suffering from major mental illness is quite high. They often stop taking prescribed medication and do not attend counseling sessions.

MENTAL ILLNESS, CRIMINALITY AND RESTORATIVE JUSTICE

bigstock-Mental-illness-in-word-collage-072313As a police officer I found jail diversion a discretionary tool that was used a great deal. Nevertheless there are times when arrest is the proper course of action but jail diversion remains a possible negotiating point for those charged with some crimes.  The correct response to intimate partner violence should include aftermath follow-up and intervention when the immediate crisis has settled from the events that brought police to this dangerous threshold. Arrest is mandated by state statute when one spouse has visible injuries. Whenever possible using a restorative justice model – often limited to incarcerated individuals – may allow those arrested for crimes against persons to reconstruct their encounters with police and gain concrete understanding of events and the impact substance abuse may have had on the actions taken by themselves and law enforcement. Some never attain empathy for victims, family members including action taken by police and wind up behind bars.  Police encounters with persons having co-occurring mental health and substance abuse are frequently violent and often result in charges for assault on a police officer and more. In the aftermath of these encounters offenders may be sent to treatment in lieu of formal charges with the understanding that sobriety and psychotherapy are indicated.  In cases of treatment avoidance police have the option to file charges later on.

Techniques for understanding mental illness may facilitate mutual understanding and establish the needed bridge to facilitate treatment as published in 2015 (Sefton, 2015). Those seeking diversion from incarceration must demonstrate the willingness to change and take responsibility for their actions.  The relationship between law enforcement and community agencies is one that requires a strong foundation and mutual understanding of the framework for reducing recidivism, criminality, and managing mental illness.


Buckley, P. F., & Brown, E. S. (2006). Prevalence and consequences of dual diagnosis. The Journal of clinical psychiatry, 67(7), e01-e01.

Sefton, M. (2015) Emotionally distraught – nearly one-quarter of all officer-involved shootings go fatal. https://msefton.wordpress.com/2015/07/01/emotionally-distraught-nearly-one-quarter-of-all-officer-involved-shootings-that-go-fatal/. Taken March 5, 2017.

Police are building bridges and throwing life savers

WESTBOROUGH, MA  – March 30, 2017  Police officers are being trained in crisis intervention techniques across the country and Canada. This training offers plenty of practice role-playing scenarios that come directly off of the call sheets affording a reality-based training opportunity. I recently spent time riding with members of the San Antonio PD mental health unit and have the greatest respect for the officers with whom I rode.  In contrast, some departments regularly have highly trained clinicians riding with officers bringing expertise in mental illness and abnormal behavior across the thin blue line.  It is thought that by sharing knowledge at working with unpredictable, drugged out, psychotic and delusional and angry who police encounter on a daily basis better outcomes may be achieved. No single model is best and all are still in the growing stages of establishing protocols for bringing those most disturbed individuals in from the margins. More and more officers are receiving CIT training every year.

The important part of crisis intervention training comes in the interdisciplinary relationships that are forged in by this methodology. Trust and respect between the police and its citizens builds slowly one person at a time.  Community policing is not a new concept but fiscal priorities often prevent its full implementation.  Just the same, there must be trust and respect between the police and the purveyors of crisis intervention and mental health risk assessment including doctors, nurses, and health care practitioners. This also takes time and training and the shared belief in the model.


“When officers are faced with a deadly situation, when there is a gun pointed at a cop, there is no time to go into mental health measures,” according to Grace Gatpandan, spokesperson for the San Francisco Police Department


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Michael Sefton, Ph.D. in 2017 photograph

The use of force continuum belies each officer contact and guides the process when police are called upon to defuse a dangerous encounter. It is best that a mental health contact be made long before violent threats are made – long before terminal rage erodes personal judgment. The community policing doctrine affords this front end contact and encourages officers to know the people living on the beat.

