Episode 72: Understanding Lone Actor Violence

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Welcome to the Mind Dive Podcast, brought to you by the Meniger Clinic, a national leader in mental health care.
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We're your hosts, Dr.
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Bob Bowen.
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And Dr.
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Carrie Hurrell.
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Monthly, we explore intriguing topics from across the mental health field and dive into hidden realities of patient treatment.
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We also discuss the latest research and perspectives from the minds of distinguished colleagues near and far.
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So thanks for joining us.
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Let's dive in.
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Dr.
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Pedro.
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Dr.
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Jones.
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Dr.
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Pedro has a longer name than Dr.
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Pedro, which is Dr.
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Peter Pedro.
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Ciahan Julmes.
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Did I do that on the case?
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Very good.
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Very good.
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Who is a psychiatrist based in Houston, Texas?
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Um, Dr.
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Pedro earned his medical degree from Tulane University School of Medicine, where he trained in psychiatry, and he also trained in psychiatry at Washington University in St.
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Louis, where he's been deeply influenced by the evidence-based approach of modern medicine.
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Dr.
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Pedro previously practiced at the Menninger Clinic as a psychiatrist on the Compass Program for Young Adults and on the outpatient assessment team, which is how I know and have got to work with Dr.
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Pedro.
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And he currently serves military veterans by offering critical psychiatric care in emergency and consult liaison situations at the Michael E.
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DeBakey VA Medical Center.
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And he's also an assistant professor of psychiatry at Baylor College of Medicine.
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Welcome, Dr.
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Pedro.
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Thank you.
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Welcome virtually back.
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Yes, much appreciated.
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I love the Mind Dive podcast, and I'm ready to dive in.
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I you know what's funny is I remember one of the first, I don't know, it was like the first couple months that we were working together.
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You said you were like, I listened to your podcast.
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And I always I have this sense that no one, not that no one listens, but I think I dissociate I dissociate the idea that anybody who I especially know listens.
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So it was really nice, but also I'm like, oh wow, people are actually out there listening.
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Hello to you, listeners.
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Yeah, me and the 12 other fans.
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We're all very excited.
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Exactly.
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Yeah, but I mean there's so much you're an expert on, but we're we're gonna talk about, you know, your interest in uh violence, lone act of violence.
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Your interest in violence.
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Well, yeah, I guess I should put it differently.
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But uh, you know, and you have like, you know, she you've been great at like training us about it.
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So I wanted you just to share it large, you know, large.
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I mean, how first like just start about yourself?
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Like, how'd you get interested in you know, assessing and and uh understanding uh violence and who does it, why do they do it?
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Exactly, you know.
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Yeah, yeah.
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How did you get into this?
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Yeah, I guess it it starts how a lot of these stories begin, where I encountered a mentor and teacher who influenced me a lot when I was at my training at Washu.
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That's Dr.
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Tahir Rahman.
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Now he's a great person, real scholar in the field, a deep thinker, just kind of a great guy.
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So I want to shout out to him.
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But he's a CL attending and forensic psychiatrist who's known in the threat assessment community and the American Academy of Psychiatry and Law as like a thought leader, specifically in the area of extreme overvalued beliefs, which that kind of dives into this topic later, but that's just kind of a clue for right now.
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Um and that concept really shifted how I was thinking about these non-delusional problems that we were encountering in psychiatry that at its face and surface don't seem based in reality and yet are not psychotic, so to speak.
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You know, areas like eating disorders and other types of um of these socially contagious disorders.
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So that was something that really piqued my interest.
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And as I learned more, I kind of got into this area of interest.
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Extreme overvalued beliefs?
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Is that the phrase?
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Yes, extreme overvalued beliefs.
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I'm sure I've heard this before because I've listened to you speak on this, but that's seeming like a that's hitting me like an important and I guess you're as compared to a delusion, is what you're saying.
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Yeah, and that is a very important concept as we talk about lone actor violence or lone actor grievance field violence, because as part of our mental status exam, we're trained to look for obsessional thinking and we're trained to look for delusional thinking.
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But there's something we encounter very often, which we are going to call extreme overvalued beliefs, which are these ideas that are shared within individuals, cultures, religions, or really these subcultural groups or fringe groups.
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And these ideas kind of get more and more polarized and amplified over time.
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They start to become very much binary and simplistic, says, I am fat.
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And there's nothing you can do about that, despite the fact that they are anorexia nervosa severe stage, their BMI's 14.
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It's a very much binary idea and concept that comes into your mental status exam, but is not delusional.
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Right.
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And if you spoke to a group in their subculture, if you went onto a deep TikTok dive into that pathology, you would hear each other, them calling each other these names and effacing these same ideas.
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So I think that's what was something that really struck me as I started to understand the difference between that delusions and obsessions.
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And that started to spark my interest in this area.
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I'm sparked.
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I think this is fascinating and in a terrifying sort of way, in like a scary way.
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Very topical.
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Um, do you want to go?
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No.
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Oh, I don't know.
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Did I look like I want to go?
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You looked like you were gonna say something.
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Okay, all right.
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I was just gonna say that, you know, so I kept I I've been sort of talking just generically about violence, but really your interest is in uh lone actor violence.
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And maybe you can sort of make for me the distinction how that differs from sort of like other types of violence.
