Wish I Had Said Some More About The Violence......

I shot a video for the 100 Miles 100 Stories charity yesterday.  Their mission is raise awareness for violence against healthcare workers.  They found me through a nurse that I used to work with who sustained a traumatic brain injury when she was assaulted in an emergency department.  The sequelae of that injury ended her career in nursing. The focus of this charity is to raise public awareness of the problem and hopefully find some solutions.  As I have posted on this blog many times, these incidents are generally preventable, but it requires both expertise and a major revision of the systems that most health professional work in every day. I had a meeting two weeks ago on the comments I could make in this area and the interview questions were based on that meeting.  I don't have a transcript or tape and the final version will be edited.  This is my recollection of what happened:

Q:  Tell us about your experience.

A:  I have been a psychiatrist for 32 years and about 22 of those years have been in acute care psychiatric settings at what is now called Regions Hospital.  It used to be St. Paul-Ramsey Medical Center before it was acquired by HealthPartners.  For about 8 of those years a neurologist and I ran a clinic for Alzheimer's Disease and other dementias.

Q:  What kind of psychiatric diagnoses did you see?

A:  Bipolar disorder, major depression, schizophrenia, schizoaffective disorder, personality disorders with a significant overlay of alcohol and substance use.

Q:  Were you ever assaulted?

A:  I was punched three times but there was no serious injury.  Threatening behavior was more a problem.  There were homicidal threats that had the most significant impact on me long term.  As an example, I started to be more conscious of home security and have home security and close circuit TV cameras installed.

The interview is biased on a personal point of view.  If I had been thinking more I could have mentioned what I had seen.  One psychiatrist punched and knocked out.  Another psychiatrist beaten up with a resulting career ending traumatic brain injury. Various injuries to nursing staff and nursing assistants who have the majority of contact with agitated and potentially aggressive patients.  One evening I was talking with nursing staff behind a window that we believed was shatterproof glass. Without warning the window exploded as a heavy chair sailed through it.  Being one step away from very serious injuries and deaths in many situations, but the downside is that may have seemed like an embellishment so I left it out.

Q:  Why do you think it is happening?

There are several reasons.  The lengths of stays in psychiatric units these days is either too long or too short.  People are discharged in 3 or 4 days or they are waiting there for weeks or months to go to a state hospital bed because they are committed.  Acute care inpatient units are not set up to accommodate people staying there that long.  When I interview people have been discharged from inpatients units they typically tell me that they were sitting around watching TV until they could convince somebody that they are not suicidal.

If we consider a person who is experiencing auditory hallucinations who goes to the emergency department for help they might not get admitted for that problem.  They will probably be told to go to an outpatient appointment in a month or two.  In the meantime - they are untreated and that symptoms gets worse.  If they come into the emergency department again, they may angry the second time.  The current system of care has a large circulating pool of partially stabilized or unstable patients that go between the ED, homelessness and homeless shelters, and acute care hospitals.

I should have used the term dangerousness.  I have written about it countless times on this blog but not in the interview.  Dangerousness is essentially the only way that people get admitted to inpatient psychiatric units any more.  That arbitrary business decision rations access to care for people who have also experienced rationing at a both the community level with less housing and at the state hospital level with a marked reduction is state hospital beds.

Q:  What do you think can be done about it?

Changes have to occur at two levels.  Government and business administrators have to open up access to more beds in both state hospitals and community housing.  There has has to be more enlightened management of those beds.  At the service provider level there needs to be a team approach to the problem.  Frequently if there is an assault related injury, there is a lot of silence and nobody talks about it.  Some splitting can occur and some disciplines may think that it can't happen to them.  The victims may blame themselves and become very isolated.  Administrators at every level need to support clinical teams to address this problem.  There needs to be in house experts to fix the problem and not outside consultants who typically know a lot less about problems and solutions.

Q:  What do you think is important about the 100 Miles 100 Stories Walk?

It raises public awareness about this issue and how it impacts health care workers. It might raise awareness about the expectation that it is part of the job and that many people expect health acre workers to accept it.  Hopefully it will also increase solidarity on this issue.

I should have added my opinion that there needs to be a zero tolerance rule for violence and aggression to healthcare workers.  They are after all doing their job taking care of people.

Q:  Is there anything else that you would like to cover?

I would like to mention that there are basically three groups the become violent in health care settings.  The first is people with severe mental illnesses who are making decisions based on a delusional thought process.  The second are people with acute or chronic intoxication states who are agitated or aggressive based on their use of an intoxicant.  The third group are people with personality disorders where aggression is a strategy or way of life.  Limits needs to be established with this group and they must be held accountable.

The interview ended at that point but there was obviously a lot more that could be said.  Like most people - I write a lot better than I speak.  I am sure that if you see the eventual clips I will be much less articulate and probably confabulated much of what I just wrote.

There is also a time constraint for these interviews and the consideration that the public probably wants to hear about the  general rather than the specific problems or proposed solutions. Certainly nobody has been flocking to this blog over the past years for my suggestions about violence or homicide prevention. 

I doubt that many people are aware of the fact that it is common that patients need to be physically restrained so that they don't injure themselves or anyone else.  I can recall being in an ICU setting when a young man suddenly got out of bed and started swinging an IV pole around his head.  An IV pole has a heavy metal base and anyone struck by that base would have been seriously injured.  He was doing this within a few feet of critically ill patients and the ICU nursing staff.  He was also delirious and completely unable to respond to verbal requests or guidance.  That is an illustration of how rapidly one of these situations can develop and also why there is a necessity for being able to respond to the problem rapidly.

