When I started writing this blog, the country was still shaking from the shootings at UC Santa Barbara. Before I finished the first draft, the shooting at Seattle Pacific University had just ended. I am in rewrite today, one day after the tragedy in Las Vegas, and while writing this very sentence I learned of the shooting in Troutdale, Oregon.
Full stop!
America, we need to call a timeout, huddle up, and get an action plan going to stop the carnage.
To prevent the next mass murder-suicide we must, simply must, get upstream from these unfolding events and identify potential suicidal shooters before they purchase weapons, load up, and open fire. Yes, suicidal shooters, not homicidal ones.
I’ve covered this a bit in earlier posts, but bear with me. If suicide contagion is real (and it is), then so is murder-suicide contagion. See one, do one. Humans are highly imitative primates – and not just of good manners, but murder, means and mayhem.
For schools and colleges, one intervention recommended by some is to arm school employees, from teachers to school safety officers, and even students themselves. Armed resistance may reduce the number of persons killed and injured, but in my view it is too little too late. When bullets begin to fly, you’re into intervention, not prevention.
Stopping smoking is prevention; heart surgery is intervention. An armed employee or student can respond to an attack – if they are not killed first – but the homicidal-suicidal person who knows an armed target awaits him at his chosen location is likely to be attracted, not dissuaded, from action. His solution, after all, is to die in a hail of gunfire.
Mass murder-suicides (from Virginia Tech to Sandy Hook to UCSB to Las Vegas) are perpetrated by people who are suicidal first, homicidal second. Once the decision to die has been made – either by their own hand or by another’s – the second decision to seek “justice” for perceived wrongs provides only a final motivation.
These are not random acts of violence. Escapes are not planned. The shooter’s intention is to die, usually at the scene. Mass murder-suicides are premeditated, planned, and therefore preventable – if three things are done:
1. Train as many people as possible to recognize and respond to suicide warning signs. This is our collective responsibility to assure ourselves of a safe and sane society. On expert retrospective analysis of these events, suicide warning signs are inevitably present before the shooting begins. Suicide warning signs can be taught and acted upon to cause a formal threat assessment to be conducted, perhaps followed by voluntary or involuntary treatment or other risk mitigation interventions, e.g., denying access to firearms.
2. Train mental health professionals. Currently, few mental health professionals are well trained in how to conduct a comprehensive suicide/homicide risk assessment. More, too many do not routinely intervene with families to see to the removal or security of firearms available to potential suicidal or homicidal loved ones. Thus, even though a potential shooter is in treatment, there is no guarantee a competent risk assessment has been conducted or that all evidence-based risk mitigation strategies have been employed, including restricting access to firearms.
The training, by the way, is called Counseling Against Access to Lethal Means (CALM) and it is available free at: http://training.sprc.org/. It was developed by a dear colleague and friend and I cannot recommend it too highly. If you own a gun, you have a new duty: take CALM training.
3. Train law enforcement officers. Police officers are likewise not well trained to recognize and respond thoroughly to suicide warning signs. If they do detain a person for evaluation, they must rely on emergency room or mental health professionals to determine the level of risk and necessary action steps. But research shows that ED staffers know even less about suicide/homicide risk assessment than do mental health professionals. In the UCSB case, after a 10-minute welfare check, the sheriffs left a number and encouraged Elliot Rodger to call for help.
He didn’t.
Wake up, people…. suicidal males rarely ask for help, and homicidal-suicidal males never do. Or if they do, it is when taking the first steps down the trail to a tragedy for all.
This step might be taken in a therapist’s office, or in a conversation with a school counselor, or with someone who might, just might, be in a position to recognize that small but ominous cloud rising from a sea of mental anguish and torment “no bigger than a man’s hand.”
I am, admittedly, an impatient man. Waiting for troubled, angry, suicidal young men to ask for help before they start killing us is unacceptable. Enough with the waiting. If we have satellite spy cameras so powerful we can read a license plate from space, surely we are smart enough to figure out how to identify these people before they gain access to guns and start shooting.