POLICE ENCOUNTERS WITH MENTALLY ILL CITIZENS

The Boston Globe Spotlight series on police encounters with the mentally ill cites one distraught parent who was quoted “I only wanted the police to disarm him not shoot him dead.” Unfortunately for this family, when faced with lethal violence it is the behavior of the subject that drives the ship in terms of what will or will not happen.  “When faced with a deadly situation, when there is a gun pointed at a cop, there is no time to go into mental health measures”. All too often people fail to see the cause – effect relationship between citizens with guns or other lethal weapons and the police officer response.  The use of force continuum follows the principle of causation by guiding police decision making based on the level of threat.

What came first the threat or the police action?  It is the primary action of the citizen the evokes the lethal response by police.  If citizens dropped weapons and listened to police officer directives during these high energy and chaotic events there would be fewer deaths.  To say they lack training in mental health is preposterous.  Almost as preposterous as saying if they were better parents the mentally ill subject might not aim his gun at police or threaten his mother with a knife.  No, the responsibility lies with the mental decision-making and subsequent behavior of the subject himself.  If mental illness drives the violent behavior than all weapons and substance use must be carefully controlled and eliminated.  When people attend psychotherapy sessions and 12-step recovery programs the proclivity for violence is greatly reduced.  Inevitably, drug abuse is a co-morbid factor that alters perception and fuels underlying anger and violent tendencies.  Who is responsible for this? When drug addition or alcoholism begin – all emotional growth including adult “problem solving” begins to fail until it is fraught with uncontrolled, impulsive violence. Rather than placing blame, greater emphasis on sobriety, counseling and developing emotional resiliency should be encouraged.


Lowery, W. (2015) DISTRAUGHT PEOPLE, DEADLY RESULTS: Officers often lack the training to approach the mentally unstable, experts say. http://www.washingtonpost.com/sf/investigative/2015/06/30/distraught-people-deadly-results/?utm_term=.86e44d33dfab Taken March 5, 2017

What are “collateral consequences” in domestic violence?

WESTBOROUGH, MA March 21, 2017 When working as a police officer I was asked to take the statements of women who were asking for protection from an abusive spouse or intimate partner.  These requests were usually granted by the on-call judge – especially if children were at risk or a history of physical abuse was suspected.  But these orders only last a short time – perhaps a weekend.  In order to have restraining orders extended the victim is expected to go to the district court and swear testimony that specifies the reasons for an order of protection including threats or actual physical harm, forced sexual contact, pathological jealousy – whatever.  Sometimes this happens and protection orders are extended usually for 6 months. During this time the couple is expected to sort out their differences and engage the help of a family therapist, if possible.  This rarely happens.


“Domestic violence is not random and unpredictable. There are red flags that trigger an emotional undulation that bears energy like the movement of tectonic plates beneath the sea.” according to Michael Sefton.  A psychological autopsy should be undertaken to effectively understand the homicide and in doing so contribute to the literature on domestic violence and DVH according to Sefton who with colleagues published the Psychological Autopsy of a case from Dexter, Maine where a father murdered his children, estranged wife and ultimately himself (Allanach, et al, 2011).


More often than not, the victim fails to appear for this process and the protective order goes away without any consequences. Why? In the time between the initial emergency order and the Monday morning when the victim is expected to substantiate her initial claims she may have been bullied by her spouse and worked over by his family, his friends and whomever he can enlist in his camp to get her to let it go. She is made to believe that she cannot function without her abuser.  When children are involved an abusive spouse will usually say that child protective services will take the children for whatever reason he comes up with.  He promises to destroy her credit worthiness, she will be penniless, and he threatens to share lies about her on social media pages for all to see. He may also promise to kill her and cut her to pieces to be used as fish bait – as I have been told in a case being investigated by my former agency. But he swears his love for her always.

This happens over and over.

In some cases the order to extend the restraining order results from elevated risk to the victim and recurring threats of violence. In these cases orders of protection go on for months or years at a time.  This type of bullying is an example of the often secretive coercion that takes place in DV and intimate partner abuse is flagrant and often goes unreported.  It must be considered whenever an initial order is not sustained especially if the victim fails to appear.