I also might have discussed the informal triage system for dealing with violence or aggression.  In Minnesota not all hospitals will receive patients with this kind of problem.  Not all hospitals train their staff to physically intervene in an appropriate way.  In most health care facilities the training ends at how to approach the potentially aggressive patient and it assumes that the verbal intervention will be successful.  That will not work with very aggressive patients and training needs to include more specific physical measures.

There is also a lot of room to discuss environmental safety plans.  What is the physical design of the clinic or hospital ward?  Can changes in the design configuration provide additional safety for patients and staff.  In some cases it is just putting receptionists in safe areas where they are not in danger from walk ins or aggressive patients.  Does there need to be a law enforcement presence?  What about internal security?  What kind of plan needs to be in place to coordinate all of the personnel in emergencies?

Whatever the focus - these discussions need to get out there for the general public to consider.  The level of injuries to hospital staff and in some cases patients needs to improve greatly.  I emphasize again that the majority of these injuries affect nurses and nursing assistants.  Physicians have been  homicide victims as the result of some of this aggression.

In the cases of conscious directed violence - the perpetrators of that violence need to be prosecuted.  No health care employee should go to work every day fearing assault and in some cases disabling and career ending injuries.   



George Dawson, MD, DFAPA



Supplementary 1:

I was sent this link to an incident of emergency department violence from 1993.  That highlights the chronicity of the problem and the lack of effective solutions.  Quotes from the article:

"Health care workers noted, however, that the incident is only the most recent example of the rising tide of violence that has spilled over into the nation's urban emergency rooms."
and:

"County-USC has been no exception. During the first six months of 1991, for example, security guards at the hospital responded to 1,400 reports of threats or attacks, six of which led to arrests. Among the assailants was a panhandler who approached four nurses in the cafeteria and plunged a pair of suture-removal scissors deep into one nurse's neck."

Supplementary 2:

Here is a link to the video I recorded that was the basis for this post.  It is a 4 minute clip edited down from about 20 minutes of interview material.  I had no role in the recording or editing of the clip.

George Dawson, MD on violence toward healthcare workers in psychiatric settings. Clip. 

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

The NYTimes Editorial On Why Mental Health Can't Stop Mass Shooters -What's Wrong With It?

There was a New York Times editorial titled "The Mental Health System Can't Stop Mass Shooters" dated February 20, 2018.  It was written by Amy Barnhorst, MD, a psychiatrist and vice chairwoman of community psychiatry for University of California, Davis.  Since it popped up it is being posted to Twitter by more and more psychiatrists.  It does contain a lot of accuracy and realism about the issue of assessing people acutely and whether or not they can be legally held on the basis of their dangerous behavior.  Dr. Barnhorst gives examples of people who allegedly make threats and then deny them.  She discusses the legal standard for commitment and its subjective interpretation.  For example, even though a statute seems to have a clear standard they are many scenarios in the grey zone, where a decision could be made to err on the safe side.  That involves hospitalizing the patient against his or her will because the risk is there and their behavior cannot be predicted.  If hospitalized, she anticipates the outcome when the patient appears in front of a hearing officer and gets released.  That last scenario is very real and I would guess that the majority of decisions on the front end in these cases take into account what might happen in court.

If the hypothetical patient did get committed he would not be able to acquire a gun with a functional background check system. That system does not currently exist. If guns were involved in his case before hospitalization, the police may have confiscated them.  Unless his legal status changes they may give him the guns back.  In some cases the patient is told to ask their psychiatrist to write a letter to get their guns back.  I am not aware of any psychiatrist who has done that.  The FBI NICS system lists all of the conditions that would prohibit a point of purchase gun sale (assuming a check is done).  That list includes: "A person adjudicated mental defective or involuntarily committed to a mental institution or incompetent to handle own affairs, including dispositions to criminal charges of found not guilty by reason of insanity or found incompetent to stand trial."   Various crimes including domestic abuse can also trigger a failure of the NICS check and when that happens the gun sale is cancelled.  Unfortunately not all states participate in this check system and there are numerous exceptions if they do.

I have diagrammed the various levels of arguments that apply to a psychiatrist doing a crisis evaluation on a person brought to the emergency department for making threats with firearms.  At the political level there is no nuance.  At this level the degree of distortion is the greatest.  The usual arguments about guns not killing people is a good example, but it extends even this morning to President Trump suggesting that more mental health resources will solve the mass shooting problem, when it clearly will not.  The legal arguments are slightly more informed, but still fairly crude.  Like most legal arguments they threaten or reassure.  For example, most psychiatric crisis statutes hold harmless anyone who reports a suicidal or aggressive person to the authorities.  On the other hand, if a psychiatrist places a person on a legal hold because they are potentially dangerous - it is typically illegal for that same psychiatrist to extend the hold if the court system has not done anything by the time it expires.  The civil commitment system has a way of starting to make decisions based on available resources and in many cases the statutes seem reinterpreted that way.

At the medical level, psychiatrists are left living with the legal and political arguments no matter how biased they may be and trying to come up with a plan to contain and treat the aggression.  It is not an easy task given the resource allocation to psychiatry - but after doing ti for 20 years - it is fairly obvious that acute care psychiatrists know what they are doing.  They are successful at stopping violence acutely and on a long term basis.  Given the legal biases they cannot do it alone.  There needs to be cooperation from the courts and the legal system and some patients should be treated in the legal rather than the mental health system. 

