Violence and psychotic people

Among the most dramatic and menacing forms of mental illness are the psychotic disorders. These include people who have uncontrolled paranoid schizophrenia, bipolar disorder, depression with psychotic features, substance intoxication, and perhaps intermittent explosive disorder. Violence is not associated with mental illness per se.  There are factors that increase violent behavior among those who are mentally ill including persecutory ideation like suspiciousness and fear, and co-occurring alcohol dependence.  The most important way in which to reduce violence among citizens who are mentally ill is to provide some form of treatment to them.  Those who go without substantive treatment including psychotherapy are at greatest risk for becoming aggressive or violent according to Coid et al. (2016). These are the citizens who fly above the radar and are seen pacing the street corners in cities everywhere reciting from some unwritten preamble.  People walking avoid eye contact further pushing them to the margins of civility.  Eventually, the bottom falls out and the preamble comes to an incoherent end.  Either they move on or they are picked up for evaluation.

There are even greater numbers of psychotic people living under the radar.  Making their way in society, flying by the seat of their pants.  These people are often cared for by family members including elderly parents. When they relapse or “go off the rails”, caregivers often need the help of police to gain compliance with their loved ones.  Sometimes the police are called to restore the peace and compel the emotionally disturbed person into treatment.  For those individuals who relapse and are substance dependent i.e. alcoholic, the risk for violence is elevated.  These people require special understanding and sensitivity in order to establish a trust and to help them see their behavior patterns and risk taking behavior for themselves.  No easy task.

More recently, meta-analyses and case register studies concluded that psychiatric disorders are associated with violence, but that the relationship is largely or entirely explained by comorbid substance misuse. Fazel et al. (2009)


Fazel S, Gulati G, Linsell, L, Geddes, JR, Grann, M. (2009) Schizophrenia and violence: systematic review and meta-analysis. PLoS Med. 6: e1000120.
Coid, JW,  Ullrich, SP, Bebbington S, Fazel, R,  Keers, R (2016). Schizophrenia Bulletin, Volume 42, Issue 4, Pages 907–915, https://doi.org/10.1093/schbul/sbw006 taken May 9, 2019

Cumulative exposure to stress: The stigma of being human

The impact of cumulative emotional reactions and Post traumatic Stress Disorder (PTSD) has significant negative impact on law enforcement heartiness, job satisfaction and career success (Polizoti, 2018). Police agencies across the country are looking for ways to mitigate the impact of accumulated stress associated with exposure to the worst of the worst of all human experience. “Arguably, everything from unattended death, domestic violence, child abuse, and a fatal motor vehicle crash may show up on the call board of any dispatcher on any day or night.” Sefton, 2014. There is no doubt that police officers and first responders are exposed to experiences that are well outside of normal human experience. On top of this requirement many officers do not feel supported by the people they serve and worse, the leadership hierarchy within the agency.

Law enforcement agencies are looking for ways to reduce the human cost of the stress and trauma LEO’s experience on the job but eliminating this all together is likely impossible. This “roller coaster” ride is often why we sign up for the police service where one can have hours of boredom sprinkled with seconds of shear terror and exposure to viral human suffering.

It has been said that LEO’s keep their internal conflict and emotions to themselves always in check and under control. Some fear being perceived as weak and feel intimidated by seeking support for the behavioral health needs resulting from the job. Strength in silence is the archaic mantra lurking behind the blue line and may be the underpinning stigma at work. This stereotype has a significant impact on family relationships, work performance, and career longevity. It has changed in the past decade but very slowly and too many officers are suffering.

Just as we have seen in a subset of the returning member’s of the armed forces, LEO’s are taking their own lives as a result of the accumulation of stressful calls year after year coupled with an erosion of coping skills rendering them vulnerable to becoming hopeless, embittered, and angry. On top of that and perhaps most dangerous is a growing mistrust and perceived lack of respect and support from community leaders, citizens, and sometimes department leaders.

Bias refers to having expectations about a class or subset of people based on unrecognized and unsubstantiated prejudice. Among law enforcement there is a perceived threat of reverse bias associated with having an emotional reaction to the law enforcement experience – at least as far as the front line troops are concerned. There is sometimes an negative attribution associated with being on stress-related leave so many officers who need support do not seek help. Over time this takes a toll on officer well-being. The health risks from years of maladaptive coping to on-the-job calls for service can be insurmountable for some leading to substance abuse, depression, heart disease, and PTSD.

