Showing posts with label aggression. Show all posts
Showing posts with label aggression. Show all posts

Friday, January 20, 2023

We Need A Model Terroristic Threat Statute

 


Over the past ten years of writing this blog, I hope that I have been clear about a few things. First, violence and aggression are complicated problems. Most of the political arguments out there today focus on peripheral issues like gun violence. In a country of gun extremists – there will always be excuses for why there is so much gun violence.  A common one is that there are mentally ill people with guns.  Some of the gun extremists have gone so far recently to suggest this is due to a crisis of untreated mental illness. Nothing is further from the truth.

Second, people with mental illness can be violent and aggressive. In political arguments where violence and aggression is being attributed to mental illness it is common to deny it. In a Community Psychiatry seminar 40 years ago – my position was “people with mental illness are no more violent than anyone else.”  My 40 years in the field has taught me that looking at violence across large groups is meaningless. In the acute care setting where I worked many if not most of the patients I treated were there for violence against others or self-directed violence.  Some were aggressive toward me and the staff I worked with – with some threats that persisted well after any hospitalization.

Third, violence and aggression can clearly be treated in many if not most cases, especially if it is a manifestation of acute psychiatric illness. Despite that being common knowledge in acute care settings – there is no effort to characterize it as a public health problem like suicide. There are no public service announcements about what to do if you have violent or aggressive thoughts. No hopeful messages that you do not have to act on any of those thoughts and that you can get help to restore your baseline thought patterns.

Fourth, violence and aggression are stigmatized in society. Most people at some point in their lives have been bullied or traumatized by other forms of aggression. In the US, incidents of extreme violence and aggression are commonplace in the daily news. There is a fascination with true crime television and documentaries about serial killers. The media seems preoccupied with discovering a “motive” for these crimes.  Apart from the usual sociopathic motives of intimidating and injuring people to get what one wants – motives are generally lacking. In fact, I would go so far to say that in the homicide cases broadcast on television the limiting factor was the availability of a firearm. In other words – no homicide would have occurred if a firearm was not present. The resulting stigma toward aggression, leads to biases toward patients with psychiatric illnesses who are violent because of those illnesses.

Fifth, there is a limited rational response to violence and aggression even if a public health response is ruled out. This occurs daily. There has been no clinic or hospital where I have worked where I have observed a well thought out plan to respond to these incidents even though aggression toward health care workers is a current epidemic. There are plenty of errors along the way whenever an incident occurs in the community. I have had patients who were in the cross hairs of a police sniper until somebody noticed they were pointing a toy gun at the police. Anyone in my field has had people who assaulted them, threatened them and their families, and in some cases that aggression has resulted in serious injury or death. The rate of intentional injury by another person is five times greater in the healthcare industry than all other industries and that rate is ten times greater in the psychiatric and substance use fields. With a healthcare system run by administrators rather than physicians – it is not clear why there are no functional approaches at the institutional level. In the case of the community and the hospital the usual approach is to send the person to the emergency department to see what they can do and if necessary, hospitalize them on a psychiatric unit.  By that time, it is common to see people who have been escalating for days or weeks and the necessary interventions are riskier than they would have been at an earlier point.

In thinking about a more functional response there are two problems – epidemiology and existing laws.  From an epidemiological standpoint there are many studies documenting specific forms of violence and how that individual may have been victimized in the past.  A joint Department of Justice (DOJ) and Centers for Disease Control (CDC) report from 2000 estimated that physical assault and stalking affected roughly 2.9 million women and 3.5 million men every year.  Intimate partner violence affected 1.3 million women and 835,000 men. Getting to the earliest point in that cycle of violence from an epidemiological standpoint seems to be missing.  At least I cannot locate any data.

From a legal standpoint, intervening before there is any physical danger is a highly problematic threshold. And if the necessary statutes exist, there is wide latitude in their interpretation by law enforcement and the judicial system. There has been some progress over the past 40 years but not much.  For example, in the past if a person was threatened – it was common for law enforcement to say they could not do anything because the threat has not been acted upon. That was clearly a suboptimal approach because threats involving lethal force often result in the precipitous application of lethal force. In many cases the lack of a firm limit on threatening behavior encouraged more of it. Contingency based systems also have the tendency to put the responsibility for action on people who have no relationship to the person making the threats.  Even though there has been substantial progress in domestic violence scenarios, it is common for the person being threatened to need to seek a court order for protection and convince a judge that threats or actual violence have occurred. In the case of threats by patients with known psychiatric illnesses, the Tarasoff decision has placed the treating professionals in the position of law enforcement with a duty to inform the person who is being threatened. A clear terroristic threat statute could address all of these issues and provide a path for early intervention.

Since most of my career was in the State of Minnesota, I will be referring to their statutes.  Preparing for this piece, I also read a paper from the University of Pennsylvania Law Review (2) highlighting some of the confusion in this area.  Minnesota, if a health care professional is threatened it is a good idea to inform the police about the threats and present them with any hard evidence (voice messages, emails, mailings, etc).  Laws enforcement who I have dealt with in these situations may refer to the threat as a “terroristic threat”. That is defined in Minnesota Statutes (3) as:

Threaten violence; intent to terrorize. Whoever threatens, directly or indirectly, to commit any crime of violence with purpose to terrorize another or to cause evacuation of a building, place of assembly, vehicle or facility of public transportation or otherwise to cause serious public inconvenience, or in a reckless disregard of the risk of causing such terror or inconvenience may be sentenced to imprisonment for not more than five years or to payment of a fine of not more than $10,000, or both.”

I have highlighted the relevant section of the statute. Minnesota legislation appears to cover both the individual case as well as larger scale incidents that would typically be equated with terrorism.  This statute allows law enforcement to exercise some judgment in dealing with threatening individuals.  For example, they can go to that person and say that if they persist, they will be arrested and charged with making terroristic threats. No other action is required by the person being threatened. In many cases that is a definitive intervention and no further action is required.

The paper by Flanders, et al looks at various scenarios that have occurred in the context of the current COVID-19 pandemic.  Their basic argument is that much of the mayhem created during the pandemic would not reach the legal standard of terroristic threats and if charges were required – they could occur under other statutes such as disorderly conduct or harassment. They are using a standard suggested by the American Law Institute Model Penal Code that includes the following:

A person is guilty of a terroristic threat if he threatens to commit any violent felony with the intent to cause evacuation of a building, place of assembly or facility of public transportation, or otherwise to cause serious public inconvenience, or in reckless disregard of the risk of causing such inconvenience.”  (2)

Note the difference with the Minnesota Statute – there is nothing about threatening with intent to terrorize another.  It is more about violent felonies that disrupt the public.  The authors in this case go on to specify the elements of terroristic threats in their “core case” model as consisting of a credible threat, use of a dangerous weapon, targeting the public or government, and the intention to create a panic or forced evacuation (p. 68).  They illustrate how this model statute has been modified and adapted in other states. I am not a legal scholar but to me – the model statute is missing one of the prime elements of terrorism – the intent to kill and injure people. The way it is written seems to make this implicit and secondary to disrupting the public. The public is disrupted because of their fear of being killed or injured. The Minnesota statute covers both cases by including the element of the individual being threatened.

Whether you are a health care professional or a member of the public, this is the level of protection from threats that is needed. Even then there is no guarantee that there will be a successful intervention by law enforcement. The person making the threats needs to be identified and the police need probable cause to intervene.  I have seen it work well even if no arrests or emergency holds are placed. Most importantly it creates clear boundaries between the police, the person being threatened, and the person who is threatening. The responsibility for action is no longer on the person being threatened.