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Yeah, that's a that's a great question.
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So lone actor violence is essentially a specific kind of targeted violence that tends to develop in similar ways, no matter who is the one that executes on it.
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So whether that is a lone actor terrorist who's driven by jihad, for example, as a cause, or whether that's a right-wing extremist who is driven by the belief that um whites are being erased from the nation and so they must act now.
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And if you look across these groups, which unfortunately becomes very politically influenced day-to-day, it's very on topic, it's very cultural, very timely, um, you find these common factors that all of them have.
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That is kind of characteristic of this lone actor violence.
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And we'll talk about their fueling by grievances that they tend to have at a later point.
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But that is a very different thing than what most of us encounter in clinical scenarios, which is psychotic violence sometimes, where someone might strike out believing that someone's trying to hurt them, harm them.
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So they strike out first.
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And we are very well equipped to manage that.
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We have medications that help us manage that.
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And that's also very different than affective violence or emotional violence or crimes of passion, violence from passion, where someone acts out because their system's overwhelmed, they're in fight or flight mode and they they just fight.
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So that's how I'm kind of parsing these apart in these different types of violence.
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And I don't know.
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I don't know if you'd agree with this.
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To me, it feels a little bit different than also like sociopathic violence, like a serial killer, like somebody who's killing or hurting or enacting violence for the pleasure of the violence.
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Like this sort of grievance-based ideological violence feels very, I think subjectively from the person enacting it to be justified.
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It's like I'm doing this not because I want to, but because I have to, because of justice or some important thing.
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Like that feels different too than like again, like more of like a sadistic sociopathic kind of violent presentation.
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Yeah, and you are totally right.
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And your intuition's spot on.
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So that kind of predatory violence that we tend to run into in people who have those sociopathic tendencies, or they are harming people for the purpose of achieving a goal where it's not exactly random violence.
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Parts of it are planned, but they're executed on purpose, such as I am going to rob the next person who looks like they can't outpower me, that they look like they don't have a gun, that no one's around.
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You know, those are the aspects that predatory violence perpetrators do.
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And that is very different, as you're saying, from the type of violence we're going to talk about today, which is usually grievance-fueled violence.
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Well, and I think maybe we can get into this more about you're saying there's these common factors.
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And I imagine then one thing we can think about is these are warning signs.
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These are things that we can be looking out for.
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And I will say I'm I'm already wanting to jump ahead to just think about, I will hold myself back.
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I do this sometimes.
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Let me hold that and let's start there.
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Can you give us a bit of an overview?
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It's just killing us.
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I know.
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Okay, okay, I'm just gonna say it's what I'm thinking is there is so much more of this presenting to psychiatric care.
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And especially working with young people.
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Like we, I feel like working on our adolescent unit, working with our young adults, as as we did together, Dr.
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Pedro, we're just seeing more and more young people who seem radicalized.
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Like that's the phrasing in my mind, that they they've developed this sort of fringe radical belief, and they're headed towards violence.
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And it feels like this is becoming a psychiatric issue in ways that it's not necessarily an issue of a psychiatric illness.
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And and so that's what I know we're gonna get to, or at least begin to think about, which is like, what's our job as therapists, psychiatrists?
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But before that, I think my guess is at least part of it is is looking for the warning signs, trying to sense how would you know?
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This is how this could be happening.
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And I know um you could spend more like a whole hour giving us like a full lecture on like these warning signs, but but could we get an overview of what are some of the things that that we should be looking out for that this is a path somebody's on?
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Yeah, I think that that's a great place we can go for.
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Um, so just as a kind of general idea, in the US of the mass shooter incidents that happen, about 80% of these perpetrators act on some form of grievance.
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So that's an important idea.
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It's kind of it's hard to get to this level of planned attack without being fueled in this manner.
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So that's an important idea for us to think about.
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You really cannot do this form of violence unless you have a specific grievance and you've started to become fixated.
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So we'll talk about what those things mean, but I'll kind of give an overview about like the two different areas that we talk about when we try to find warning signs.
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Okay.
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So one area is called, those are called distal characteristics.
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So basically you can think about this as storm clouds on the horizon, as Dr.
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Ramon said.
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So it's like putting a storm watch out there.
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We have all the ingredients there that could cause a storm to happen.
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Right.
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We do not see actual violence like on this horizon, but the soup is there.
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All the necessary pieces are there.
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That's very different from the proximal factors we can talk about.
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And that's when essentially a storm warning must be initiated because the storm is imminent.
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It is coming.
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So you got to sound the alarms.
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So we kind of talk about characteristics in both of those areas.
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And I think as clinicians, we will naturally scoop these details up in the person's narrative when we just talk to them.
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So our job is just to recognize them and start paying attention.
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And we can kind of go into an overview of a few of them.
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But I think some of the I think that'd be helpful.
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Yeah, I think some of the most important ones for us to go through in the distal characteristics, number one we should talk about is personal grievance.
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And the way I like to introduce this is we all know some uncle out there who said, Ah, if I had just, if that coach had just let me in the game, I would be in the NFL.
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And this guy's 53 years old, out of shape, does not play football.
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But yet we know that this is we can laugh about it, and yet we can tell that these grievances are quite common and people will hold on to them for many years.