Getting back to Dr. Barnhorst's article one sentence that I disagreed completely with was:

"The reason the mental health system fails to prevent mass shootings is that mental illness is rarely the cause of such violence." 

She cites "angry young men who harbor violent fantasies" as basically being incurable.  The problem with mental illness and gun violence is that it is dealt with at a political level rather than a medical and diagnostic one.  The facts are seldom considered.  There are political factions that see violence as stigmatizing the mentally ill and political factions who want to scapegoat the mentally ill and take the heat off the gun advocates.  The reality is that people with severe mental illness are overrepresented in acts of violence compared with the nonmentally ill population. It is a small but significant number. In studies of mass homicides the number increases but it depends on the methodology.  There are for example school shooter databases that record events as anytime a firearm is discharged in a school.  That results in a very large number of weapon discharges but most where nobody is injured.  There are databases that just list events but there is no analysis of whether mental illness was a factor or not.  In mass shootings in half the cases the shooter is killed or suicides.  Even when the shooter survives the data is affected by the subsequent hearings - so there is rarely a pure diagnostic interview available.  The data analysis depends on making sure that both the events and the mental health diagnoses are as accurate as possible.

The most parsimonious assessment of this data was published by Michael Stone, MD in 2015 (1).  The paper is fairly exhaustive and I am not going to discuss the obvious pluses and minuses.  I do see it as a break from the usual sensational headlines and the analysis of the trends in mass homicide over time, especially associated with semiautomatic firearms - leaves no doubt that this is a large problem.

He identifies 235 mass murderers, and estimates that 46 (22%) of them were mentally ill.  His definition of mentally ill as essentially being psychotic.  He goes on to say that in the remaining fraction and additional 48 had paranoid personality disorder, 11 were depressed, and 2 had autism spectrum disorders. In other words another 26% of the sample had significant mental disorders that were not considered in the analysis because he did not consider them to be psychotic.  Another 45 (19%) has either antisocial personality disorder or psychopathic personality disorder - both mental conditions associated with criminal activity and thought to have no known methods of treatment.  Using this conservative methodology - it is apparent that mental illness in this population is not rare at all.  What should not be lost is that although mass shootings are very noticeable events - they are rare and therefore any overrepresentation of mental illness in this group, is diluted by what happens across the entire population where the majority of violent activity is associated with people having no mental illness and the overall trends in violent crimes are at a 20 year low.

My proposed solutions to the problem of semiautomatic weapon access and mass shooters/murders is approached this way:

1.  Increase the purchase age to 21 years.  Eliminate access to military style weapons.

2.  All purchases must be cleared through the NICS system.  All states must participate. Currently only 12 states participate in full point of contact background checks on every gun sale.

3.  The NICS system should include terroristic threats, stalking, and any gun confiscation by the police because of mental health grounds as exclusion criteria.  In other words, you are eliminated from gun purchases if you have been reported for these problems.  That may sound a bit stringent but I think there is precedent.  You cannot make threats about air travel at an airport.  If you have been charged with domestic abuse (Misdemeanor Crimes of Domestic Violence (MCDV)
 the are special instructions on what it takes to keep firearms from you.  I consider the safety of children in schools to be on par with these two cases (air travel and domestic violence threats).

4.  At the level of law enforcement, any firearms confiscated during a threat investigation should not be returned and that person should be investigated and reported to NICS Database.

5.  Uniform protocols need to be in place for terroristic threat assessment.  It is no longer acceptable to wait for a person to commit an act of aggression before there is a law enforcement intervention.  The person making the threat should be removed from that environment and contained pending further investigation.

6.  On the mental health side - rebuilding the infrastructure to adequately deal with this problem is a start.  Hospitals with large enough mental health capacity should have a unit to deal with aggression and violence.  There should be specialty units that collect outcome data on the diagnoses represented and work on improving those outcomes.

7.  On the law enforcement/corrections side there needs to be recognition that not all mental health problems can be treated like mental health problems.  Violent people with antisocial personality disorder and psychopathy are best treated in law enforcement setting and not in psychiatric settings.  In psychiatric setting they have a tendency to exploit and intimidate the other patients in those settings as well as the staff.  They should be treated by psychiatrist with expertise in these conditions and been seen in correctional settings.  Probation and parole contingencies may be the best approach but I am open to any references that suggest otherwise.

8.  In the early years of this blog - I was an advocate for violence prevention and I still am.  Violence and aggression have the most stigmatizing effects of any mental health symptoms.  I think it is safe to day that most psychiatrists actively avoid practicing in setting where they may have contact with aggressive patients.  It needs to be seen as a public health problem and education and prevention are a first step.

Those are my ideas this morning.  I may add more to this page later.  If you have a real interest in this topic Dr. Stone's paper is a compelling read.  If I find others of similar quality I will post them here.  Don't hesitate to send me a reference if you have one.

The bottom line is that no psychiatrist can operate in the current vacuum of realistic options and hope to contain a potential mass shooter.  And yet there is a clear overepresentation of mental illness in this population.  Some level of cooperation as suggested above will result in a much tighter system for addressing this issue.  We do it in airports and in domestic violence situations.  We can also apply more uniform and stringent expectations to schools.


