Tag Archives: dangerousness

Voice of Experience: Disorders with the potential for dangerous outcomes

By Gregory K. Moffatt August 30, 2023

A person's feet in sneakers standing on a street before the word caution written in yellow chalk

My first trip to a psychiatric hospital was in 1978. I was a first-year college student, and one of my classes toured a state-run hospital. Like my classmates, I’d seen plenty of movies about a scary “crazy” person who escaped from a hospital and terrorized the community. But I learned on that trip — and my career experience has shown it to be true — that most people in hospitals like that came in on their own accord for help.

Our guide, the director of the facility, noted that the fence around the gigantic property was not there to keep the patients in, but rather it was there to keep others out. In fact, many of the patients in that facility could have walked out the front door any time they wanted. But they didn’t want to. They wanted help.

This trip reaffirmed what I have found to be true in my work with clients throughout my career: Most people with a mental illness are not dangerous. In fact, they are often more of a danger to themselves than others. But there are a few mental illnesses that can have potentially dangerous outcomes for others.

Three disorders associated with an increased risk of violence

Research is weak regarding which mental illnesses are correlated with dangerous behaviors. I’ve researched this area for close to 40 years, and I can assure you there is no simple answer. But here are three disorders that have the potential for dangerous outcomes and always give me cause for concern.

Reactive attachment disorder. In terms of dangerousness, reactive attachment disorder is the king. This disorder, which affects children, is one of the scariest due to the developmental limitations in children in terms of coping skills and problem-solving.

I’ve seen these children cut, pinch, hit, and even kill infants and young children. I’ve seen cases in which children as young as five years old have threatened their guardians with knives. I’ve had clients under the age of seven sexually assault younger children, and I’ve seen older children with this disorder kill family pets as well as rape adult women. Children with this diagnosis need 24/7 supervision along with intensive treatment plans.

Antisocial personality disorder. Antisocial personality disorder is the adult cousin of reactive attachment disorder. Clients with this disorder can exhibit their dysfunction in several ways. One key characteristic is that people with this disorder manipulate people. They can do this in a variety of ways, some of which don’t include violence.

But clients who choose to manipulate others physically or sexually can be dangerous. They have little compunction regarding the injury they cause others. The desire to manipulate others and see pain can lead to horrifying behaviors. These patients will attack staff or fellow patients in hospital settings, and they can easily attack therapists in outpatient settings. Individuals with this disorder are often the characters many of us know of as serial killers and serial rapists. Much of what I’ve seen of these individuals over my career is not far flung from the movies.

(For more on this disorder, see my article “Counseling encounters with the puppet masters,” which was published in the February 2019 issue of Counseling Today.)

Delusional disorders. My wife and I visited a restaurant in downtown Atlanta recently. As we approached the restaurant, I saw a man pacing back and forth on the sidewalk in front of us near the front door. He was clearly homeless and suffering from delusions. We gave a wide berth to the guy as we entered, but from our table, I could still him through the window. It grieved me to watch this gentleman outside the restaurant suffering in front of me.

As with antisocial personality disorder, individuals with delusional disorders exhibit their symptoms in a variety of ways. Only some of their expressions are dangerous. The sensory hallucinations (auditory, tactile, visual, etc.) that these clients experience are absolutely real to them.

But unlike antisocial personality disorder, these individuals are not dangerous out of spite or cruelty. Instead, the delusions they experience and the chaotic worlds in which they live can cause them to feel threatened and, in response, act out. This is why I steered clear of the homeless man as I entered the restaurant.

In other cases, their delusions lead them to think they are helping when they are doing the opposite. For example, Russell Weston, a 42-year-old man with schizophrenia, killed two Capitol police officers in 1998. He believed he was saving the world from aliens and was trying to access the “ruby satellite” he believed to be housed in the U.S. Capitol.

Violence risk assessment tools

Assessing dangerousness is a complicated process and an inexact science, and this can cause some mental health professionals to worry about assessing and treating clients with these disorders. But there are clinical tools that can help clinicians better assess the risk of potential violence.

I developed the Violence Risk Assessment Checklist in the 1990s (available at gregmoffatt.com) and have used it for years in businesses. This hierarchical checklist, like a suicidal ideation checklist, helps counselors evaluate for increased or decreased risk of potential violence. It contains twenty-eight items. Of the top eight, the more items the counselor checks when assessing the client, the higher the risk of violence.

The National Institute for Occupational Safety and Health provides a list of violence risk assessment tools that have been developed specifically for determining a person’s potential for violence to themselves or others. This list includes the Dangerousness Assessment Tool, which is a quick assessment scale clinicians can use to determine if an individual who is displaying signs of potentially dangerous behavior is a risk to others.

Clinicians need to realize, however, that just like assessing for risk of suicide, these instruments are only guides for decision-making and intervention, not precision tools.

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Next month, I’ll address who isn’t dangerous and how I know.

Gregory K. Moffatt is a veteran counselor of more than 30 years and the dean of the College of Social and Behavioral Sciences at Point University. His monthly Voice of Experience column for CT Online seeks to share theory, ethics and practice lessons learned from his diverse career, as well as inspiration for today’s counseling professionals, whether they are just starting out or have been practicing for many years. His experience includes three decades of work with children, trauma and abuse, as well as a variety of other experiences, including work with schools, businesses and law enforcement. Contact him at Greg.Moffatt@point.edu.

Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Counseling encounters with the puppet masters

By Gregory K. Moffatt February 5, 2019

Utter the words sociopath or psychopath in any public forum, and everyone knows what you’re talking about. “Like serial killers, right?” Yeah, like serial killers. Even in clinical settings, these dated terms are sometimes still used. They’re simply easier to say than antisocial personality disorder (APD), the label currently given in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).

Years of working with law enforcement agencies on cases involving shootings, serial crimes and sexual homicides have given me plenty of exposure to APD. But diagnosing was rarely my role with those cases, and the subjects were always men in trouble with the law — a distinctly biased sample. In clinical settings, I rarely found use for the APD diagnosis until about a dozen years ago, when my entire perspective was transformed by reading Martha Stout’s 2006 book The Sociopath Next Door. Stout, a clinical psychologist, does a masterful job of describing the disorder and providing examples of the various ways in which the disorder manifests. As I should have known, not everyone diagnosed with APD is — or will become — a serial killer.

As a young clinician many years ago, I assumed that I wouldn’t see APD in my general practice. After all, serial killers weren’t known for voluntarily pursuing psychotherapy. Knowing what I know now, however, I must have seen clients with APD many times without realizing it. Estimates on the frequency of the disorder vary widely, but according to the DSM-5, the presence of APD in the U.S. population is about 4 percent. Given the broad effects of APD, this is a very large number, and mere probability means that most clinicians will be exposed to APD at some point in their careers. After reading Stout’s book, I began to understand why. My two experiences — homicide work and the clinical office — might also explain the wide-ranging estimates. My law enforcement sample increased my exposure to individuals with APD. In the clinical setting, on the other hand, I was misdiagnosing or underdiagnosing — thus limiting my perception of the existence of APD.

Hiding in plain sight

This is an oversimplification, but I probably missed correctly diagnosing APD because I associated it only with criminals. Although many individuals with APD are criminals, there are many other manifestations of the disorder.

In brief, the DSM-5 criteria for APD require that a person be at least 18 years of age and do the following: lie, deceive, have a reckless regard for the safety of others, be impulsive or irritable, manipulate, lack remorse for actions, fail to conform to social norms and behave irresponsibly. This very broad and generalized set of criteria can be exhibited in a variety of ways. According to the DSM-5, APD is much more common in males than in females, and my experience — both in the world of criminal justice and in the clinical setting — reflects that claim.

Some years ago, I was consulting with a business, helping with team building among its upper-level administrators. One senior administrator in particular frustrated me. Alex (not his real name) would give the impression that he was working on something for our project, but then it would become evident that he had no intention of doing anything. If I asked Alex directly if he planned to do the project work, he wouldn’t come right out and say “no” in defiance of his superiors. Rather, he was simply evasive.

I didn’t trust Alex, and he gave me little reason to. He gave slippery answers to simple questions, and more than once, I noted contradictions in things he told me. On some occasions in private conversation with me, he would slip into an arrogant attitude regarding his bosses, as if he perceived that he — rather than the CEO — should be leading the company. A time or two he even tipped his hand to me, describing how he had lied to his co-workers or others. He seemed quite proud of getting away with his deceptions. I reasoned that if Alex lied to others and was proud of it, he would probably lie to me too.

In the few meetings Alex attended and in conversations in the hallways, he could be kind and often flattering. He used all the right lingo, especially if the boss was around, and in my view seemed so overly effusive on occasion that it bordered on disingenuous. At other times, Alex condescended to his fellow employees, the secretarial staff and other “underlings,” both in private and in front of others, as if these co-workers were idiots. He would then cast glances at those around him, suggesting that they were all in on some big joke of which the target was unaware. His attitude came across as if he believed everyone was too stupid to see what he was doing.

Alex consistently failed to show up at meetings where his presence was critical, including during my final week with the project, when he was supposed to lead the meeting with our team. Instead, he left us all waiting in the conference room. I found out he had instead decided to go on a picnic with his family. He had left a message with a secretary saying he would get back to me about rescheduling, knowing full well that I wouldn’t be returning after that week.

It was no wonder this administrative team had troubles. Alex wasn’t lazy and he most definitely wasn’t incompetent. In fact, he was very bright and capable. At times he seemed so on top of his game that I wondered if he might be bored with the relatively minor challenges of his job. But that wasn’t his problem.

Instead, I think it delighted him that nobody could tell him what to do. He believed he was pulling the wool over the eyes of his bosses, his colleagues and his “underlings.” I think he reveled in messing with them, making their jobs harder and knowing that they couldn’t do anything about it. For example, I don’t believe that Alex had any reservations about leading my final meeting or that he hadn’t done the work. On the contrary, he probably had. It was part of his insurance package. If the boss had asked Alex about his work, he would have pulled it from his hip pocket in a heartbeat. Instead, the picnic with his family was a way of flipping me the bird and knowing that I couldn’t do anything to stop him. After reading Stout’s book, the APD diagnosis for Alex seemed obvious. That diagnosis answered all my questions regarding his behavior with me and with his co-workers.

But these individuals with APD aren’t always men. One client from years ago was referred to me from an employee assistance program because she was exhibiting symptoms of paranoia. In my assessment, Linda (not her real name) was indeed clinically paranoid. In a cruel twist of irony, however, her boss was working hard behind the scenes to get Linda fired and, more relevant to this conversation, a fellow employee (whom I’ll call “Millie”) knew that Linda was troubled and used that realization to her advantage. So, although Linda was clinically paranoid, people really were out to get her.