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And it becomes very critical in that person's personal narrative.
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Yes.
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Most people that meet them will know this grievance.
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They'll they'll bring it up at some point.
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So that is the same thing that's happening for people who are committing lone actor violence.
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They have some sort of grievance or they feel some sort of moral outrage that something is happening to a group that they identify with, such as a white supremacy cause.
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Right, right, right.
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And it becomes embedded in the context of their personal life, such as if this was a, you know, let's say white supremacist, right-wing extremist, perhaps their mother had been assaulted by minorities at some point or just some random attack on a neighbor they had.
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And that becomes a critical piece in their grievance and they will talk about that.
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So that's one of the things to spot, because that's one of the first things they'll bring up when you start to unpack this.
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Is there a sense?
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Because this is where one of the places I could imagine this intersects with psychiatry, that this is doing something for their self-esteem.
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That if they are somebody who's who's struggling or they're not getting support they need or they feel put down, that to kind of locate that like some group or some system is is hurting them.
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Like it's a way to feel better about themselves.
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It's a way to feel like they're and again, I don't know if that's a globalized thought that everybody fits into that kick that you're Yeah.
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You know, I'm I I'm not speaking from data at this point for this question, but I like to think that there's there's something that having a grievance does for us.
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Maybe it makes us feel stronger, maybe it makes us feel more justified, but it can kind of serve a lot of purposes and saying certainly like externalizes like the blame, right?
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I mean, uh, you know, I I guess it's easy to think that uh I didn't get into Harvard because of, say, affirmative action or something.
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Right, right.
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As opposed to the fact that, well, no, actually my grades just weren't all that good.
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Right.
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You know, and that maybe I didn't I shouldn't go to Harvard.
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Right.
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Yeah.
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Yeah.
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So I think there are there may be some of those pieces in there.
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It's hard to say.
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So there's defin but but like there's it's likely serving some function and then there's a fixation on it.
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Okay, what what comes kind of what what are some of these other if there are other distal factors that you think are important?
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I think some of the other uh ones for us to just know about is it that this grievance for these folks that are on the pathway to violence, they start to frame the grievance into some sort of ideology.
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So this one grievance about let's say I was being bullied at my elementary school starts to get framed by this idea that perhaps, you know, men are being targeted by women across the nation and we are being demasculinized or emasculated.
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That might be something you'd find in um the incel community as an idea.
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So you get this grievance that happened, and then you hear how they framed it into an ideology.
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This would be a very common core thing across many different groups that commit these types of violence.
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And the in incels are an online like fringe group of men involuntarily celibate.
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That's where the name comes from, if I understand.
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Is that right?
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Yeah.
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I don't think I ever knew that.
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Yeah, that it's like thank you.
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And that they're they're like angry about it.
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They feel like it's women's fault.
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I see for this.
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Yeah.
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Okay.
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So then there's like an ideology that develops.
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That makes sense.
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Yeah.
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Then I think the other thing to come, there's two, there's two other ones we'll talk about, but yes, one of them is quite curious.
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It's a curious pattern that's very common.
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Failure of sexual pair bonding is a very common characteristic in these groups of individuals who, um, these lone actors who uh commit violence.
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So they have this failure to form lasting sexually intimate relationship, and they may engage in like sexualization of violence.
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Either they compulsively use pornography or they exclusively use prostitutes, or they often sexualize weapons.
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So that's a very curious finding that is just rampant in this group of people who commit this violence.
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I don't mean to be flip about it, but is it that curious?
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Like to me, that checks out.
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That like, I guess the reason why it checks out to me is that people who are in healthy, committed relationships or have this capacity for intimacy, who are able to connect with people, at least in part than be able to use empathy, connection, attachment.
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Then yeah, I I just it's harder to imagine that they would they would be hours on the internet developing these non-delusional, obsessive ideas of victimization.
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It just feels less likely to me.
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Yeah.
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Well, I guess uh based off your comment, Carrie, I think it's it's not a surprise that later we will say the vast majority of these folks who commit violence are men.
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Yes.
00:16:59.919 --> 00:17:00.240
Yeah.
00:17:00.240 --> 00:17:01.679
So that it is curious.
00:17:02.080 --> 00:17:05.039
I I will say I'm developing a presentation on this right now.
00:17:05.039 --> 00:17:25.039
Uh, I won't go on too much of a soapbox, but I do actually think that this might be at least in part related to a real diffusion of identity that's been happening over the last few decades, where I think it used to be much more common that, like, if you were, let's say, a man of a particular socioeconomic status, if life looked a certain way, it was really kind of carved out to like you go do this.
00:17:25.039 --> 00:17:26.079
And same for women.
00:17:26.079 --> 00:17:28.799
There, the the roles were much more restrictive.
00:17:28.799 --> 00:17:30.720
And that was problematic in its own right.
00:17:30.720 --> 00:17:35.359
But it didn't lead to this sense of like, what am I doing with my life and where do I find my sense of belonging?
00:17:35.359 --> 00:17:40.240
And my sense is that as roles have become more diffuse, there's more opportunities and there's more freedom.
