Jan 30, 2013

The Five Step Way to Think about Security, Suicide and Guns

As Mark Cross testified today at the U.S. Senate hearing on gun violence, “When dangerous people get dangerous guns we are all more vulnerable.”

But who is too dangerous to own weapons? What weapons are too dangerous? And what will be effective security to stop dangerous people gaining access to weapons?

The answer to these questions depends on context. When considering if it is too risky for someone to have access to a gun, one choice may be right for public policy, but another may be right for our homes.

Answers also differ based on a person’s point of view. As we listen to people offer answers to these questions, we can spot the mental lenses the speaker uses to frame the issue. One person views the issue from a moral lens. Another may use a gun rights lens. Someone else has a lens tuned in to the rights of people with mental illness. Another may use a lens tuned to safety.

All these points of view help us make choices about security. Security involves trade-offs and choices. Real security depends on rational, not emotional, process.

Security expert Bruce Schneier notes
Security is not an isolated good, but just one component of a complicated transaction. It costs money, but it can also cost in intangibles: time, convenience, flexibility or privacy... No security is foolproof, but neither is all security equal. There’s cheap security and expensive security. There’s unobtrusive security and security that forces us to change how we live. There’s security that respects our liberties and there’s security that doesn’t. There’s security that really makes us safer and security that only lets us feel safer, with no reality behind it.
In his book Beyond Fear: Thinking Sensibly about Security in an Uncertain World, Schneier offers a framework for thinking about security choices.

Step 1 – What asset are you trying to protect?

Schneier says that people often forget this step. Protecting schoolchildren from foreseeable harm, protecting families from violent intruders, and protecting public spaces from stray bullets are separate problems, with separate security solutions.

Step 2 – What are the risks to these assets?
The issues here focus on the need for security. What is being defended? What are the potential consequences of a successful attack? How might the attack be carried out? What motivates the attacker?

Step 3 – How well does the security solution mitigate those risks?
If the proposed solution does not actually solve the problem, it’s not a good option. This is a complicated step, because every countermeasure is imperfect. Solutions that are not 100 percent effective may still be appropriate if vulnerabilities in the potential solution are addressed by other parts of the security environment.

Step 4 – What other risks does the security solution cause?
This is the “unintended consequence” issue. Every action in a complex system has ripple effects. Many things that look good at first glance actually make the overall system more fragile. According to Schneier, “The trick is to understand the new problems and make sure they are smaller than the old ones.”

Step 5 – What costs and trade-offs does the security solution impose?
Schneier’s point is that every security effort has costs and trade-offs. Often the cost is money, but trade-offs can be anything from the loss of personal freedom, to increasingly complicated transactions and loss of convenience. Is the security advantage you gain worth the cost?

Let’s try applying this framework to the issue of removing guns from households where a person has a risk of suicide.

Step 1 – What asset are you trying to protect?
The assets to be protected are the person at direct risk, the other people who live in the house, the first responders who might come to the scene, and unforeseen external targets who might be threatened by the way the suicide is carried out (e.g. through a rampage shooting suicide attack).

Step 2 – What are the risks to these assets?
Suicide is an infrequent occurrence with terrible consequences. The person at risk of suicide has some factor that makes the situation more dangerous and risky. For each of the other potential targets, the frequency of exposure to the risk may diminish, but any occurrence involves potential mortal danger.

Step 3 – How well does the security solution mitigate these risks?
Removing guns substantially lowers the potential dangers within the household. It reduces potential lethality of any suicide attempt. It increases opportunities for rescue. It reduces lethality of spontaneous or impulsive action. It offers opportunities for others in the household to defend themselves, interfere with the commission of a suicide, or escape. It places obstacles in the way of people who might attempt suicide only if it is imagined to be immediately lethal and therefore painless. It requires a suicidal person to confront more complicated, bloodier and painful methods of harming themselves. It permits someone to stay with the person at risk without fear of encountering mortal danger. 