Millie tormented Linda, dropping hints that this person or that person in the company was asking about Linda or questioning the quality of her work. Millie carefully crafted comments that went to the very heart of a paranoid individual’s anxieties. As Millie inflamed Linda’s paranoid thoughts, those thoughts exacerbated Linda’s annoying behaviors in the workplace — the very things that led Linda’s boss to seek options for her dismissal.

At other times, Millie would overtly lie, saying a manager or vice president had come by looking for Linda when she was out of the office. These statements would aggravate Linda’s fears that she was in trouble or that her bosses thought she wasn’t working — neither of which were true. Out of fear of confrontation, Linda wouldn’t ask any of the administrators if they had come by to see her. If she had, Millie would have been exposed, but Millie knew Linda wouldn’t risk that confrontation.

Millie did similar things to other co-workers. For example, one woman was struggling with the fear that her husband was having an affair, and she confided this to Millie. Thereafter, Millie would find opportunities when she was alone with the woman to talk about a movie she had seen in which a man was unfaithful or to gossip about a co-worker who was suspected of philandering. On another occasion, she shared details about a friend whose husband had been exposed for having a long-term affair and how “foolish” her friend had been not to have seen it.

Millie’s purpose was not to gossip but rather to cause turmoil within these two employees — throwing gasoline on the fire of paranoia with one and on the fire of emotional anguish with the other. All the while, she could innocently defend herself, saying she was merely discussing company business or the sad facts behind a broken marriage.

Antisocial personality simplified

The abridged way that I describe APD beyond the DSM-5 criteria for my students and interns is twofold, with one additional caveat. First, we have to think of those with APD as puppeteers — a metaphor that I borrow from Stout. Each time the puppet master moves the wooden cross pieces of the marionettes, the strings move the puppets below them. These puppeteers are essentially saying, “Dance for me.” Millie made my client and other employees dance any time she wanted. To Millie, these women were toys she could manipulate at will. Both Millie and Alex were very good at covering their tracks so that they could keep their jobs. They had perfected plausible deniability.

The second thing to know about individuals with APD is that they are takers. In some cases, they can be violent, such as the taking of another person’s life in the case of serial killers or the taking of someone’s sexuality in the case of rapists. But there are many other things that people with APD can take. For example, they take advantage of the goodness of others, becoming leeches who move into someone’s home under the guise of getting back on their feet. Instead, they won’t leave until they are kicked to the curb. Some people with APD become police officers and federal agents, reveling in the taking of another person’s freedom. And some of these individuals become hucksters, taking money whenever they can for the sheer pleasure of getting away with it.

Individuals with APD create chaos in their homes, workplaces, sports teams and social environments, taking peace from those around them. I served as the vice president for student life at a Southern university for several years in the late 1980s and early 1990s. During one particularly challenging year, the first several weeks of school brought one crisis after another. Issues in dormitories, in classrooms, on athletic fields and even in the cafeteria had me investing hours, on a daily basis, to manage these crises. By October, it dawned on me that one particular student had been involved to some degree in each and every major problem that had come across my desk. He was either the complainant or the target of a complaint in each instance.

In the end, this student had stolen credit cards, jewelry and cash from various students. He repeatedly lodged baseless accusations of racism against professors, staff and fellow students. He was suspended for the stolen property issue and left our campus — but stayed in his dormitory room until the very last minute he was required to vacate. And he wasn’t done yet.

In true APD style, he later filed a baseless lawsuit against our university with the American Civil Liberties Union (ACLU) and used his college mailing address on the paperwork — an address that obviously was no longer valid. He also listed me as a reference for a job he applied for just hours after leaving our campus, undoubtedly hoping that the company wouldn’t follow up on his references. In his job interview, he completely misrepresented the reasons for his withdrawal from school, telling this employer that he had decided to take some time off to figure out what he wanted to do in life. The ACLU lawsuit was dropped for lack of evidence, and the employer did, in fact, follow up on references. Fortunately for us, after this student was dismissed, peace returned to the community.

The caveat that accompanies these two descriptors regards the conscience. It is an oversimplification to claim that individuals with APD have no conscience. In fact, some argue that they must have a conscience. It is proposed that to enjoy the suffering of others, one must have at least a minimal sense of right and wrong and one must have the ability to imagine what others are thinking and feeling. We know this as empathy. Simply put, our conscience is a powerful voice that keeps our behaviors in check, even when primal urges push and pull us in other directions. This voice allows us to empathize and causes us shame when we violate its dictates. But in clients with APD, these violations cause pleasure. At a minimum, there is either a deficit in that governing voice with these clients or they lack it altogether.

Prognosis and the APD continuum

The most common question I get regarding clients with APD is whether they can be treated. That is not an easy question to answer. There is very little research on the efficacy of therapy for these clients. There is also the problem of biased samples. Most research is done on hospitalized patients or on those who have been mandated to counseling, which may not be reflective of the population of individuals with APD at large. Given APD’s symptoms, we can expect that many, if not most, of these clients won’t engage in counseling voluntarily. Therefore, in therapy we may see only those who want help (motivated clients) or those who have been mandated (resistant clients).

But there is hope. A 2010 comprehensive report by the National Institute for Health and Care Excellence (NICE) in the U.K. provided some important information for clinicians, including that treatments for APD do exist. The study notes that treatment is most helpful when there is early intervention. The second important bit of information is that even though there is no “cure” for personality disorders, symptoms can be treated. Medication and treatment for comorbid issues (anger management, social skills training and relaxation training) are the most likely areas of focus.