00:17:40.240 --> 00:18:00.240
Again, like for a for a small minority of people, that level of just like there's not a lot containing you to like what you're supposed to do or where you're supposed to find your belonging is one of the reasons why people might be at risk for ending up in these positions of kind of be getting radicalized and ending up in these kind of fringe pseudo-political online arenas.
00:18:00.559 --> 00:18:01.759
I guess that's one way of thinking.
00:18:01.759 --> 00:18:05.359
I mean, is it well, you tell me, uh, is it correct?
00:18:05.359 --> 00:18:08.720
I mean, it's certainly seems much more common than it once was.
00:18:08.720 --> 00:18:11.599
I I do think it's much more common than it once was.
00:18:11.599 --> 00:18:12.799
I think there's multiple factors.
00:18:20.079 --> 00:18:23.519
Yeah, it it definitely is going up, unfortunately.
00:18:23.519 --> 00:18:25.920
I think it is a storm of factors.
00:18:25.920 --> 00:18:27.200
I keep using the storm word.
00:18:27.200 --> 00:18:28.160
I'm not a meteorologist.
00:18:28.160 --> 00:18:29.440
I don't know if I keep talking about storms.
00:18:29.759 --> 00:18:30.160
I love that.
00:18:30.240 --> 00:18:30.400
Yeah.
00:18:30.400 --> 00:18:37.200
But uh yeah, I think there's some comeuppance of both, you know, the internet age, the loss of identity.
00:18:37.200 --> 00:18:57.440
And then I I think some of it might be that because these extreme overvalued beliefs are socially contagious, I think that in the internet age, it's also easier for them to spread, especially with a lot of the notoriety given via media publishing on these events.
00:18:57.440 --> 00:19:01.599
Um, so it's becoming more popular, uh, whether we like it or not.
00:19:02.160 --> 00:19:03.519
You can like find other people.
00:19:03.519 --> 00:19:11.039
Whereas, like if you were like the only kid in your high school who felt this way, you might not be able to find other people, but you can find people now across the internet.
00:19:11.039 --> 00:19:12.160
That makes sense to me.
00:19:12.160 --> 00:19:19.759
I realized this was a juncture from the third distal factor of not developing intimate pair bonding sexual relationships.
00:19:19.759 --> 00:19:22.640
But I think you were saying there's one more in the different categories.
00:19:23.599 --> 00:19:29.359
Yeah, the other one that I would say would be good to just know would be the changes in thinking and emotion.
00:19:29.359 --> 00:19:42.559
So there's some point that gets driven by either obsessions, delusions, or extreme overvalued beliefs where the person's thinking becomes more strident, simplistic, and absolute.
00:19:42.559 --> 00:19:51.279
And my favorite quote in this area is when those folks show changes in thinking and emotion, argument ceases and preaching begins.
00:19:51.279 --> 00:19:57.039
So that's that's where they start to show up is their beliefs are fact.
00:19:57.039 --> 00:20:06.400
And uh you're basically just caught up in their storm winds of what their belief system is when they show those changes in thinking and emotion.
00:20:06.400 --> 00:20:13.680
And we as psychiatrists treat two of those three causes of changes very regularly in our practice.
00:20:14.720 --> 00:20:25.279
It makes me think about this idea that I have shared with patients pretty frequently, which is that if logic didn't get somebody into a belief, logic's not going to be the thing that gets them out.
00:20:25.279 --> 00:20:33.279
Like if it's some emotional experience or need that gets somebody into a belief, it's not going to be logic that gets them out of it.
00:20:33.279 --> 00:20:35.440
It's going to be some new emotional experience.
00:20:35.440 --> 00:20:44.799
And I that sound, I'm usually talking about that more for like a painful self-hatred or like a, you know, some internal belief that's got somebody stuck in a maladaptive pattern.
00:20:44.799 --> 00:20:46.480
But I imagine that fits here too.
00:20:46.480 --> 00:20:50.799
Like some likely like emotional attachment, pain.
00:20:50.799 --> 00:21:00.319
Something happens is usually these people that then got them into like this as a way of coping, that then is not something, yeah, you're gonna logic and argue your way out of with somebody.
00:21:00.319 --> 00:21:05.279
It's not it's it reminds me of some of the research on cults that there's that they're self-sealing.
00:21:05.279 --> 00:21:14.880
There's like, there's no way to argue people out of it because they can always come up with another reason for yeah, making sense as to why they do what they do or exist in the way they exist.
00:21:15.200 --> 00:21:15.440
Yeah.
00:21:15.440 --> 00:21:22.720
I mean, I I think your framework's very helpful for kind of like understanding some of the causes and and what's behind this.
00:21:22.720 --> 00:21:24.559
I mean, how how useful is it?
00:21:24.559 --> 00:21:36.319
I mean, often when you when something very tragic happens, like the mm, you know, like like a like a murder of of a public figure or something like that, you know, it always comes up, where was psychiatry?
00:21:36.319 --> 00:21:40.079
How come we weren't able to spot this and and predict this and stuff?
00:21:40.079 --> 00:21:46.960
And and occasionally you'll you'll see people who do go through some psychiatric treatment, but you know, all the same this happened.
00:21:46.960 --> 00:21:48.640
I mean, what's your sense?
00:21:48.640 --> 00:21:53.200
How how how likely it is that you can spot people like this and predict this?