There are also potential benefits in terms of earlier intervention in the case of psychiatric illnesses associated with threatening behavior.  There is a current awareness that crisis intervention services may be a better early option than the police and that may be a better early intervention.  The epidemiology of threats needs additional work.  My speculation is that there are tens of thousands of people who are trying to live every day with these kinds of threats.  They are a disenfranchised group whose needs have only partially been addressed by domestic violence and civil commitment laws.  A more functional terroristic threat statute like the one in Minnesota could result in early intervention and providing significant relief from that stress.

And finally early intervention can provide relief to many of the people I treated in inpatients settings for 22 years.  They were generally suffering from severe psychiatric disorders and substance use problems. I saw most of them recover to the point that they regretted the aggressive and violent behavior and were appreciative of the treatment they received to resolve that problem. It is easy in our society to view these folks as hopeless and as outcasts – but every acute care psychiatrist knows that is nonsense. The first step in making a societal change is to get the message out that violence and aggression can be treatable problems and earlier treatment generally leads to better outcomes.  More functional and comprehensive laws on aggressive behavior are a part of that.

 

George Dawson, MD, DFAPA

 

Supplementary 1:

A better terrorist threat standard also may also serve to improve the likelihood of early firearms interventions.  Just from news reports the main obstacles seem to be a combination of easy gun access, gun extremist rhetoric, the ability to avoid background checks, legal action to defeat any gun access legislation, and extraordinary efforts necessary by law enforcement to restrict gun access to individuals who are either at high risk or proven risk based on their recent behavior. If a person meets a statutory terroristic threat standard - that could trigger red flag laws or laws to block or remove gun access at the local level by statute.


References:

1:  Tjaden P, Thoennes N.  Prevalence, Incidence, and Consequences of Violence Against Women: Findings From the National Violence Against Women Survey, Research in Brief.  Washington, DC: U.S. Department of Justice, National Institute of Justice, 1998, NCJ 172837.

2:  Chad Flanders, Courtney Federico, Eric Harmon & Lucas

Klein, “Terroristic Threats” and COVID-19: A Guide for the Perplexed, 169 U. PA.

L. REV. ONLINE 63 (2020), http://www.pennlawreview.com/online/169-UPa-

L-Rev-Online-63.pdf

 

3:  Various MN Statutes:

 

609.713 THREATS OF VIOLENCE.

https://www.revisor.mn.gov/statutes/cite/609.713

 

609.79 OBSCENE OR HARASSING TELEPHONE CALLS

https://www.revisor.mn.gov/statutes/cite/609.79

 

609.795 LETTER, TELEGRAM, OR PACKAGE; OPENING; HARASSMENT

https://www.revisor.mn.gov/statutes/cite/609.795

 

609.749 HARASSMENT; STALKING; PENALTIES

https://www.revisor.mn.gov/statutes/2022/cite/609.749

 

Graphics Credit:  Tim McAteer, CC BY-SA 3.0 <https://creativecommons.org/licenses/by-sa/3.0>, via Wikimedia Commons.  Page URL:  https://commons.wikimedia.org/wiki/File:SWAT_team.jpg


Friday, May 11, 2018

A Psychiatric Perspective on Beatdowns









My opinion on this is probably long overdue.

A beatdown is popular vernacular for beating someone mercilessly - often into an unconscious state. From the video I have seen of these scenarios - it is at least implicit that the person had done something to "deserve" the beatdown.  The best source of this video materiel is TMZ.com that follows the hip hop culture more closely than most mainstream television.  In watching those videos it is apparent that even the wealthiest and most influential celebrities are not averse to being affiliated with these activities, encouraging them, or even commenting on them.  Any casual observation of what happens during a beatdown illustrates that it is a situation with a very high likelihood of serious injury or death to the person who is being assaulted.

Take for example this TMZ clip entitled Cardi B Security Accused of Post-Met Gala Beatdown.  You see two young men punching a man who is on his back on the ground.  They are punching him rapidly and repeatedly.  When they finish another man runs in and kicks the victim as hard as he can while the victim is still laying defenseless on the ground.  I listened to the TMZ pundits analyze the situation.  One of those pundits is Harvey Levin who is the co-host and is also an attorney.  The consensus seemed to be that nobody had any problem with this man being repeatedly punched by two men when he was paying defenseless on the ground.  Only Harvey Levin thought that the kick was a little extreme and could result in legal charges.

The very first assault case that I was involved in occurred at a University Hospital outpatient clinic.  I was on the consult team and the clinic called to say that they had detained an outpatient who assaulted one of their clerical staff.  When she wasn't looking the patient hit her over the head with a cane as hard as he could.  I went down to assess the patient.  He was very calm and had no evidence of major psychiatric disorder.  He explained that he got impatient because the receptionist was not working fast enough and that was why he struck her. He had absolutely no remorse for injuring her. He minimized the potential for injury by hitting someone over the head with a relatively heavy object when they were not expecting to be hit.  He used the familiar rationalization: "If she didn't want to get hit she should have worked a little faster."  He was not intoxicated at the time.  I discussed the case with my attending and we both agreed that there was no psychiatric disorder and no reason why he should not go to jail to be charged for assault.

My attending psychiatrists at the time always tended to analyze the aggression. Punching or kicking someone when they were unable to protect themselves was viewed as a particularly negative sign and an event more commonly seen in antisocial individuals.  It led me to reflect on people I had known in my peer group who had been killed in fights.  One guy I played sports with who went away to college and ended up getting in a brawl at a large college bar.  He was apparently kicked in the side when he was on the ground. He went back to his dorm room and died that night of a ruptured spleen.  In another fight resulting in a kick to the head - that student went home and expired from a cerebral hemorrhage.  Both students were very bright, full of promise, well-liked and had no history of aggressive behavior but they were killed by blows that are commonly observed in movies and television shows. There are thousands of men incarcerated in this country for punching or kicking someone in a fight and killing them.  I can almost guarantee that at some point in their court proceeding somebody said: "I did not believe that hitting him that way could kill him."

There are mitigating factors in some of these situations.  Psychiatric disorders usually are not.  Personality disorders and intoxicated states are but not from a legal standpoint. Being intoxicated or a sociopath is not a defense in the American legal system.  The best chance to beat the charge is to appeal to sub-cultural mores: "Boys will be boys - it was just a fight gone bad and somebody died.  Nobody is to blame here!"  Or claim it was an accident or there was no intent to do harm.  In both of the cases I was personally aware of there was no case in one and in the other charges were dismissed by the court even though the victim in the case never threw a punch or acted in an aggressive manner.  American law is highly subjective and it is not likely that these cases can be decided in a consistent or necessarily rational manner. 

A medical and psychiatric perspective allows a different analysis.  The human brain has a gel like consistency and it floats inside the skull in cerebrospinal fluid. Any sudden force applied to the skull leads to a shock wave that is initially dispersed as the brain impacts the inside of the skull where the forces was applied (coup injury)  and then when the brain rebounds and strikes the opposite inside area of the skull (contre coupe injury).  Which each violent movement thousands of axons are sheared off in the white matter adjacent to cortical areas.  Some forces shear veins and even arteries that can lead to very rapid death if not treated.  Treatment may consist of neurosurgery that requires opening the skull to remove large blood clots and repair blood vessels.  In extreme cases a piece of bone needs to be removed and stored to allow for the expansion of brain swelling to reduce the chances of death.   Lesser forces lead to more persistent cognitive, personality, and neurological changes.  From a strictly medical perspective - given the amount of damage, morbidity, and mortality that a beatdown can cause it is obviously not a good idea to engage in this kind of activity.  Even widely approved activities like football and boxing can lead to brain damage and death from severe brain  injuries.

I have seen plenty of the victims in clinical practice.  People whose lives has been altered by being exposed to this kind of violence.  Traumatic brain injuries, cognitive disabilities, and post traumatic stress disorder.  Careers and marriages lost from these effects. 