Step 4 – What other risks does the security solution cause?
The person whose weapon is removed may become angry and react in an aggressive manner, but this will likely be transitory and less lethal than the potential violence of the situation before the weapons were removed. A person intent on harming himself or others may commit a crime in order to obtain another firearm, but this only replaces the pre-existing risk.

Step 5 – What costs and trade-offs does the security solution impose?
The person who removes the weapons may face potential liability for the action, but very likely has a valid defense of necessity in view of the elevated risk of suicide. The person deprived of access to his weapon loses access to his weapon. On the other hand, the situation within the household is much safer. 

Think about security in the larger context. Imperfect measures like traffic signals keep people safer. They don't prevent all traffic passing through, but we are safer because of them.

Jan 28, 2013

Jail suicide prevention lessons for post-Newtown America

When I was putting together suicide prevention training programs for courts and jails, one of my favorite resources was Jail Suicide/Mental Health Update, a quarterly newsletter from Lindsay Hayes, Project Director of the National Center on Institutions and Alternatives.

Every issue reinforced a single concept: You can’t base safety policies on what inmates say about their intentions.

Case after case of death in custody involved a quote from a deputy jailer about the deceased inmate to the effect that “the decedent denied that he was suicidal.”

Jail suicide experts know the correct response to that denial is “So what.”

Effective suicide prevention, like any security process, involves more than one line of defense. Certainly one must do more than rely on what a person in custody says. As Kay Redfield Jamison notes in her book Night Falls Fast, “If suicidal individuals were either willing or able to articulate the severity of their suicidal thoughts and plans, little risk would exist.”

Effective jail suicide prevention programs are systematic. They involve multiple overlapping sets of proactive measures: Intake screening that takes objective factors into account. Access to mental health services. Observation. Safe environments.

Systematic suicide prevention saves lives in jails. It can save lives in our larger society too. It is our best hope for preventing mass murder tragedies like Columbine, Virginia Tech, Sandy Hook, the Portland mall shootings, the Aurora theater killings, the Sikh Temple shooting, the Chardon school shooting, and others.

Mass killers are suicide killers, with homicidal intent layered on. According to Adam Lankford’s new book The Myth of Martyrdom: What really drives suicide bombers, rampage shooters and other self-destructive killers, these “indirect suicidal killers” inflict damage on others to induce their own deaths. Consciously or subconsciously, the attacker is telling a story of bravado or revenge or martyrdom, in order to hide a life filled with failure and rage, and cover over the stigma and disgrace of conventional suicide.

The only effective mass murder prevention strategy is bigger than gun control, bigger than mental health. It’s suicide prevention. At a minimum, the strategy must address three elements.
  •     Suicidal intent
  •     Access to weapons
  •     Access to targets
More to come.

Lankford, Adam. (2013). The Myth of Martyrdom: What really drives suicide bombers, rampage shooters and other self-destructive killers. New York, NY: Palgrave MacMillan

Jan 25, 2013

Mental health system dissenters join the civic debate about safety and risk

The mental health community has never had a day without conflict. Our system was invented by 19th Century old-school men with bourgeois values. They had dim views of women and a number of power trip hang-ups. Yes, there has been progress, but even today there’s an undercurrent of conflict with, and sometimes even disdain for, the people the system serves.

One thing the system has been good at is perpetuating fear and stigma. The privacy enshrined within mental health care systems implies that what people share is shameful, and that people have good reason to be afraid to talk. Those who reject the system’s conceits,  and those who have been traumatized by its coercive strategies, find themselves labeled as outcasts. People who disavow the system are shunned. This deprives our larger society of opportunities to hear the truths that system leaders do not want to have made known.

After 125 years of contemporary psychology, we have ended up with two, parallel, sealed up, self-reinforcing mental health communication silos. One is the mainstream system, the other is the world of mental health dissenters. People who have opted out and people who have opted in pitch rhetoric at each other, and flame each other on the internet.

I believe both sides have something valuable to say. At the very least, everyone is safer when everyone has a way to communicate about wellness, safety and risk.

I’ve teamed up with Corinna West and her team at Wellness Wordworks to convene an event that aims to bring dissenting voices out. My part is to listen, and to offer opportunities for everyone to pitch in.

