Bombs and killers, what makes them tick?

About six months later I get a call out to the same county holding and when I hear the name I knew it was him. Then I found out that it was a busy night and since he was a minor we would have to escort him to a non locked building across the way with no back up. Thankfully my clinician in training was a big guy at 6'3.  I was fearful the patient would be really upset with me, I was the bad guy last time and it was clear he didn't want to go to the hospital. On the way over to the other building I told him it was a fresh start, nothing would be held against him, that we were here to listen to his needs but he had to be honest this time.   He was in fairly good spirits and didn't seem to care that it was me doing the assessment again. When we first sat down I said, " last time I wasn't sure what you needed, I told you I could be wrong but that I thought you needed to go to the hospital. Looking back, was I right or wrong?"  Then something profound happened, he openly and honestly said, " I needed to go. I didn't want to go. I had stashed the gun back in my room and had planned to go back and finish what I started. Because I went to the hospital, I wasn't able to kill myself. I needed to go."

How do you know?

This week has been sad. The Boston Marathon is a tragedy  Who does something like this? Why do innocent people and children have to get hurt?  For over 10 years I worked in the Mental Health field. My specialty, assessing children for suicide and homicide. I had to assess whether they would actually commit acts of violence against himself or someone else. How can you tell? What is at the basis of the mental state of someone trying to harm others or himself?

It's a complicated web that takes investigation. First, are they noticable? Do they look like the crazed deranged person portrayed on TV? Sometimes, I've seen both. Some are cool and calculating, those are generally the personality or conduct disorders. Some have overwhelming pain and agony from life or chemical/hormonal imbalance. They act out, yell, scream, make threats. I prefer the ones that are talking even if they scream. It's the quiet ones... those are the dangerous ones. 

I was called in late one night to the county 5150 holding for a teen who was reported by the school psychologist as suicidal. She stated that the teen told her, and a friend confirmed, that he had a gun, pointed it at his head, shot it but missed and it went into the ceiling    When he came in to be interviewed we asked him all the usual questions to assess suicide  How are you feeling? Has any major tragedy happened lately?  Tell us about the gun and what happened, etc. there's a 2 page list of questions. Some really basic and some pretty clinical. In the end  we couldn't get a read on him. He answered all the questions, seemed pretty pleasant, denied all the claims about the gun and said they just made it up (even though a parent confirmed the bullet in the ceiling so we knew he was lying but you wouldn't be able to know that unless we had concrete evidence otherwise). So I was perplexed, what do you do? No clear suicidal ideations, no crazy behavior, we were at an impasse  You cannot commit a child if they don't have a means, method or opportunity that can't be remedied.  We had none of the above. But we KNEW he was lying and we had a sinking feeling. So we used the oldest technique in the book good cop /bad cop.  I was the bad, I thought he needed to go to the hospital and be evaluated further. My partner did also but was less convinced so she did the "pleading on his behalf". I proceeded to poke and prod him, saying I wanted  to send him to the hospital because I believed he wanted to kill himself and  the other clinician didn't and so she and I began a verbal back and forth as to why he should and shouldn't go. All the while he grew more and more intense we could feel it but still no behavior. Then it started seeping out. First he started to clench his jaw, his words got tighter like a searing  he started to grab the base of his chair and locking his arms.  The other clinician and I saw it and had to keep going because we needed verbalization or behavior to show necessity to keep him for evaluation.  It didn't take long, maybe 5 minutes before he broke the chair in half and stood up rigid with fear and anger in his eyes. He was tall and lean and we were no match for him. The other clinician hit the panic button on the wall and two large men  (yes its true big guys come in but they weren't wearing white coats) and restrained him. He fought like he was doing battle with himself  Screaming and kicking, screaming and spitting. It was horrible. I know you are mortified, we were also... but there is more....
I was appreciative and honored by his honesty and stunned at how a bit of very uncomfortable prodding lead to a much needed intervention to save his life. On a side note, we hospitalized him again that night. He made the choice, verbally stated why he was feeling like dying and went peacefully to the unit. We saw him once more, that time we were able to avoid hospitalization and he and his dad worked out an agreement on how to be safe and what he needed. We never saw him again after that but, what if? What if we did the easy thing and took his word for it? What if  we did not work with the teacher, parents, and psychologist?  It's a very scary thought. We all need to know our kids and the kids they hang around with. 

Full Circle

So how do we know the kid or adult is going to want to harm himself or society? How can we tell if we are in danger?  There are lots of answers and lots of unknowns. Sometimes you can tell and sometimes you can't. The key is to be aware, ask questions, observe your surroundings and don't  ignore signs. For instance if your child is writing a story and it's full of doom and gloom, kids getting injured etc, and it's NOT part of the assignment to have that context, ask them, what does this story mean to you? When this character does xyz why is she/he doing that?  This will give you insight into what that person is thinking and help explore if it's creativity or something more. It's okay to ask.

 If there is a concern, help get that person to a doctor. Encourage medical tests for oxidative stress, hormones, basic micronutrient panel, etc. Many times low mood is related to a medical condition that can be helped before it turns to a long term change in our chemical and DNA make up. Catch it early don't wait! If the medical doctors clear them, turn to a qualified mental health professional that has worked with the concern (anxiety, depression, etc). They are in that field because they love helping others. But, please don't stay with the same doctor or mental health professional if you don't feel they have your best interest at heart. I've worked with many good but there are some who don't really care, get out. You can CHANGE your medical/mental health provider. They are a part of your team and if they aren't adding to your health, look for someone who will, it's okay, really it is!

As for the Boston bombing  there is now way to protect us from an unknown enemy. We have to live our life to the fullest. Train ourselves to be smart. Look at ways to teach our children and have action plans for emergencies. This is true in so many area's of our life. Teach, train, and learn!   It's a great model for anything we do in life.