From a psychiatric standpoint, the only acceptable reasons for using force against another are self-defense and stepping in to assist a person who cannot defend themselves.  The latter situation can be difficult to assess and personal safety is always a priority. Those criteria rule out a lot of common altercations based on insults or taunts.  If that happens -  the safest solution is to walk away.  These criteria also rule out violence and aggression as a solution to problems.  If that is an issue, find help for anger control and problems with aggression.  The criteria rule out intoxicants as a reason for using physical force.  If that happened repeatedly with alcohol or drug induced intoxication states - get help with the drug or alcohol problem.  Even self defense may not be an adequate excuse for becoming aggressive and injuring or killing someone.  If you are bigger, stronger, a better fighter, or armed and you can easily handle the aggressor - killing or injuring them might make a self defense strategy less likely to succeed.  The initial example would appear to be a case in point.  Two men on top of the man vigorously punching him at the outset of this clip for pursuing an autograph would violate the acceptable reasons. The next man kicking him is far worse if these blows resulted in significant injury. It is tempting to put these situations in a legal framework - an individual's conscious state is probably more applicable. If you kill or permanently disable someone as the aggressor in one of these situations your conscious state is permanently altered.  You have become a person who is capable of excessive violence and that is remembered the rest of your life. Your entire moral development up until the time of that incident is called into question.  Guilt, shame, doubt, and regret become a major part of your life.

Age is certainly a factor in these situations. I have not seen any statistics but most of the protagonists seem to be in their 20s and 30s.  That is not universal.  I have seen many videos of older assailants beating the elderly or assaulting people randomly on the street.  The vigor, poor judgment, problematic peer pressure, and excessive use of intoxicants make this demographic group the likely perpetrators of beatdowns.

If you like my standard spread the word. There should be no beatdowns of any kind.  They endanger lives, lead to disability, and and can have far ranging effects for perpetrators and victim - both physically and  psychologically. They are unnecessary in what are typically nuisance situations where there are better ways to resolve the problem, including just walking away.

Beatdowns can kill people. They are a throwback to ancient civilizations when conflicts were resolved by violence and the object was to kill all of the adjacent tribes members.  The toll is great and the next time somebody asks you if someone "deserved a beatdown" - let them know that nobody does.

And let them know that two or three people hitting someone when they are down and vulnerable is unconscionable.       



George Dawson, MD, DFAPA

Tuesday, July 18, 2017

The Anarchist Cookbook




I am a child of the 1970s and I am still trying to figure out what happened back then.  Most people think that the history has already written, but that is not what generally happens in the USA.  The real history isn't typically written until after the major players are dead.  Usually until they are dead for a long time.  It was in that spirit that I watched a Netflix documentary about William Powell a few days ago.

William Powell wrote The Anarchist Cookbook in the 1970s when he was 19 years old.  In the documentary that single act was a thorn in his side for practically all of his adult life.  The documentary is set in the home of Powell and his wife Ochan Powell.  Ochan participated in the interviews.  They were living in France and Powell had no inclination to return to the USA but his wife did.  The interviewer asks Powell about his early life, the writing of the book, how his authorship had plagues him at times in his life, his knowledge about how it had been used and whether or not he had any regrets. Powell is introspective to a fault.  In many cases it is clear that he is trying to find the correct words and I think it is natural to speculate about whether or not he is being defensive.  He is confronted by the interviewer who is asking him tough questions about widely known incidents like terrorism and school shootings where someone happened to find a copy of the Cookbook in possession of the perpetrator(s).  The New York Times obituary is a summary of the Netflix documentary.  Please read that to determine if you want to see the film. I will focus on a few points in it that were under emphasized.

The depiction of his early life, emphasizes a pathway to alienation.  A Long Island born boy goes to England due to his father's occupation where he is viewed as an outsider.  The family then returns to the US where he is viewed again as an outsider and mocked for having a British accent.  He is sent to boarding school where he is molested by a teacher and at that point leaves and goes to New York City where he decides to write the Cookbook.  In journalistic (and documentary) style these conditions are all presented as sufficient for him to write this document.  I think an argument can easily be made that a large number of boys and men are alienated from society for various reasons and they eventually find a way to join the rest of the herd.  I would not find it too surprising that at some level it is related to brain maturation processes that we now know extend into the 20s.  There is another group of boys and men who are fascinated with weapons and explosives.  The vast majority of these boys are not dangerous in any way to other people.  Some of them are dangerous to themselves and end up getting killed or disabled by some of their experiments with explosives or setting up explosions.

Powell's description of how he wrote the Cookbook, by going to a public library and sitting in the military section that contained all of the material he needed is totally plausible.  I have some of these very books in my library and they were purchased off of Amazon.  As early as elementary school, I was being taught to use the Encyclopedia to write reports and a good deal of technical information was available in those general volumes.  You could find the general recipes for gunpowder, nitroglycerin, and even a detailed drawing of the inner workings of an atomic bomb.  All of this material was openly available in 1960s Encyclopedias.  Powell makes this argument a couple of times in the documentary as well as the disclaimer in the Cookbook that what he is presenting is general information.  At no point does he or the interviewer touch on the notion that putting generally available information into the political context of anarchism and revolution, although the interviewer does consistently push for some level of accountability.

At some point in his early life Powell found a calling - teaching emotionally and developmentally delayed children and teaching teachers about how to engage those children. There seemed to be a brief thread about how some of the school shooters may have had these problems.  In the course of his career he was boycotted for various positions when parents discovered that he had written the Cookbook.  He described a scenario where there was some initial concern and he e-mailed every parent to let them know that he had written the manual and was willing to answer any questions about it.  They did not have any additional questions.  During some of the interviews, his wife commented that he went through difficult times because of his association with the Cookbook.  Like most documentaries, editorial license is involved.  In the final shot Powell is asked a questions about some of the parallels between his life and some of the alienated people who read his book.  The scene fades at that point and we never hear his response.  I am sure that he had one.  The final announcement was that he died unexpectedly on July 11, 2016.

The central point of the documentary from the interviewer's standpoint was the effect that knowing the book was found in the possession of some infamous perpetrators of violence had on him and whether he felt he had any responsibility.  He was very clear that he was responsible for writing the book but not how people used it.  He acknowledged that he did feel badly about these associations and it did cause him to try to take action to get it removed from print.  On Amazon, he has published a detailed letter about how he came to write the book and the fact that he no longer believes that violence is an acceptable way to cause political change.  He refers to it as a "misguided and potentially dangerous publication which should be taken out of print" after discussing how he attempted to get his original publisher to take it out of print.  He also wrote a detailed letter to the Guardian on December 13, 2013 that was apologetic requested that the book go out of print and that is available on their web site.    

In the end I was left with the impression that William Powell had done something that he regretted at age 19 and spent the rest of his life trying to make up for it.  Unlike those of us who made similar mistakes, he was able to find a publisher that resulted in his big mistake being put into print.  If I look back on those times, revolutionary rhetoric was commonplace and only rarely acted upon.  Rebellious youth found no level of public support for a wide scale revolt.  Most Americans then as now just want to put in a day of work and go home to their families.  The other interesting aspect of trying to hold an adult man far removed from his rebellious teenage years accountable for that person is that it is developmentally incorrect.  At a wider philosophical level, much more dangerous information is now available both in books and over the Internet.  Anyone still reading the Anarchist Cookbook has not done much research.

For me the developmental questions always linger.  Why the fascination with explosives and violence?  It seems to be an area that is consistently ignored.



George Dawson, MD, DFAPA




References:

1:  American Anarchist. Netflix documentary: https://www.netflix.com/title/80143794

2:  Richard Sandomir.  William Powell "Anarchist Cookbook" Writer Dies at 66.  New York Times March 29, 2017.