It is important for clinicians to recognize that most mental health issues exist on a continuum. We formally recognize this continuum in several areas, including autism, suicide risk and developmental delay. Although the DSM-5 does not provide a continuum for many disorders — APD included — anyone who has been in the field for very long can recognize that the continuum exists. Most of us have seen clients with major depressive disorder who cannot get out of bed, and we have also seen clients with the same diagnosis who function far better. Personally, I miss the Global Assessment of Functioning scale in previous DSM editions because it provided exactly the continuum I’m describing.

Follow-up on Alex

The case involving Alex had an interesting conclusion. A few months after my summary meeting with Alex’s company, I got a call from the CEO asking me to see Alex on a one-to-one basis. The CEO wanted to retain Alex but was considering firing him because of a series of problematic behaviors like the ones he exhibited when I was working with the management team.

For weeks, Alex and I worked together as I tried to help him salvage his job. He resented his employer, and he resented having to come see me. Every session was a battle for control — Alex trying to manipulate me and me trying to stay on task.

I wish I could say that I discovered some therapeutic magic trick and that Alex changed. Unfortunately, he did not. I tried anger management, relaxation, social skills training, perspective-taking exercises, problem-solving exercises and long-range planning. I repeatedly appealed to Alex’s self-interest in keeping his job. Nothing worked. Alex’s marriage was cold and emotionless, he had only cursory involvement with his two daughters, and he had no hobbies or activities that brought him pleasure outside of work — the one place where his puppet stage was always open. My therapeutic attempts were interrupting his theater.

Even though I tried to give Alex control as much as possible, just as I do with most of my clients, we butted heads repeatedly. He fought me every minute of our monthslong therapeutic relationship. Just like when we worked together on the team-building project, I suspect Alex had no intention of working on anything in counseling from the start. In the end, we terminated therapy after his required period of intervention. The CEO fired him, and I’ve never heard from Alex again.

But this doesn’t discourage me. The NICE study confirmed what I experienced: The older the client with APD is, the harder it is to intervene. Despite my frustrations with Alex, I don’t regret trying to help him. As I tell my clinicians-in-training, anyone can work with the easy clients. Professionals work with the hard ones. Sadly, Alex wasn’t one of my success stories. Linda, on the other hand, was.

Follow-up on Linda

Helping clients whose lives are being disrupted by individuals with APD is no easy task either. Just like people who batter their spouses, people with APD are very good at manipulating others while making it appear that they didn’t. This causes the individual being manipulated to introspect rather than to see the inexcusable behaviors in front of their eyes.

Linda was mandated to counseling because of her paranoia and the challenges in her job. Yet because of her paranoia, she was convinced that people were trying to get her fired, and that was a claim that I couldn’t deny. However, by acknowledging that people really were out to get her, I risked feeding her paranoia. What a challenge.

This is what I did. We spent much of our early clinical work polishing relaxation techniques. Then we moved to reality testing. This helped Linda in two ways. First, when she feared someone was plotting something, she now had tools to evaluate the legitimacy of that claim. For example, when Millie said a boss had come by “wondering” where Linda was, we looked for ways to confirm or deny such claims.

We then worked on Linda’s assertiveness skills. This, combined with reality testing, almost completely put a stop to Millie’s manipulations. The next time that Millie said Linda’s boss had come by or implied that a supervisor might think that Linda wasn’t doing a good job, Linda confronted Millie and asked her whom she was referring to specifically. Then Linda went to that boss to see what she might do to improve. Millie never counted on Linda taking that assertive action. When she could no longer easily manipulate Linda and predict what she would do, Millie moved on to other targets.

These three skills also helped Linda salvage her job. Because she was more relaxed at work and felt more confident when she faced her fears head-on, her paranoia no longer created workplace issues. As a result, her boss who had been seeking a way to fire her backed off and let her do her job.

Summary

There is no question that many people involved in crime could be diagnosed with APD. Actions that seems so reasonable to them are sometimes comical. One individual I worked with explained his stealing behavior to me: “I saw the woman’s purse in her car and the car was unlocked. So, I’m like, ‘God brought that purse with the money in it to me, and I helped that lady because I taught her not to leave her car unlocked.’”

But as Stout so clearly outlines in her book, there are many other ways that APD is manifested. Individuals with this disorder can be cutthroat businesspeople or politicians. They can be covetous psychopaths — individuals with an inordinate desire for the possessions of others. They can be individuals who steal, lie and commit fraud. They can appear lazy — living in a rent-free house, sleeping on someone’s couch, or taking advantage of their spouse and children. They can be people like Millie who “gaslight” others, a descriptor taken from a movie of the same title in which a man tries to drive his wife mad. If those with APD are intelligent, like Millie and Alex, they can manipulate social impressions. Those with APD who are less intelligent end up in trouble, in prison, homeless or dead.

These individuals aren’t bothered by cheating on their spouses, causing chaos at work, or defrauding and stealing from their friends. They use their charisma to deflect attention from their devious behaviors, essentially hiding in plain sight. Their accomplishments, such as financial success, can conceal their dysfunctional motives. And when challenged, they use intimidation and their domineering personalities to cause anyone who might question them to back off.

And perhaps most important for us to know as counselors, individuals with APD will manipulate us if we aren’t careful. We will see these clients in our offices, but what is even more likely is that they will be the husbands and wives, sons and daughters, bosses and co-workers of our clients. The seemingly inexplicable behaviors that our clients relate to us will make much greater sense in the context of the potential APD diagnosis for these people in their lives. That powerful knowledge can help us set goals and establish solutions for managing these situations.