The central hub for what we’re planning is a Cincinnati-based conference weekend February 15-17. See the  Facebook event link that follows this post. I am excited about the prospect of more civic engagement about mental health. I’ll report back in as this progresses.

The Facebook event can be accessed here:

Here is the full announcement.

Doing, Thinking, Feeling: To move beyond emotional distress we must learn to have conversations about stuff we've never talked about. How do we find language and share peer support for this? We are merging mental health advocates with two back to back community engagement conferences in Cincinnati to move peer support out of our silos and across the entire country.

On Friday, February 15, join the audience at the Innov8 for Health Idea Expo. Listen to the best and newest ideas to change health care, get inspired to find your own new approach, and support mental health pitches from Corinna West and Paul Komarek, the event hosts. Afterwards, we’ll gather to dine and debrief.

Innov8 for Health: http://innov8forhealth.com/

On Saturday, February 16, our group of mental health advocates has a special invite to join Cincinnati’s Neighborhood Summit on the campus of Xavier University, where we are learning skills to connect and grow communities in any city.

Neighborhood Summit Information and Registration Linkhttp://www.investinneighborhoods.com/summit.html

On Sunday, we are hosting an Unplanned Unconference: everyone that wants to present something pitches their ideas at the beginning of the day, then we put ideas into time slots and people vote with their feet. Corinna will present about Connect Power, a time banking program that allows 17 way barters and unlimited jobs for peer supporters.

There's lots of time for fun, family, sightseeing in Cincinnati, with many great museums and an award-winning zoo.

Cincinnati Museum Center: http://www.cincymuseum.org/
Cincinnati Museum of Art: http://www.cincinnatiartmuseum.org/
Cincinnati Zoo & Botanical Garden: http://cincinnatizoo.org/

Cost to participate is $25. We are organizing a block of rooms at a local hotel. Free lodging at crowdsurfing.com and cheap lodging at airbnb.com. We hope to fund 6 X $150 travel scholarships through a crowdfunding campaign. Food expenses are on your own except lunches during the local conferences.

This event is limited to the first 36 registered participants - register by RSVPing yes here at this facebook event link and pay using the donate button on http://wellnesswordworks.com/

Jan 22, 2013

Best comment by a police officer on the ramifications of armed teachers in schools

I read this comment on a Police One website post.

My nightmare is responding to an active shooter situation and upon entry, several civilians in a hallway with guns. I'm not clairvoyant! I hope this concern is being addressed. If the shooter is terminated before we get there, fantastic. We still have to clear the bldg. 

Read about Ohio's active shooter training for school teachers here

Jan 19, 2013

Suicide and gun risk are worth checking out

Lately I've been reading blog posts and news items contending enhanced mental health gun purchase background checks will increase mental illness stigma or infringe somehow on a person's rights. I don't think so. I also believe that doctors who encounter people with mental illness must inquire about weapons in the home. The issue is risk. Not just a person's individual risk, but also risk to bystanders and first responders.

Suicide attempts are not just lonely tragedies with one potential immediate victim. The presence of weapons puts others in danger too. A good illustration is the report of the Portland Police Bureau's mental health calls for service from November 30, 2012 through mid-January 2013, which the Mental Health Association of Portland posted to its blog. http://www.mentalhealthportland.org/?p=18010

The report lists 27 separate incidents over 45 days. Seven of the incidents involved guns. Eight involved knives or swords. Most were incidents in progress. Many of these cases required police to disarm unstable people. These were dangerous events.

I believe recovery is about maximixing a person's capacities, reducing vulnerabilities, improving capacity to handle stress, and addressing the risk of something going wrong. I'm not pre-judging any particular individual's suitability to be a gun owner, but certain factors are known to indicate increased risk of suicide. People with these factors should not have access to lethal weapons. Suicide risk threatens others too.

Jan 17, 2013

Sanity and the Sandy Hook Plan

The President’s plan to address gun violence in the wake of Sandy Hook is far stronger on gun control than it is on mental health, but I am not unhappy with it. There is a built-in Round Two that offers real hope for progress.