Friday, May 19, 2017

Luncheon Consensus - Management Continues To Do Nothing About Hospital Violence






I had lunch last weekend with staff from several psychiatric facilities in the Twin Cities.  The group included nurses, nurse practitioners, and health unit coordinators.  Many of them were at the retirement party that I described a couple of years ago.  At one point in time we all worked on the same inpatient unit and that was the common bond.  Over the several hour long lunch the discussion gravitated to one of our favorite topics - violence and aggression in hospitals against medical and nursing staff.  There was the usual litany of injuries - concussions, a stabbing, beatings, and musculoskeletal injuries.  At one point I heard how a staff nurse in her fifties with knee replacement surgery and back problems had to interject herself between a patient she was admitting and a violent and aggressive person who walked in off the street.  In that situation she had to hope that security got there in time to protect her.  I listened to another nurse tell me how the assault charges were determined after she was assaulted - first degree assault only because she had a concussion.  The other forms of being punched and kicked that she sustained that day were all lesser forms of assault.  I also heard how some members of the hospital administration minimized the incident and how her assailant eventually was not charged with anything.

This is one of many areas where the army of health care administrators really don't seem to be able to do anything productive.  Every hospital in the country has posted non-discrimination policies.  They discuss how every patient will be treated respectfully.  These same rules do not apply to their own staff.  When staff are assaulted there is a common belief that it is an occupational hazard.  It is all part of the job.  The other crucial part of the problem occurs at the committee level in higher levels of administration.  When ever there is a potential problem resulting in injury, a standard administrative strategy is to move it to a committee or Task Force.  That is where real problems occur because there is no expertise on the committee in assessing and resolving problems with violence in medical settings.  That lack of expertise is common.  A corollary is that administrators are in the position that they do not believe that they can defer to clinical staff with much more expertise because of the chain of command.  That is a recipe for inaction and manipulation.  If a staff person brings up a concern that the administrators can't solve - the issue is tabled or the person is not asked to come back.  Even more problematic, some administrators embark on their own ideas about how to solve the problem.  I have listed some instances of this happening on this blog that have resulted in more staff injuries.  A final strategy is to bring in consultants.  I have seen situations where expensive business consultants are brought in to either tell the staff that their patients are not any more aggressive than the patients seen in other hospitals in the state.  If that doesn't work - bring in a consultant who will try to demonstrate that he or she knows more than the current staff.  Both administrative strategies fall flat when the staff is dealing with some of the more significant problems with aggression in the state and they have the most experienced clinicians.

No - the violent outbreaks that are described in most hospitals are the result of administrative failures at several levels.  A failure to recognize the issue exists.  A failure to recognize that your staff has the expertise to deal with it.  A failure to recognize that aggression toward the staff is not the result of staff failing to treat people in a particular way or due to a deficiency of the staff person.  And most of all - a failure to facilitate a team approach among the staff in the hospital or clinic with the most expertise.  It is really that easy.

In our discussion, several instances of these manipulative responses to hospital violence were noted.  Even very basic requests for additional security staff and to prevent aggressive people from walking in off the street are ignored.  There is no shortage of meetings and I have participated in many.  One of the administrative strategies is blaming physicians for the problem.  There is nothing like having a dedicated and skilled staff with as much expertise as can be found anywhere - suddenly being blamed for the problem.  In some of these situations the administrators bring in "consultants" to tell senior clinics who have been treating the problem for 20 years.  I am speculating that is right out of "Power Plays 101" in administrator school.  It is not difficult to see how all of this administrative drama and expense fails to solve the problem.  In most cases it ends up looking like nobody is even trying.  A scapegoat has been found - let's leave it at that.

There has been a laudable effort by nurses.  In my home state, the Minnesota Nurses Association (MNA) has been very vocal in terms of the number of aggressive incidents toward nurses in Minnesota hospitals very year.  A 2004 study showed that that nurses were physically assaulted at a rate of 13.2 assaults per 100 persons per year.  17% of nurses were threatened and 34% were verbally abused in the preceding 12 months of the study.  The MNA has also been active to get legislation to legally protect nurses from aggression and assault.  This link to their proposal does not indicate whether either of their proposals have been successful.  

It appears that there are no comparable efforts by the state psychiatric association or medical association.  I am sure that if this luncheon group meets again, there will be reports of further injuries and a continued lack of response to the violence and aggression toward health care workers.

It probably makes sense in terms of the American inertia in dealing with violence and aggression in general.  But it also makes sense because health care administrators really don't do anything to support clinicians or improve the environment where they work.

Replacing all of those administrators is the best place to start.



George Dawson, MD, DFAPA              


References:

1:  Phillips JP. Workplace Violence against Health Care Workers in the United States. N Engl J Med. 2016 Apr 28;374(17):1661-9. doi: 10.1056/NEJMra1501998. Review. PubMed PMID: 27119238.

2: Nachreiner NM, Gerberich SG, McGovern PM, Church TR, Hansen HE, Geisser MS,Ryan AD. Relation between policies and work related assault: Minnesota Nurses' Study. Occup Environ Med. 2005 Oct;62(10):675-81. PubMed PMID: 16169912; PubMed Central PMCID: PMC1740877.

3: Gerberich SG, Church TR, McGovern PM, Hansen HE, Nachreiner NM, Geisser MS, Ryan AD, Mongin SJ, Watt GD. An epidemiological study of the magnitude and consequences of work related violence: the Minnesota Nurses' Study. Occup Environ Med. 2004 Jun;61(6):495-503. PubMed PMID: 15150388; PubMed Central PMCID: PMC1763639



Supplemental:

Aggression and violence and their prevention is one of my interests on this blog.  A sampling of posts can be found at this link or by selecting any of the links from the right margin.






Saturday, July 16, 2016

What Is Missing From The Divisiveness Debate?



Migratory routes of Homo heidelbergensis from East African origins (numbers are approximate years in past) - see attribution for reference.  Homo heidelbergensis is thought to be the common ancestor for Neanderthals, Denisovans, and modern humans - Homo sapiens.


The recent high profile incidents involving the shooting deaths of young black men and police officers and the associated news coverage and involvement by high profile celebrities and politicians has sparked a social activism, debate, and dialogue.  Like any complex issue, there are people who have opinions that mirror their political party lines, people who have their own opinions and they are not interested in changing them and people who are more open to a dialogue.  Practically all of the dialogue seems focused on high risk incidents that happen in a matter of seconds that involve deadly force.  I have seen some neuroscientific ponderings about how unconscious or implicit biases can affect those split second decisions.  I thought that was possible until I went to the web site and took the tests involving implicit bias.  There was not a single case where I could not predict the outcome ahead of time based on what I already know about myself.  To me it appeared that unconscious bias was not operating in the decision.  Since I am a white psychiatrist and not a police officer, I am not going to suggest specific solutions for police officers or the black community.  I do see a number of scientific dimensions that nobody or very few people are talking about so it is time to add my two cents:

1.  We are all from Africa -

Practically all of the debate centers on race.  There are statistical studies that show black drivers are stopped at higher rates than white drivers.  There are more white people killed by the police but as a proportion of the population black people are overrepresented.  The numbers are real and require serious analysis, but the larger picture is ignored.  That larger picture is that race is a social and cultural convention and not a scientific one.  On a scientific basis, everyone in the world - all human beings originated in East Africa about 200,000 years ago.  At some point, different races were described but at the time this genetic evidence was unknown.  The genetic evidence for racial and ethnic differences is still an area of active investigation.  Those studies illustrate the difference in skin color for example may come down to mutations in two genes (1, 2).  At the proteomic level, a recent study (3) looked at an analysis of interindividual variation in the total number of proteins that could be identified in cerebrospinal fluid (CSF) and urine and found considerable variation between individuals.  There was a 26% difference across 968 urinary proteins and a 18% difference for 512 CSF proteins.  Those numbers are very large compared with the difference between 1 or 2 skin proteins.