00:21:53.519 --> 00:21:55.839
Well, you know, I think that's a great question.
00:21:55.839 --> 00:21:59.680
And uh it brings me up to a uh a lecture I did.
00:21:59.680 --> 00:22:06.720
I did this kind of area lecture for residents, and one of them said they they chived up, they said, Why do we have to learn this?
00:22:06.720 --> 00:22:08.160
I don't want to do this.
00:22:08.160 --> 00:22:11.039
And I and I I agreed.
00:22:11.039 --> 00:22:13.119
I said, no one wants to do this.
00:22:13.119 --> 00:22:17.519
Um, unfortunately, everyone thinks it's our job to do this.
00:22:17.519 --> 00:22:17.839
Yeah.
00:22:17.839 --> 00:22:23.839
And so if something happens and they had been to a hospital, it is the psychiatrist's fault.
00:22:23.839 --> 00:22:27.440
That's how society believes this works right now.
00:22:27.440 --> 00:22:57.839
Now, even though if you look at Malloy's 2016 article where he took all these factors and looked at people who actually committed mass murder, and only about 40% of them had any history of a mental disorder, even though it's only about 40%, maybe someone had depression, maybe someone else had psychosis or someone had schizophrenia, even though it's only 40%, we will be evaluated by society as being responsible for 100% of the ones we miss.
00:22:57.839 --> 00:22:58.559
Yep.
00:22:58.559 --> 00:23:02.880
So that's that's where we're at in this in our society right now.
00:23:02.880 --> 00:23:06.720
I don't I'm not saying it's fair, but but that is the perspective.
00:23:07.039 --> 00:23:08.079
Well, how fair is it?
00:23:08.079 --> 00:23:10.720
I mean, should we be blamed for not doing a better job?
00:23:10.720 --> 00:23:11.920
Or what's your take on that?
00:23:11.920 --> 00:23:12.880
Yeah, it's a big question.
00:23:13.119 --> 00:23:16.640
But my my take is this, and this is what I said to that that resident.
00:23:16.640 --> 00:23:22.319
I said, I don't think it's fair, and yet we have some opportunity here.
00:23:22.319 --> 00:23:23.119
Okay.
00:23:23.119 --> 00:23:33.200
So I I would rather we do something than nothing, even though we suffer with the paradox that if we do something and it works, then nothing happened.
00:23:33.440 --> 00:23:33.680
Right.
00:23:33.680 --> 00:23:36.319
You really can't prove that you prevented anything.
00:23:36.640 --> 00:23:48.000
Well, yeah, that is exactly where my mind is at, because especially working with young people, I feel like we're intercepting more young people into psychiatric care because their family, their parents, bring them to care.
00:23:48.000 --> 00:23:53.920
And these are not necessarily people who would have shown up saying, like, yes, I really want help or I'm struggling, but like their family's worried.
00:23:53.920 --> 00:24:03.119
They find some printed out materials or books or internet search histories that are that are uh scary, that feel, you know, concerning to the family.
00:24:03.119 --> 00:24:05.839
And then, you know, like let's say you have someone come in, Dr.
00:24:05.839 --> 00:24:06.240
Pedro.
00:24:06.240 --> 00:24:09.519
And I'm gonna be honest, I don't know that we covered the proximal warning signs.
00:24:09.519 --> 00:24:13.440
So maybe we can think about that too, if there are some of those you'd like to share.
00:24:13.440 --> 00:24:18.480
But like if someone comes in and they have these warning signs, I'm like, but they haven't done anything.
00:24:18.480 --> 00:24:18.799
Right.
00:24:18.799 --> 00:24:28.079
It's like you don't call the cops on someone because you think that there's like a chance, right, that they're gonna hurt an unidentifiable possible person.
00:24:28.079 --> 00:24:37.759
Anyway, so I I I think where my question is, is like, what do you do when you when you encounter somebody who hits the warning signs, especially in our clinician?
00:24:38.240 --> 00:24:39.200
That is a great question.
00:24:39.200 --> 00:24:52.079
And I love that question because I think that I want to empower clinicians in this area because the exact same thing happens to us when we're presented with the storm clouds of suicide risk.
00:24:52.079 --> 00:24:52.400
Okay.
00:24:52.400 --> 00:24:56.000
And we often very much have a lot of the same feelings.
00:24:56.000 --> 00:24:58.640
We feel like, why is this our job?
00:24:58.640 --> 00:25:00.480
How do we how can we prevent this?
00:25:00.480 --> 00:25:01.759
What if we do prevent it?
00:25:01.759 --> 00:25:04.559
No one can tell we can because nothing happened.
00:25:04.559 --> 00:25:04.880
Right.
00:25:04.880 --> 00:25:12.720
And yet we can still, as clinicians, we will sometimes be in the room and we will notice things and we can do something about it.
00:25:12.720 --> 00:25:18.960
And that's why I'm empowering clinicians to learn more about this stuff because you might be the person in that room.
00:25:18.960 --> 00:25:21.680
And it's better to do something than nothing in that area.
00:25:21.680 --> 00:25:23.519
So can we spot the signs?
00:25:23.519 --> 00:25:31.759
Do we think we can spot the signs at someone who maybe has some of the risk to commit suicide someday?
