Forensic Mental Health: Contemporary Issues and Interactions Involving Justice-Involved Persons with Mental Illness

neacjs-logo-US-left-colorv21-300x251WESTBOROUGH, MA April 30, 2017 The Northeastern Association of Criminal Justice Sciences has announced the date for its upcoming annual conference to be held in Rhode Island at Roger Williams University in Bristol.  The conference will be held on June 7-10 2017.

The topic this year is Forensic Mental Health: Contemporary Issues and Interactions Involving Justice-Involved Persons with Mental Illness that has been in the news when it comes to police encounters with those so afflicted.  In Massachusetts alone over 120 people thought to suffer with mental illness have been involved in lethal force situations with law enforcement between 2008-2016.  The program is still being drafted but I have been invited to present the Psychological Autopsy as a Forensic Tool along with my colleague Brian Gagan and co-author of the Psychological Autopsy of Steven Lake – Dexter,

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Dr. Sefton discussing psychological autopsy of Steven Lake with coauthor Brian Gagan (left)

Maine Homicide-Suicide in 2011.

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.

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

A wolf in sheep’s clothing

WESTBOROUGH, MA January 2, 2017 I grow contemplative with the change of each calendar year and wonder where the time has gone since 2000 when one of our closest friends dressed as the pink millennial elephant and danced on the front yard to the delight of the four boys who were stuck at home with nothing to do. It was a big surprise to us all and was meant to make us laugh and bring joy. I cherish these friends and am fortunate to have so many more.  For those of you who regularly read these posts I wish you all a happy new year – oa-wolf-in-sheeps-clothingne that is safe and prosperous. I expect that most people wish others peace and prosperity on New Years Day.

Intuition and deviance

I know there is a subset of people who may not be who they would have us believe they are.  The world has seen unconscionable acts of barbarism in lone wolf terrorists in 2016 that I will not revisit here.  Deviance comes in many forms of disguise.  Workplace violence is nothing new and continues to be on the radar screen of human resource and security experts.  Vester Lee Flanagan, 41, a disgruntled television reporter killed WDBJ colleague Alison Parker and her cameraman as she did her job on live television. He had been escorted off the station property following repeated attempts at bullying the people he worked with in Roanoke, VA in summer 2015.  The live twitter posts, videotaping the shooting, and horrific execution of the victims by Flanagan will be a specter for years to come. People may have anticipated this behavior by looking closely at his prior employment patterns and behavior that were highly erratic. Mental health advocates might argue that Flanagan had depression or some other debilitating psychiatric illness that he chose to ignore. In his 23 page manifesto he cited discrimination, harassment and bullying as the reason for his actions.

“Like dozens of mass killers before him, the shooter embodied a deadly mix of resentment, delusion, and thwarted aspiration” according to Sarah Kaplan (Washington Post, August 27, 2015).

Each of us needs to be aware of our environment and the possibility of a wolf in sheep’s clothing in our midst. Do not be surprised by the behavior of wolves – especially those looking to feed their hubristic conceit.  Relationship and intimate partner violence takes on special significance in this new year and there are well documented red flags that forewarn offering a glimpse of the wolf lurking below the surface flash and excitement of what is new. Gavin deBecker offers the textbook – The Gift of Fear as an essential reminder for each of us to closely be aware of our inner feeling states such as the sense of fear – when in the presence of those who might do us harm. Understand fear as a prehistoric memory trace genetically programmed into each of us. It allows us to feel a warning as the wolf gets us in his sites.  deBecker owns a security firm that provides employee threat assessments and interviews victims to see what they were thinking and feeling before being attacked. Many reported an odd sense of foreboding just before being assaulted or attacked. By listening to and acting on one’s internal sense of fear you may save your own life.

The possibility of home-grown violence erupting in the life of the average American is greater than ever before. As recent events have illustrated there are marginalized people living on all sides of us – some of whom are brooding – blaming.  The reasons for homegrown violence: relationship and workplace violence are very complex and beyond the scope of what can be explained in these pages.  As a society the identification and containment of those who depravedly evoke fear in others is requisite to social order. The next generation of leaders should find a balance between public safety, treatment and rehabilitation for those living with mental illness and ardent protection from the brooding haters who dress as sheep in order to make us afraid and bite our throats.

Happy New Year and be aware of your surroundings and watch for the wolf in sheep’s clothing.

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.”

DVH in MA: 4-year old child begs father not to murder his mother

  • “… He stood in the doorway with a loaded gun and talked about killing himself and/or children and myself. He was bringing up old verbal threats and I thought they were going to come true”

Amy Lake – July 2010

WESTBOROUGH, MA September 15, 2016 The words above were taken from a requested order of protection in the state of Maine in 2010.  The threats upon this victim and her family became a reality exactly one year to the day after this order was put in place in 2011. Lake and her two children were murdered by her husband Steven Lake who killed himself as well. Immediately following the killings a Maine district attorney said “there was nothing we could have done to prevent these killings”. These were the words that triggered a team of professionals including myself to research the sequence of events that lead to this event.  A formal psychological autopsy was undertaken in 2011 following these murders and over 50 recommendations were generated (Allanach, et al 2011).