Although the total number of proteins identified in the human proteins is 10,500, estimate of the true size has varied from 10,000 to several billion (4) making the number of proteins responsible for skin color differences even less significant.  More skin specific information is available from the Human Protein Atlas.  Their analysis shows that there are 95 skin enriched genes and 412 genes with enhanced expression in the skin.  Only three of these genes MLANA, DCT, and TYR involve melanin synthesis or skin pigmentation.  Person to person variation on an arbitrary racial classification based on skin color is obscured by the expected genetic variation among members of the same race.

Further evidence is available to anyone by sending their DNA for analysis by the National Geographic Genographic Project.  You will receive a map of how your ancestors migrated from East Africa and information about marker that you share with other ethnic groups across the world.  The analysis will also include information about DNA that you share with ancient humans specifically Neanderthals and Denisovans.  The current project also estimates regional ancestry based on markers that appeared over time if migration from Africa occurred.  All of these science considerations should point to the fact that what we have generally considered to be racial boundaries may have political and cultural meaning to people - but there is no scientific meaning.  Every human being on the planet is descended from a small group of ancestors in East Africa.  Time to put the cultural and political stereotypes about race behind us.        

2.  Every person in the world has a unique conscious state -

One of the concepts that I am careful to mention whenever I am discussing aspects of psychiatric diagnosis is human consciousness.  From a neurobiological perspective the human brain has evolved to be a very efficient information processor.   Plasticity leads to experience dependent changes in the brain.  Experience can have a biasing effect of the general form that "my experience is everyone's experience" or "my experience is more valuable than anyone else's experience" or in the extreme case "my experience is the only one that counts."  Fortunately the human brain also has top-down controls like empathy, the ability to recognize that other unique conscious states exist, and the ability to correct its own erroneous biases.  Just the fact that every person on earth has a unique conscious state has significant ethical and moral implications for how one person interacts with another.  Those individual ethical imperatives are seriously watered down by political and legal limits that often target the lowest common denominator.    

3.  Anger has a predictable biasing effect -

Let me start off by saying that this paragraph is not meant to discount anyone's anger.  Anger is a universal human emotion, but the analysis of anger usually stops at the point of whether it is justified or not.  The analysis seldom looks at how anger biases subsequent decisions or how it might affect the initial encounter between the police and suspects.  Any student of social media can observe the very predictable polarizing arguments that occur following these incidents.  Partisans will frequently post arguments and counterarguments followed by statistics and counter statistics.  In many cases the arguments are rhetorical at at some level fallacious.  The dynamic driving these arguments is never mentioned and that dynamic is anger.  Anger has been studied by cognitive scientists and it functions to squarely focus blame on a specific person whether that is accurate or not.  This is as important for the police officer on the scene as it is for the secondary clashes between protesters, the public and the police.  When police officers confront a suspect and start swearing angrily at him/her to comply with their demands - that may be part of their training, it may be something that happens spontaneously, but in either case any real anger on the part of the officer implies that the subject has done something wrong and that the officer's decision-making capacity may be affected by his/her emotional state.  Emotions are critical in human decisions, but not all emotions result in a focus on another person as a source of wrongdoing.  

4.  Human reaction time is a limiting factor - 

The human nervous system takes time to process information.  There is surprisingly little public data available on how much time there is to make a decision to shoot an armed suspect.  The only study I could find (6) involved a simulation where an untrained armed suspect was either holding a handgun to his own head because he was allegedly suicidal or holding a handgun at his side when confronted by a police officer.  In the case where the suspect decides to fire a shot at the officer instead - it took an average of 380 msec.  Highly trained officers shot in 390 msec.  That translated to inexperienced suspects shooting first or tying the officers in 60% of the scenarios.  An interesting article in the literature also suggests that shooting errors in high threat situations persist even after weeks of practicing these scenarios (7).  For comparison, this web site allows for a determination of reaction time in a scenario that is completely free from distractions and noise - like anxiety and trying to determine if what the suspect is holding is really a firearm or not.  It is obvious that these decisions to fire by both officers and armed suspects are not like they are portrayed in television programs and films.  In real life there are no prolonged standoffs with officers and suspects pointing firearms at one another while they talk.    


5.  Human beings have a long history of solving difficult problems through violence and aggression -

One of the major lessons of human history is that lives matter only up to a point and if nobody agrees at that point - people will die.  In human history there are very few exceptions to that concept.  The best analysis of the situation that I have seen comes from anthropology (8) and the detailed study of modern and ancient warfare.  Several authors have written about the attractiveness of war to some of the participants - most prominent Chris Hodges (9).  The powerful combination of war and winning a conflict by force and being reinforced by the secondary aspects of camaraderie, teamwork, meaningfulness, and the political illusions of what an armed conflict can accomplish are all powerful incentives to avoid peace and conflict resolution.  The last time there was as serious peace movement in the USA it was largely a reaction to a prolonged and unnecessary war in Vietnam.  Since then there have been three unnecessary wars and no corresponding peace movements.

The war metaphor doesn't stop at the level of nations fighting nations.  At the next level it is always local governments and police departments fighting drug dealers, gangs, terrorists and various criminals.  I don't think that the reinforcers that occur at a global level stop just because the conflict is at a local level.  Americans in general want to see the bad guys stopped in any way possible.  With that attitude there are invariably serious mistakes.    


6.  Widespread availability of firearms ups the ante -

I have written about firearm related issues in many places on this blog.  My primary focus have been to suggest that violence, especially firearm related deaths including suicide, homicide, and mass shootings can probably be stopped by public health measures.  Very few people agree on those points and there are various political reasons why they do not.  Stopping firearm related violence does not necessarily require addressing firearms availability, but make no mistake about it - firearms access rather than mental illness is the number one cause of these deaths.  The problem with high risk scenarios involving either firearms or the threat of firearms with the police is even more obvious.  Statistics are available for the number of people killed by the police in a number of countries and the numbers are skewed in the expected manner toward the US.  It is clear that widespread availability of firearms is dangerous for both the police and the people who are being policed.  A lot of that comes down to being able to assess the threat and react in less than a half second.  That is the time a police officer has in a high threat scenario.

The six dimensions I briefly described are critical but unmentioned in the current debate.  The current debate is framed in terms of race, immutable interracial relationships, and a lack of scientific consideration at several levels.  At the cultural level, the notion of race having some specific meaning needs to be put to rest forever.  There is no scientific basis for classifying people based on skin color or other so-called racial characteristics.  Racial diversity is nothing compared with genetic diversity and that needs to be the new standard.  The second scientific consideration is based on the unique conscious state of humans.  This important concept should form the basis for everyone being treated with respect and consideration.  That is not to say that will preclude criminal conduct or violent acts against bystanders, but it should be a standard for everyone else.  The expression of anger especially sustained anger has a particular biasing effect that is never mentioned.  We hear that anger is appropriate or justified, and therefore it should be expected.  Appropriate, justified and expected anger still affects human decision making in a predictable way.  The angry - no matter who they are need to realize that they may not be seeing things clearly due to the predictable and biasing effects of that emotion.  The technical aspects of human reaction time and the fact that decision making in high threat situations does not improve - even with training is a sobering fact that all police officers need to deal with.  Given the quoted statistics, in high threat situations when a subject is armed - the outcome of that confrontation will essentially be a coin toss.  The only logical approach to the situation is to design a new situation where it does not come down to reaction time and every officer knowing they have a 50:50 chance of being able to shoot first.  There is an innate human tendency for conflict resolution by aggression and choosing sides on how that plays out is not the best way to resolve the problem.  All that I have seen in social media and the press highlights a string of arguments designed to support one side or the other.

Considering the science behind this problem will lead to permanent, long term solutions.          



