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

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Saluting a fallen brother and bringing him home

WESTBOROUGH, MA March 18, 2017 Most people leave their homes and go to work.  Many work in sales or IT or perhaps they teach school.  It doesn’t matter because that all changes when you are a member of the fire service or a brother police officer. Then you become a member of a family that many say takes a hold of you like no other.  There is a bond among fire fighters and a respect that runs deep within the fire service – the family of firemen.  The bonds are forged in the hours of training, answering calls, and sitting chewing on the issue of the day.  And then one day someone goes down.  In police service it’s called the “oh shit” moment when something happens so quickly that your response is purely defensive sometimes too late as in the case of the Flagstaff, AZ 24-year old officer whose body camera recorded the oh shit moment that took his life last year.

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Boston Globe photo

Firefighter funeral traditions show our deep gratitude and respect for the honorable contribution they make to society. When a firefighter dies, he is considered a “fallen hero” and his funeral will indicate such an honor.    D. Theobald

The fire service is even more protective of its ceremonial reverence for the ultimate sacrifice made by a heroic fallen firefighter.  Everything stops. Every one steps up and does whatever is needed to support the surviving family and each other. Someone is usually assigned to stay with the bereaved family 24 hours a day. The ritual of bringing home a fallen fire fighter is age-old. Firefighters remain with the body and bring it home with care and reverence afforded a fallen hero.  This custom was once again brought to bear when Watertown, MA firefighter Joseph Toscano, 54 died while fighting a 2-alarm house fire this week.  The death of a fire fighter is a rare occurrence but happens frequently enough that most people can remember the show of reverence from members of the fire service everywhere.  In 2014, 2 Boston firefighters were killed in a wind-driven conflagration on Beacon Hill and who can forget the 6 Worcester firefighters who lost their lives in December 1999, or the Hotel Vendome fire in Boston that took the lives of 9 Boston firefighters over 40 years ago.

Watertown, Massachusetts has seen its share of catastrophe in recent years in the police and now fire services. The funeral will be attended by thousands of local firefighters and those from across the United States. Fire houses in Watertown, Boston, and elsewhere will make accommodations for out of town brothers and sisters attending the funeral. No member of the fraternal family is ever turned away.  The coffin will be on display for those of us so moved to pass by and offer a final salute to the firefighter and his family.  The honor guard will stand at head and foot in solemn deference for the ultimate sacrifice. The surviving spouse will be strong as she has been for many years over many calls for service.  Her husband has helped so many people.  He has seen much and has dealt with this before.  But as the flag draped coffin is moved into place the release of emotion will be palpable for all.  The fire chief will present the folded flag to Maureen Toscano his wife of over 20 years.  He will offer words of comfort to his five children. They will never be forgotten because they are part of the extended family of firefighters.  The 150-year old ritual of bagpipes will play Amazing Grace while men from Newton, Boston and Cambridge stand guard at the Watertown fire houses to allow every Watertown firefighter to attend the service. To grieve and begin the healing process.

A Catholic Mass will be held.  The streets of Randolf where the family lives will be lined with a sea of blue uniforms each one holding back tears – having been through this before.

As Watertown firefighter Joseph Toscano knows it could well have been any one of his brother officers who fell that day and he would never have stood by for that.  A heroic effort was made to save the life of Joseph Toscano by members of the Watertown Fire, EMS and Police departments. He was rushed to Mount Auburn Hospital in Cambridge – the same place where MBTA Officer Richard “Dic” Donohue was rushed after the 8 minute firefight during the search for the marathon bombers in 2013.  Officer Donahue survived but lost nearly all of the blood in his body. Donahue retired from the Transit Police in 2016 after his promotion to sergeant and deals with chronic pain on a daily basis.  Emergency crews at Mt. Auburn were not able to revive Joe Toscano.

His body was carefully moved from the chief medical examiner’s office in Boston – just 5 miles away to Randolf – but he was never alone. Members of his department including his chief rode on Watertown Engine 1 and a ladder truck leading the hearse and a legion of police officers.  Firefighters from neighboring cities stood along highway overpass with hand salute as Firefighter Toscano was headed home. Among the most powerful of ceremonial rituals is “the last call.”  This occurs when the fallen officer is called on the fire band radio for all to hear – “Firefight Toscano come in….” there is silence.  The fallen officer’s call sign is again dispatched – silence once more.   Finally, the dispatcher indicates that the fallen officer has gone “10-7” signaling that he is no longer on duty – in this case signaling – the end of his watch.  A bell sounds 15 times indicating the firefighters final call.  Often the dispatcher will say something like “You have served your community with honor and reverence, good sir, we will take the watch from here.  Rest in peace – Firefighter Toscano and know you are a hero and will never be forgotten.”


Firefighter’s Prayer


When I am called to duty, God,
wherever flames may rage,
give me strength to save a life,
whatever be its age.
Help me embrace a little child
before it is too late,
or save an older person from
the horror of that fate.
Enable me to be alert,
and hear the weakest shout,
quickly and efficiently
to put the fire out.
I want to fill my calling,
to give the best in me,
to guard my friend and neighbor,
and protect his property.
And if according to Your will
I must answer death’s call,
bless with your protecting hand,
my family one and all.

Goals for Crisis Intervention – 5 stage model

5 Stages of Police Crisis Intervention

  1. Scene safety – Assess for presence of firearms – obtain history of address from dispatch – have back-up
  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
  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).


Roberts, A. R., & Dziegielewski, S. F. (1995). Foundation skills and applications of crisis intervention and cognitive therapy. In A. R. Roberts (Ed.), Crisis intervention and time-limited cognitive treatment (pp. 3–27). Thousand Oaks, CA: Sage.

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

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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 and jail became the containment locale in the absence of the venerable state hospitals. 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.

Behavior regulation and fire: an overlooked sign of inner conflict

WESTBOROUGH, MA March 1, 2017 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

Risk of substance abuse elevated when treatment stops

WESTBOROUGH, MA January 30, 2017 Criminal behavior and mental health issues are not mutually exclusive.  Culpability does not end when someone becomes afflicted with a mental health illness. People remain personally responsible for their actions even when depressed or anxious or when they have ADHD or some other problem.  The pendulum now swings toward treatment for mental illness and away from incarceration for those so afflicted. Given the current awareness of the large percentage of inmates that suffer with mental illness a growing consensus of researchers are appalled that little treatment seems to occur for those living behind bars.

There is a growing push to circumvent incarceration for those with mental illness although the personal responsibility for treatment is too often overlooked. As I have said in other posts the person with mental illness almost always denies he or she has a problem.  As a result, those most at risk are frequently lost to treatment and fail to follow through with therapy and prescribed medication. Who is responsible for the failure to follow a plan of treatment?  There must be some accountabilty by the individual and his family to stick with the recommended treatment. Substance abuse starts with a 12-step recovery program that are available in every city and town. Only then can treatment for mental health needs be effectively addressed.

There is a strong likelihood of substance abuse for those who go without mental health treatment raising the specter of violence associated with comorbid substance abuse and mental health problems.

Who is responsible for providing treatment for the thousands of inmates said to be suffering with mental illness – many of them in isolation with little hope or support?  Care for the mentally ill remains with providers who specialize in the diagnosis and treatment of nervous and mental diseases.  The police encounter unstable people on a nightly basis.  These encounters are made exponentially worse by drugs and alcohol ingested by citizens.  Also on a nightly basis.

“The underpinnings of violence are often present in some form or another whether or not someone has a mental illness ” according to Michael Sefton, Director of Psychological Services at Whittier Rehabilitation Hospital in Westborough, MA.