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.

Failed system – where are the families?

One third of all police shootings — 55 in all, fatal and nonfatal — involved an apparent mental health crisis” according to the Boston Globe Spotlight story  written by Jenna Russell in July 2016.

imgresWESTBOROUGH, MA January 20, 2017 Where are the families of the mentally ill?  Where is the personal responsibility for accessing and staying in treatment. The mental health system has not failed here in Massachusetts but changes are needed. The Globe’s Jenna Russell highlighted the frustration and agonizing pain felt by the wives and mothers and fathers of people suffering from mental illness. Russell cited the lack of of resources available to those in need leaving them to emotionally languish. During these times they sometimes come into contact with police raising the likelihood of both substance abuse and violent encounters. Families must be educated for what options they have while waiting for help but ultimately they must work to keep their loved one clean and sober.  In doing so the likelihood of violent police encounters will drop substantially – perhaps saving a life.

One third of all officer involved shootings involve someone with mental health issues according to the Boston Globe Spotlight report.  “Such provocations are motivated not by violent intent, typically, but rather by self-destructive despair or delusions” resulting in police using lethal force to end the threat.  No police officer anticipates the reaction he or she may have to this scenario and are often traumatized by their encounters. Yet all police officers are conditioned to respond with lethal force when they are met with life threatening, violent comportment – whether mental illness is the underlying cause or not. They train for it. It is often impossible to determine subject motivation and intent when someone is menacing with a firearm or edged weapon. The tragic reality is only realized in retrospect where everyone has 20-20 vision.  The Boston Globe recently spotlighted what was described as a “failure” in the mental health system in Massachusetts.

SUBSTANCE ABUSE CONFOUNDS DEMEANOR – DEEPENS DESPAIR AND HOPELESSNESS

The use of drugs and alcohol elevate the risk for lethal police interactions.  These risks are extreme when persons living without treatment loose control and want to die.  When working as a police officer, I was involved in a violent fight with a depressed and intoxicated 40-year old female who was also taking drugs. She was yelling “kill me, go ahead and kill me” over and over. There were 3 officers on the scene including myself.  The female had no weapon that we could see.  The level of violence that was needed to take her into custody was stunning and resulted in broken windows and destroyed furniture. It was shortly before we obtained taser training and this would have been an ideal scenario to use that tool.  The combination of drugs, alcohol and depression yields a person of interest who has intentions that are difficult to assess and more difficult to predict. They experience their emotions deeply often with poor impulse control and amplified hopelessness.  Once this woman lost control of her behavior the violence escalated dramatically raising the risk of injury or death to officers and herself. Ultimately she was taken into custody and brought for a mental health evaluation.  Her emotional behavior and despair lessened as her level of intoxication decreased as it does with so many others.

We all went home feeling like we had been through a battle but we were safe and unhurt.

Police as therapist: the inherent risk of unconditional positive regard 

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

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

POLICE ACT AS CRISIS MEDIATORS WITH MENTALLY ILL

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

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

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

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

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

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

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

ALTERNATIVE SENTENCING

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

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

The interaction of substance abuse and mental illness is complex.  Persons with drug and alcohol addiction must be expected to become sober with the help of substance abuse treatment and family support. The risk of violence and suicide declines when sobriety can be maintained.  The 12-step programs have great success and are free to anyone willing to attend. Family members may attend Al-Anon or some drug-specific family support group.

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


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

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.