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Gregory K. Moffatt is a licensed professional counselor, a certified professional counselor supervisor and a professor and department chair of counseling and human services at Point University in Georgia. He has been in private clinical practice for more than 30 years, specializing in work with traumatized children for much of that time. An author and international speaker, he has also worked as a consultant to the FBI and as a homicide profiler. Contact him at greg.moffatt@point.edu.

Letters to the editor: ct@counseling.org

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Why do cops avoid counseling? Eight myths about law enforcement officers and mental health treatment

By Jessika Redman January 23, 2018

Most clinicians who work with law enforcement officers will tell you that the experience can be a little different. Sometimes, it seems to incorporate elements of a spy thriller. First, the call from the unknown number. Then, the interrogation from the unidentified caller, asking about your experience with cops, your ability to keep secrets and if you are in any way affiliated with the department. James Bond must be on the other end of the phone.

Let’s start by exploring the impacts that a career in law enforcement can have on officers. Law enforcement officers are a special population (like military and paramilitary personnel and other first responders) who experience coexisting medical and behavioral health issues with links to job-related stressors. According to a landmark study published by researcher John Violanti with the University at Buffalo in 2012, various factors contribute to the very serious physical and mental health concerns experienced by many law enforcement officers. These factors include:

Shift work
Long hours
Unpredictable schedules
Exposure to critical incidents
Being the frequent focus of public attention and criticism
Various physical demands
High rates of on-the-job injuries

The major concerns identified in Violanti’s study are high blood pressure, insomnia, heart disease, diabetes, posttraumatic stress disorder, obesity, depression, anxiety, cancer, substance abuse, relational distress and suicide. This special population often presents with higher rates of depression, substance abuse and suicide than does the general public.

In the October 2010 Issue of the FBI Law Enforcement Bulletin, Daniel Mattos, a law enforcement veteran for more than 30 years, described the psychological impact of police work: “By the very nature of what we do as police officers, we are unavoidably exposed to a host of toxic elements that can be likened to grains of emotional sand that ever so gradually are placed on our psychological backs. As time goes on, the sand increases in volume. Without the proper tools to remove it, the weight can become unbearable. In fact, in some cases, the sand becomes so heavy that it can collapse officers. The result of the sand’s weight takes a heavy toll on us; substance abuse, anxiety, depression, failed marriages, and other emotional and physical ailments that rise well above societal averages plague our profession.”

In an international meta-analytic study completed in 2012, researchers Claudia Morales-Manrique and Juan Valderrama-Zurian identified strong links between the high-demand/low-control nature of police work and the high stress levels that negatively impact the physical and mental health of police officers. In high-demand/low-control careers, individuals are required to be at constant peak performance levels, stemming from the unpredictability and wide range of scenarios that can be presented to them.

Research suggests that officer rates of completed suicides are three times higher than in the general population. In January 2014, Perry Mason, a retired Canadian constable (police officer), publicly described in an interview with The Hamilton Spectator his suicidal thoughts and a very near suicide attempt during his career. During 34 years of service, Mason also recounted that seven of his fellow officers had died from suicide. Mason admitted that he sought help, but also kept it highly secret because of his fears of possible repercussions to his career. He never disclosed his suicidal thoughts until after he retired.

Dilemmas and challenges complicating treatment

The high rates of physical and mental health conditions among law enforcement officers reflect the need for medical and behavioral support and treatment. However, treatment resistance is often a significant barrier.

In 2002, the American Psychological Association recognized the need to take a closer look at law enforcement as a special population and to define guidelines for forensic psychology. Ensuring public safety requires that officers are mentally, emotionally and physically stable and deemed “fit for duty” to perform effectively.

Law enforcement personnel often struggle to manage the challenges associated with competing demands. Very intense and difficult circumstances must be addressed while simultaneously mitigating the impact those demands have on personal health and well-being. Seeking and adhering to needed medical and behavioral treatments can present specific dilemmas and challenges.

Law enforcement officers are legally and ethically mandated to maintain good physical and mental health. However, the stressors these individuals face, ranging from inconsistent shift work to frequent and unpredictable threats to life, result in both physical and emotional challenges for the majority of officers during an average career. Law enforcement employers are legally obligated to verify and monitor officers to ensure physical, mental and emotional stability, as well as job performance capability. As a result, any signs of behavior that are in question, either on or off duty, are subject to scrutiny by the officer’s department or chain of command.

Every single law enforcement officer undergoes fit-for-duty evaluations that entail a combination of psychological testing and interviewing. In the book Practical Police Psychology: Stress Management and Crisis Intervention for Law Enforcement (2006), Laurence Miller writes that failure of the evaluation may result in job loss or suspension. An unintended consequence is that the majority of officers are hesitant to seek help with mental, emotional, relational or even physical issues because it could result in their inability to work.

According to retired police officer and psychologist Joel Fay in the April 2012 issue of the POA Journal, officers presenting with medical or mental health concerns often struggle taking medications as prescribed to address symptoms. Officers are restricted from having certain types of medications in their systems. For the safety of the public and the officers, police departments have policies against the use of certain classifications of medications such as strong painkillers and benzodiazepines. An officer-involved accident or shooting is often subject to a review of the incident that includes blood tests to determine the possible presence of chemicals or medications that may have played a role in the incident. Officers recognize that doctors may be unaware of these restrictions. Unable to fully understand the classifications of medications, officers may consequently resist taking prescribed medications.