(To my fellow Americans in the NSA reading this blog post: How about lending us all a hand here? As tax payers, you work for us not the other way around, right?)
Back to the cops who, in this case, and in my view, might have tried the slick Lt. Colombo maneuver to get into the shooter’s house without a warrant, as in, “Oh, by the way… I wonder if it would be OK if we looked around just to make sure, etc. etc.” Stiff resistance to this polite request would raise the index of suspicion and perhaps trigger a deeper investigation.
If police officers cannot be trained to detect suicide risk, and then conduct suicide/homicide risk assessments in the field, then pair them with trained mental health professionals and create competent, quick-acting crisis response teams who understand that early identification and intervention may go unrewarded by the general public, but is still heroic. Mental health/law enforcement teams must be fully funded to respond to these threats and yet, currently, many communities are without them.
In the UCSB tragedy it is clear that the two groups of professionals who had contact with Mr. Rodger before he started killing people did not, or could not, communicate with each other about the risk that alarmed his parents and a roommate. The parents acted, but the roommate did not, later saying, “Why did I not say anything?”
The parents did say something, but we can only guess that the professionals involved may not have had the kind of training needed to a) recognize suicide/homicide warning signs, b) conduct a comprehensive suicide/threat assessment, and c) employ their collective civil authority to cause a change in the trajectory of the unfolding event, e.g., a voluntary or involuntary hospital hold to determine how much risk to self and others was present.
It’s a cheap shot for me to opine about this UCSB event while unencumbered by the facts, or the reality of actually having been there, but I have reviewed all of the other high-profile mass-murder suicides in recent history and the pattern is the same again and again and again. And as an old spy myself (retired), I have a pretty good idea of what’s missing. It’s called Intel.
From the 1955 Hoover Commission on American spy work, “Intelligence deals with all the things which should be known in advance of initiating a course of action.” Intelligence is used to prevent violence, and we cannot expect our mental health and law enforcement officers to initiate a course of action to avert violence without better intelligence. The dots are there; they are just not being connected.
But what about confidentiality?
What confidentiality? When lives are at stake, confidentiality is moot.
Too often confidentiality is the screen behind which mental health professionals stand to protect themselves from extra work, like talking to parents or family members when conducting a youth suicide risk assessment. Yes, they don’t get paid for intelligence gathering beyond that provided by their patients, but they should, and this can be fixed with a stroke of the regulatory pen.
Any clinician who relies solely on the statements made by a suicidal and possibly homicidal patient to assess and manage potential risk for violence is either untrained or naive. (Sometime I will share my Top 10 Reasons to Lie to Your Therapist if You Are Suicidal).
When I directed a large emergency service for 25 years and had the authority to invoke involuntary detention to determine if treatment was indicated for anyone suicidal or homicidal or both, people sometimes threatened to sue us over their loss of privacy. None did. But if they had, I was fully prepared to make the case for a temporary suspension of a person’s civil rights in the name of safety for all.
Some say these mass murder-suicides are unpredictable and therefore cannot be prevented. I disagree. The dots are all there. Through training, education, better intelligence gathering, better intelligence sharing, and better communication among observers, we’ve shown we can greatly reduce American battlefield causalities. Now all we have to do is apply what we already know how do in our own back yards.
Dr. Paul
onsuicide 
What a wonderful articule, if we could only stop the madness.
I forwarded it to my son who is with SPD.
Thanks,
Anne
Thanks for the shout-out re CALM!
I do think we need to figure this out. However, it is so much easier to identify risks AFTER the fact than before. But, I agree – in most cases, the dots ARE all there just waiting to be connected. We need to train people to ASK and to move forward with their concerns – to involve others – who may/should also be concerned. I am wrestling with whether a civil society can protect both the right to bear arms and the right to privacy. One or the other perhaps.
As always, you make me think!!
