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.

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Decisions on Bail for Domestic Violence

THERE IS MOVEMENT TOWARD VICTIM SAFETY IN CASES OF DV

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Michael Sefton (right) BDN photo

WESTBOROUGH, MA   Is there any coincidence that Democratic House Speaker Robert DeLeo has joined forces with Attorney General Martha Coakley to bring forth a new bill that will provide for stiffer bail conditions and tougher sanctions for repeat DV offenders?  This bill was brought forth just 2 weeks after the Massachusetts SJC ruled on the case of one abuser against whom a permanent restraining order has been in place for over 10 years.  In that ruling, a man against whom a protective order was written is seeking its dismissal under the broad assumption that he is no longer  a threat to the former girlfriend because he now lives 3000 miles away.  Not so fast said the Massachusetts SJC.

The Commonwealth’s highest court reviewed the historic data in the case record and made its decision based on the documented threat of violence the abuser posed and convictions for DV against more than one partner dating back to the 1990’s.  They voted against dismissing the permanent restraining order writing that victim safety is more important than the purported rights of abusive men.  In the SJC decision the limitations placed on the abuser based on having a “protective order” against him were the collateral consequence of the behavior they exhibited early on.  The abuser believed he was unfairly being prevented from owning a firearm and had limited opportunity to work with children because of the unfair restrictions placed on him by the permanent order of protection.  Furthermore, the SJC also acknowledged that the abuser must show “convincing evidence” that they have made substantive emotional and personality changes that render him no longer a threat to the estranged spouse.

The bill proposed by Speaker Rober DeLeo asks for tougher bail conditions most notably a 6 hour delay before an alleged abuser may be released from custody.  The highly publicized case of Jared Remy who was released from custody hours before be allegedly killed his live-in girlfriend served as a stimulus to the proposed change in the law.  An important consideration not mentioned in the proposed bill is that to do with subjects with known violence in their history and how best to protect victims from revenge abuse once the abuser is released from custody.  Presumably, the new bill affords potential victims the opportunity to put in place a safety plan and affords those making decisions about bail added training about the cycle of abuse, red flag predictors, and greater access to the history of violence of the person in custody.

Unfortunately, the bill does not go far enough in its current raw form to assure that victims of violence receive the needed protection once they decide to break away from dangerous and dysfunctional entanglements.  It is this time when abuse victims are at greatest risk of death due to domestic violence as in the case of Amy Lake, a victim of domestic violence homicide whose case was carefully studied in the Psychological Autopsy of the Dexter, Maine Domestic Violence Homicide (Allanach, 2011) that occurred in June 2011.  Maine has been reviewing bail conditions since this unique study made over 50 recommendations for reducing the incidence of domestic violence homicide in that state.   This report was presented to the Governor’s Domestic Violence Homicide Review Panel in November 2011.  Only recently was a domestic violence suspect held without bail for his history of felony assault and battery on his spouse and a prior domestic partner for over 20 years.  In that case, the abuser was arrested three times in one month for violating an active order of protection during which time he threatened to kill his estranged wife.

Red Flags and Bail Conditions

In Massachusetts, Speaker Robert DeLeo warns that red flags often foreshadow an abuser’s behavior giving clues as to the intentions and the proclivity toward violence.  These are facts that are well described in the literature on DVH.  It is suspected that perpetrators ostensibly inform others about their intentions and all to often, these individuals do nothing to stop the violence.   In a prior paper, I have argued that a domestic violence registry may be useful for keeping track of those who repeatedly abuse or batter their domestic partners.  This would be similar to the sex abuse registry that requires those adjudicated for sexual abuse of children must register whenever they move from place to place.  I have also written extensively on the need for containment of those at highest risk to offend including a pertinent history of physical violence e.g. choking coupled with threats of death, access to firearms, prior violation of an order of protection, the presence of more than one simultaneous protection order (multiple victims), and other forms of coercive control such as destroying personal mementos like favored Christmas ornaments and personal photographs.   A pattern of substance abuse further elevates the risk for domestic violence and DVH.

There are changes taking place in the way in which domestic violence is handled in many states here in the U.S.  Bail conditions are being reviewed with more stringent constraints being placed upon abusers including no bail containment of the most egregious and violent cases.  Further options like GPS monitoring and a domestic abuse registry are being considered in some jurisdictions.  Some experts are calling for added training for judges and greater access to DV history before making decisions about bail conditions.  Arguably, these examples will all add to greater victims security but do very little when emergency protection orders are issued by judges during the night.  Police are frequently asked to present information to an on-call judge in an effort to provide immediate protection following a suspected incident of DV.  This information is critical in conveying what risk exists to the victim or potential victims.  Many police agencies are using dangerous assessment tools to compile and enumerate the red flags that may be the harbinger of terminal rage and the end of one’s timeline somewhere.

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.

THE LACK OF CRIMINAL HISTORY REVEALS LITTLE ABOUT INTENT TO HARM IN CASES OF DV

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Sedona, AZ

 Michael Sefton, Ph.D.

New Braintree, MA  Once again domestic violence has resulted in deadly force being used to stop one man from killing his intimate partner and the child they have together.  This cowardly man paid no attention to the court ordered protection order that was in place bringing lethal force to bear upon his family.  His guns were not removed from his control leaving him armed and dangerous.  Only this time, it is he who died in the violent final act before he could finish what he had come to do.  Police were ready for violence and met force with appropriate force resulting in death.  The surviving victims are fortunate for the action of the brave and courageous officers on duty in Calais, Maine on this night or they may have lost their lives in a murder-suicide – now all too common in northern, Maine.

The details of this Calais, ME case of domestic violence are being carefully guarded.  It is known that Daniel Phinney, 26 was out on bail after being arrested and charged with domestic violence and criminal threatening in May 2013.  At that point he must have both physically assaulted his significant other and threatened to kill or maim his family resulting in the charge of criminal threatening.  Police are quick to say that Phinney had no prior criminal history perhaps in an effort to circumvent the obvious outrage evoked by the system of bail in Maine that releases violent abusers over and over again.  Had anyone made an effort to determine the degree of risk posed by Daniel Phinney prior to his release?  Had anyone registered safety concerns based on the defendant’s behavior and history?  Had they undertaken a psychological assessment of Phinney that may have provided important details about his impulse control, substance use, and proclivity toward violence?  These details may become more apparent in the coming days.  Perhaps a second look at the Psychological Autopsy of the Dexter Maine Homicide may be of value in terms of understanding risk and red flag behaviors that warrant containment of domestic terrorists.

The Phinney case is reminiscent of the 2011 Steven Lake homicide in Dexter in too many ways.  Lake had twice been released on bail before murdering his family.  The medical autopsy concluded that “in spite of psychological counseling (the state) failed to appreciate the degree of anger and violence in (Steven Lake)”.  He too had been charged with criminal threatening after holding his family at gunpoint as he drove home the point about how much he loved them but he could not let Amy move on.  Perhaps criminal threatening behavior should trigger a closer look at risk factors when setting conditions of bail.

I was a member of a team that conducted a psychological autopsy on Lake that resulted in over 50 recommendations to the esteemed Maine Attorney General’s Homicide Review panel in November 2012.  At first glance what is clear is brash indifference toward the court protection order and the availability of firearms to the defendant.  It is now important to study the case of Daniel Phinney and learn from the many red flags he waved in the weeks prior to his death.  These events can be stopping and containments points in future cases of domestic violence and domestic violence homicide.  No family should be kept in fear by a spouse whose loathsome behavior derails all human spirit and sense of dignity.