Discretion, Treatment and Alternatives to Jail

PART 2

WESTBOROUGH, MA July 16, 2017 In last weeks publication I introduced the problem of mental health and co-occurring substance abuse with some ideas about alternative restitution and treatment. These involve greater discretionary awareness among police officers.  More importantly options to jail require viable alternatives that will end the revolving door of minor criminality coupled with treatment for the breadth of addiction seen on a daily basis by law enforcement.

Mental and Physical Health Screening

At time of arrest the individual must have some level of mental health assessment if mental illness is suspected or documented. When I was a police officer prior to 2015 we often asked the D.A. to provide a court clinic assessment of the suspect to rule out suicidal ideation or delusional thinking. This must also include a screening for dangerousness especially when a subject is arrested for intimate partner abuse. Next a health history questionnaire should be undertaken to screen for co-occurring illness – both physical and mental. If a diabetic suspect is held without access to his insulin he is at great risk of death from stroke. Similarly, a person arrested for assault who suffers from paranoid ideation is at greater risk of acting violently without access to psychiatric medication. Finally, an alcoholic brought to the jail with a blood alcohol level greater than 250 is at great risk for seizures and cardiac arrhythmias when delirium tremens begin 6-8 hours after his last drink. The risk to personal health in each of the scenarios above must be taken seriously and the obtained data should be factually corroborated. Police departments across the United States are pairing up with private agencies to provide in-house evaluation and follow-up of individuals who fall on the borderline and may not be easily discerned by the officer in the field.

Diversion Safety Plan

Next, the probation and parole department must obtain an accurate legal history prior to consideration for bail. A nationwide screen for warrants and criminal history based on previous addresses is essential. In many places these are being done routinely. In the case of someone being arrested for domestic violence he may have no convictions thus no finding of criminal history. For these individuals the dangerousness assessment may bring forth red flag data needed for greater public safety resulting in protection from abuse orders, mandated psychotherapy, and in some cases, no bail confinement when indicated. Releasing the person arrested for domestic violence without a viable safety plan increases the risk to the victim and her family, as well as the general public – including members of law enforcement.

Bail, Confinement, Mandated Treatment

There is some thinking that higher amounts of bail may lessen the proclivity of some offenders to breach the orders of protection drafted to protect victims and should result in revocation of bail and immediate incarceration when these occur. I have proposed a mandatory DV Abuse Registry that may be accessed by law enforcement to uncover the secret past of men who would control and abuse their intimate partners. This database would also include information on the number of active restraining orders and the expected offender’s response to the “stay away” order. In cases where the victim decides to drop charges there should be a mandatory waiting period of 90 days. During this waiting period the couple may cohabitate but the perpetrator must be attending a weekly program of restorative justice therapy and substance abuse education. Violations of these court ordered services are tantamount to violation of the original protection order (still in place) and victim safety plan and may result in revocation of bail. If the waiting period passes and the perpetrator has met the conditions of his bail than he may undergo an “exit” interview to determine whether or not the protection order / jail diversion plan may be extended.

Guardianship

In many jurisdictions the mentally ill cannot be forced to take medication nor can they be forced into treatment. Adherents to this belief advocate on the behalf of the chronically mentally ill for the right to make these individual choices – treatment or no treatment. Ostensibly advocates seem unconcerned for the public health risks associated with ongoing drug addiction and major mental illness. There needs to be an active system in place to provide guardianship to individuals with repeated failed treatment that mandates treatment for those who cannot remain in a program of sobriety and psychotherapy in lieu of incarceration. In many cases a family member may be appointed temporary guardian for up to 180 days that allows decisions to be made about patient care up to the guardian not the patient himself who may be unable to stay on track.

 

 

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

New age cops – the future innovation of community policing

WESTBOROUGH, MA December 29, 2016 I have long been an advocate for prompt and comprehensive treatment for those afflicted with mental illness.  Now police are increasingly linking up with mental health agencies as a way of diverting mentally ill person’s from jails into treatment for their emotional affliction.  In my experience this is no easy task.  In some cases criminality and mental illness are not mutually exclusive.  Some who suffer with emotional issues like bipolar depression, drug addiction or anxiety may respond poorly to treatment and may need containment. Those most refractory to treatment often become most difficulty to manage in society.  The untreated mentally ill have a higher rate of violence than those in voluntary treatment.

psychology2As early as 1984, I served the pediatric population in Boston at the Boston City Hospital Pediatric Emergency Department as the on-call clinician in psychology. That same year I was appointed to the ED at Hale Hospital in Haverhill, MA for screening people in crisis.  Those who were stable and had support systems in place would be released – usually with an outpatient referral. Meanwhile, patients without at-home safe guards who could not plausibly answer the question “what brought you to the decision to harm yourself?” were admitted to the hospital.  Other mitigating factors like healthy living arrangements, employment, sobriety, and no history of suicidal behavior were positive indicators of future outcome.  It was a position I loved and is an important clinical role to this day across the United States.  Later as a community mental health psychologist in Long Beach, CA, I served the Children’s Service as someone charged with screening adolescents in crisis living across Los Angeles County. In each of these locations I worked closely with social workers, case managers, police and gatekeepers at state and county psychiatric units to find open beds for kids in need.