So, what can we do as clinicians to help reduce the stigma and minimize the fear that going to counseling has for many law enforcement officers? The first step is to help officers understand their rights to privacy. I asked the legal experts at Bruno, Colin & Lowe P.C., with more than 60 years’ combined experience in protecting the rights of law enforcement officers in Colorado, and Mariya Dvoskina, a police and public safety psychologist with Nicoletti-Flater Associates, experts in the evaluation and critical incident response for law enforcement officers, to give me “just the facts.”

Collectively, we identified eight myths that keep many law enforcement officers from seeking support through counseling. Because each state may have some independent legislation in this regard, it is important for clinicians to verify the legal standards in the individual states in which they practice.

The myths

Myth #1

Departments/agencies have the right to obtain information about officers that seek help from licensed mental health professionals.

False! Licensed mental health professionals are legally and ethically bound to protect client privacy. If an officer reaches out to a therapist on his or her own — in other words, if the officer wasn’t ordered to see a therapist by a court or the officer’s department — then the employer doesn’t even have the right to know that the officer is attending therapy. Nothing that is said in counseling can be released to anyone without the officer’s written consent. The U.S. Supreme court has ruled that the confidential relationship between a psychotherapist and an officer is privileged. To learn more, see http://www.apa.org/about/offices/ogc/amicus/jaffee.aspx

The only times confidentiality can be broken are for the reasons below, which apply to every client/patient.

A suspected incident of child abuse or neglect must be reported.
A threat of imminent physical harm by a patient must be reported to law enforcement and to the person(s) threatened.
A mental health evaluation must be initiated for a patient who is imminently dangerous to self or to others, or who is gravely disabled, as a result of a mental disorder.
A suspected threat to national security must be reported to federal officials.
Suspected abuse of a senior adult (70 years of age or older), including institutional neglect, physical injury, financial exploitation or unreasonable restraint, must be reported.

Myth #2

Rights to privacy change if you use your insurance or employee assistance program (EAP).

False! Treatment by a licensed mental health professional that is paid for by your insurance company or your EAP is protected by HIPAA (the Health Insurance Portability and Accountability Act), and the same rules apply.

Sometimes patients choose not to use insurance benefits so that their outpatient treatment remains separate from their medical record.

Myth #3

There is no reason to see a licensed professional because the rules are exactly the same with a peer support team.

False! Limits to confidentiality vary by department and the standards may be different than those that licensed professionals have. The peer support member must disclose these limitations in the first meeting. In addition to the exceptions to confidentiality listed in Myth #1, most peer support teams are also expected to report crimes and sometimes policy violations. Outside of those limitations, conversations between a peer support member and an officer are confidential.

Myth #4

The department or agency automatically has a right to know if an officer receives a mental health diagnosis or takes medication.

False! HIPAA protects both diagnosis and medication or other treatment methods because they are part of the clinical record and therefore confidential. If an officer would like the department to know this information, he or she must sign a release of information. Otherwise, the professional treatment provider cannot disclose anything related to the client/patient to the department or anyone else.

Myth #5

If an officer seeks help from a hospital or a rehabilitation facility voluntarily, the department automatically has the right to this information.

False! The department can only access information that an officer has granted it permission to have, as is the case with any other medical condition.

Myth #6

If an officer is placed on an M-1 hold, he or she automatically loses their right to carry and possess a firearm.

False! When there is a court-approved certification for an involuntary mental health hold, restrictions to weapons are limited while the certification is active. If the provider that requested the certification acknowledges that the client/patient is no longer a danger to themselves or anyone else, then the restriction can and should be released as well.

Myth #7

If an officer seeks the support of a licensed mental health professional, that automatically means that the officer is not fit for duty.

False! Seeking counseling voluntarily would NEVER automatically mean that an officer is unfit for duty.

Myth #8

Counseling is the same as a fit-for-duty evaluation.

False! The most important question to ask is “Who is the client?” If the officer is seeking support on his or her own, all of the rights stated above belong to the officer. If the department is the client, as is the case in a pre-employment evaluation or a fitness-for-duty evaluation, then the information most often belongs to the department.

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Jessika Redman is a licensed professional counselor, a national certified counselor and the founder of Well Relate LLC (http://www.wellrelate.com) in Castle Rock, Colorado. Contact her at jessika@wellrelate.com.

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Angry nation: A counseling perspective

By Carol ZA McGinnis January 18, 2018

“O say does that star-spangled banner yet wave …” is a favorite line in our country’s National Anthem because it seems to simultaneously confirm our current liberties and challenge us to answer how relevant this symbol still is. In light of the events of the past year — horrific shootings, kneeling protesters, the ravages of addiction and various controversies that pitted one patriot against another — it prompts us to ask, “Does the flag wave for me?”

Some who have responded with unreasonable aggression may be answering that question in anger. I would argue that Americans as a whole do not have healthy anger modeling readily available to them. Consider audience behavior at select sporting events, the returns experience at customer service counters and vigilante films from Hollywood. Our culture does not offer a wide variety of positive angering examples.

Anger is a research topic that has not received much attention. For that reason, it is important to ask a question: What if the root of this violence and political division stems from a limited understanding of how to anger in a healthy way? It could be that our nation suffers from dysfunctional anger associated with a wide variety of diagnoses.

Dysfunctional anger

Regardless of our personal thoughts on this topic, it is important to note that President Donald Trump conceptualized the Nov. 5 shooting at the First Baptist Church in Sutherland Springs, Texas, as being the result of a mental health problem. If we are to approach this from a sociocultural counseling perspective, it makes sense to add our professional thoughts on how that may be so.

