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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Police are building bridges and throwing life savers

WESTBOROUGH, MA  – March 30, 2017  Police officers are being trained in crisis intervention techniques across the country and Canada. This training offers plenty of practice role-playing scenarios that come directly off of the call sheets affording a reality-based training opportunity. I recently spent time riding with members of the San Antonio PD mental health unit and have the greatest respect for the officers with whom I rode.  In contrast, some departments regularly have highly trained clinicians riding with officers bringing expertise in mental illness and abnormal behavior across the thin blue line.  It is thought that by sharing knowledge at working with unpredictable, drugged out, psychotic and delusional and angry who police encounter on a daily basis better outcomes may be achieved. No single model is best and all are still in the growing stages of establishing protocols for bringing those most disturbed individuals in from the margins. More and more officers are receiving CIT training every year.

The important part of crisis intervention training comes in the interdisciplinary relationships that are forged in by this methodology. Trust and respect between the police and its citizens builds slowly one person at a time.  Community policing is not a new concept but fiscal priorities often prevent its full implementation.  Just the same, there must be trust and respect between the police and the purveyors of crisis intervention and mental health risk assessment including doctors, nurses, and health care practitioners. This also takes time and training and the shared belief in the model.


“When officers are faced with a deadly situation, when there is a gun pointed at a cop, there is no time to go into mental health measures,” according to Grace Gatpandan, spokesperson for the San Francisco Police Department


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Michael Sefton, Ph.D. in 2017 photograph

The use of force continuum belies each officer contact and guides the process when police are called upon to defuse a dangerous encounter. It is best that a mental health contact be made long before violent threats are made – long before terminal rage erodes personal judgment. The community policing doctrine affords this front end contact and encourages officers to know the people living on the beat.

POLICE ENCOUNTERS WITH MENTALLY ILL CITIZENS

The Boston Globe Spotlight series on police encounters with the mentally ill cites one distraught parent who was quoted “I only wanted the police to disarm him not shoot him dead.” Unfortunately for this family, when faced with lethal violence it is the behavior of the subject that drives the ship in terms of what will or will not happen.  “When faced with a deadly situation, when there is a gun pointed at a cop, there is no time to go into mental health measures”. All too often people fail to see the cause – effect relationship between citizens with guns or other lethal weapons and the police officer response.  The use of force continuum follows the principle of causation by guiding police decision making based on the level of threat.

What came first the threat or the police action?  It is the primary action of the citizen the evokes the lethal response by police.  If citizens dropped weapons and listened to police officer directives during these high energy and chaotic events there would be fewer deaths.  To say they lack training in mental health is preposterous.  Almost as preposterous as saying if they were better parents the mentally ill subject might not aim his gun at police or threaten his mother with a knife.  No, the responsibility lies with the mental decision-making and subsequent behavior of the subject himself.  If mental illness drives the violent behavior than all weapons and substance use must be carefully controlled and eliminated.  When people attend psychotherapy sessions and 12-step recovery programs the proclivity for violence is greatly reduced.  Inevitably, drug abuse is a co-morbid factor that alters perception and fuels underlying anger and violent tendencies.  Who is responsible for this? When drug addition or alcoholism begin – all emotional growth including adult “problem solving” begins to fail until it is fraught with uncontrolled, impulsive violence. Rather than placing blame, greater emphasis on sobriety, counseling and developing emotional resiliency should be encouraged.


Lowery, W. (2015) DISTRAUGHT PEOPLE, DEADLY RESULTS: Officers often lack the training to approach the mentally unstable, experts say. http://www.washingtonpost.com/sf/investigative/2015/06/30/distraught-people-deadly-results/?utm_term=.86e44d33dfab Taken March 5, 2017

What are “collateral consequences” in domestic violence?

WESTBOROUGH, MA March 21, 2017 When working as a police officer I was asked to take the statements of women who were asking for protection from an abusive spouse or intimate partner.  These requests were usually granted by the on-call judge – especially if children were at risk or a history of physical abuse was suspected.  But these orders only last a short time – perhaps a weekend.  In order to have restraining orders extended the victim is expected to go to the district court and swear testimony that specifies the reasons for an order of protection including threats or actual physical harm, forced sexual contact, pathological jealousy – whatever.  Sometimes this happens and protection orders are extended usually for 6 months. During this time the couple is expected to sort out their differences and engage the help of a family therapist, if possible.  This rarely happens.


“Domestic violence is not random and unpredictable. There are red flags that trigger an emotional undulation that bears energy like the movement of tectonic plates beneath the sea.” according to Michael Sefton.  A psychological autopsy should be undertaken to effectively understand the homicide and in doing so contribute to the literature on domestic violence and DVH according to Sefton who with colleagues published the Psychological Autopsy of a case from Dexter, Maine where a father murdered his children, estranged wife and ultimately himself (Allanach, et al, 2011).