George Dawson, MD, DFAPA


References:

1:  Amy Barnhorst.  The Mental Health System Can't Stop Mass Shooters.  New York Times February 20, 2018.  Full Text Link

2:  Stone MH.  Mass Murder, Mental Illness, and Men.   Violence and Gender. Mar 2015: 51-86. Free Full Text Link



Graphics Credit:

Photo of the M4 Assault Rifle is per Shutterstock and licensed through their agreement.

Layered arguments graphic was done by me in Visio.

 

Mass Shootings in America - Why They Are not Terrorism

You will find more statistics at Statista

American media is so used to mass shootings that many are set up to reflexively release provocative and often poorly thought out theories after the incident.  The fact that there is rarely much more information about the shooter's motive reinforces this process.  The tragic event in Las Vegas is no exception.  It is currently the worst mass shooting incident in the USA and here is a link to the previous two.  There is the usual gun debate and public relations maneuvers by wide gun access advocates.  There are the rational responses by citizens calling for some measure of gun control.  I say rational because there is excellent evidence (1) that stricter gun laws enacted after a mass shooting incident, prevent further mass shooting incidents.  In the media coverage after this incident and on various social media cites there appears to be some confusion over whether American mass shooters are terrorists or not.

Before I go on, I have noticed that in social media many people are posting state statutes that equate terrorism with acts of violence.  The US Code defines both international and domestic terrorism as intimidation or coercion on a domestic population in order to influence the conduct or policy of the government.  I would take it a step further in that there needs to be an ideological message.  All of the news about who takes "credit" for these incidents implies this is a critical dynamic along with all of the publicity generated by many of these groups with very explicit messages.

For all of these reasons, typical mass shooters in the United States are not terrorists.  There is no ideology, no message, and no attempt to influence the government.  There certainly may be mental illness, but that alone is insufficient to produce a typical mass shooter.  There are many more mass shooters that are not technically mentally ill than those who are, but I will admit that the methodology for studying the problem is inadequate since many of these perpetrators are dead or unwilling/unable to produce a coherent story.  I will also be the first to admit that this is my impression, because the data on mass shooters is large and I have no access to all of that data.  For example, the NY Times came out with a graphic showing that in the past 477  days in the US there were 521 mass shootings (2).  They use the criteria of 4 or more people killed or injured qualifying as a mass shooting.  I have no access to that data.  There have been attempts to look at the data according to specific types of mass shooters like rampage killings.  The most recent FBI study looked at where the events occurred, if there was any connection between the shooter and the location.  It did not focus on the potential motivations of the shooters despite having access to all of the data:

Though this study did not focus on the motivation of the shooters, the study did identify some shooter characteristics. In all but 2 of the incidents, the shooter chose to act alone. Only 6 female shooters were identified. Shooter ages as a whole showed no pattern. However, some patterns were seen in incident sub-groups. For example, 12 of 14 shooters in high school shootings were students at the schools, and 5 of the 6 shooters at middle schools were students at the schools. (p. 20).
  
It did look at some specific locations and the relationship of the shooter (employee, family member)  to that location.  The critical analysis of this report was that it appeared that although mass shootings have occurred a long time in the United States - they appeared to be increasing in rate and lethality as indicated by the following graphic from that report:

The graphic points out that not only is the general problem of mass shooting being ignored from  policy perspective, the increasing rate and lethality of these incidents is being ignored.  From the FBI report some of the motivations clearly involve enraged employees or former employees.  Mental illness was omitted as a possible motivation.  All of the vignettes of each incident are attached to the end of the report.

My views on mass shootings, violence prevention, and even homicide prevention have not changed from my previous posts in this area.  I will add one more dimension to the issue and that is the cultural meme of the mass shooter in America.  Granted there are various etiologies that can produce a mass shooter, but after terrorism has been  eliminated there is a prominent cultural meme present in the USA and that is - if I feel like I have been wronged - I can pick up a gun and and make things right (at least in my own mind).  Americans are oblivious  to the presence of this thought pattern in our culture and what it implies.  The most significant implication is that reality is suspended if I merely feel like I have been wronged.  The reality of why I was fired, divorced, arrested is secondary to my thoughts on the matter.  Most adults in this country have had experience dealing with somebody who had this pattern of thinking.  To some extent most people with some level of self awareness can catch themselves in the process of making the same errors - most frequently when angry or emotionally upset.  Varying degrees of road rage is a classic example.  There is an anthropological argument that violence, aggression, and homicide are age old solutions to often minor disagreements.  In many cases the aggression spreads to a  larger number of targets than were involved in the original conflict.

There is the issue of violent and homicidal fantasy being common in both normative and violent criminal populations (4).  Various theories about the function of these homicidal fantasies exist.  Some homicidal fantasies seem higher risk than others but the study of fantasy per se, is limited by inadequate methodology including degree of self disclosure and lack of long term follow up.  Much of the work is anecdotal.
   
At the cultural level is there a larger problem in America?  American culture unquestionably has viewed firearms as tools for settling disputes.  That plays out time and time again in various movies and to varying degrees in American subcultures where being capable of violence and aggression is synonymous with being respected. To be very clear most people can tell the difference, but cultural influences can have a powerful effect.

No matter what the intrapsychic or cultural ground for gun violence, one thing is obvious if a firearm is available it is more likely to be used in both incidents of suicide and homicide.  We currently have a Congress and various political factions that are in denial of that basic fact.  Unless there is a radical change in that political approach and/or a concerted effort toward violence and homicide prevention reversing the trend in the FBI graph is unlikely.