________________________________
Paul,
Your blog is spot on, as always. When are we going to wake up?! However, please make your call for training more inclusive rather than exclusive. You point out the general public (“as many people as possible to recognize and respond to suicide warning signs”), “mental health professionals,” and “law enforcement officers.” We have discussed this before – the most trusted of healthcare professionals historically has been “the family doctor,” yet with our current incentives they absolve responsibility for mental health care to ‘the professionals.’ This is where and when the lag in getting help begins as few primary care clinics are integrated with behavioral health colleagues for same day access. Granted, primary care providers are becoming an ‘endangered species’ in our current healthcare delivery non-system. Crisis intervention rules the day in this country, not prevention. The Primary Care Team is where the first bread crumbs are dropped, loafs of bread, in most cases, if we’d only open our eyes and pay attention, listen. By aiming training needs on crisis teams without emphasizing primary care teams, we are missing a huge opportunity to provide the prevention you call for. That said, we must routinely intervene with families and trusted friends of the client to get the ‘rest of the story.’ Unfortunately, we let misunderstood HIPAA rules and misplaced civil rights get in the way of saving not only the public but the suicidal person themselves.They take this privacy and their rights to their graves. Street intervention teams, as utilized in Phoenix, are a great secondary and tertiary prevention effort, but primary intervention occurs best when primary care is informed when a client has become ‘known’ as a risk by their behaviors at home, school, and at work or play. A competent risk assessment must include family and friends as well. We are together on this point. Informed consent release forms listing trusted friends and relatives to call on when they are making life-threatening decisions must be signed on first meeting our client when they are first seeking help, not after they are depressed and/or acting out. And if the answer to the question, “Who’s your Primary Care Provider?” is met with a blank stare, we know where to start to rectify their lack of care – get them to a primary care team and include that team with intervention done by wonderful people doing good things, but currently silo’d by protected funding streams and lawyers recommending keeping information ‘private.’
Right on, George…. And you know we passed 2315 here in Washington to mandate at least six hours of training in suicide risk assessment, treatment, and management for all 148,000 primary care professionals licensed in our state. I like the idea of a first visit consent form signed that allows the provider to do what is in the best interest of the patient when it needs to be done, including talking directly with family members. An irrevocable release would be nice. As a lawyer friend once said of a patient discharged from our state hospital who died by suicide one day later – in part because the man’s family was never informed of the risks and actions that could be taken to reduce those risks – “At least he died with his rights on.” Paul
We also need to give family members the right to commit those who cannot/will not get help on their own. My brother suffered from deep mental issues and could not make rational decisions for himself. As a result he was repeatedly in confrontations with law enforcement personnel who came to know and understand him but what a waste of resources when involuntary commitment would have put him somewhere that he could have been supervised and medicated in ways to manage his illness. He died at 38! Thank goodness he did not hurt anyone but the potential was there.
I’m very sorry for your loss, Isaac. We have much work ahead, but things are beginning to move, and in support of families like yours. I’m watching a bill in Louisiana right now, and a resolution just passed both houses. Here’s a clip from a press release:
“(WASHINGTON, DC) The Louisiana State Legislature formally passed a resolution through both chambers urging enactment of the Helping
Families in Mental Health Crisis Act (H.R. 3717). Congressman Tim Murphy (R-PA), a clinical psychologist with thirty years’ experience,
introduced H.R. 3717 following a year-long investigation of the nation’s health system that he conducted as Chairman of the Energy and Commerce Oversight and Investigations Subcommittee.” You can Google the bill and learn more. Best, Paul
Isaac, so sorry to hear of your loss. You were there, willing to help, but our laws and services were not. Unfortunately, being able to be admitted to a ‘psych ward,’ voluntary or involuntary, isn’t the answer, either. I convinces a Vet to admit himself to a VA lock-up in March when he admitted he was losing it again, and they discharged him in two days without a single meaningful intervention or call of family and friends to become a safety net for him. The psych staff do not collaborate with primary care either. Very disappointing. Perhaps your brother and my son can give us some heavenly guidance from above?