The upwelling of professional disdain toward the police and outright lack of support from the public arising from use of force and incidence of fatal officer involved shootings adds to the LEO “disidentification” with the police service. Once an officer has disidentified with the job he or she is vulnerable to a host of professional challenges associated with becoming at risk for career burn out and embittered.

“Pain is lessened by ceasing to identify with the part of life in which the pain occurs. This withdrawal of psychic investment may be supported by other members of the stereotype-threatened group—even to the point of its becoming a group norm. But not caring can mean not being motivated. And this can have real costs.” according to Steele (1999) who studied achievement in African American college students.

Whether one is speaking about academic achievement or career satisfaction and job performance in the police service “disidentification is a high price to pay for psychic comfort” according to Steele (1999).

The reason for this falls back to deeply held bias toward mental illness that cuts across all segments of society. But it hits particularly hard among law enforcement and first responders. This is especially true when a brother officer is silently suffering.

Elevated mental health distress includes suicidal ideation, anxiety, and depressive symptoms. Some LEO’s preferred to seek help from a chiropractor or physiotherapist rather than a clinician or mental health provider” which reveals the true extent of underlying stigma and bias (Berg et al., 2006).

Polizoti, L. (2018) Career resilience and hardiness. LEO presentation. Worcester, MA.
Steele, Claude (1999) Thin ice: Stereotype threat and black college students. The Atlantic Magazine.

Berg et al. (2006). Fighting Police Trauma: Practical Approaches to Addressing Psychological Needs of Officers

Police Stress Intervention Continuum: An introduction for LEO’s and command staff to reduce officer suicide