In some cases there is more than one order of protection issued to protect one or more intimate partners. This is a red flag and should have bearing on the bail requirements but seldom does. There should be some follow-up with the original complainant by the police department to investigate her reasons for not pursuing the extended order of protection and determine what impact bullying may have played on the victim’s decision.  In rare cases permanent orders are granted because of compelling evidence that the victim and her family remains at risk – usually the result of stalking.

In March 2014, I published a blog in which the Massachusetts Supreme Judicial Court granted a permanent restraining order even though the former spouse was living in Utah and was remarried. In 2014 the Boston Globe did a story on the case written by Martin Valencia essentially raising the spector of the abuser in this case and the current impact the court order has on his day to day life in Utah.

Kevin Caruso was unable to get a job as a youth baseball coach because of a continuing order of protection here in Massachusetts that shows up on his CORI report. He could not own a firearm and was sometimes hassled at airports. The SJC ruled that Kevin Caruso must submit “clear and convincing evidence” that he no longer poses a danger to former girlfriend in a case dating back to 2001.  The Supreme Judicial Court  in Massachusetts has required that Mr. Caruso provide proof that “he has ‘moved on’ from his history of domestic abuse and retaliation”.  It is well-known that male abusers move from one abusive relationship to another.  A colleague Dr. Ron Allanach wrote “In the Caruso case, the Court is proactive, sensing the burden is on the offender rather than the victim; thus, the responsibility for proof that Mr. Caruso has “let it go”, poses no danger to the victim and has done the necessary therapy on his own behavior and to figure strategies to change, rests precisely on the shoulders of the offender where the burden should always remain.” The SJC called the frustration felt by Mr. Caruso the “collateral consequence” of the permanent restraining order put in place initially issued as a result of his threats to kill his former girlfriend.  Time alone and location has no bearing on whether a permanent order is sustained.  No person should live is fear that a former partner is going to appear at her workplace or stand behind her in the line at Starbucks while she thinks about what blend of coffee she might want.

“Substantive decisions about bail or no bail holds will be more reliable by having access to the violent history of domestic violence offenders and the protective orders that have been issued time and time again.” Michael Sefton


Allanach, R. Court is proactive. Personal correspondance. March 2014

Sefton, M. 2014,  https://msefton.wordpress.com/2014/03/11/collateral-consequences-stay-away-orders-that-are-forever/ taken January 21, 2017

Valencia, Milton. SJC rules on Utah man’s permanent restraining order. Boston Globe March 11, 2014, taken March 24, 2017

Behavior regulation and fire: an overlooked sign of inner conflict

Playing with fire can be the most dangerous of all childhood behavior and a sinister expression of rage among adults with severe psychopathology. It is often overlooked as an expression of emotional problems among persons of interest with whom the police encounter. Early in my career at Boston City Hospital I was a member of the Juvenile Arson Program that evaluated children who were referred with fire setting as the primary sign of distress.  I worked with Inspector Al Jones of the Boston Fire Department and Dr. Rita Dudley at the Center for Multicultural Training in Psychology (CMTP) at BCH.  Rita was instrumental in growing the program into a regional center for the assessment of juvenile arson.  Inspector Al Jones of the Boston Fire Department was our liaison with front line investigators.  It was a fast paced program that got kids in for assessment and treatment quickly because we knew that some of the children we were seeing were at high risk of repeated fire setting and some were merely curious with their match play.

During my fellowship year I evaluated 49 children who were sent to us by fire departments in the Boston area.  I worked with Dr. David K. Wilcox, a Boston area practitioner and Dr. Robert Stadolnik, then at Westwood Child and Family Services, as key colleagues in my development and expertise in this area of psychology.  Bob published Drawn to Flame, a book about childhood firesetting in 2000.  The key for those of us involved in the program was to identify individuals who were most at risk of repeated fire setting and determine the underlying cause of their immense emotional turmoil.