In 25 years since there has been very little innovation and fewer still treatment beds for those in need. Today’s depressed and emotionally wounded often spend days in emergency department hallways further wounded by a demoralizing system of delivery that is overwrought and has no place to send them.  This scenario was the case in 1985 and remains the case in 2016.  In Massachusetts and counties across the United States publicly funded hospital beds – including state hospital beds have been eliminated.  In the 1970’s and 1980’s the pendulum of advocacy swung toward community-based care and away from hospital-based treatment.  This left the chronically mentally ill without a support net for treatment, medication management and long range hope.  Many became homeless, unemployable and abusive of drugs and alcohol.

Police provide frontline intervention – often with little training

Police officers became the first line of defense as the hospital beds were eliminated. The mentally ill and those addicted to any number of drugs or alcohol grew homeless and sometimes menacing as they struggle with symptoms. Now police officers are being trained to intervene with these marginalized citizens with crisis management skills.  This poses a conundrum for the current zeitgeist of community policing theory in that the notion of dangerousness relies on critical scrutiny of the underpinnings of human behavior and often nonverbal indices of psychopathology. Some believe this is state of the art police science.  Departments from Augusta, Maine to Los Angeles, CA to San Antonio, TX are using frontline officers as crisis resolution specialists for police encounters with the acutely mentally ill. Many are paired with licensed clinicians while others are working the streets alone.

The collaboration between police and mental health personnel is not new.  But the use of police officers as crisis intervention specialists is innovative and gaining traction in many places around the country. Yet these officers must always be aware of the uncertainty of some encounters with police and those suffering with paranoia or psychotic, illogical delusions, PTSD, or traumatic brain injury that may not respond to verbal persuasion alone.  Decisions about when to utilize greater force for containment of a violent person is sometimes instantaneous.

The use of force must be fluid and officers in the field are expected to modulate the force they apply to the demands of the situation and be ready to respond to changing threat levels.             Michael Sefton, 2015

In 2002, I was appointed to a Massachusetts police department having once served in southern Maine right out of college.  As a psychologist I made an effort to bring mental health concepts into police work without much fanfare or interest.  Mental health topics are not as sexy as defensive tactics or firearm training, I was once told, so finding numbers was sometimes tenuous.  There are still many myths about intervening with those who are making suicidal and homicidal threats and training opportunities are taking on more importance.  Especially these days.  Suicide by cop became a phenomenon that no officer ever wants to confront. All violent police encounters guide officer behavior. “The degree of response intensity follows an expected path that is based on the actions of the perpetrator not the actions of the police” (Sefton, 2015).

Suicide by cop – predicting behavior

In the 2014 FBI Bulletin, Suicide by cop (SBC) is defined as “a situation where individuals deliberately place themselves or others at grave risk in a manner that compels the use of deadly force by police officers” according to Salvatore, 2014.  This happens more than one might expect and is often preceded by rehearsal events according to Salvatore.  “Suicide rehearsals are practice for the attempts that will follow within a few hours or days. SBCs may be tested. Officers should use caution when recontacted by an individual who previously presented signs of mental illness, had no need for assistance, was standoffish when asked what was needed, or was anxious to assure the officers that everything was fine. The initial contact may have been practice for an SBC.”

The best predictor of behavior is past behavior.  The prior demeanor that police have observed in those frequent flyers who pop up on police radar over and again often sets the stage for violent conflict later on. But not always.  Situations grow exponentially more grave in the presence of drugs and alcohol raising the level of lethal unpredictability. For many struggling with depression or other serious mental illness being sober or drug free can be the healthiest thing they can do for themselves.  The uncertainty of the SBC scenario makes the likelihood of a successful de-escalation a tenuous exercise in the life and death force continuum.

The motives for SBC are multifactorial and undeniably linked to poor impulse control associated with drug and alcohol intoxication.  The triggers are identified by Salvatore as “individuals who feel trapped, ashamed, hopeless, desperate, revengeful, or enraged and those who are seeking notoriety, assuring lethality, saving face, sending a message, or evading moral responsibility often attempt SBC”(2014).  Some believe they will become famous and earn large monetary settlements for their surviving families following a SBC scenario.  Other victims are tortured souls who make no demands and offer no insight into their suicidal motive and are killed when they advance on police or turn a weapon toward responding officers.