Scope of the Problem: Police Suicide and the goal to eliminate it
Police job-related stress is well-identified and reported in the media daily and the rates of suicide nationwide are being debated by Aamodt and Stalnaker. They are actually less than one is led to believe but even one law enforcement officer suicide is too much.
Stress is defined as any situation that negatively impacts an officer’s well-being. The rate of suicide and divorce among law enforcement is approximately the same or lower than the general public according to a meta- analysis conducted by Professor Michael Aamodt.  But there are areas in the country and agencies that have higher rates of self-inflicted death.
When the suicide rate of police officers (18.1) is compared with the 21.89 rate for a comparable demographic population, it appears that police officers have a lower rate of suicide than the population according to Aamodt, 2008.
Incidence of suicide tend to be elevated in cities like Chicago, where chronic gun violence and a murder rate in the hundreds per year means cops see a staggering amount of trauma and may gradually become numb to the exposure of pain and suffering (Joyner, 2009). A Department of Justice report found that the suicide rate in the Chicago Police Department is 60 percent higher than the national average.  According to the Chicago Sun Times, in a note to department members Wednesday, CPD Supt. Eddie Johnson said, “Death by suicide is clearly a problem in Law Enforcement and in the Chicago Police Department. We all have our breaking points, a time of weakness where we feel as if there is no way out, no alternative. But it does not have to end that way. You are NOT alone. Death by suicide is a problem that we can eliminate together” CST September 12, 2018.  Chicago PD is not alone with the problem of suicide among its men and women in blue.
Law enforcement officers (LEO’s) encounter the worst of all experience on a routine basis. The people who call the police may be society’s best upstanding citizens but on this occasion it could be the worst day of their lives and they seek help from police.  Many times it is not the pillars of society seeking help but those people in the fringes or margins of society now victims of violent crime or abuse.
According to Hartley, et.al., 2007, “repeated exposures to acute work stressors (e.g., violent criminal acts, sad and disturbing situations, and physically demanding responses), in addition to contending with negative life events (e.g., divorce, serious family or personal illness, and financial difficulties), can affect both the psychological and physiological well-being of the LEO population.” When these officers are identified there needs to be a planned response using a peer support infrastructure that provides for a continuum of service depending upon the individual needs of the LEO and the supports available. In many agencies, especially smaller departments lacking resources, officers’ languish and sometimes spiral downward without support and without somewhere to turn.  Police officers must have support available to them long before they are expressing suicidal urges.
As programs are identified and service continuum grows the risk of peer conflict over perceived betrayal of trust must be addressed. This must be addressed in the peer support training with emphasis on preservation of life over maintenance of confidentiality or the status quo of abject silence. “In itself, it’s a product of centuries of police culture in which perceived weakness is stigmatized. Cops know their brothers have their back, no matter what, but they still don’t want to be seen as the one who’s vulnerable.” according to a recent Men’s Health article written by Jack Crosbie in a report about suicide in the NYPD published during Mental Health Awareness month in May 2018.
The argument is made that the recurring uncertainty of police calls for service often leave LEO’s with low-level exposure to trauma of varying degrees. It is common that LEO’s move from one violent call to the next without time to decompress and process what they have seen.  The repeated exposure to trauma can slowly whittle away LEO resilience – defined as the capacity to bounce back from adversity. In a national media study published by Aamodt and Stalnaker, legal problems were a major reason for the law enforcement suicides yet no other study separately cited legal problems. In another study, relationship problems accounted for the highest percentage of suicides at 26.6% (relationship problems plus murder/suicide), followed by legal problems at 14.8%. In nearly a third of the suicides, no reason was known for LEO suicide.
Police suicide has been on the radar of advocates of LEO peer support for months or years.  The incidence of suicide has remained stable across the country but some agencies have higher rates of suicide.  Smaller departments – those with less than 50 officers in general have the highest rates of suicide.  This may be linked to the lack of availability of peer support programs and a paucity of local practitioners to provide professional service with knowledge in police psychology. “While police officers may adapt to the negative effects of chronic stress, acute traumatic incidents necessitate specialized mental health treatment for police officers (Patterson, 2001)”.  A referral to the department EAP often falls flat and makes it more difficult to make the hand-off when peer support is not enough.
Real-time model of change
The use of force continuum is well described in the LEO literature and ongoing criminal justice narrative. What does that have to do with stress intervention in police officers? It sets the tone for officer behavior whenever they meet potential resistance and or increased aggression during citizen encounters. It may also be used for initiating peer support needs whenever an incident use of force has occurred.  LEO’s change the force response based on the situation they encounter in real-time in a flexible and fluid manner. In this same way, peer support programs can flexibly shift to the needs of a presenting LEO and intervene early on – rather than when an officer is at a breaking point. “This continuum (use of force) has many levels, and officers are instructed to respond with a level of force appropriate to the situation at hand, acknowledging that the officer may move from one point on the continuum to another in a matter of seconds.” NIJ publication.  Peer support too, must accommodate a law enforcement officer in real-time to begin the process of building a healthy, resilient response to sometimes horrific exposures and provide a continuum of unbiased employee assistance and when necessary professional consultation.
Protective Factors begin in Academy training
What topics should addressed while LEO recruits are in training?  Ostensibly, the resilience of LEO’s depends upon the opportunity for in-service training in topics of mindfulness, stress management, physical health maintenance, nutrition, and trust.
“Emotional resilience is defined as the capacity to integrate the breadth of police training and experience with healthy, adaptive coping, optimism, mental flexibility and healthy resolution of the traumatic events. In general, resilient people are self-reliant and have positive role models from whom they have learned to handle the stressful events all police officers encounter” according to Leo Polizotti, Ph.D. a police consulting psychologist (Sefton 2018).
Police programs for health maintenance
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The Police Stress Intervention Continuum or P-SIC, involves a system of police support that varies in its intensity depending upon the continuum of individual needs of the LEO including physical debility or other significant components impacting career success and satisfaction. The intervention protocol is flexible and fluid as well. The entry point into the peer support continuum initiates from supervisory observations of LEO history and behavior, peer recommendations, and exposure to a range of traumatic events.

 

Generally speaking, a police officer’s behavior change is a function of the resilience they develop throughout their careers. Greater attention to physical health and emotional well-being are now being espoused in police academies across the country.   Greater awareness of the correlation with the recent trauma and frequency of exposure to trauma such as the death of a child, exposure to dead bodies, suicide of a colleague, etc. have negative impact on officer well-being.  Perceived support from supervisors and the organization hierarchy builds resilience.

Career success requires that officers learn stress tolerance and healthy habits to manage the daily challenges of police service. Physical exercise and healthy routines often afford the stressed officer an outlet for reduced risk of stress-related physical afflictions in addition to the emotional and health effects of repeated exposure to unpredictable violence.