George Dawson, MD, DFAPA




References: 

1:  Chapman S, Alpers P, Agho K, Jones M. Australia's 1996 gun law reforms: faster falls in firearm deaths, firearm suicides, and a decade without mass shootings. Inj Prev. 2015 Oct;21(5):355-62. doi: 10.1136/ip.2006.013714rep. PubMed PMID: 26396147.

2:  The Editorial Board.  477 Days. 521 Mass Shootings. Zero Action From Congress. New York Times; October 2, 2017.

3:   Blair, J. Pete, and Schweit, Katherine W. (2014). A Study of Active Shooter Incidents, 2000 - 2013. Texas State University and Federal Bureau of Investigation, U.S. Department of Justice, Washington D.C. 2014.

4: Gellerman DM, Suddath R. Violent fantasy, dangerousness, and the duty to warn and protect. J Am Acad Psychiatry Law. 2005;33(4):484-95. PubMed PMID: 16394225

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:

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.

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

Anger and Projection Are Not Political, Racial Or Gun Control Problems

Anger and projection are mental and public health problems.

The homicides of two young broadcast journalists yesterday continues to stimulate the same media response that it always does - mourning the victims, discussing the tragic aspects of the event, and doing a media profile of the perpetrator.  Anyone who has read this blog over the last three years knows my positions on this.  Lengthy posts and academic references don't seem to matter so I thought that I would keep this brief and reiterate the main points before it becomes the usual media circus about gun control and speculating about the perpetrator's mental state.   The most rational analysis considers the following points:

1.  This is first and foremost about the mental state of the perpetrator:

Without the perpetrator there is no tragedy.  Preliminary descriptions in his own words that he was a powder keg that was waiting to go off.  He had a pattern of angry conflicts with coworkers that severely complicated his life, led to job loss, and ongoing conflicts.  I heard a detailed analysis of an alleged pattern of behavior that results in this kind of homicide on the morning news today and it was too pat.   It sounded like the old "stages of grief" model that people used to adhere to.  I think there is a lot of confusion out there about what is normal anger and what kind of anger is pathological.  Anger is a socially and culturally difficult construct.  In many places like my home state of Minnesota it is generally unacceptable.  It is difficult to recognize when anger becomes a problem, if your reality excludes it as a possibility.

Anger is a problem when it is persistent and pervasive.  Normal anger is transient and does not persist for days, weeks or longer.  It is necessarily transient because it can activate physiological processes like hypertension that are not conducive to the health of the individual.  Persistent anger also gets in the way of normal social interactions that all people need in order to function properly.  Human beings are undeniably social animals and we do not function well if we are isolated or cut off from one another.  Anger tends to automatically focus people on an outside source for their problems and frustration while minimizing their own potential role in the process.  Persistent anger does not allow for the necessary productive interactions with family members, coworkers, or in many cases casual contacts in everyday life.

Projection is the attribution of a feeling state or problem to another person.  It is commonly experienced when observing a person blame other people or circumstances for problems they are having in life.  How rational that level of blame seems may be an indication of the severity of the problem.  In my years of treating people in inpatient psychiatric units, it was rare to encounter a person who did not see me as the root of their problem, even though I had barely met them, had nothing to do with why they were in the hospital, and was the person charged with helping them get out.  Some might think that was just a part of me representing an institution, but that goes out the window when the reasoning being given is that I am white or jewish or racist or I am physically attracted to the patient.  Those were typically the mildest accusations.  In many cases, this anger and projection was obvious to family members and coworkers for months or even years before the person was admitted to my unit.  Threats of physical violence or actual physical violence in these situations was common.

2.  This is a public health problem:

People with anger control problems and projection generally do not do well in life.  At the minimum these problems are significant obstacles to a successful career and social life.  One public mental health focus should be on optimizing the function of the population and preventing this social morbidity that is also associated with somatic morbidity and mortality.  In some cases, these mental states are also precursors to violence including suicide and homicide.  In some cases they have led to mass shootings.

There are very few people who talk about this kind of violence and the associated mental state as a preventable or treatable problem.  Part of the issue is that anger is socially unacceptable and it seems like a moral issue.  We should all learn how to control our tempers and keep ourselves in check.  If we don't, well that's on us and we should be punished for it.  Another part of the problem is that some people want to see it as a strictly mental health problem and turn it into a problem of prediction.  The argument then becomes the inability to predict who will "go off" and harm someone.  The additional issue that will heat up at some point is the gun control issue.  Any reasonable person will conclude that gun access in the US is too easy and the amount of firearm injuries and deaths are absurdly high for a sophisticated country.  That said, there appears to be no practical way to alter this problem within our current legislative system.  Even if all guns were removed, it would not stop the problem of people with anger control problems and projection from not doing well in life or harming innocent victims.

To address the problem, we need to take an approach that is similar to suicide prevention.  I am not talking about screening.  I am talking about identifying people at risk.  The best way to do that is to develop strategies to help them self-identify and request help or to help people in their lives assist them in getting help.  Typical ways this works in suicide prevention is public service announcements, volunteer hotlines, referrals through law enforcement and the court system, and referrals through the schools.  Suicide is also identified as a major public health issue and as such it is a focus of many organizations that do advocacy and intervention work in the area of mental health.  There are no similar resources for anger and violence prevention.

That is my basic message involving the most recent incident of preventable homicide in the United States.   I wanted to get this out after seeing just one broadcast on the issue and before I saw too many stories politicizing the incident.  I think that the factors that have resulted in lack of action in this area are obvious and several of them will be on display over the next few days.

