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
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
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