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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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.

The Myth of Mental Illness and School Violence

Westborough, MA March 3, 2015 This blog was initially published in March 2013 as a retrospective on the recent spate of “active shooter” tragedies across America.  There have been several high-profile shootings in the past 3 years that have involved perpetrators whose mental health is in question.  This is often not the case in school violence whereas the perpetrator of the action was deceased at the conclusion of the incident.  In these cases an effort must be made to uncover substantive causal factors in the perpetrator’s terminal actions.

The true incidence of violence among people diagnosed with a nervous and mental disorder is quite low. It is a common misconception that whenever something hideous occurs it must be mental illness that is the driving force behind its fury. In most cases this is neither the reality nor the underlying cause of terminal rage. In light of the information being uncovered about the Newtown, CT mass murderer, the specter of mental illness insures a convenient scapegoat. Updated information from Newtown recently confirmed that Adam Lanza had studied the media stories of prior mass killings as he planned for his despicable final melt down. In retrospect, I wonder what “red flags” have been uncovered that offer insight into his substantive motivation. People will speculate about random causes of Lanza’s behavior with uncertainty unless it can be studied scientifically.

There are some instances when mental illness has be associated with serial homicide such as the Son of Sam killer who plied his murderous delusions in NYC during the 1970’s using a Charter Arm’s Bulldog .44 caliber revolver. David Berkowitz used that weapon to kill 6 and wound 7 during his spree. He claimed to have been commanded to kill random couples he saw in cars by a dog he believed possessed by the demon. After spending time in a mental institution following his conviction he was transferred to the state prison at Sing Sing and finally Attica to serve 6 life sentences. When he was on trial Berkowitz plead not guilty by reason of insanity – the delusions he had about communicating with demons. In the end, it was determined that Berkowitz was not mentally ill. The Columbine, CO high school killers, Klebold and Harris were methodical in their planning of the attacks on the school and its students. They built explosive devices and practiced their attack in the weeks before the assault on the school. By outward appearances these two were from middle class families with involved parents. Many believe Klebold and Harris were the victim of bullies.

Psychological experts believe mentally ill persons lack the higher order planning to execute the complex steps necessary for these types of crimes. Neither Dan Klebold nor Eric Harris was mentally ill. The Virginia Tech killer Seung-Hui Cho murdered 31 students and faculty in 2007 after a period of decompensating rage. He wrote a profanity laden manifesto blaming everyone for their maltreatment of him that sounded paranoid and vindictive yet was able to send the videotaped diatribe to a news agency. Cho had been held in a psychiatric hospital 2 years prior to his rampage after becoming marginalized. Cho was able to organize his crime preparation and sequence the needed steps to meet his murderous goal. Was he mentally ill?

The Psychological Autopsy is a clinical assessment of the time line and antemortem behavior and emotional comportment of the perpetrator of compelling and despicable events. These types of case studies explore changes in cognitive and behavioral functioning immediately before a terminal event of homicide. An extensive review of a case from 2010 that was published in 2011 generated over 50 recommendations about DV and factors to consider when victims are at greatest risk (Allanach, R., 2011). The cost of these interviews and substantive case review is the primary reason they are not regularly conducted.  It is also less compelling when the perpetrator has killed himself and survivors want to turn the page.

Recently, at least 2 shooters have survived mass killings or have been captured after their alleged attacks.  In 2012 in Aurora, CO movie theater James Holmes was arrested and charged with multiple counts of murder.  He has pleaded not guilty by reason of insanity.  In 2011, Jared Lee Loughner was arrested at an outdoor political event in Tuscon, AZ after the shooting of U.S. Representative Gabrielle Giffords and killing 6 others. Loughner plead guilty after being found that he was capable of standing trial.He is serving 140 years in prison.  The Aurora case remains open.

It is hoped that important information may be gleaned from the rigorous study of motives, personal history, and triggers to their rage.

REFERENCES

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. (2011) The Psychological Autopsy: Provides a host of pre-incident indicators. Blog:  http://www.enddvh.blogspot.com/2011/11/psychological-autopsy.htm, taken May 26, 2014.

Sefton, M (2013) Asperger’s Disorder: Not linked to violence. https://msefton.wordpress.com/category/active-shooter/ Taken March 2, 2015

Michael Sefton, Ph.D.
Read more at: http://www.msefton.wordpress.com

Active shooter evoke images of horror – fear

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DC shooting scene taken off news channel

Right now in Washington DC, Metropolitan police officers are searching for the motive to today’s shooting onslaught that took place at a heavily guarded Naval facility in the southeast section of the nation’s capitol.  Arguably, Washington DC has the highest per capita number of law enforcement officers in the country.  Between federal law enforcement agencies like ATF, FBI, National Park police, Capitol police, and the full complement of highly trained Metropolitan officers, the city is well guarded.  Or so we thought.

The active shooter call is one that no officer ever wants to get.  It requires fast action, teamwork, and herculean bravery like no other call.   The “active shooter” refers to just that – ongoing, systematic slaughter of innocent civilians with the specific purpose of violence and murder.  These events start and end quickly averaging only 7-10 minutes before the shooter is dead.  Usually killed by his own hand but not before the execution or injury to scores of men, women and children.   Most police officers have taken the active shooter training programs that evolved after the Columbine HS shooting.  Since then, officers are trained to “move to contact” – go find the bad guy – do not to wait for special weapons teams as the former response zeitgeist once required.  Many behavioral scientists believe shooters give off clues before they act on their violent plans.

The active shooter has become an all too frequent happenstance that we cannot ignore.  In a blog published in April, 2013 information became apparent about Jared Loughner’s change in mental status and growing detachment from others (Sefton, 4-24-13).  People suspected that Loughner was becoming a danger to himself and others.  Unfortunately, there was no in-depth assessment of his mental status before he went on the bloody rampage.  Loughner plead guilty to the Tuscon shooting of Rep. Gabby Giffords and killing or wounding 18 others.  He is serving 111 years in prison.

WHAT HAPPENS TO THE HUMAN EXPERIENCE

The repeated exposure to horrific events  such as the DC Navy base shooting and too many others raise the risk of making toxic our collective conscience toward the images and horror and loss of life.  People feel denuded and afraid when they hear about shooting events such as these but something more needs to be done.  What drives these individuals?  In the coming weeks or months more information about the apparent shooter will become known.  Behavioral experts will make assumptions about his motive and the underpinnings of the violent onslaught.  “The psychological autopsy is a detailed analysis of the pre-incident emotional comportment and behavior of the violent decedent although this is rarely done” according to Michael Sefton.   More of these studies should be undertaken to establish high risk conditions that may create stopping and containment points for derailment of action and greater understanding of those with a proclivity toward terminal violence – such as what happened today.

What is certain is the need for each of us to be more aware of our surroundings and to those who might do us harm.  When confronted with evil it is incumbant upon each of us to think and take aggressive action that may save your own life and the lives of others.

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.