Mental Illness and Violence Toolkit Robert W. Glover, Ph.D. Executive Director National Association of State Mental Health Program Directors
Toolkit Purpose This toolkit is intended to serve as a resource for State Mental Health Commissioners, policymakers, advocates, and others who need to navigate high profile incidents in which individuals with mental illnesses commit violent crimes that capture significant media or legislative attention. The project is a joint venture of NASMHPD and the Council of State Governments.
What makes an incident high-profile? Prominent media coverage, likely to contribute to stigma against people with mental illnesses When violent acts occur and a person with mental illness is explicitly or implicitly related to the act When the perpetrator has a mental illness When the perpetrator is presumed to have a mental illness Does not include natural disasters (e.g., mental health system responses in the aftermath of a hurricane)
Pres. Reagan & John Hinckley Shooting Agents tracing Hinckley s path find a shift to violent emotion New York Times John Hinckley: Legally mad or just disturbed? Washington Post March 30, 1981
April 16, 2007 Gunman Kills 32 at Virginia Tech In Deadliest Shooting in U.S. History
Troubled state of Virginia Tech killer was known in '05 (April 18, 2007) Before Deadly Rage, a Life Consumed by a Troubling Silence (April 22, 2007)
Seung Hui Cho The Struggle to Understand a Killer THE VIRGINIA TECH SHOOTER Cho Didn't Get Court-Ordered Treatment Seung Hui Cho never received the treatment ordered by a judge who declared him dangerously mentally ill less than two years before his rampage at Virginia Tech, law enforcement officials said, exposing flaws in Virginia's labyrinthine mental health system, including confusion about the law, spotty... THE VIRGINIA TECH SHOOTER Isolation Defined Cho's Senior Year Hyang In Cho was so desperate to find help for her silent, angry son that she sought out some members of One Mind Church in Woodbridge to heal him of what the church's head pastor called "demonic power."
August 2, 2009 New Questions on a Tragedy; Two years after the Virginia Tech massacre, discovery of the shooter's mental health records should spark fresh inquiries
Arizona Shooting Tragedy January 8, 2011 After Tucson shooting, scrutiny on mental health cuts Our Take: Is alleged Arizona shooter evil or mentally ill? When the mentally ill turn violent Psychologists view Loughner as a man with serious mental issues going on
Mental health ward attacks in Australia Nurse almost killed after fears ignored ₁ 2011: Patient punched, kicked, and attempted to crush the skull of a nurse 2008: Patient stabbed a doctor multiple times in the face Blacktown Hospital ignored many high-risk safety concerns Nurse dies after being stabbed at Bloomfield Hospital in Orange 2 2011: Patient attacks and kills nurse Attacks and stabs second nurse 1. Vollmer, T. (2011, January 11). Nurse almost killed after fears ignored. The Daily Telegraph. 2. AAP. (2011, January 06). Nurse dies after being stabbed at Bloomfield Hospital in Orange. Sunday Times. Nurse from Blacktown Hospital
Man who slashed dad off medication: court -- January 4, 2011 Man slashes and stabs father with stolen knife Deemed having serious mental health issues Un-medicated Psychotic killer warned hospital he had thought of strangling baby -- June 30, 2010 Man murders 10-month-old baby Severe depression and psychotic features Told in-ward psychiatrists he thought of killing the baby Released to live with the baby s family before the murder
In the Australian community cont d Mental health system failed Tyler Cassidy ₅ -- 2008 15-year-old Tyler struggled and displayed signs of serious mental illness Confronted and threatened police with stolen knives Police shot and killed Tyler Tyler Cassidy 5. AAP. (2010, December 15). Mental health system failed Tyler Cassidy. Herald Sun.
Te Whetu Tawera Hospital Mental health worker stabbed, beaten by patient -- January 5, 2010 Patient stabbed, punched, kicked, threw boiling water on staffer Patient charged with attempted murder Patient attacked at hospital May 6, 2010 Te Whetu Tawera in Auckland, NZ Patient raped another patient Released patients committing suicides, murders Hospital under severe criticism 100 % occupancy Mental health care in parlous state
Suicides stir cry for action -- October 7, 2010 Increasing suicides Seven suicides in one month Criticism of mental health services for adolescents Mentally ill killer released on leave -- October 22, 2010 Man released, then viciously murdered his friend, about to be re-released unescorted again
December 9, 2010 Mother on charge of baby murder Mother released from Christchurch Hillmorton Hospital guilty of murdering and disposing of her newborn baby Murders and disposes of her second newborn baby in the same year Re-submitted to the hospital
What makes an incident likely to be picked up by the media? Sensational nature of the incident Perceived failure of the mental health system to provide appropriate treatment to the person (i.e., they slipped through the cracks ) Perceived failure of legislators to provide adequate funding to law enforcement or mental health treatment Perceived failure of the mental health system in collaborating with law enforcement and other criminal justice agencies
Virginia Governor Tim Kaine
The Truth About Mental Illness and Violence Denying that mental disorder and violence may be in any way associated is disingenuous and ultimately counterproductive (Monahan, 1992). Among persons with severe mental illnesses, substance abuse coupled with medication nonadherence is a significant predictor of serious violent acts (Swartz et al., 1998). However, most people who are violent are not mentally ill, and most people who are mentally ill are not violent (Friedman, 2006).