Since the Columbine tragedy in 1999, research has shown that ostracism and isolation are correlated with aggressive actions. The perceived injustice of being left out or treated unfairly often results in dysfunctional anger and violence. Could it be that we have an epidemic gap in social modeling for functional anger? If so, how can we in the counseling profession begin a national process for addressing this psychoeducational need?

This may seem like crazy talk to many people. When news breaks of another Sandy Hook, the Las Vegas shooting or the more recent Baptist church tragedy, there are those who ask, in genuine bafflement, “Who does this?” We have difficulty making sense of such senseless acts. We want to reassure ourselves that the individuals who carry out these acts are much different from the rest of us in the “normal” population. To this question of “Who does this?” I would like to present the Lucas scenario.

The Lucas scenario

Imagine an ordinary classroom of preschool children. The room features a large space in which to play with building blocks. Every child in this room has access to the same number of blocks and the same space to work, either independently or together, as desired. Imagine that all of the children are happily at work, building towers, bridges, cities or whatever else comes to mind.

In the corner, Lucas is busily stacking block after block in his effort to build a tower when someone walks by to open the door for a parent. This action shifts the rug just enough to interfere with the balancing act of Lucas’ creation. As a result, the stack of blocks falls. Lucas collects the blocks and begins anew, taking care to brace the bottom of the tower with heavier reinforcements. He gets his tower back to the previous height in a short amount of time.

Minutes later, one of the other children throws a wadded paper ball that Lucas tries to catch. Inadvertently, he knocks the top of his own tower over. He must rebuild half of his tower yet again. Undaunted, Lucas is excited to be moving into the second phase of his design when the teacher stops to give him encouragement and suggest that he consider replacing the bottom blocks with thicker options because of the height his tower is reaching. When he tries to swap those blocks out, the tower crumbles yet again. When Lucas expresses dissatisfaction with this event, the teacher scolds him gently and tells him, “Just start again.”

Having already endured multiple mishaps that required him to start over, Lucas twice more attempts to build “the highest tower ever.” When a friend falls close by and knocks over his highest version yet, Lucas reaches the end of his rope. He has lost all hope. He is frustrated and angry that everyone else has been able to build without interruption. He feels this injustice at the very core of his being. Nothing that he has attempted has worked. Even the teacher was complicit in his failure to have what everyone else has had.

What do you think Lucas’ next move might be? What models for anger has he witnessed at this young stage of development? What choices are available?

More than likely, Lucas will want to exact justice by leveling the playing field. To destroy everyone else’s towers would help them all to know firsthand what Lucas had had to endure, and doesn’t he deserve a little payback? Why should he be the only one to suffer? Why shouldn’t the other children feel as miserable and alone as he does?

It is not difficult to see how this response might also play out in the adult world, where the prospective offender is provided with guns, bombs, cars and other means for leveling the field. The fact is that many people never learn how to anger in a healthy way; it is our job as counselors to fill that gap.

Theoretical explanations

This scenario is just one possibility for Lucas, but the point is clearly made when we consider the decision for otherwise “normal” people to decide on a whim to obtain a gun, or a vast array of guns, and go shoot innocent men, women and children. What if this breaking point is not only understandable but preventable if we can introduce another way to anger?

Gun laws and mental health funding may be important to consider as we begin to address violence in our society, but it is also easy to see how new theoretical explanations will be needed. Some counselors may ask whether these violent outbursts are tied to a resilience issue, whereas others will want to learn if these responses are related to cognitive processes, behavioral reinforcement or social modeling.

No matter what orientation is taken, however, it seems obvious that anger must be included in research on this topic. According to most theoretical approaches, our work does not stop at the individual level but must also attend to the larger community. The ACA Code of Ethics also calls for our aspirational response to the needs of the larger community.

One way to do that is to consider how we can help people find alternative ways to express their anger without using a gun to shoot innocent people. Might cultural role models such as Mahatma Gandhi, Martin Luther King Jr. and Jesus Christ provide a starting point? What options can we introduce for clients who may not have skills in this area? How might we begin the process of helping others to express anger in positive ways?

Let’s hold President Trump to his opinion on this topic with requests for research funding that will help to create change in angering. Together, we can help our Angry Nation become a community of change and resolution without the need for violence.

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Related reading, from the Counseling Today archives: “Angry words”

Counselors often face the delicate challenge of helping clients to view anger as a helpful symptom and tool rather than something to be avoided: wp.me/p2BxKN-3ho

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Carol ZA McGinnis, a licensed clinical professional counselor and national certified counselor, is a pastoral counselor and counselor educator who specializes in anger processing. Her passion involves teaching with attention paid to religion and spirituality as positive factors in both counseling and counselor development. Contact her at cmcginnis@messiah.edu.

Letters to the editor: CT@counseling.org

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Adding a counselor’s voice to law enforcement work

By Bethany Bray March 17, 2016

For Gregory Moffatt, counseling and crime solving go hand in hand.

Moffatt, a licensed professional counselor (LPC), runs a private practice in which he specializes in working with children who have experienced physical or sexual abuse. He is also a professor of counseling at Point University in West Point, Georgia.

The other half of his career, however, is a little more unconventional. He’s a risk assessment and psychological consultant for businesses, schools and law enforcement agencies. Moffatt has done everything from assisting with hostage situations and unsolved cold case investigations to teaching at the FBI National Academy in Quantico, Virginia. In addition to providing training and consultation, he evaluates police officers who have been involved in a duty-related shooting to determine if they’re ready to return to active work on the force.