As a psychiatrist who has worked in this area for nearly 30 years, I can say without a doubt that this unnecessary loss of life can be prevented and preventing it does not require psychiatric services, but it does require people who are willing and able to address the problem.

We just have to stop pretending that it can't be stopped.


George Dawson, MD, DFAPA



Supplementary:

1.  Previous violence prevention posts here.

2.  Previous homicide prevention posts here.





    

More On Violence And Aggression In Minnesota Hospitals

There was a recent incident (see link within that article) that occurred in a Minnesota hospital a few weeks ago that resulted in serious injuries to nursing staff.  There are various sites on the Internet where you can view the videotapes that were obtained from the hospital's security cameras.   It shows an out of control man chasing and striking nursing staff with a metal bar or pipe, in some cases repeatedly.  The patient in this case was eventually apprehended outside of the hospital and died suddenly after he was tasered, taken to the ground, and handcuffed.   Preliminary information suggested that the patient involved in this situation was probably experiencing an acute change in his conscious state because it was a total departure from his personality and he had no previous episodes of aggression or violence.  Nursing staff sustained serious injuries including a pneumothorax.  Autopsy results have not been released at this time.

Many people were shocked by this activity and yet is is a fairly common occurrence.  People may expect this kind of agitated and aggressive behavior to occur only on psychiatric units, but the reality there is that is happens only on a few psychiatric units.  Most psychiatric units are managed to limit the admission of patients with a high potential for violence.  It happens on medical-surgical units for a number of reasons and the effects are more dangerous at times because of the availability of objects that can be used as weapons.  I have seen stands used for hanging intravenous solutions being swung in a wide circle through an intensive care unit.  These stands have heavy bases that can inflict serious injuries and destroy a lot of equipment in an ICU.  There are many possible reasons for this kind of aggressive behavior ranging from delirium and psychosis on one end of the spectrum to antisocial behavior and wanting to intimidate medical staff on the other.  Although it seems incongruent with a controlled hospital environment, many families have an experience with a family member who suddenly loses control.  The proscription on aggression and violence and the moral interpretation of this behavior often makes it difficult for families to comprehend what is happening.  Families and medical professionals alike often lack the vocabulary for describing this behavior and can just lump it together as "bad" behavior.

I saw the preliminary description of this incident and the video clips and decided not to comment on it until after the results of the autopsy and investigation were known.  The idea that  this problem would be approached by making this behavior illegal made me change my mind for a couple of reasons.  First, there is a very high probability that this behavior was precipitated by a medical problem that led to a change in consciousness to the point that this individual had no control over his behavior.  Anyone who has been delirious has experienced this at one point or another.  In my own family one of the male relatives who was a well driller was apparently "blown up" in a well one day and the resulting brain injury led to permanent and extreme changes in his behavior.  From that day on he was extremely aggressive and the aggression was directed toward property.  He continuously overturned furniture and smashed dishes until the entire house was trashed.  In those days before any care or containment was available, the expectation was that the family would care for him and they did until he died.  The home environment was constantly disrupted by rage attacks until that day.  In my capacity as an inpatient psychiatrist, I would routinely see people brought to the hospital after they suddenly became aggressive at home.  When their relatives arrived they were always shocked to find that the patient had been admitted to a psychiatric unit.

My second reason for concern is the involvement of politicians in what is a misunderstood medical problem.   An acute medical problem causing aggressive behavior in not a criminal act - it is a medical problem.  Attempting to incarcerate or fine a person for aggression that occurs in that circumstance does not make any sense at all.  It may be a way to secure political capital from a special interest groups, but criminalizing a medical problem is not a reasonable approach.  Even suggesting that this is something that should be debated in a court of law is questionable.  I base that on the known track record of the not-guilty-by-reason-of-mental-illness defense.  It is widely known that there is a low probability of that defense succeeding.  It is also widely known that people who have committed criminal acts and who clearly have severe mental illness  are typically convicted.  All it usually takes is a expert testimony suggesting that despite any mental illness diagnosis, the defendant appeared to be taking planned steps to achieve a goal.  In the case of aggression those steps would involve assaultive behavior and destruction of property rather than random activity.  I can say that in every case of aggressive behavior that I have witnessed in a hospital, even in cases where the patient had no subsequent recall of the incident that their behavior appeared to be planned and the assaults were directed.

On the non-medical side of the spectrum, there are people whose conscious state is not altered at all and they have directed violence as part of their personality structure.  Threatening and assaulting people are a way of life.  They frequently have criminal backgrounds or an arrest record.  They often give a history of fighting and may have harmed someone when they were defenseless or felt no remorse if their aggressive behavior resulted in injury or disability.  In my experience the majority of these persons can control themselves in medical settings with a few exceptions.  Any drug or alcohol intoxication state makes them more unpredictable.  Seeking prescriptions for controlled substances like opiates or stimulants can also create confrontations if they don't get the prescription that they are seeking.  There may be a question about whether any special legislature penalizing what is essentially criminal assaultive behavior would be useful.  My guess is that it would not for the same reason that civil commitments fail to work - the laws are not utilized.  Hospital administrators and courts tend to ignore aggression toward medical and nursing staff from patients who are willfully directing violence toward them as a product of their usual conscious state.  Administrators always explained it to me as an occupational hazard, especially on the part of the nursing staff.  That casual attitude often leads to inadequate safeguards at every step.  There should be a zero tolerance attitude for personality disordered violence and that should include prosecutions for assault.