The cumulative stress associated with a career in law enforcement cannot be understated.  In the setting of police stress and stress support there is an intervention protocol that relates to the peer-support program continuum.  Depending on where officers enter the peer support network will impact the level of intervention they may require in the P-SIC program.  Peer support is not psychotherapy but officers occasionally must hand off the officer in trouble to a  higher level of care.  These hand-offs are key to linking at-risk LEO’s with range of professional support needed to keep them on the job. Yet fear of reprisal for acknowledging the cumulative impact of stress and its impact often derails the hand-off to the professional. The highest risk for suicide to a LEO is when he is denuded of badge and gun because he may be a threat to himself.
The career success they have may be directly related to the application of resiliency training to build and maintain physical and emotional hardiness that lasts a lifetime according to Leo Polizoti, 2018. Before this can happen the stigma associated with reaching out must be reduced.

Points of entry to Peer Support – Stress Intervention Continuum
copyright Michael Sefton
  • Exposure to highly stressful events in close sequence
  • Change in work assignment, district/station, deployment undercover or return from deployment
  • Increased absenteeism – over use of sick leave
  • Increased use/abuse of substances – impacting job functioning, on-the-job injury
  • Community – citizen complaint(s) for verbal abuse, dereliction of duty, vehicle crash
  • Citizen complaints of excessive force during arrest, supervisory or peer conflict, or direct insubordination.
  • Abuse of power using baton, taser or firearm, recurrent officer involved use of force. Officers are sometimes strongly embittered and angry at this point in their career due to perceived lack of support and powerful feelings career disappointment and alienation.

NIJ Publication (2009). Use of Force Continuum. https://www.nij.gov/topics/law-enforcement/officer-safety/use-of-force/Pages/continuum.aspx. Taken November 17, 2018
Aamodt, M. G., & Stalnaker, N. A. (2001). Police officer suicide: Frequency and officer profiles. In Shehan, D. C, & Warren, J. I. (Eds.) Suicide and Law Enforcement. Washington, D.C.: Federal Bureau of Investigation.
Aamodt, M. (2008). Reducing Misconceptions and False Beliefs in Police and Criminal Psychology. Criminal Justice and Behavior 2008; 35; 1231 DOI: 10.1177/0093854808321527.
Patterson, G T. (200l). Reconceptualizing traumatic incidents experienced by law enforcement personnel. The Australian Journal of Disaster and Trauma Studies, 2.
Joyner, T. (2009) The Interpersonal-Psychological Theory of Suicidal Behavior: Current Empirical Status. Science Briefs, American Psychological Association, June.
Sefton, M. (2018). Police Training: Revisiting Resilience Blog post: https://msefton.wordpress.com/2018/07/27/police-training-revisiting-resilience/. Taken November 18, 2018
Hartley, T., et.al.(2007). Associations Between Major Life Events, Traumatic Incidents, and Depression Among Buffalo Police Officers. International Journal of Emergency Mental Health, Vol. 9, No. 1, pp.
John M. Violanti, Anna Mnatsakanova, Tara A. Hartley, Michael E. Andrew, Cecil M. Burchfiel. (2012). Police Suicide in Small Departments: A comparative analysis. Int J Emerg Ment Health. Published in final edited form as: Int J Emerg Ment Health. 2012; 14(3): 157–162.