The expression of underlying anger using fire is a malevolent sign conflict and detachment – sometimes psychosis and delusional thinking.  It represents inner conflict and emotional turmoil as I mention in a post published in 2013. Although quite rare, fire as a symbolic expression of delusions is documented. More commonly though, fire is a signal of emotional dysfunction in the life and family of a child or adult who is suspected of arson.  To what extent it represents underlying trauma requires a comprehensive psychological assessment and careful history. In the most dangerous cases, hospital care is required for the safety of the child or adult with firesetting behavior.  In the adult, arson for hire or an insurance scam represents a large proportion of those arrested for fire-related behavior.

Fire as an expressive behavior

Fire is instrumental in the expression of culture, ritual and is symbolic of great emotion and excitement. Its use at public events, celebrations and parties is commonplace.  People enjoy the dramatic sensory experience associated with seeing and feeling fire.  At what point is it a sign of conflict or burgeoning emotion? The expression of anger may be something as subtle as burning one’s own clothing in a small ceremonial fire in the living room fireplace.  Who would do that you might ask and why?  One example is a person who has lost a large amount of weight may exemplify the accomplishment by burning the larger clothes.  It is a symbolic way of saying goodbye to the old habits that may have caused the weight gain. Ok – that is plausible.  Another person might burn clothing as a way of undoing internalized feelings of shame and self-hatred engendered by early childhood trauma.  Also a plausible explanation of hidden psychopathology that often has deadly results. Some firesetting may represent a preoccupation with flame as an expression of fear and dread coming from exposure to violence within a dysfunctional home. This is a larger subset of persons than one might think and represents a sign of growing emotional lability.

The question for psychologists and police officers is how to identify persons of interest with the emotional coping deficits that place them at risk for using fire as an expression of their feelings and conflict. “The underpinnings of violence are often present in some form or another and may be represented by a marginalized demeanor and extremist views” according to Michael Sefton, Ph.D., Director of Psychological Services at Whittier Rehabilitation Hospital in Westborough, MA.

“The inconsistent and unpredictable exposure to violence contributes to excessive and unpredictable behavior” according to Michael Sefton in a 2013 blog post

The treatment model involves individual and group therapy to assit patients in the identification of inner emotions and feeling states.  I have worked with pediatric patients whose behavior is totally unregulated and unpredictable and yet when you ask them what they were feeling at the time of the fire they cannot tell you. Fire may result in a discharge of emotion like lightning. In the same way some persons are physically abusive – others set fires to release their strong emotions. The current reality suggests that errant use of fire material represents one of the most lethal expressions of underlying emotional turmoil and unbridled conflict in people. There are few programs equipped to understand and treat people with these behaviors and firesetting is often an exclusionary behavior  for entry into treatment programs everywhere.


Sefton, M. Juvenile Firesetting, blog post:  https://msefton.wordpress.com/2013/12/10/juvenile-firesetting/,  taken January 14,2017

What are immediate signs?

“…there are cases in the literature that identify a pattern of behavior that is observable in the days, months or years preceding these monstrous events that may signal a need for high risk containment”

Taken from Psychological Autopsy of Steven Lake in 2011 presented to Governor’s DV Abuse Board

Allanach et al. 2011

WESTBOROUGH, MA October 31, 2016 People often see signs of imminent violence in the days weeks or months in the lead up to DVH.  As a society, these signs must evoke action on behalf of potential victims. The roadmap to understand domestic violence requires clarity and courage that should not be placed solely in the hand’s of victims.

It is frequent that the abuser tips his hand as to what his intentions might be.  In the Lake homicide-suicide in 2011 in Dexter, Maine, Steven Lake hinted to his son that “the cost of a divorce is 25 cents – the price of one bullet.” Lake also verbalized that when he “did it – it would be on CNN.”