George Dawson, MD, DFAPA


References:

1: Murase D, Hachiya A, Fullenkamp R, Beck A, Moriwaki S, Hase T, Takema Y, Manga P. Variation in Hsp70-1A Expression Contributes to Skin Color Diversity. J Invest Dermatol. 2016 Apr 16. pii: S0022-202X(16)31047-8. doi: 10.1016/j.jid.2016.03.038. [Epub ahead of print] PubMed PMID: 27094592.

2: Yoshida-Amano Y, Hachiya A, Ohuchi A, Kobinger GP, Kitahara T, Takema Y,Fukuda M. Essential role of RAB27A in determining constitutive human skin color. PLoS One. 2012;7(7):e41160. doi: 10.1371/journal.pone.0041160. Epub 2012 Jul 23. PubMed PMID: 22844437; PubMed Central PMCID: PMC3402535.

3: Guo Z, Zhang Y, Zou L, et al. A Proteomic Analysis of Individual and Gender Variations in Normal Human Urine and Cerebrospinal Fluid Using iTRAQ Quantification. Pendyala G, ed. PLoS ONE. 2015;10(7):e0133270. doi:10.1371/journal.pone.0133270.

4:  Elena A. Ponomarenko, Ekaterina V. Poverennaya, Ekaterina V. Ilgisonis, et al., “The Size of the Human Proteome: The Width and Depth,” International Journal of Analytical Chemistry, vol. 2016, Article ID 7436849, 6 pages, 2016. doi:10.1155/2016/7436849.

5:  Skin specific proteome.  The Human Protein Atlas.  Accessed on 7/16/2016.

6:  Blair JP, Pollock J, Montague D, Nichols T, Curnutt J, Burns D.  Reasonableness and reaction time.  Police Quarterly Dec 2011; 14: 323-343 (especially pages 15-20).

7:  Nieuwenhuys A, Savelsbergh GJ, Oudejans RR. Persistence of threat-induced errors in police officers' shooting decisions. Appl Ergon. 2015 May;48:263-72. doi: 10.1016/j.apergo.2014.12.006. Epub 2015 Jan 16. PubMed PMID: 25683553.

8:  Lawrence H. Keeley. War Before Civilization. Oxford University Press, 1997.

9:  Chris Hodges.  War Is A Force That Gives Us Meaning. Public Affairs, New York, New York, 2002.


Attributions:

Attribution:  Graphic at the top is by Altaileopard SVG by Magasjukur2 [CC BY-SA 2.5 (http://creativecommons.org/licenses/by-sa/2.5)], via Wikimedia Commons at: https://upload.wikimedia.org/wikipedia/commons/4/41/Spreading_homo_sapiens.svg

Sunday, February 14, 2016

A Real Case Of Psychosis And What Can Happen




Public radio continues to be a rich source of information when it comes to real life psychiatric problems.  In this case the NY Times was also involved.  Considering the date the story was filed the usual critics have not chimed in yet.  They may not be able to since no psychiatrist or psychiatric medication was involved in the care of this patient - and it shows.  There is no more compelling story that psychiatric disorders exist, are severe, and for various reasons can end catastrophically.  I won't  belabor the point that I have treated hundreds of people with very similar problems.  For 22 years, I treated people with severe psychiatric disorders and most of them had psychotic disorders.  The episode of psychosis described in this story is the kind of psychosis that psychiatrists treat, not the vague symptoms described in a recent paper that suggested that some symptoms of psychosis are a normal experience.

Before I get into a brief discussion of the scenario, I would like to acknowledge the patient Alan Pean for sharing his story.  I heard his story on This American Life and the host Ira Glass was explicit that Mr. Pean  had signed a release of information so that the hospital records and a 50 page report of the incident could be used to construct what had happened. His family members were also available for the interview.  In this age where health care companies view patient information as proprietary corporate information I applaud Mr. Pean's decision to make this very personal private information public.   There are numerous lessons to be learned from this incident that I hope to make explicit  at the end of this post.

For anyone interested in listening to the audio version of this story go to the This American Life web site and look up episode 579 My Damn Mind.  This amazing story begins after Mr. Pean has been shot in the chest and is bleeding to death on the floor of his hospital room.  There is blood  everywhere on the floor and people entering the room have to put on shoe covers.  Later in the story we learn that he lost about 1/3 of his total blood volume.  A trauma surgeon is demanding that the police take the handcuffs of Mr. Pean because even though he is shot and immobile, he is handcuffed lying on the floor.  According to the Centers For Medicaid and Medicare (CMS) report he was trying to get up after he was shot and saying that he was "Superman". From there,  Ira Glass starts to interview Mr.  Pean about the 20 hours prior to this incident.  He describes being anxious and at times panicky.  He was sleeping 4 hours per night and recognized he was manic from his past experiences in 2008 and 2009.  He was diagnosed with possible bipolar disorder treated with medication and had no further episodes in 6 years.  He was trying to unwind by playing a video game online with his friends.  He started to think that the video game controller had been reprogrammed by the enemy and was switching on a processor inside of him.  He could not logon to the game because he knew that drones would triangulate on him if he did and destroy his apartment.  He called his brother for advice.  His brother told him to lay down and put cold water on his face.  He concluded that his circuits were overheating like a robot and his brother knew this.  At one point he knew he had to escape from his third floor apartment balcony because snipers were closing in on him.   As he looked down he thought remember your training - you are trained for this.  At that point Ira Glass jokes with him about that point and they both laugh.  He of course had no training and it was apparent to me that Glass had not talked with many delusional people.  Pean executes a perfect drop to the second floor balcony and grabs the railing.  From there he notices two air conditioning units on the ground swings past then and jumps.  He hits the ground running for his car because he has called in a drone strike in his apartment building using Google Maps.  He jumps in his car and heads out of the parking lot.  When the gate doesn't open he rams it until it opens.  At this point he is thinking that his rendezvous point is the hospital.  In a moment of clarity he also realizes that he needs Geodon, the medication that he takes for psychosis.  He feels like he is a bionic person or a cyborg driving the car at a high rate of speed toward the hospital.  As he approaches, he loses control and hits several autos and the hospital building totaling out his car.  An EMT sees the crash. puts him on a gurney and wheels him into the Emergency Department.

This entire sequence of events was driven by delusions.  In the narrative Pean described an intense fear for his life and the fact that his "adrenaline was pumping" at times.  That combination of emotion, especially high anxiety and delusional thinking can lead to impulsive behavior and a lack of typically rational decision-making.  It is an example of "dangerousness" or the emergency criteria that governs whether a patient with psychiatric problems is offered inpatient treatment or not.  The problem is that Pean's actions are all internally consistent with his delusional state.  He talks with his brother on the phone and does not mention that he thinks he is delusional.  In this state of mind, it is very likely that anyone assessing him for "dangerousness" would seriously underestimate what he was capable of.  A lot of his acts are also environmentally determined.  His delusional biases interpret the information as he sees it.  When he was speeding toward the hospital, he was convinced that some of the buildings he was passing were going to explode at any minute.  Despite the non-psychiatric interview, I think the emotion driving the delusionally based decisions is apparent.  Ira Glass points out that the narrative though irrational is internally consistent like a movie and not what he expected.

Pean is eventually admitted to the trauma surgery service for further observation of injuries from the car crash.  There was ample information that he had a significant psychiatric disorder including direct statements from his father who is a physician.  He is noted to be disoriented and believes that it is 1989.  His speech at time is incoherent, but the staff observe him to be lucid at times.  Immediately prior to the incident, several staff report the patient coming out of his room into the hallway either nude or partially clothed.  He had to be redirected back into his room and asked to put a gown back on.  He was dancing and in some cases danced away from staff trying to help him into the gown.  With his history (and assuming that brain trauma has been ruled out) these can all be features of a severe psychosis.  His parents are concerned that they plan to discharge him without psychiatric consultation.  The hospital they are in does not have an acute inpatient psychiatric unit and he has not seen a psychiatric consultant.  They leave at some point to rent a car so that they can drive him to psychiatric facility if necessary.  While they are gone he becomes extremely agitated.  He is tasered several times and ultimately shot in the chest just 40 minutes later.