In the wake of such incidents, the public Often misunderstands the likelihood of violent behavior among individuals with mental illnesses and the role of the mental health system in preventing and/or responding to such incidents May believe that treatment is ineffective and that re-institutionalization in State psychiatric facilities is the answer
In the wake of such incidents, State Mental Health Commissioners must Respond appropriately to the specific tragedy Be champions for the principles of recovery Promote public safety Coordinate the responses of law enforcement, educational institutions, military installations, etc. Field media and legislative inquiries Many of these tasks seem to conflict with one another; all happen quickly, under intense pressure and outside scrutiny.
Toolkit Development Experts Meeting, Fall 2009, including: State commissioners who have been involved in highprofile incidents Advocates Crime victims Consumers of mental health services Media experts Professional writer and media expert developing text
Consensus on the need for Accurate, defensible information on the relationship between mental illness and violence Resources for 3 stages: before, during, and after a critical incident Backgrounders Fact Sheets Customizable checklists Disaster Planning Resources
Toolkit Outline Introduction/Background Anatomy of a Crisis: before, during, and after a critical incident (with resources in each section) Each of these three sections is divided into four parts: Understand your role Understand your agency Understand your State Understand Crisis Communications Additional Resources
Additional Resources Backgrounders: These provide background information about strategic issues, such as effective leadership and working with the media, and about politically sensitive issues you may be asked to address, such as outpatient commitment. Fact Sheets: These include information you can share with the public and the press to keep them better informed. Customizable Checklists and Contact Sheets: These are forms you can fill out to have vital information on hand such as list of contacts within your agency, State, and the media as well as to guide you during the high-pressure environment these incidents create. Mental Illness and Violence Literature Review
Backgrounder Topics Mental Illness and Violence Involuntary Commitment Standards Firearms Regulations/Gun Control Laws Understanding Privacy Laws Crisis communications Effective crisis leadership (with pocket card) Working with the media
Backgrounder Examples
Fact Sheet Topics (1) What Do We Know About Mental Illness and Violence? (2) Predictable Reactions to Trauma/Resilience
Checklist Topics Incident Response Checklist My Agency Emergency Contact List My State Emergency Contact List Content Experts Emergency Contacts List Media Contacts List General Contacts log Media Contacts Log
Before an Incident/Your role Understand in advance who will play a key role in shaping the message (may be the Governor s office). It is important not to step into a role that you don t have the authority or resources to take on.
Before an Incident/Your agency Internal communications checklist Who speaks to press Who receives updates and communicates with Governor/other lawmakers The need to develop or review formal policies Internal emergency management team checklist Who is a member How and when they are convened To whom they report What responsibilities they have
Before an Incident/Your State External emergency management team checklist Know your relationship to other agencies (e.g., Governor s office, police, substance abuse and public health agencies, military installations, etc.) Applicable State and Federal laws checklist Outpatient commitment HIPAA Gun registration Victims services Others Resources for information in these areas
Before an Incident/Communications Media checklist Contact information Advice on establishing working relationships with reporters Links to resources for communicating with the media in a crisis Fact sheet: Key talking points about mental illness and violence
Before an Incident: Example
During an Incident/Your role Compassion, action, perspective Fact sheet: Predictable reactions to tragic events Fact sheet: Responding to different communities (e.g., college campus, shopping mall, military installation, etc.)
During an Incident/Agency, State, Communications Fact sheets on what to do/what not to do Agency gather your emergency team; brief your public information officer State brief your external partners Communications make yourself accessible, with tips for how to do so
After an Incident/Your role Ongoing support Reassurance Information Resources Be prepared for anniversaries Be proactive in planning for future incidents Learn from your successes and your mistakes
After an Incident/Agency, State, Communications Fact sheets on what to do/what not to do Agency o Record everything you do o Review what did and didn t work; revise internal communications and emergency plans, as needed State o Anticipate calls for immediate legislative responses (with examples of how other States have responded) o review with partners what did and didn t work; commit to revise plans, as necessary Communications o Provide regular updates; keep local media in the loop, update contact lists, invite press critiques
Leadership During Disasters