00:25:31.759 --> 00:25:44.400
What would we do for that person and try to apply those same ideas to the person who's bringing up a grievance, who started to frame with an ideology, who's feeling isolated, who maybe had suffered from depression?
00:25:44.400 --> 00:25:46.880
Say, okay, is there something I can treat here?
00:25:46.880 --> 00:25:49.680
Can I get this person involved in some community?
00:25:49.680 --> 00:25:52.559
Can I build an alliance with this person?
00:25:52.559 --> 00:25:59.039
Can I start to work on the things that are making their ego vulnerable to injury here?
00:25:59.039 --> 00:26:01.440
Can we work on some of the coping skills?
00:26:01.440 --> 00:26:04.000
Can we keep, can we take the guns out of the house?
00:26:04.000 --> 00:26:05.279
Can we get gun locks?
00:26:05.279 --> 00:26:18.559
Those are the things I want clinicians in the rooms to think about when they're confronted with grievance, moral outrage, or worse, proximal behaviors, which is essentially suicidal preparatory behaviors.
00:26:18.559 --> 00:26:23.759
So I just want the clinician to say, okay, I actually have been trained in this.
00:26:23.759 --> 00:26:29.359
I actually can know when there's some danger versus when the danger is imminent.
00:26:29.359 --> 00:26:38.400
And although I cannot ultimately prevent every suicide or mass shooting, perhaps I can do something for this person in the room.
00:26:38.400 --> 00:26:40.880
And that's that's what I want people to feel empowered to do.
00:26:41.119 --> 00:26:44.000
We're not obtuse to the to the issue.
00:26:44.000 --> 00:26:46.480
I do find my okay, I know you just said this.
00:26:46.480 --> 00:26:54.240
The proximal warning signs are similar to those of people who are suicidal or preparing for suicide.
00:26:54.240 --> 00:26:57.519
Can you say more though about like for lone actor violence, what those are?
00:26:57.519 --> 00:27:03.680
Because I think I've heard you say some of this before that it's like there is preparatory, there's people, they're they're looking to see their capacity for injury.
00:27:03.680 --> 00:27:05.920
Like, can you say a little bit more about those?
00:27:06.240 --> 00:27:06.400
Yeah.
00:27:06.400 --> 00:27:17.599
So with that frame in mind, I'll just caveat this by saying if anyone wants to read more about this, you can go find the trap 18, the terrorist radicalization.
00:27:17.599 --> 00:27:23.359
And you can you can read the trap 18, which is a structured assessment of these distilled proximal factors.
00:27:23.359 --> 00:27:24.799
Um, it's great.
00:27:24.799 --> 00:27:43.119
However, just as a clinician, learn to think, if we can think with that lens of preventing suicide, well, then we would recognize if someone is developing pathway to violence, i.e., they start to research, think about, plan, or start to prepare for implementation of an attack.
00:27:43.119 --> 00:27:48.880
That would be very much like someone who went and purchased a gun with a plan to go shoot themselves.
00:27:48.880 --> 00:27:54.400
Have they been Googling how to make a bomb or Googling how to commit suicide?
00:27:54.400 --> 00:28:01.759
This is very much in that same kind of clinician thinking that we have when we spot someone at imminent risk of suicide.
00:28:01.759 --> 00:28:05.039
The other thing that we should spot is fixation.
00:28:05.039 --> 00:28:20.480
And this is where someone becomes increasingly pathologically preoccupied with some grievance or ideology, and it starts to cause a deterioration in all aspects of their functioning.
00:28:20.480 --> 00:28:31.680
Their social functioning, as in they're not spending time with friends, not going to church anymore, not spending time with family members, or they're occupational functioning.
00:28:31.680 --> 00:28:34.000
They start to get worse performance in work.
00:28:34.000 --> 00:28:37.920
Maybe they lose their job, maybe they stop showing up to school.
00:28:37.920 --> 00:28:43.279
Those would be the same things we'd worry about for someone who's trying or thinking about committing suicide.
00:28:44.559 --> 00:28:53.359
Well, and it makes me think about I I really liked what you said about that we have some things we can do and we have skills that we're trained in as clinicians.
00:28:53.359 --> 00:28:54.960
It that felt very helpful to me.
00:28:54.960 --> 00:28:59.039
Cause I'm not gonna lie, I sometimes struggle with my hopefulness around this.
00:28:59.039 --> 00:29:03.279
You know, we have somebody come in and they they seem like they're checking off some of these things.
00:29:03.279 --> 00:29:05.519
As a team, we're kind of freaked out.
00:29:05.519 --> 00:29:10.720
We're like, oh, we want to intervene appropriately and we're we're scared this person could do something dangerous.
00:29:10.960 --> 00:29:11.119
Right.
00:29:11.119 --> 00:29:11.839
But what can you do?
00:29:11.839 --> 00:29:17.599
You feel it is it's like, oh no, like if you call the police, they're not gonna, you know, there's no reason they could hold this person.
00:29:18.160 --> 00:29:21.839
I think we run into this place of feeling like, well, their thinking is really compromised.
00:29:21.839 --> 00:29:29.839
But one thing I'm appreciating that you're saying that I'm liking, and I'm I'm just wanting to reiterate, is that people's thinking gets so much more compromised in isolation.