Gun control is such an important factor. When will America recognize that and push to make it happen. Restricting access to suicide means works…it’s an important part of the answer. Unfortunately, gun access + suicidal intent = a “perfect” storm.
Ann, Unfortunately controlling one means only leads the weary to look for another method. Societies where guns are not available have shown us that. Clearly we must look at addressing depression and lack of belonging before that ‘dark place’ encircles them. But you are right, keep very depressed people away from guns, bridges, medications, ropes, etc. This is done by people putting their arms of safety around a loved one until the medical system responds. Access to meaningful therapy that includes caring family & friends is where suicide prevention begins and ends.
Thank you for this! I’ve been working on documentation for a potential issue. I work at a college and I’m adding this article to my documentation. I’ve found the hard way that doing the right thing can have consequences, but you will feel good about what you did in spite of any backlash.
I welcome backlash, Valerie, it means I’ve made someone uncomfortable. Paul
Paul, I will be asking my state senator and representative to follow in the pioneer foot steps of the state of Washington and require the same training in Kentucky. How many police officers have to state the same thing “they said they were suicidal and I took them to the emergency room. But, they were out the door before I could finish the paper work. If the hospitals are not going to require ER personnel to be trained to evaluate a suicidal person then lets put the requirement in place through state legislation. Keep up the great work, you are saving lives!!!
Another great one Paul…keep on keeping on.
Norm Braveman
nbraveman@hotmail.com
Date: Tue, 10 Jun 2014 23:13:01 +0000 To: nbraveman@hotmail.com
This is a great read – thank you!
Dear Paul;
Your email is as thought provoking as always. However, this one has even elicited action on my part. We are now encompassing into our patient intake forms a specific release of information regarding an individuals danger to themselves or others. We are quoting the WAC on this and some less governmental language regarding danger to self and others. We are also asking for three contacts: A family member, a close friend and a neighbor with all the contacts phone numbers, emails and addresses. We are also putting in language regarding the guidelines on confidentiality etc. and sweetening the whole thing about the care and concern we have for our patients and their welfare.
As I told you once before last year, we had a male therapist working for us who we kept sending new patients to and then they would not come back. I spot checked his notes and one in particular stood out to me: that of a 50 year old man who two weeks before had a shot gun in his mouth. This “therapist” did not schedule another apt telling me that the patient promised not to do it again and the patient understood his stressors and was OK. I couldn’t believe it! This therapist had been practicing therapy for over 30+ years. I got pretty emotional when talking to him about it (teary eyes and all) telling him how hard it is for a male, a man in his 50’s to come into a therapy office and share with a person he has never met before what serious behavior that he had had. This therapist had the guts to tell me, “In all my years of practice I have never lost a patient to suicide”. (You and I both know another guy who made the same claim, I told you about him when we first met 25 years ago). Believe it or not, I didn’t fire the therapist but insisted he immediately get supervision, gave him books to read etc. He chose to quit instead. My point is that even some therapists and psychologists don’t recognize or, are afraid to recognize, the seriousness of their patients mental illness and if they do they refer them out, I mean why break a “perfect” record.
If some trained mental health professionals are this clueless I can only imagine what the primary care physicians are faced with. Also, regarding PCP, our office communicates with the PCP or the referring physician anyway. I don’t believe it is a HIPPA violation from one medical person to refer to another, or is it?
Hi Janice,
Thanks for your good note and observations about a therapist with a “perfect record” and what appears to be “firing” suicidal patients. I wish I could tell you this is a rare event, but it is not – which is why mandatory training seems to be required. As to your question about HIPPA violations, I consider issues of suicide ideation, attempts, family history, and other known risk factors to merit disclosure to other providers with – and this is not hard – patient permission. If the patient will not agree, then suicide risk may be higher than first estimated, and a reassessment – including with family members – is in order.
Best,
Paul