The Elevated Stress Response: Selling when Nobody’s Buying

I am preparing for an upcoming presentation at the annual Society of Police and Criminal Psychologists in Sarasota, Florida held in early October each year.  So far I have offered several police departments an opportunity for free in-service training in the area of risk assessment and domestic violence.  No interest.  I can even say that one of the chiefs I approached is a friend of mine and still there was no interest in hearing about updated issues in domestic violence and the risk associated with intimate partner abuse. This has been both a surprise – given my passion about the topic and self-ascribed expertise, but also because it brings up great anxiety when I think about the expectation for my presentation at a national conference consisting of my peers.  This post is all about how to deal with the flood of anxiety associated with presenting one’s ideas to an audience that may not be interested in what I am selling.
“If we perceive our available resources to be insufficient, along comes the ‘threat’ mindset. When threatened, stress has a catastrophic effect on our ability to perform. We receive an enormous sympathetic surge (adrenaline/noradrenaline dump), and our HPA axis pumps out cortisol. High cortisol levels have a very detrimental effect on higher cognitive processes – decision-making and prioritization” or triage as described in a blog written by Robert Lloyd and physician in the U.K.
Lloyd goes on to say “that breathing is the only autonomic process that we can consciously control (other than blinking – less useful). By doing so, we access the ‘steering wheel’ of our sympathetic nervous system, and can regain a feeling of self-control in a moment of extreme stress. Heart rate and blood pressure come down when practiced. The process of deliberately controlling ones breath in the midst of a stressful moment that is key to lowered autonomic overdrive and greater physiologic homeostasis.  Mindfulness and reslience training converts a ‘threat’ to a ‘challenge’ mindset by building resilience to a controlled stressful stimulus.” It arms you with prophylaxis against condition black when the organism is fighting for its life.
   Stress has undeniable impact on all human functioning and public health. Not enough is being done to infuse knowledge and understanding into the emotional maelstrom created by chronic stress (Sefton, 2014).  Healthy coping and productivity breaks down when uncontrolled stress occurs over and over. According to Leo Polizoti, Ph.D., the primary author of the Police Chief’s Guide to Mental Illness and Mental Health Emergencies stress can lead to a breakdown in adaptive coping. “Learned resilience can be taught and leads to reduced stress and psychological hardiness rather than psychological weariness. Psychological weariness is a drain on LEO coping and adaptation to job-related stress and the efficiency for handling everyday calls for service. As the demand for police service becomes more complex, officers must adapt their physical and emotional preparation for service or risk premature career burnout” according to Polizoti. Resilience and career satisfaction are important components of law enforcement and individual officer training, behavior and longevity. Positive resilience will reduce officer burnout.
In its absence police officers and their agencies are at greater risk for conflict both internally and with the general public in the form of civilian complaints of police officer misconduct.
So in anticipation of my own decrease in internal homeostasis and elevated production of stress hormones, I will breath and adjust my thinking for a positive outcome and not be hurt by the buyer beware myth my topic may evoke. I will take a few moments to relax and breath slowly in anticipation of the quiescence it will bring and my belief in learned resilience.

Protecting the Victim’s of Intimate Partner Abuse: The aftermath of domestic violence homicide

DV_note B&W
Victim passed this note to Veterinarian staff – Photo VCSD

“You can’t say that nothing can be done, because nothing will be done,” said Michael Sefton, a former Westbrook, Maine  police officer who is a psychologist and former police sergeant in Massachusetts at the New Braintree Police Department.

Bangor Daily News

Public Awareness Needed for Meaningful Jail Diversion

teachinginprison

“If mental illness drives the violent behavior than all weapons and substance use must be carefully controlled and eliminated.” Sefton, 2017

Westborough, MA December 21, 2017 Jail diversion is a hot topic across the country even here in Massachusetts. Since July, 2017 the Massachusetts Legislature has passed sweeping changes in the Criminal Justice System.  Locally and across the country, the numbers of persons incarcerated for minor offenses and drug crimes has grown in some cases exponentially. Many of these individuals have mental illness or drug abuse in addition to their criminality. The interaction between poly-substance abuse or dependence and exacerbation of underlying mental health symptoms is complex and multifactorial. The interaction of the two is sometime lethal as reported by the Globe Spotlight team It is the focus of mental health advocates and criminal justice experts nationwide as it pertains to jail diversion, alternative restitution and reduced police use of force. In Massachusetts, there is a move away from mandatory minimum sentences for all drug crimes except for those involving the sale and distribution of narcotics. Arguably, the impact on behavioral functioning when persons are gripped with co-occurring illness, such as alcoholism, is a recurrent problem for law enforcement and first responders. I have written about the impact of co-occurring illness such as alcoholism on mental and behavioral health is previously published posts here on Word press Human Behavior (Sefton, 2017). It is difficult to uncover which comes first – the addiction or the diagnosed mental illness and yet these are inextricably linked in terms of the strain on public resources and health risk to those so afflicted. Why is this important?

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 MH advocates insist that with the proper treatment violent police encounters may be reduced and jail diversion may be achieved. The referral and treatment infrastructure needed to provide a continuum of care in this growing population is available in very few places across America.