Training in police-mental health encounters has slowly taken hold.  This innovation in community policing offers hope for reducing fatal encounters.  No amount of training in crisis management will reduce incidence of SBC to zero but ongoing training to identify the behavioral indices of imminent violence, psychosis, and suicidal/homicidal ideation will reduce these lethal encounters.  Most officers are highly skilled at using their verbal skills to de-escalate a violent perpetrator without using lethal force – even when a higher level of force may have been warranted.


Salvatore, T. (2104), Suicide by Cop: Broadening our Understanding. FBI Law Enforcement Bulletin, September. Taken 12-29-16 Bulletin website https://leb.fbi.gov/2014/september/suicide-by-cop-broadening-our-understanding.

Sefton, M (2015) Blog post Law Enforcement- Mental Health collaboration. Taken 12-28-16, https://msefton.wordpress.com/2015/11/27/law-enforcement-mental-health-collaboration/

By the hand of a father’s son

Vermont patricide shows complex impact of veteran’s plight and DVH

WESTBOROUGH, MA  June 12, 2104  The Vermont killing of a veteran warrior this spring brought to light the high price being paid by military veteran’s who returned to civilian life unable to function.  Much has been published about the wait for treatment that many of the most needy veteran’s experience.  As Father’s Day approaches readers are urged to think about this case. It is particularly unsettling because the man’s death came at the hand of his son.  Kryn Miner, 44 was shot and killed by his son after threatening his wife and stating that he was going to kill his family.  Miner threatened his family with a gun a year before his death but the event was never reported to police. The shooting was called a justifiable homicide and no charges were filed against the teenage child who fired the fatal shots.  The child has not been identified out of privacy concerns and by all accounts may have saved the lives of his mother and 3 siblings.  The victim’s wife Amy has spoken out about the plight of veteran’s who are not getting the help they need. “The truth of the matter is if we can’t take care of our veteran’s we shouldn’t be sending them off to war” said Amy Miner.

The victim in this story was a 25 year Army veteran who returned from Afghanistan in 2010 after being deployed 11 times from 2007 to 2010. Miner was a career soldier and was well liked. He was shot 5 times in his Vermont home after threatening his family with a gun and throwing his son a loaded pistol saying “Do you want to play the gun game?” Mr. Miner had served tours of duty in Panama and Iraq as well.  He was suffering from the residual effects of a traumatic brain injury and experienced symptoms of post traumatic stress disorder. He was injured in combat after a blast threw him into a concrete wall. Ironically, after becoming dissatisfied with the V.A., Mr. Miner turned to the Lone Survivor’s Foundation for help and eventually becoming a spokesman for the foundation.  To his credit, Miner was committed to helping veteran’s suffering with emotional and physical symptoms from combat-related PTSD and was receiving treatment himself for this enduring injury.

The Department of Veteran’s Affairs is finding it difficult to manage the influx of veterans in need of care.  Ostensibly, the volume of cases exceeds the resources available at VA hospital and clinics throughout the country.  The Phoenix, AZ regional director has resigned because of the wait listing of patients and the obfuscation that occurred once the facts became known.

The story is one that compels the author to look at the complex interplay of domestic violence, guns, and the ongoing plight of war veteran’s.  The sheer number of men and women returning from the theater of war over the last decade is staggering.  It is estimated that 15 percent of these veteran’s are experiencing PTSD and/or the effects of traumatic brain injury from blast waves and other wounds. Arguably, this number may actually exceed 20-25 percent of all returning war veterans by some accounts.  The case of Mr. Miner is particularly troubling because it involved a history of domestic violence and criminal threatening that was never reported to authorities.  Had it been reported the Miner family may have been helped.

The immeasurable impact of this violence on the family may be reflected in the actions of one of its own – who must now live with the consequence of patricide.  The killing was justified according to the Vermont State Attorney General.  But how can one justify this when so young?  The killing of one’s father is often the manifestation of long felt anger, emotional pain, and in reaction to enduring humiliation.  The motivation in this case is not clear aside from the threat posed by Miner and the child’s immediate defense of a loved one – his mother and siblings.  Just how emotionally equipped this boy is to recover from this remains to be seen.  He will never forget what has happened to him and his family as long as he lives.  Each day this family must experience some loss and recurring trauma inextricably linked to the events of April, 2014.  Some responsibility lies with the victim who issued the threats and was armed with a gun.  He died by the hand of a father’s son that should never have been touched by such things.