The key to protecting medical and surgical staff and their patients from aggression associated with acute changes in consciousness is to have a heightened level of awareness.   The patient's history prior to admission is critical.  Prompt recognition of delirium from many causes and acute drug and alcohol intoxication and withdrawal states is necessary.  Adequate staffing is critical.  There needs to be a definite team approach, all of the staff on the unit need to be aware of the potential for violence, and the priority needs to be on protecting the nursing staff delivering direct care to the patient.  Medical staff and nursing have to be on the same page and there can be no factors present that lead to split treatment.  Enlightened administrators may be helpful in preventing that dynamic, but in my experience I have not found any.

One of the common problems is that staffing on some of these cases involves 1:1 observation preferably by a trained psychiatric technician or nursing assistant who knows how to help patients de-escalate.   Just having a reassuring person in the room can often have the same effect.  There are protocols that address the physical environment to reduce the likelihood of post operative delirium.  Where necessary it is useful to have experienced staff treat acute agitation in hospital settings with medications.  Some large hospitals have psychiatric consultation 24/7 to address the problem and in some cases where the patient is medically stable transfer them to a more secure psychiatric environment for assessment and treatment.  Medical and nursing staff need to be in close contact 24/7 in order to make rapid adjustments in the treatment plan.

Making the aggressive behavior associated with explainable medical problems a crime is the wrong approach.

When I see legislators talking about what medical professionals do or do not know about containing violence and aggression my typical response is to cringe.  I put it on the long list of all of the other things that legislators think they needed to train physicians in - like how to prescribe opiates (in the year 2000) and then how not to prescribe too many opiates (in the year 2010).  There are plenty of people who come out of training who known how to assess and treat aggression.

They are called psychiatrists and psychiatric nurses.




George Dawson, MD, DFAPA            

Why Would A Psychiatrist Carry A Gun?

I thought I could resist commenting on this issue, but after seeing what the press did with this issue today - somebody needs to set things right.  What may be going through a psychiatrist's mind as they think about arming themselves?  I don't need to speculate about another psychiatrist.  As I recently posted, I have had to make the decision and in talking it over with colleagues many of them had to make similar decisions.  It is definitely not a linear process.  Here are some of the elements:

1.  Contact with aggressive and violent patients who have severe mental illnesses:  In another recent post - the most familiar scenario is the person with paranoia or a severe personality disorder and who uses the psychological defense of  projection or projective identification.  In the popular vernacular a person who tends to blame other people for their problems, even when there is no realistic connection.  That can happen to psychiatrists because of the unique a aspects of the relationship and nature of treatment, but it can also happen to other physicians, therapists, and counselors.   In many  cases the blame is projected onto anyone who works for the organization or clinic and that puts everyone in danger - including the clerical staff.

2.  A significant substance use disorder:  The usual scenario is the severe psychiatric disorder, aggressive behavior and a substance use problem.  Most intoxicants are disinhibiting and they have the potential for activation, increased paranoia, and increased psychosis with impaired judgment.  They can also lead to aggressive or suicidal behavior that occurs during blackouts.  That not only increases the likelihood of action on a threat but makes any contact with patients in this context very problematic.  That includes crisis intervention centers, emergency departments,  acute inpatient psychiatric facilities, and detox facilities.  It is crucial that all of these settings have adequate staffing and crisis plans to contain both any  aggression that occurs and ways to limit access to people with weapons or people who are out of control.  In some cases patients with acute intoxication need to be rapidly sedated to prevent self injury or injury to staff.

3.  A specific threat against self or family:  Any threat needs to be taken seriously and this is also a training point.  Every mental health professional needs to learn how to address this issue and the first step is to make sure that everyone in the workplace is aware of the threat.  A threat assessment needs to be done and matched with the appropriate plan.  Those plans could range from an immediate call to the police, emergency hospitalization,  civil commitment, and interventions about how the clinic or hospital will interact with that person in the future.

4.  Police involvement:  This is not a debate about gun rights.  Nobody tells you in medical school that homicidal patients are an occupational hazard.  Nobody tells you that if somebody threatens to kill you - you may be on your own.  When you hear about some of these scenarios on television and in the movies one of the themes typically is:  "Well these are just threats.  He/she hasn't actually done anything yet so we can't do anything."  That was a very common attitude from law enforcement 20 years ago.  

Attitude problems can also exist at the court level.  I have testified in hearing about threats where it was suggested that this was an occupational hazard for psychiatrists and therefore less relevant as evidence of criteria for commitment.  Nursing staff are also subjected to these illogical attitudes.  Assaults on nurses are commonly viewed as an occupational hazard and the administrative response is generally that the responsible patient is never prosecuted.  In this era where civil commitment is often watered down to the point that it is completely ineffective, court ordered treatment from a criminal rather than a civil court may be the only available treatment.

A lot of laws have changed in the past two decades and the police should be able to do a lot more at this point.  In recent cases of telephone threats, even very indirect telephone threats, the police will often make a visit to the person making those statements and explain new laws about terroristic threats.  Any mental health professional should not accept the idea that something beyond a threat needs to happen before law enforcement can get involved.  The only action necessary is a threat.  What the police actually do is frequently a determining factor in whether a firearm is acquired.