Yet in places like Bexar County, Texas – including San Antonio and 21 other towns or cities – the county jail population has dropped by over 20 percent as a result of crisis intervention training for police officers and mobile mental health teams to intervene with those in crisis. I have seen this for myself during a visit with the San Antonio Police Department where I rode with two members of the Mental Health Unit – Officers Ernest Stevens and Joseph Smarro. These men are exemplary in their assessment and intervention skill for keeping identified subjects off radar screens and out of the revolving door of the county jail.  It takes ongoing training, medical and psychiatric infrastructure, community compassion, and active engagement with members of the community to fly under the radar and effectively reduce the jail population. When necessary those most in need must have 24-hour availability for detoxification, emergency mental health, and access to basic needs such as food, clothing, and medicine. In San Antonio, they offer so much more including pre-employment training, extended housing, interview preparation including clothes, and opportunity for jobs.

The unpredictability of behavior by those who carry a “dual” diagnosis has emerged as a confounding factor in the criminal justice system raising the specter of frustration over the limitations within the system. Jail diversion programs and treatment options are needed in order to retain public safety goals and provide for needs of the mentally ill and substance dependent. In Massachusetts, cities and towns are grappling with how best to intervene with the mentally ill in terms of alternative restitution for drug-related misdemeanor crimes in lieu of mandatory jail sentences that many crimes currently require. The Massachusetts legislature has taken up Criminal Justice Reform and passed a bill in late 2017 making changes in the mandatory minimum sentencing laws.  Some believe, as much as 20-40 percent of all incarcerated persons suffer with mental health diagnoses and are not getting the treatment they require. To provide a bare bones system would add billions to state and federal dollars spent on the needs of inmates at a time when measurable outcomes for in house care are limited.

In my practice, I see many cases of co-occurring pain syndromes with other physical debilities such as stroke or traumatic brain injury. Some of these cases are substance dependent and live lonely, chaotic lives.  Generally the emotional impact of two or more diagnosed illnesses yields a greatly reduced capacity for adaptive coping and puts a great stress on the individual system. The importance of addressing co-occurring substance abuse or dependence is now well recognized and with treatment can result in healthy decision-making, growth in maturity, and greater self-awareness. If legislators have a serious desire to reduce statewide numbers of incarcerated persons a comprehensive plan must be considered for both pre-arrest and post-arrest. Programs greater understanding of addiction and added treatment options must be explored through a joint public and private initiative.

Mental and Physical Health Screening

At time of arrest the individual must have some level of mental health assessment if mental illness is suspected or documented. When I was a police officer prior to 2015 we often asked the D.A. to provide a court clinic assessment of the suspect to rule out suicidal ideation or delusional thinking. This must also include a screening for dangerousness especially when a subject is arrested for intimate partner abuse. Next a health history questionnaire should be undertaken to screen for co-occurring illness – both physical and mental. If a diabetic suspect is held without access to his insulin he is at great risk of death from stroke. Similarly, a person arrested for assault who suffers from paranoid ideation is at greater risk of acting violently without access to psychiatric medication. Finally, an alcoholic brought to the jail with a blood alcohol level greater than 250 is at great risk for seizures and cardiac arrhythmias when delirium tremens begin 6-8 hours after his last drink. The risk to personal health in each of the scenarios above must be taken seriously and the obtained data should be factually corroborated. Police departments across the United States are pairing up with private agencies to provide in-house evaluation and follow-up of individuals who fall on the borderline and may not be easily assessed by the officer in the field.

Diversion Safety Plan with Mandated Revocation

Next, the probation and parole department must obtain an accurate legal history prior to consideration for bail. A nationwide screen for warrants and criminal history based on previous addresses is essential. In many places these are being done routinely. In the case of someone being arrested for domestic violence he may have no convictions thus no finding of criminal history. For these individuals the dangerousness assessment may bring forth red flag data needed for greater public safety resulting in protection from abuse orders, mandated psychotherapy, and in some cases, no bail confinement when indicated. Releasing the person arrested for domestic violence without a viable safety plan increases the risk to the victim and her family, as well as the general public – including members of law enforcement.

Bail, Confinement, Mandated Treatment

There is some thinking that higher amounts of bail may lessen the proclivity of some offenders to breach the orders of protection drafted to protect victims and should result in revocation of bail and immediate incarceration when these occur. Mandated treatment may be more successful when legal charges are held as leverage where after 6 months of sober living and regular attendance at 12-step recovery meetings charges can be dismissed or modified to each individual case.  This takes a complete overhaul of the front end of criminal justice system and requires buy-in by judges, district attorneys, and individual family members.