More often than not, the victim fails to appear for this process and the protective order goes away without any consequences. Why? In the time between the initial emergency order and the Monday morning when the victim is expected to substantiate her initial claims she may have been bullied by her spouse and worked over by his family, his friends and whomever he can enlist in his camp to get her to let it go. She is made to believe that she cannot function without her abuser.  When children are involved an abusive spouse will usually say that child protective services will take the children for whatever reason he comes up with.  He promises to destroy her credit worthiness, she will be penniless, and he threatens to share lies about her on social media pages for all to see. He may also promise to kill her and cut her to pieces to be used as fish bait – as I have been told in a case being investigated by my former agency. But he swears his love for her always.

This happens over and over.

In some cases the order to extend the restraining order results from elevated risk to the victim and recurring threats of violence. In these cases orders of protection go on for months or years at a time.  This type of bullying is an example of the often secretive coercion that takes place in DV and intimate partner abuse is flagrant and often goes unreported.  It must be considered whenever an initial order is not sustained especially if the victim fails to appear.

In some cases there is more than one order of protection issued to protect one or more intimate partners. This is a red flag and should have bearing on the bail requirements but seldom does. There should be some follow-up with the original complainant by the police department to investigate her reasons for not pursuing the extended order of protection and determine what impact bullying may have played on the victim’s decision.  In rare cases permanent orders are granted because of compelling evidence that the victim and her family remains at risk – usually the result of stalking.

In March 2014, I published a blog in which the Massachusetts Supreme Judicial Court granted a permanent restraining order even though the former spouse was living in Utah and was remarried. In 2014 the Boston Globe did a story on the case written by Martin Valencia essentially raising the spector of the abuser in this case and the current impact the court order has on his day to day life in Utah.

Kevin Caruso was unable to get a job as a youth baseball coach because of a continuing order of protection here in Massachusetts that shows up on his CORI report. He could not own a firearm and was sometimes hassled at airports. The SJC ruled that Kevin Caruso must submit “clear and convincing evidence” that he no longer poses a danger to former girlfriend in a case dating back to 2001.  The Supreme Judicial Court  in Massachusetts has required that Mr. Caruso provide proof that “he has ‘moved on’ from his history of domestic abuse and retaliation”.  It is well-known that male abusers move from one abusive relationship to another.  A colleague Dr. Ron Allanach wrote “In the Caruso case, the Court is proactive, sensing the burden is on the offender rather than the victim; thus, the responsibility for proof that Mr. Caruso has “let it go”, poses no danger to the victim and has done the necessary therapy on his own behavior and to figure strategies to change, rests precisely on the shoulders of the offender where the burden should always remain.” The SJC called the frustration felt by Mr. Caruso the “collateral consequence” of the permanent restraining order put in place initially issued as a result of his threats to kill his former girlfriend.  Time alone and location has no bearing on whether a permanent order is sustained.  No person should live is fear that a former partner is going to appear at her workplace or stand behind her in the line at Starbucks while she thinks about what blend of coffee she might want.

“Substantive decisions about bail or no bail holds will be more reliable by having access to the violent history of domestic violence offenders and the protective orders that have been issued time and time again.” Michael Sefton


Allanach, R. Court is proactive. Personal correspondance. March 2014

Sefton, M. 2014,  https://msefton.wordpress.com/2014/03/11/collateral-consequences-stay-away-orders-that-are-forever/ taken January 21, 2017

Valencia, Milton. SJC rules on Utah man’s permanent restraining order. Boston Globe March 11, 2014, taken March 24, 2017

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

What are immediate signs?

“…there are cases in the literature that identify a pattern of behavior that is observable in the days, months or years preceding these monstrous events that may signal a need for high risk containment”

Taken from Psychological Autopsy of Steven Lake in 2011 presented to Governor’s DV Abuse Board

Allanach et al. 2011

WESTBOROUGH, MA October 31, 2016 People often see signs of imminent violence in the days weeks or months in the lead up to DVH.  As a society, these signs must evoke action on behalf of potential victims. The roadmap to understand domestic violence requires clarity and courage that should not be placed solely in the hand’s of victims.

It is frequent that the abuser tips his hand as to what his intentions might be.  In the Lake homicide-suicide in 2011 in Dexter, Maine, Steven Lake hinted to his son that “the cost of a divorce is 25 cents – the price of one bullet.” Lake also verbalized that when he “did it – it would be on CNN.”

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.

 

 

Intimate Partner Violence

“Despite receiving some mental health counseling, it is apparent, in retrospect that the degree of violence and anger possessed by the abuser was not realized”, according to the chief medical examiner in Maine following the 2011 domestic violence homicide in Dexter, Maine. Red flag behaviors are those that give off clues to the degree of risk posed to victims who have been abused. The abuser in this tragic case exhibited quite typical behaviors that raised the degree of risk to the victim exponentially. Some police officers verbalized a fear for the victim well before she was murdered by her husband.

Police and domestic violence experts need greater understanding of pre-incident behavior and red flags. These factors then become decision points for prosecutors who must decide conditions of release, including bail. The case described in Maine was researched by a team of current and former police officers with experience and training in domestic violence (Allanach,R., Gagan, B. Laughlin, J., Sefton, M. 2011). The findings of this research was published in a report of Psychological Autopsy of the Domestic Violence Homicide in Dexter, Maine submitted to the Domestic Violence Homicide Review Panel in Augusta, Maine in November 2011.