5.  A secure treatment environment:  There are many aspects to this dimension including access to the physical environment, staffing, and the security arrangements.  Are there security cameras?  Are they actually monitored by security staff.  Is physical access to the environment limited to a few staff?  Most inpatient psychiatric units are locked.  I have been grateful many times that the locked door was more useful for keeping people out rather than preventing patients from leaving.

6.  An awareness that psychiatrists and other staff are killed by aggressive patients:  This happens frequently and it has been going on for a long time.  It tends not to make the papers anymore.  Here is an old New York Times article that was uncharacteristically blunt about the problem.   It described a full spectrum of homicidal aggression toward psychiatrists back in 1983.  That was the same year that I became an intern and I don't remember ever seeing this article.

7.  A functional administration:  Lack of an administrative support that prioritizes the treatment of violence and aggression and an associated systems approach to violence prevention is critical.  The appearance that a single psychiatrist is in a confrontation with a potentially violent and aggressive perpetrator needs to be avoided at all costs.  Staff splitting that encourages patients to act on aggressive wishes toward a staff member need to be avoided at all costs.  This may sound like common sense function, but in my 30 years as a psychiatrist, I have never seen a situation like this handled appropriately by administrators.  In fact, I have seen just the opposite when administrators dislike a staff person and suddenly there are rapid succession of administrative, staff, and patient problems focused on that person.    

It is very likely that the business oriented, "customer friendly" approach to patients that has been promoted by managed care has the potential for making these situations much worse.  It is hard to imagine a worse situation than to find out that a potentially aggressive patient who has threatened you is now being taken seriously by various patient representatives, customer service representatives and ombudsman.  Many of these patients realize that the state medical board is a gold mine in terms of being able to continue the harassment of the object of their aggression.  Multiple complaints against multiple parties can be filed even when it means that egregious threats made by the patient are included in the medical documentation will be sent to the medical board.

8. Dynamic issues:  There are a number of critical issues related to individual and group psychodynamics.  I have heard the term "therapeutic grandiosity" used to describe a situation where a psychiatrist failed to anticipate a dangerous situation and ended up injured or killed.  I think it is far more likely that the psychiatrist involved did not recognize different conscious states of the patient and the fact that one of those conscious states was capable of severe aggression.   Many people seem to be confused about legal definitions or reduced capacity here.  The law believes that a rational act that is internally consistent with a given psychotic state means that the person is responsible for their actions.  Every psychiatrist knows that there are mood disordered and psychotic states that result in decisions that the person would never have made if they did not have a mental illness.  One of those decisions is deciding whether or not to become aggressive toward their psychiatrist.   Making that determination can depend on very subtle findings.   If they are missed and there is an agreement to meet about an issue, especially if it is after hours the clinician may find that they are interacting with an unexpected person.  The structure of a clinic schedule and a crisis plan for that clinic can provide a basic background for not making these mistakes.

On an individual level, it is possible to view a patient's aggression as a personal failing on the part of the psychiatrist.  Many psychiatrists who have been assaulted are full of doubt about what they missed and whether the care being provided was adequate.  It is easy to lose sight of the fact that any physical aggression toward a physician is grossly inappropriate.  In the cases I have been personally aware of most of the psychiatrists were spontaneously assaulted and were not even interacting with the aggressive patient at the time.  In many cases the assaults occurred by patients who did not even know them.

There are also interpersonal dynamics that are disquieting at times.   Other staff speculating on the origins of the assault or threats, acting like the aggressive behavior can be interpreted.  This often occurs with little knowledge of the patient and their unique characteristics.  In some cases assaultive behavior is explained away on psychological grounds and the person who has been assaulted is unsupported  and alienated from the rest of the staff.  In my experience, this is a very dangerous position for the the staff to be in.  In an incredible twist, the aggressor seems to have more support than the victim even when the victim has sustained obvious injuries.   Although it has not been studied, it would not be surprising to find that staff in this position would conclude that they have no support, can expect no help, and need to arm themselves or risk annihilation.

9.  Cultural hate of psychiatrists:  There is no doubt that the haters of psychiatry have some influence here.  It is always easier to perpetrate violence against any minority group that is routinely vilified in the media and seen as a stereotyped monolithic group.  The people involved may have difficulty distinguishing symbolic hate and annihilation from the real thing.

All of these factors come in to play in considering whether or not to arm oneself to ward off a potentially homicidal threat.   From the psychiatrists I have talked with, next decision is the threshold for self defense.  Do you carry a weapon or is the threshold your front door?  Are security cameras and alarm systems enough?  I knew a psychiatrist who carried a rifle with him when he was riding his lawn mower.

The critical factor comes down to the threat assessment and all of the mitigating factors listed above.

For anyone second guessing a psychiatrist in this position, the critical question becomes:  "Where would I allow anyone to kill me?"  Is that thought compelling enough to ignore competing ethical considerations, even though there is nothing in medical ethics about a patient trying to kill their physician?  Is that thought compelling enough to ignore the law in order to protect yourself and your family?  What is your threshold for making those kinds of decisions?

For people interested in stopping this kind of aggression, the points above are all considerations of what can be done to stop it cold - long before there is any gunfire.  At that level of analysis, psychiatrists thinking of carrying guns or walking around with them is really a sign as well as an outcome.  It is a sign that multiple systems in society and medicine are either inconsistent, have failed or been corrupted.  We have these systems in place in some places and they can work.  I have seen every one of them work well at some point and prevent aggression and violence.

Fixing that larger problem should benefit everyone including the involved patients.

George Dawson, MD, DFAPA