When it comes lack of compliance and repeated domestic violence, I have proposed a mandatory DV Abuse Registry that may be accessed by law enforcement to uncover the secret past of men who would control and abuse their intimate partners. This database would also include information on the number of active restraining orders and the expected offender’s response to the “stay away” order. In cases where the victim decides to drop charges there should be a mandatory waiting period of 90 days. During this waiting period the couple may cohabitate but the perpetrator must be attending a weekly program of restorative justice therapy, 12-step recovery and substance abuse education. Violations of these court ordered services are tantamount to violation of the original protection order (still in place) and victim safety plan and may result in revocation of bail. If the waiting period passes and the perpetrator has met the conditions of his bail than he may undergo an “exit” interview to determine whether or not the protection order / jail diversion plan may be extended or whether he/she has met all requirements.  In any case further police encounters will be scrutinized and prior charges may be re-instated or filed as needed.

Michael Sefton


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

Police as crisis interventionist: CIT as it is meant to be

San Antonio, TX  – February 25, 2017 Police officers wear many hats these days.  I have spent the last few days learning about a specialized police unit in San Antonio Texas with the SAPD. The Mental Health Unit is a small, well-trained group of police officers who have committed themselves to the positive interaction of police officers and citizens with presumed mental illness. These police officers have a unique window into the chaos some families experience and the opportunity to bring calm to crisis (Sefton, 2014). In many cases, the correct response to this dysfunction should include a follow-up visit in the aftermath of the initial call when the dust has settled from the crisis that brought police to this threshold.  When this is done it establishes a baseline of trust, empathy, and resilience. It works and I have seen it for myself.

Over a 15 year span the SAPD has established relationships and built a continuum of service whose mission is jail diversion and treatment for those who are afflicted with mental illness and substance abuse.  The Restoration Center  in downtown San Antonio is the nucleus for this “smart justice” model. It includes a mobile crisis outreach, 48 hour hospitalization, if necessary, a 90-day homeless shelter with job training e.g. resume building and job interview clothing, childcare and apartment units for those who qualify.  As subjects move through the continuum they are provided referrals for individual psychotherapy, substance abuse education, Alcoholic’s Anonymous and the range of 12-step recovery programs.  And everyone working there buys in.

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.  Michael Sefton blog post 2013

mental-health-squad
SAPD Officer Ernest Stevens PHOTO Jenny Snow Kaiser Health News

I was given the complete tour and introduced to some key players including Ms. Amanda Miller coordinator at the Mobile Outreach program.  The experience was enriching and illustrated the range of possibilities of humane care for those most vulnerable and often incompetent to make healthy choices for themselves.  I wasn’t sure what to expect but I came away wishing I could have stayed on longer. The project diverts citizens into treatment in lieu of incarceration and also serves as an in-house resource where brother officers can turn when times get tough. And the mental health unit has seen its share of despair and self-destruction on their side of the blue line with sometimes insufferable results.

Police officers’ department-wide are trained in techniques of crisis intervention by the same two officers I was fortunate enough to ride with. For years, too many emotionally troubled citizens wound up among the incarcerated criminal population in state and county jails and did not receive the care they needed. In Bexar County, Texas, which includes San Antonio, with a growing population of over 1.5 million the main jail now has 800 open beds where it was once filled to capacity.

“CIT provides police with all kinds of useful resources. And when combined with adaptive strategic thinking, access to mental health professionals, and good leadership and good culture around applying the lessons of CIT, it can save lives,” said David M. Perry, an associate professor of history at Dominican University in Illinois and a journalist who has written about police violence and disabilities recently cite in a CNN story written by Liza Lucas in 2016.

San Antonio and over 22 communities share the services of the Restoration Center in downtown San Antonio


Culpability and Mental Illness

Are those with mental illness culpable for their behavior? Technically they are responsible unless determined to be unable to discern right from wrong based upon their mental incapacity. Does the fact that they suffer with conditions like bipolar depression, schizophrenia, or drug addiction render them not responsible?  There is a national trend to view those with active mental illness as “not responsible” for their behavior largely due to the common belief that if the mental illness were being treated than the criminality in which they may be embroiled would plausibly diminish. Whenever something sensational happens like a school shooting or some other senseless criminal act people universally remark “he was sick” or “she must have been out of her mind” to do that.  Not so fast say the social scientists where as the true prevalence of diminished capacity is quite rare.