Of the dozen legislative proposals, only one aims squarely at mental health, providing financing to expand mental health programs for young people. There’s more mental health content among the 23 executive actions, but most of these are leftovers, overdue action items addressing technicalities within the health care system.

It’s the last item on the list that offers hope for the future:
Starting a national dialogue on mental health led by Kathleen Sebelius, the Secretary of Health and Human Services, and Arne Duncan, the Secretary of Education.
That dialogue may actually help us turn a corner. We need to talk about mental health to change mental health.

I volunteer to host the first chat.

Jan 11, 2013

World's biggest task force, but nobody says anything new

So we have just had these big post-Sandy Hook come-to-Jesus meetings. NAMI and the NRA walk in the room. Which group says something new?

Neither.  The gun folks say we need more guns. NAMI says to write more checks for more services. We have seen these talking points before.

Gun control is one thing. Let's do what we can in that area, but let's do something real for mental health.

Implement my plan. You can find it right here.

-- Access to treatment. Set up phone centers so everyone can find the right way to get service.

-- Housing. Put more money into affordable housing for people with mental illness.

-- Criminalization. Invest in diversion programs at every level of the criminal justice system.

-- Police killings of people with mental illness. Improve training protocols for law enforcement.

-- Violence and suicide connected with mental illness. Better communication, coordination and data exchange. More emphasis on ordinary people getting training.

-- Suicide among veterans and military personnel. Increase the capacity of soldiers, families, churches, community groups and employers to detect problems as they are developing.

The single interest institutional groups have only talking points. To rethink mental illness, start with the capacities of ordinary people. Let everyone use the skills they have.

Vice-President Biden, a few new items for your mental health plan

Vice-President Biden

I heard you were going to address gun control on Tuesday. Here's an update on mental health.

In addition to my original post here and my update about states that don't fund the most they can under Medicaid, here are some additional things worth considering that I collected from comments on a LinkedIn forum.


In the housing area, add "changes to the rules governing creation of housing for the disabled." Today's rules make it very difficult to house more than 4 - 6 people with disabilities together. Yet those with significant issues need additional staffing, and the economics just don't work to handle them when housing only 4 - 6 people. The result is that what housing exists goes to those who are the easiest to care for, while those who may have occasional behavior challenges are left out. This is akin to building a hospital, but leaving out the intensive care unit because those patients are too difficult! When the difficult patients with mental illness get ignored, we end up housing them in prisons or having them homeless on the streets, like the woman who pushed a subway rider to his death last week. No, we don't need to return to the days of institutions for 400 people...but we do need some 12, 18, 24, or 30 bed options for those who would do better in such a setting.


This is a very good plan....I've worked on CSU (crisis stabilization unit) for 5 years and these are good points to develop a unified guideline from a national level, with room to tweak at state and city levels.
However our largest population right now are young people 18-25, who resist the belief that they are ill and refuse medication and terrify their families. This group will slip between the cracks, even with this well-developed plan, leaving them to possibly become the most dangerous,,,,,.
I spend every day looking for answers to encourage this group to accept the help they so gravely need.

Establish additional collaboratives in the community to help families learn and identify MH and also to help providers learn about cultures that would prevent folks from getting care.

And one final matter:  Please ask families to start talking to each other about how they feel. Family members are usually the only ones who can sit with a person in trouble to figure out a way forward. This is not some technical issue.

For people who need reminding about how to start a conversation, here is a little script, just four questions.

-- What have you accomplished since the last time we met?
-- What are you facing?
-- Who are your allies?
-- What is your plan?

If someone detects hopeless, isolated, tunnel-vision thinking, follow up with a direct question about suicide: "Are you thinking about killing yourself?" and if the answer is yes, stay with the person, and call the national suicide hotline 1-800-273-8255.