The New York Times article goes into detail about the issue of armed security in hospitals.  It reviews the number of people with mental illness who were shot or tasered and killed.  I have pointed out some of the problems with firearms in psychiatric hospitals in an article about visitors carrying firearms into Texas state psychiatric hospitals.  The same issues apply in this case.  Firearms are not a deterrent when confronting a person who is agitated and psychotic.  In this case the patient recalls that he was some kind of cyborg secret agent.  In that frame of mind he is likely to interpret any efforts to contain his agitation and aggression as potentially dangerous to him and it would provoke extreme behaviors to counter that aggression.  In every security setting where I have worked, security and law enforcement lock up their weapons and do not take them into patient care areas even if a patient is highly aggressive and out of control.  It takes well trained staff and security to be able to do this and recognize why this is the best approach.  It also involves a contingency plan to physically restrain the patient in a safe manner as quickly as possible if the patient does not respond to verbal deescalation.

The CMS document discloses several important pieces of information that are not in the media.  The first eye opener is that the hospital administration said the security officer was justified in shooting the patient because he had assaulted them.  That statement grates on any inpatient psychiatrist or nurse who recognizes that is not the appropriate frame of reference for this incident.  This is not a street fight.  This is a vulnerable patient in a hospital whose rights and standard of care needs to be recognized.  One of the implicit assumptions in most hospitals is that psychiatrists and psychiatric staff are supposed to view aggression as an occupational hazard.  A unidentified staff member speaks to that in the radio piece and is very explicit about the amount of aggressive behavior that he sees in the hospital and the fact that he gets hit.  That is not the case in other parts of the hospital where aggressive behavior is more frequently seen as criminal behavior.  Early statements from the hospital administration suggested that the law enforcement officers here were justified in shooting Alan Pean, but they were subsequently modifying their position.  He was also charged with 2 counts of aggravated assault on both of the law enforcement officers who entered his room.  Clearly this is a psychiatric problem and the patient needs  protection.  As I read through the 50 page document from CMS, the suggested solution varied from being vague to solutions that many hospitals already have such and an emergency response team for behavioral emergencies.  They suggest that armed law enforcement officers should be only in the ED, not be involved in the behavioral emergencies until all other resources have been exhausted and intervene only in the case of life-threatening or criminal activity.

One of the primary conclusions of the This American Life piece is that is could have been prevented if the patient had received a psychiatric evaluation.  A hospital staff person pointed out that this was standard procedure and also that any number of staff used to encountering aggressive patients could have contained the patient without firearms.  There is apparently an inpatient psychiatric unit at this medical center where he could have been transferred.  Alan Pean responds to Ira Glass's question about how it is that he went to the hospital with mania and psychosis and ended up getting shot in the hospital instead.  One of his conclusions is that he is a young black man and he does not think that it would happen if he was white.  He remains understandably traumatized by his near death experience.

The only logical conclusion here is one that I have already reached many times in many posts on this blog.  Violence and aggression are treatable problems when they are associated with psychiatric illnesses.  There needs to be psychiatric and psychiatric nursing expertise in major hospitals at several levels.  One of the unusual parts of this story was all of the information available suggesting that the patient in this case had a significant mental illness.  That was made even clearer when his physician father made the statement, requested the psychiatric evaluation, and was told that the patient was being discharged instead.  The CMS report does not address staffing levels in the hospital and whether there are adequate staff to address the problem.  In my experience, a nurse and another staff person going to address a situation where there is potential aggression by a young manic patient is not enough staff.  I have personally found myself in many situations when I walked in a room and there were four highly trained nursing assistants out in the hallway, ready to intervene if necessary.  In every case our goal was to protect the patient from injury.

The lesson in this case is that if you go to a hospital with aggressive behavior due to a psychiatric disorder somebody on the receiving end needs to know what to do to keep you safe.  Only a fraction of American hospitals are set up to do this and provide the necessary psychiatric care to resolve the crisis.  Some hospitals will never be equipped to deal with this problem and the practical solution in most communities is to triage violent and aggressive people to more appropriate facilities.  Even though the New York Times article points out that there has been a 40% increase in hospital violence, many of the people with that problem never make it there.  There needs to be enough capacity to treat people so that people with violent and aggressive behavior from a psychiatric illness can go to a hospital knowing that their problem will be diagnosed and treated and that their safety will be assured.  
             
Nobody should ever have to experience what Alan Pean went through.



George Dawson, MD, DLFAPA




References:

1:  This American Life.  579: My Damn Mind.  February 12, 2016.

2:  Elisabeth Rosenthal.  When The Hospital Fired The bullet.  New York Times February 12, 2016.

3:  Department of Health and Human Services Centers for Medicare and Medicaid Services.  Statement of Deficiencies and Plan of Correction.  St. Joseph Medical Center; 1401 St. Joseph Parkway, Houston Texas 77002.


Supplementary 1:

In the report by This American Life, it was apparent that at least some authorities were looking for evidence that the patient had aggressive tendencies outside of the episodes of mania and psychosis.  They did this by asking his family if he had any criminal convictions.  In the original hospitalization he was also noted to have THC in his toxicology.  The fact that there were no other drugs present and that THC can persist a long time was emphasized in the This American Life piece.  In fact, THC is not a trivial compound in this case.  No conclusions can be made based on the existing data and the lack of direct assessment of this patient, but this compound should be avoided by anyone diagnosed with bipolar disorder, especially if there is any doubt about the diagnosis.


Twitter Graphic:
















Saturday, October 10, 2015

Does Publicizing Mass Shooters Benefit Anyone?





I ran across this perspective posted on the Kottke blog.  It is basically a journalist writing an opinion piece about why the names of mass shooters should be used in the media.  I think it is a reaction to the banning of the use of the names and details of mass shooters by some law enforcement and the media.  The Sheriff in the most recent mass shooting incident refused to release the name of the shooter.  The argument against releasing the name of the shooter goes something like this.  At least part of the motivation of some of these shooters involves the fame and publicity that they will achieve based on the incident.  The mass shooting incidents have been in my estimation fairly compared to terrorist incidents where the victims are killed in some of the most horrible and sadistic ways possible as part of the media campaign by these organizations.  It enhances any kidnaping and extortion threats that they may have and also enhances their image as a ruthless and single-minded entity.  Until recently that behavior was also a ticket to widespread international media exposure.  When the media cycle becomes knee jerk in response to mass shootings or terrorist events it is predictable no-cost publicity to both types of perpetrators.

There is additional evidence in the personal effects of many of these shooters and well as evidence from the staging of the events that publicity is a strong motivating factor.  The shooters often have computers and written statements about the motivation for their acts, and some of that material describes the event as something for the world to see.

The counterargument from the journalist seems to be that it is important for the public to hear all this information.  He makes the expected argument of the press that all of the news needs to be reported.  He also spins the political angle and suggests that conservative gun advocates including the sheriff involved in the most recent incident and then Fox News have elected not to name the perpetrator and connects this with the right wing tendency to talk about mental illness being the problem and not uncontrolled access to firearms.

I am at the point where I cringe when reading these highly politicized arguments probably because that is all that I hear when it comes to psychiatry.  The general form of the argument is that people taking a certain position have a certain ideology and therefore the conflict of interest issue reigns supreme.  Because a news service or a sheriff have been identified as being right wing and supporters of continued open access to firearms, anything they say about maintaining the anonymity of the perpetrator can be discounted based on conflict of interest.  In other words, by maintaining the anonymity of the shooter and focusing on the mental state of the shooter, the focus is shifted inappropriately away from more functional legislation to reduce firearm access.  The writer acknowledges that part of the motivation of some of these shooters is publicity or infamy whether they survive or not.  It is hard to deny because a review of the personal effects of some of these shooters makes it explicit.  The author takes the view that denying this publicity essentially gives the appearance that something is being done and this is bullshit.