I strongly believe that mental illness does not exempt 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. The reason for this is to deescalate potential violence and thereby reduce the incidence mentally disturbed persons who wind up in jail.  This speaks to the importance of getting those most in need into treatment and off the streets sometimes by having a judge mandate they enter treatment. When charges are brought forth alternative sentencing models may offer leverage that include mandated treatment in lieu of jail time know as alternative sentencing. Studies show that those who remain in treatment are less violent than those who fail or drop out of treatment, Torrey, et.al., 2008. In Massachusetts where I served as a police officer for 12 years too many myths entangled the process of accessing treatment for the mentally ill.  Officers were sometimes unsure of their options when a Q-5 prisoner was brought it and rarely made referrals for mental health care.  Q-5 is the nomenclature used when referring to someone with a history of mental health issues – usually suicidal threats. These prisoners were required to be on one to one supervision when held in jail. At least that was the myth at the time I was serving.

Community Policing and Aftermath Intervention

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Michael Sefton with SAPD-  officers Ernest Stevens (center) and Joseph Smarro (right)

I learned several important things about police officer interaction with citizens having mental illness.  It is a complex and time consuming endeavor that requires follow up in the aftermath of a crisis.  Police officers build credibility and trust in the process of this community interaction with citizens and those in the treatment continuum like physician Roberto Jimenez, M.D., a psychiatrist who has been there from the beginning in Bexar County. Dr. Jiminez began his career in Boston at the once revered Boston City Hospital where I completed my postdoctoral fellowship. He said to me “we had the national model in Boston….” referring to the system in place for police-mental health interaction in 1980. At the time, his service was utilized in conjunction with the state department of mental health and an active system of neighborhood health centers throughout the city. He referred to himself as the police psychiatrist.  By then, the Massachusetts state hospital system had been deconstructed and was no longer in the continuum of care. The chronically ill fell off the treatment radar.  Importantly in Massachusetts, this triggered the swing away from hospital-based care to the community health centers who became the front line for those in crisis.  At this point the myth of mental illness began its insidious transformation. Jail became the containment locale in the absence of the venerable state hospitals for better or for worse. In January 2017, Massachusetts Governor Charlie Baker expanded number of available beds at the Bridgewater State Hospital for care of those in crisis.

Officers in the SAPD Mental Health Unit undergo specialized training in crisis intervention. Officers Stevens and Smarro teach the 40-hours class to police officers from across the country. All police recruits in the SAPD academy are given this training as part of their early law enforcement education suggesting strong support from the command hierarchy. Importantly, the CIT model teaches officers to return to the scene of their calls to make referrals for care as I observed in February.  The follow-up call is key in rebuilding trust and illustrates the commitment in police-mental health care continuum. Just as importantly is the relationship created among police officers and direct service personnel like Dr. Jimenez who share the understanding of what can be done for those most in need.

Ostensibly, building relationships with network psychotherapists, physicians, addiction specialists, court judges, and other support service like Child and Family Services is essential.  Officers Stevens and Smarro spent hours on the telephone reaching out to the network of physicians, judges, hospital admission personnel and brother officers all in the service of a single case they picked up one evening while on an overtime patrol shift. Had they not caught the call on that night the complainant family may have flown under the law enforcement radar forever and a 33-year old depressed and delusional male may have become increasingly morose perhaps violent.  Instead he was put into treatment with the real eventual possibility of receiving social security disability payments to help he and his family and the treatment he needs to begin life again. Next is a strong conviction in what you are being asked to do. It is necessary and constitutive work that often flies below the radar and out of the headlines. It requires patience, flexibility and the right temperament.  And finally, officers need to follow-up on calls and build bridges and trust with those they serve including members on the same side of the thin blue line.

Setting the San Antonio program apart is the routine followup in the aftermath of high intensity calls such as domestic conflict or the run-of-the mill calls to houses where families are struggling with under employment, substance use or any number of social problems.  A brief second or third visit may just do the trick to hook in a family or individual otherwise in the margins of society bringing forth growth and human contact.


REFERENCES

Perry, D.  2016. Changing the way police respond to mental illness. http://www.cnn.com/2015/07/06/health/police-mental-health-training/

Sefton, M. 2014 Aftermath Intervention: Police first to the threshold. https://wordpress.com/post/msefton.wordpress.com/599

Sefton, M. 2017 Police as therapist: the inherent risk of unconditional positive regard. Blog post. https://msefton.wordpress.com/2017/01/16/

Torrey, CF et. al. 2008. 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.