Jan 7, 2013

The political economy of Medicaid and mental health

Uniform levels of good care for people with mental health issues will only happen if America federalizes mental health care, and fixes Medicaid rules to make mental health services economically feasible for healthcare providers. In essence, this means restoring Community Mental Health Center funding, the mental health funding stream created by the Kennedy Administration, expanded by the Carter Administration and wiped out by Ronald Reagan.

We have Medicaid, but Medicaid is not a uniform system. The quality of Medicaid depends  on the extent to which individual states are willing to impose taxes to pay for services. In states with a high degree of income disparity, tax rates are kept low in order to benefit the most powerful residents, and the poor – which includes most people with mental illness – are left to suffer.

Consider, for example, Texas, which has decided not to participate in the Affordable Care Act’s Medicaid expansion.
  • 16.5% of Texans live in poverty
  • 25% of Texas children live in poverty
  • 24.8% of Texans do not have health insurance
  • Texas ranks 1st among states in the percentage of the population that is uninsured.
  • Texas ranks last in per capita mental health spending.
Because Texas will not be participating in Medicaid expansion, even parents of young children (the largest category of "medically needy" Texans) will continue to have less access to mental health services than parents elsewhere in the US.  Parents of young children must be "super poor" to qualify for Texas Medicaid. According to a 2011 report from the Mental Health Policy Analysis Collaborative,
The 2009 income threshold for jobless parents with dependent children applying for Texas Medicaid is 13 percent of Federal Poverty Level (FPL), or $2,256 [per year].Working parents can earn up to 27 percent of FPL, or $4,824.These income thresholds are less generous than the US average of 41 percent and 68 percent, respectively.
In Texas and other states that do not maximize access to Medicaid,  what ordinary people who need mental health services get is crisis-only care in hospital emergency rooms.

“If someone shows up with an acute mental health crisis, you get in the door but when your crisis is over you go on a waiting list,” NAMI Texas Executive Robin Peyson said in a 2011 interview. “You wouldn’t put people with diabetes on a waiting list, they’ll die.”

A separate Medicaid reimbursement rule restricts access to inpatient care even for Medicaid-eligible people who need that level of service. According to the Mental Health Policy Analysis Collaborative,
Patients can only be admitted (with payment) to general hospitals that have psychiatric care. This type of facility is very limited in Houston as most psychiatric beds are located in free-standing psychiatric facilities. This limits access for indigent patients and causes financial loss for those facilities treating these patients…As a result of this occurrence, many facilities have reduced their bed capacity so as to not have to take on this additional population without reimbursement.
Medicaid’s so-called Institutions for Mental Disease rule limits access to inpatient care not only in Texas, but throughout the United States.


Study: Texas Ranks Last in Mental Health Spending. (2011). The Texas Tribune. Downloaded 1/7/13 from http://www.texastribune.org/2011/11/10/texas-ranks-50th-mental-health-spending/

Mental Health Policy Analysis Collaborative. (2011). Medicaid in Harris County A Mental Health Perspective. Houston, TX: Author. Downloaded 1/7/13 from http://med.uth.tmc.edu/departments/psychiatry/mentalhealthanalysis/medicaid.pdf

Jan 2, 2013

Families recover from mental illness too

A child’s mental illness can turn a parent into a helpless bystander, a witness, sometimes an enemy. I have heard so many heartbroken people talk about what happened to their grown-up children who saw nothing going wrong with their lives, and no need to talk with anyone about it, let alone a need for treatment.

There is a pattern to this. As parents react to alarming conduct, and as the child reacts to the experience of life, a battle of wills eventually turns into a frustrating tug of war.

It’s a tug-of-war that everyone can lose. People at one end of the rope get dumped in the pit, while those at the other end fall down backwards. When this happens, people disappear. I know one family who spent their weekends looking in shelters and under bridges in cities 100 miles away trying to locate their son. When I worked at Social Security, we had clients who disappeared for months on end, receiving their monthly checks on a stop-start basis. Their parents would come in asking for clues, and workers would listen even though we couldn’t offer much help. And I can’t even begin to count the number of times I have encountered systems failures that ended in overdoses, suicide or murder. That’s when parent-witnesses tend to show up, and tell the hardest stories.