00:29:29.839 --> 00:29:37.440
Like this is where I think people's thinking falls apart so profoundly is when they are alone with their mind and they just spiral further, further into it.
00:29:37.440 --> 00:29:43.359
And I think this idea that people have more community, and even just a clinician to be like, wait, say more about that.
00:29:43.359 --> 00:29:45.119
Can you help me understand how you think this?
00:29:45.119 --> 00:29:53.119
Like it's it's it's bringing in another mind that I think can be like a really important first stage of getting people to come out of that spiral a little bit.
00:29:53.119 --> 00:29:54.720
Obviously, that's not foolproof.
00:29:54.720 --> 00:30:00.880
People can get really concrete and really rigid in their thinking, but to just have more minds to be like, I'm Not sure I'm following that.
00:30:00.880 --> 00:30:02.880
Or like, can you help me this make more sense to me?
00:30:02.880 --> 00:30:09.039
Can I think introduce get people out of that isolative thinking that just spirals them so much further into that?
00:30:09.039 --> 00:30:16.160
That I think if that that that is hopeful, like getting people talking, getting them to connect to other people, helping them to see that like maybe there's other ways to think about this.
00:30:16.160 --> 00:30:24.160
Like that feels like it could really jar something that could feel so concrete if people were not getting any sort of help or there was no people to think with them about this.
00:30:24.480 --> 00:30:25.599
I I'm curious though.
00:30:25.599 --> 00:30:26.960
Did you want to respond to that?
00:30:26.960 --> 00:30:29.359
Or I that was honestly great.
00:30:29.359 --> 00:30:31.599
I I don't have much else to say.
00:30:31.599 --> 00:30:32.799
That was Yeah, right.
00:30:32.799 --> 00:30:33.839
That's kind of how I felt.
00:30:33.839 --> 00:30:34.799
It is a challenge.
00:30:34.799 --> 00:30:37.759
I I'm just curious, what usually brings these people?
00:30:37.759 --> 00:30:39.680
Like, why would you be assessing them?
00:30:39.680 --> 00:30:41.920
They don't see themselves as having a psychiatric illness.
00:30:41.920 --> 00:30:48.079
They're not gonna, they're unlikely to on their own just decide to come see a psychiatrist for their thoughts of violence.
00:30:48.079 --> 00:30:49.519
So what would bring them in?
00:30:49.519 --> 00:30:51.200
Yeah, that's a great question.
00:30:51.440 --> 00:30:59.039
So, you know, I'm thinking about some of the cases that came in in my clinical care just under general psychiatric practice.
00:30:59.039 --> 00:31:02.079
A lot of them are not brought in because they wanted to.
00:31:02.079 --> 00:31:06.400
I have run into them in emergency departments, in hospitals.
00:31:06.400 --> 00:31:08.480
Sometimes they're brought in by police.
00:31:08.480 --> 00:31:12.480
Perhaps they made quote unquote terrorist threats to a school.
00:31:12.480 --> 00:31:16.480
The police evaluated them and said something's wrong with them.
00:31:16.480 --> 00:31:19.680
Maybe we should take them to be psychiatrically evaluated.
00:31:19.680 --> 00:31:26.960
So something about that interaction, the police officer investigator brought them for psychiatric evaluation.
00:31:26.960 --> 00:31:29.440
So that's one scenario that can be common.
00:31:29.440 --> 00:31:32.480
Some behaviors, people are caught by happenstance.
00:31:32.480 --> 00:31:38.400
Perhaps they've been acting strange at work, and then they're found in the parking lot with a gun.
00:31:38.400 --> 00:31:46.720
So that might be something where, well, no law has been broken here, but people are worried about, you know, we'll just throw in a name, Jonathan.
00:31:46.720 --> 00:31:48.000
People are worried about Jonathan.
00:31:48.000 --> 00:31:50.319
He's been acting strange for the last three weeks.
00:31:50.319 --> 00:31:53.200
They get brought to the emergency department for an evaluation.
00:31:53.200 --> 00:31:56.880
Or maybe they get a short-term commitment at the hospital.
00:31:56.880 --> 00:32:00.319
Those are a lot of the ways that these folks show up.
00:32:00.319 --> 00:32:01.920
Someone's worried about them.
00:32:01.920 --> 00:32:03.759
They're not sure what's going on.
00:32:03.759 --> 00:32:07.200
And that's how they get brought to the attention of us clinicians.
00:32:07.519 --> 00:32:11.440
You know, this is going to be a little bit of a complicated reflection.
00:32:11.440 --> 00:32:14.319
And I'm just saying that because I hope it makes sense as it comes out of my mouth.
00:32:14.319 --> 00:32:26.559
But I've been thinking about this a lot that I think psychiatry, being a medical discipline, has this obsession sometimes with, you know, having kind of these compartmentalized mental illnesses, these disorders that we know the etiology of it.
00:32:26.559 --> 00:32:33.680
And those are distinct and separate from so social, you know, individual psychosocial factors.
00:32:33.680 --> 00:32:39.440
And I've been hearing that brought up more and more recently, that it's like, well, that's not a psychiatric issue, that's a psychosocial issue.
00:32:39.440 --> 00:32:44.559
As almost to say, a psychiatry and allied, you know, professionals, it's like wiping our hands.