First off, that does not meet my definition of bullshit from the definitive essay by Frankfurt.  According to Frankfurt, the main differentiating point between bullshitters and liars is that bullshitters have a blatant disregard for the truth.  The truth in this case is that irrespective of political motivations it is highly likely that denying these men the publicity that they seek will result in fewer of these crimes.  It might even provide a public health path to treatment for many of these individual instead of acting out.  I would suggest statutes that address the issue of how mass shooters should be handled in the event of any incident and would not only see anonymity as being important, but also confiscating property and all of the written material and images from the perpetrator and making them available for academic study, but not for the evening news.

The author also seems blind to the role of journalists in this process.  Every massacre triggers the standard response from journalists that I have written about on this blog many times.  All of the shocking details, the interviews with the aggrieved, the response from politicians, and the "profiling" of the perpetrator.  Then after a few days, the President comes on and we are all told to move on.  It seems that the President in his latest address has questioned the value of this process before members of the press have including this author.

My conclusion is that there has to be obvious progress in the area of gun control (yes - I said control).  But I have also accepted the fact that the power structure in this country does not have to yield to public opinion.  My decades of treating violent and aggressive people have also led me to understand that this is also a public health problem and as a public health problem - multiple measures need to be in place.   Restricting wide spread publicity for the perpetrators is one of many logical options.

There is also the issue of contagion.  Does a large incident with a lot of news coverage trigger copycat crimes?  There have been some anecdotal reports that copycat crimes occur in the specific area of school shooting.  The authors of a recent PLOS article (2), analyze the USA Today Mass Killing database and the the Brady Campaign School Shooting database.   The original databases and any modifications to them are available at this link.  The authors comment that a contagion model has been applied to several natural events like the financial markets, burglaries and terrorist attacks.  The authors specify the model they are using and go on to show that according to the USA Today database there was a mass killing (involving 4 or more people killed) every 12.5 in the US.  For the Brady database school sooting occurred every 31.6 days.  The authors illustrate there is a contagion effect for mass killings involving firearms but not mass killings that do not involve firearms.  They also show correlations between state prevalence of firearm ownership and mass shootings, but the authors note that mass shooters commit suicide 48% of the time and that is much higher than the expected suicide rate by perpetrators committing a single act of homicide (5-10%).  Mass shooters who commit suicide also kill 22% more people than mass shooters who do not.  The graphics and statistics in this article are great and I highly recommend a look at the graphs showing what part of the data is due to the contagion effect.  I also applaud the authors efforts to publish essentially public health research in an area that has been actively suppressed by Congress.  Scientific research on firearms policy is apparently incompatible with the Second Amendment.

So it turns out that there are probably legitimate reasons for withholding the identity of mass shooters and decreasing the disclosures about the incident and in some cases the audiovisual material that they have produced to promote their activity.  There is a well known journalistic tendency to wrap themselves in the flag when it comes to their not having complete access and the ability to disclose information, but the process is far from perfect and in many cases they defer to national security.   In the case of the databases involved there is clear asymmetry in terms of which incidents get publicity and which do not.  This is an opportunity for them to provide some news about public health interventions to prevent violence and mass shootings.

I don't think the importance of the notoriety or contagion factors in motivating mass shooters can be cancelled out by a conflict of interest argument.  But the conflict of interest card seems to be played like it is the trump card these days.

I also don't accept the "we as a society have made our choice" argument.  It's not really them it is us.  That argument is a stark contrast to how our government runs.  "We" are no more responsible for a society flush with guns that "we" were for three unnecessary wars based largely on fictional threats.  That oligarchy can function primarily with the full cooperation and lack of critical analysis by the American press.  The fact that late night comedians can produce more analysis of these issues than mainstream journalists is an indication of how much serious reporting is lacking.

There is probably no better example of reporting deficiency than how mass shooting incidents have been handled for decades.


George Dawson, MD, DFAPA


1:  Josh Marshall.  The Great Evasion.  TalkingPointsMemo.com  October 2, 2015.

2:  Towers S, Gomez-Lievano A, Khan M, Mubayi A, Castillo-Chavez C. Contagion in Mass Killings and School Shootings. PLoS One. 2015 Jul 2;10(7):e0117259. doi: 10.1371/journal.pone.0117259. eCollection 2015. PubMed PMID: 26135941.



Friday, October 2, 2015

Is President Obama Reading This Blog?




Not really, but you can find the mass shooting links on this blog at this link.  They extend back three years and they overlap with a number of posts on homicide prevention.  They also overlap in many areas with the President's speech.  This was President Obama's 15th address to the nation following a mass shooting incident.  A couple of other landmarks - this was the 40th time this year that a gunman opened fire in a school and the 294th mass shooting incident this year.  Both of these markers illustrate how tragic but absurd this problem is in America.  How can responsible people allow this to happen?

The President is coming to the only logical conclusion that a person can come to about mass shootings and the relationship to firearms.  That point in this speech was when he said that our thoughts and prayers for the families and survivors are not enough.  We cannot keep making these pat statements in response to continuous mass shootings as though nothing can be done to prevent them.  We cannot treat mass shootings like they are routine:

"Earlier this year, I answered a question in an interview by saying, “The United States of America is the one advanced nation on Earth in which we do not have sufficient common-sense gun-safety laws -- even in the face of repeated mass killings.”  And later that day, there was a mass shooting at a movie theater in Lafayette, Louisiana.  That day!  Somehow this has become routine.  The reporting is routine.  My response here at this podium ends up being routine.  The conversation in the aftermath of it.  We've become numb to this."

 The familiar refrain about condolences to everyone and now it is time to move on needs to stop.  With governments that regulate what a lot of us do at work every day - right down to how we cross the Ts and dot the Is - it is difficult to believe that more functional gun control laws cannot be passed.  In his speech he points out that this is possible and there are laws that have been shown to work in other countries and in specific counties and municipalities in the United States.

At one point he speaks to the mind of the perpetrator:

"We don't yet know why this individual did what he did. And it's fair to say that anybody who does this has a sickness in their minds, regardless of what they think their motivations may be. But we are not the only country on Earth that has people with mental illnesses or want to do harm to other people. We are the only advanced country on Earth that sees these kinds of mass shootings every few months."

People tend to get hung up on whether specific perpetrators have a diagnosable mental illness and whether it is treatable.  They tend to get hung up on whether the behavior of violent individuals can be predicted over time.  They tend to be very pessimistic about the nature of the problem and whether insightless people will ever be able to get the kind of help that they need to prevent mass shootings.  It might be easier if there was some education about the types of situations that lead to these problems and the fact that in most of those cases, help is available.  That specific help will prevent homicides and prevent the unnecessary loss of lives of both the perpetrators and the victims.  

The President ended with a comment on the political process and an appeal to gun owners on the issue of whether they are being supported on this issue by an unnamed organization or not.  It was a compelling speech and the arguments are powerful.  As a politician, he is focused on political action and on common sense gun safety laws.  I have stated that it might be best to proceed from a public health standpoint and a focus on violence prevention and forget about legal approaches largely because there has been no political will on this issue.  President Obama has given one of the most compelling speeches on this issue that I have ever witnessed and it will be interesting to see the result.

From the medical and psychiatric side, our advocacy still needs to be on the public health side of the equation.  For me that comes down to seeing the problem to a significant extent as violence and homicide prevention.  We need more public education on the predisposing mental states and how to get assistance when these states are recognized.




George Dawson, MD, DFAPA


References:

Statement by the President on the Shootings at Umpqua Community College, Roseburg, Oregon.  October 1, 2015.  Transcript