But I have also seen things work out better. I have seen families recover from the effects of mental illness in exactly the same way that any individual does. Imagine calling an end to the tug-of-war. The game ends with nobody in the pit, nobody falling over. And maybe the rope is still worth holding on to.

It takes time, but this is something that families can decide to do, something that pays dividends. Recovery for families is the same as anyone's recovery from a serious illness. The focus is just wider. It becomes a process of building a family’s capacity, empowering every family member to overcome the effects of the illness.

Every family has a mix of strengths, talents and abilities, a variety of vulnerabilities, a certain capacity to withstand stress, and a certain risk of harm when things go wrong. We can build a family recovery plan from these four elements, by answering four questions and considering everyone in our family as we think things through. What helps us make the most of our talents? How can we reduce the areas where we are vulnerable? How can we improve our ability to cope with stress? How can we deal with the risk of something going wrong?

Connect the answers with a little bit of strategy, some basic framework that people have been using for centuries to grapple with difficult challenges. Learn about what we are facing. Recruit allies to help us. Find resources to work with. Plan long term and short-term. Follow the plan.

The first step, learning, is not just aimed at problems. It also pays to think about strengths, and about process. Learn as much about how families work as you do about the challenge you are confronting.

Families are strong medicine, built from years of intimacy, learning, emotions, and shared culture. If you are a parent, your key strength is the relationship you have with your child. Look for areas that you and your child agree on. You love your child, and your child loves you, or at the very least probably wants to love you. Everyone wants each other to be safe. Everyone needs groceries. Everyone wants a way to stay in touch. Everyone wants the others in the family to succeed in the world. Everyone deserves independence, autonomy, freedom of action, a sense of purpose, relationships, faith, future. Everyone should take care of themselves, stay healthy. Everyone knows that families have disagreements. When someone has been harmed, there’s accountability and forgiveness. It’s okay to make mistakes and learn what works. Do what you must to preserve family life, no matter what. This is a goal, not just a tool.

Also be aware of the process of change. Change is a process that moves in stages. There is “precontemplation” (when something is not even on a person’s radar) then “contemplation” (once someone notices a blip) then “engagement” (when a person takes action) then relapse prevention. Your goal is to get the message on the radar (move past precontemplation) usually with very cheap low-intensity messages, since even sirens and shouted warnings will likely be ignored. You might try to focus on safety and remaining connected, or finding something about the future to aspire to. Once the person begins to notice discrepancies or problems (contemplation) you can amp up your efforts to prompt the sort of learning that moves the person to the point where they take action (engagement).

Recruiting allies is another step. Allies provide support and expertise. Line up a lawyer to advise on legal options. Find a medical advisor to advise about a path to wellness. Every medical person counts “restoration of family life” as important. Try to find advisors who will work with the whole family. If everyone has compatible goals, even confidentiality barriers can melt away (with the right paperwork).

Resources are important too. Family relationships are not only important to a person’s identity, and a key goal of health, but also connect with resources. Economic capacity is not spread evenly in families. People have always depended on each other.

You can plan short-term and long-term. For example, you can list things you can do right now to maintain safety and relationships, and you can visit the library or do an internet search to set a goal or figure out what needs to happen later, when the time for action arrives.

The final step in any strategy is to follow the plan. Try to match things you do for now with something that will come in handy later.

Recovery is a tough sell sometimes. It’s a process, a struggle, not a goal. We want the people we love to find relief, but we do not experience the unpleasant aspects of treatment in our own bodies. And we are all capable of actions that hurt or alienate people we love. But the payoff for aiming at a family-supported recovery, or a recovery for our families, is pretty good. We’re no longer witnesses because we are active participants, partners and teammates. For many people whose families have been walloped by mental illness, the simple opportunity to face a challenge together is a victory.

I have been reading up on strategies to connect with people who are experiencing psychosis. Every one of them involves building a relationship, and thinking through issues together. The relationship is as important as the cognitive training process. People learn and feel their way through recovery, and do better when they are not alone.