He’s also filming on-camera commentary as a psychological consultant for a new cable television show on hostage situations. The program, titled “Deadly Demands,” premiers March 21 on Investigation Discovery, a network of the Discovery Channel.

After years of working with corporations and law enforcement agencies, Moffatt is often the person they call to evaluate unusual situations, such as when an employee is making co-workers uneasy or

Gregory Moffatt, LPC and professor of counseling at Point University

a case arises that doesn’t fit the norm. It’s not a niche that he initially set out to carve for himself, but rather one that he entered “through the back door,” he says.

When Moffatt first started teaching at Point University more than three decades ago, he was the only professional counselor on campus. One day, the university’s administration approached him and asked for his help with a situation involving a student who was stalking another student.

“Stalking laws weren’t in place. Back then, even the term [stalking] wasn’t an everyday term,” says Moffatt, an American Counseling Association member. “Back then, hardly anyone did work in violence risk assessment.”

As he got involved in the case, Moffatt started researching risk assessment methods, which grew into a personal area of interest. He eventually established his own consulting business, through which he provides workplace violence assessment and training. The FBI contacted him to provide training at its academy in Quantico after he published an article in an academic journal on violence risk and assessment.

Law enforcement agencies are good at lots of things, but threat assessment isn’t always one of them, Moffatt says. That’s where his skills as a professional counselor can help fill in the “why” of a situation, he says.

Moffatt uses his counselor training to look at a specific situation’s “collection of evidence,” he says. For instance, how does the person tell his or her story? What indicators can be found in the language the person uses? What does his or her past behavior indicate? What coping skills does the person have?

“My job is to tell them [a company or law enforcement], ‘This is what I think; this is what you’re looking for,’” Moffatt says. “The question for us, in mental health, when someone’s sitting in our office is, ‘Is this person a risk?’ Sometimes the answer is yes. … How many coping skills does he [the client] have in his toolbox? If it’s a pretty empty toolbox, then I’m worried.”

For example, Moffatt was contacted by local law enforcement to evaluate the threat level of some letters a judge was receiving in the mail. Officials suspected the letters were being written by a man who had come through the judge’s courtroom for a minor infraction, he says.

Moffatt looked at the man’s behavior history (he had brandished a firearm in the past but never fired at anyone) and the language used in the letters. His counselor training helped him pick up clues — for example, symptoms of delusion and other things that would make a person unpredictable — to determine that the man was a “big talker,” but that the letters were most likely a way of “puffing out his chest” rather than an actual threat.

“I thought there was a very low possibility that he would shoot this judge. Years later, nothing has come of it,” Moffatt says.

Today, he works regularly with the Atlanta Police Department’s cold case squad and writes a regular column on children’s and family issues for The Citizen, a newspaper distributed in Fayette County, Georgia.

Moffatt says he is drawn to the sometimes gritty specialty of crime and violence assessment because he likes being part of the solution and helping to bring some closure to the victims of crimes.

“The world is not made up [solely] of bad guys and good guys,” he says. “If you go to any prison in the country, you will find a small percentage [of the inmates who] are horrible and need to stay locked up for the rest of their lives. The rest are human beings who have made a mistake. The hardest part about our job [as counselors] is to have compassion. We can take people, in any condition, and help them become more functional.”

Q+A: Gregory Moffatt

You encourage all counselors to learn more about risk assessment, whether through reading, professional development, trainings, etc. Why do you feel this particular topic is important for counselors to know?

Risk assessment is necessary in any clinical context. Violence happens in homes, schools, workplaces, on the bus, on the street and in the synagogue/cathedral. Assessing for violent behavior against others is just as important as assessing for suicide risk, [which is] something we do regularly. You don’t have to specialize in workplace violence or school violence for this to be part of your assessment toolbox.

Do law enforcement professionals often think of or turn to psychologists first when looking for help with mental health expertise? From your perspective, what can a professional counselor offer in this area that is different than other helping professions?

Actually, I don’t think most law enforcement people know the difference. Even when they do, they often have limited or no budgets for outside consultation. Professional counselors are cheaper than psychologists, typically. Counselors are just as competent to offer fitness for duty interventions/assessments, post-shooting intervention, violence intervention/anger management and other common needs in law enforcement as any psychologist — assuming, as always, that one is trained to deal with that population. This training is readily available to LPCs.

What suggestions would you give to counselors looking to help or make a connection with their local law enforcement or violence prevention agencies?

Law enforcement agencies are notoriously fraternal, and even agency to agency there is little cooperation. A given agency believes it is better than any other agency, and going outside law enforcement is seen as a negative. However, developing relationships and bringing skills to the table — especially if it is cost-effective — is the way in the door over time.

What are some of the main takeaways that you’ve gleaned from your work with law enforcement and risk assessment that you want professional counselors to know?

Behavioral/mental health issues are present in all corners of life. Finding a way to apply your interests in mental health in specific climates — e.g., schools, law enforcement, court — is what makes one’s career fascinating and rewarding. I look back on 30 years of work — opening doors, looking for opportunities and taking those opportunities — and I couldn’t be happier. I’ve helped hundreds of children, written hundreds of articles and numerous books, spoken to thousands of audiences and helped put many bad guys in jail — hence, making the world safer and people happier. Who could ask for more?

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Read more about Gregory Moffat’s work and find a list of suggested resources on trauma, violence, parenting and other topics at his website, gregmoffatt.com

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Bethany Bray is a staff writer for Counseling Today. Contact her at bbray@counseling.org

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