I am sick to my stomach as I write about another senseless killing of Wanda Rosa in Methuen, Massachusetts in late summer 2016.  The case resembles so many cases of domestic violence homicide – manipulation and control.  Ms. Rosa had a permanent order of protection but had recently modified the order to allow Emilio Delarosa to see the child they had in common. Why in the world would anyone allow Delarosa to see his son? He is no role model and the potential for terminal violence was readily apparent as depicted in the order of protection.  He expressed his intent to kill his girlfriend on more that one occasion.  Delarosa’s history of intimate partner violence had risen to the level of a permanent ban – signaling that the pattern of violence was undeniable and the red flag indicators for domestic violence homicide (DVH) were apparent in the eyes of the police and judiciary when the permanent order was granted.

Permanent orders of protection are rarely granted unless the pattern of violence was so prevalent and unremitting that the potential of harm or death to the victim and her family was unsurpassed as in this case.  It is known that Delarosa was manipulative and controlling of his girlfriend getting her to drop charges over and over and later alter the terms of the restraining order – ultimately resulting in her death.  Secondly, the person against whom the stay away  order is granted must have demonstrated a blatant indifference of the order of the court by having recklessly violated the order over and again. It should not have been altered.  In the past 18 months cases meeting these requirements (such as this one) have resulted in intimate partner violent deaths.  The Jarod Remy 2013 murder of Jennifer Martin is a despicable reminder of the need for change in cases of DV. Remy killed his girlfriend by stabbing her multiple times as the couple’s 4-year old child bear witness. In spite of laws designed to reduce the likelihood of DVH Rosa was not adequately protected.

Rosa’s boyfriend Emilio Delarosa is on the run as of September 20.  He is accused of murdering his former girlfriend after years of abuse, strangled her to death as their 4-year-old boy pleaded with him to spare her life, according to court records. “No Dad” the child was heard to say over and over. As in the Remy case, the 4-year old witnessed his father choking  Wanda Rosa until she was dead.

“I suspect there is a strong likelihood that he too will be among the deceased in the coming days as is the common eventuality among those who commit the unconscionable, violence that manifest in this terminal event” according to Michael Sefton, Ph.D., director of psychology and neuropsychology at Whittier Rehabilitation Hospital in Westborough, MA.  When some men violate the permanent protection order it is the result of unbridled rage and defiance against a “system” they believe has failed or unfairly humiliated them said Sefton in a release. They are murderous and often turn their rage inward in an act of suicide. I would look for the triggers of what set Delarosa’s terminal rage into action.  It could be something as simple as being told he needed to have monitored visitation with is son or learning that the female was seeing another man – both conjectural on my part.  After the alleged killing Delarosa was heard to say “It’s over, it’s over, it’s over” when speaking to his sister.

“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 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 Michael Sefton who with colleagues published the Psychological Autopsy of a case from Dexter, Maine where a father murdered his child, estranged wife and ultimately himself (Allanach, et al, 2011).  In the days preceding the murder there are usually red flags or pre-incident indictors that people see that signal the intentions of the murderer.  These clues provide police and the judiciary with data to craft protection plans and are the commonalities found in cases of DVH across the state and across the world.  Some red flag behaviors signal the emergence of imminent terminal anger that can be seen in the social media accounts of intimate partners who go on to kill their spouses.  I am quite interested in the compelling reasons that Delarosa may have argued that resulted in the change in the permanent order of protection.  The outstanding Boston Globe article about the slaying is a sad reminder of the early warning signs of DVH.  All the red flags were present.  In a blog published in 2013 I list the tell tale warning signs of intimate partner homicide and the need for tougher bail conditions (Sefton, 2013).

The impact on the child will be lifelong. At age 4, children are developing their sense of gender identity in the setting of developmental growth, cognitive maturity, social functioning and continued individuation. Imagine the child who is reunited with his parent after a period of mandated protection due to DV.  He is now able to see his family and may be fraught with both excitation and fear.  It would be normal for the child to have fantasies of reunification of the family and perhaps self-blame for not having stopped the action of his father. Just like the daughter of Jennifer Martin and Jarod Remy this 4-year old boy will forever be reminded of the life he will not have.

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. The red flags of intimate partner violence. Blog post taken October 2, 2016.

Sefton, M. Prior history of crime not predictive of DVH. Blog Taken October 2, 2016. post: http://enddvh.blogspot.com/2013/07/prior-criminal-history-used-to.

Is a DV registry an abuse of rights?

“The implementation of a domestic violence registry would inform potential victims that they are at risk and greatly reduce the cases of domestic violence in New York state.”  NY State Senator Michael Nozzolio

WESTBOROUGH, MA April 4, 2016 The prospect of mandated reporting in cases of domestic violence will add to already the over burdened state and federal bureaucracy. It cannot be done and may be a violation of the privacy rights of those accused of domestic violence.  Or at least that is what they tell us.  I have encountered abusive men who I have escorted off someone’s property after a verbal argument – before it became a physical encounter. In conducting my investigation, I learned that the guy had active protection from abuse orders that were taken out by three different women. That should be fuel for thought and the first question asked on the dating websites.  

In New York, state Senator Michael Nozzolio has proposed a bill that would create a registry for those convicted with violent felony domestic violence.  The bill entitled Brittany’s Law after a 2009 murder in which Brittany Passalacqua and her mother were killed in a domestic violence homicide. It has been passed in one form or another by the NY State Senate four times but the state legislature has yet to take up the bill.  Why? Some believe that a published list of abusers is a violation of human rights – like if a guy shows up on the list he may not be able to get anyone to date him anymore.  That seems like a reasonable consequence for beating up an intimate partner or two.