The Myth of Mental Illness and School Violence

This blog was initially published in March 2013 as a retrospective on the recent spate of “active shooter” tragedies across America.  There have been several high-profile shootings in the past 3 years that have involved perpetrators whose mental health is in question.  This is often not the case in school violence whereas the perpetrator of the action was deceased at the conclusion of the incident.  In these cases an effort must be made to uncover substantive causal factors in the perpetrator’s terminal actions.
The true incidence of violence among people diagnosed with a nervous and mental disorder is quite low. It is a common misconception that whenever something hideous occurs it must be mental illness that is the driving force behind its fury. In most cases this is neither the reality nor the underlying cause of terminal rage. In light of the information being uncovered about the Newtown, CT mass murderer, the specter of mental illness insures a convenient scapegoat. Updated information from Newtown recently confirmed that Adam Lanza had studied the media stories of prior mass killings as he planned for his despicable final melt down. In retrospect, I wonder what “red flags” have been uncovered that offer insight into his substantive motivation. People will speculate about random causes of Lanza’s behavior with uncertainty unless it can be studied scientifically.
There are some instances when mental illness has be associated with serial homicide such as the Son of Sam killer who plied his murderous delusions in NYC during the 1970’s using a Charter Arm’s Bulldog .44 caliber revolver. David Berkowitz used that weapon to kill 6 and wound 7 during his spree. He claimed to have been commanded to kill random couples he saw in cars by a dog he believed possessed by the demon. After spending time in a mental institution following his conviction he was transferred to the state prison at Sing Sing and finally Attica to serve 6 life sentences. When he was on trial Berkowitz plead not guilty by reason of insanity – the delusions he had about communicating with demons. In the end, it was determined that Berkowitz was not mentally ill. The Columbine, CO high school killers, Klebold and Harris were methodical in their planning of the attacks on the school and its students. They built explosive devices and practiced their attack in the weeks before the assault on the school. By outward appearances these two were from middle class families with involved parents. Many believe Klebold and Harris were the victim of bullies.
Psychological experts believe mentally ill persons lack the higher order planning to execute the complex steps necessary for these types of crimes. Neither Dan Klebold nor Eric Harris was mentally ill. The Virginia Tech killer Seung-Hui Cho murdered 31 students and faculty in 2007 after a period of decompensating rage. He wrote a profanity laden manifesto blaming everyone for their maltreatment of him that sounded paranoid and vindictive yet was able to send the videotaped diatribe to a news agency. Cho had been held in a psychiatric hospital 2 years prior to his rampage after becoming marginalized. Cho was able to organize his crime preparation and sequence the needed steps to meet his murderous goal. Was he mentally ill?
The Psychological Autopsy is a clinical assessment of the time line and antemortem behavior and emotional comportment of the perpetrator of compelling and despicable events. These types of case studies explore changes in cognitive and behavioral functioning immediately before a terminal event of homicide. An extensive review of a case from 2010 that was published in 2011 generated over 50 recommendations about DV and factors to consider when victims are at greatest risk (Allanach, R., 2011). The cost of these interviews and substantive case review is the primary reason they are not regularly conducted.  It is also less compelling when the perpetrator has killed himself and survivors want to turn the page.
Recently, at least 2 shooters have survived mass killings or have been captured after their alleged attacks.  In 2012 in Aurora, CO movie theater James Holmes was arrested and charged with multiple counts of murder.  He has pleaded not guilty by reason of insanity.  In 2011, Jared Lee Loughner was arrested at an outdoor political event in Tuscon, AZ after the shooting of U.S. Representative Gabrielle Giffords and killing 6 others. Loughner plead guilty after being found that he was capable of standing trial.He is serving 140 years in prison.  The Aurora case remains open.
It is hoped that important information may be gleaned from the rigorous study of motives, personal history, and triggers to their rage.

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.
Sefton, M (2013) Asperger’s Disorder: Not linked to violence. https://msefton.wordpress.com/category/active-shooter/ Taken March 2, 2015
Michael Sefton, Ph.D.
Read more at: http://www.msefton.wordpress.com