00:32:44.559 --> 00:32:46.160
We don't have not my domain.
00:32:46.160 --> 00:32:47.279
That's not a psychiatric issue.
00:32:47.279 --> 00:32:50.960
I feel like it would be really easy to look at this and be like, this is not a psychiatric issue.
00:32:50.960 --> 00:32:58.240
You know, if the police say, hey, this person's starting to like act funny or they're posting things, terroristic violent threats, la la la.
00:32:58.240 --> 00:33:01.519
That like I could imagine all people being like that's not a psychiatric issue.
00:33:01.519 --> 00:33:03.440
This is not, this isn't a delusion.
00:33:03.440 --> 00:33:05.359
This isn't, you know, depression.
00:33:05.359 --> 00:33:09.200
But I feel like that is not a fair thing to say.
00:33:09.200 --> 00:33:13.759
That these aren't, these are again, like psychiatry isn't obtuse to these things.
00:33:13.759 --> 00:33:21.359
And I know we've kind of already talked about that, but I I wonder if you have any additional thoughts for again clinicians who might say, like, well, this isn't the this isn't psychiatric.
00:33:22.319 --> 00:33:23.599
Angry, violent person.
00:33:24.079 --> 00:33:25.759
Yeah, this is not an issue of psychiatry.
00:33:25.920 --> 00:33:26.079
Yeah.
00:33:26.319 --> 00:33:35.200
Yeah, I would say that right now, this is still a burgeoning area where there is a lack of good structure in society about what to do.
00:33:35.200 --> 00:33:35.599
Yeah.
00:33:35.599 --> 00:33:54.480
And I I think that unfortunately or fortunately, depending on your perspective, it kind of falls into the lap of mental health leadership to work with law enforcement and to work with institutions like hospitals and schools to start developing plans about what to do.
00:33:54.480 --> 00:33:59.200
Because it's not exactly a police matter if they haven't broken a law.
00:33:59.200 --> 00:34:09.440
It's not exactly a psychiatric problem if it's not related to schizophrenia or depression, but it's somewhat related to all of it.
00:34:09.440 --> 00:34:12.320
And society thinks it's all of our job.
00:34:12.320 --> 00:34:14.880
So some places do a good job of this.
00:34:14.880 --> 00:34:26.639
I'll give an example, for example, the the VA across the nation, you know, they have seen and started to implement um threat assessment programs for both employees and veterans.
00:34:26.639 --> 00:34:34.480
Those are things that could be developed and instituted at schools, at school districts, at hospitals.
00:34:34.480 --> 00:34:36.880
And yet we're not quite there yet in the US.
00:34:36.880 --> 00:34:57.599
And I think that that discrepancy of how much we're seeing this happen and how little we have implemented as an institution uh to engage and deal with this, I think that highlights why psychiatrists or whatever clinician needs to say, hey, I know it may not be my job, but we got to do something about this.
00:34:57.920 --> 00:35:00.400
We're studying and thinking about the human mind.
00:35:00.400 --> 00:35:01.920
We have something to say about it.
00:35:01.920 --> 00:35:02.960
I have to say, Dr.
00:35:02.960 --> 00:35:08.559
Pedro, I could ask at least 10 more questions and keep talking about this for several more hours.
00:35:08.880 --> 00:35:09.199
Yeah.
00:35:09.199 --> 00:35:24.880
So for a person who's not yourself, who's not an expert on these things and stuff, what advice would you have to us as we, you know, we just happen to encounter someone in our practice or if we're covering an emergency room or in just various situations?
00:35:24.880 --> 00:35:29.440
Um I I I guess I'm particularly interested in like, how do you get them to talk to you?
00:35:29.440 --> 00:35:31.280
They're they're probably there under duress.
00:35:31.280 --> 00:35:34.960
They're probably haven't agreed to like, you know, cooperate.
00:35:34.960 --> 00:35:40.960
How do you gain enough sort of rapport or trust to kind of like, you know, get them to talk with you?
00:35:41.280 --> 00:35:44.159
Well, this is something that really makes me respect.
00:35:44.159 --> 00:35:44.880
Yeah.
00:35:44.880 --> 00:35:49.280
It really makes me respect the Menninger Clinic, which, you know, it's a psychodynamic hospital.
00:35:49.280 --> 00:35:54.000
It's one of the most world-class institutions for psychiatry and clinical practice, period.
00:35:54.000 --> 00:36:04.559
But very often you speak to a psychodynamic, inclined therapist, analyst, whatever, they will say that if you get someone to talk, they will bring up their pain.
00:36:04.559 --> 00:36:12.000
And so these are folks who may not have psychiatric problems, but they are pained in a way that deeply disturbs them.
00:36:12.000 --> 00:36:15.840
And we need to put on our therapy hats.
00:36:15.840 --> 00:36:25.840
What do we do with people who showed up to therapy because they're brought in by their wife or brought in by someone court-ordered that says you have to go to therapy?
00:36:25.840 --> 00:36:28.400
How do we bring them into the therapeutic space?
00:36:28.400 --> 00:36:30.079
How do we make it useful?
00:36:30.079 --> 00:36:35.679
How do we welcome them without saying you're being judged for what brought you here?
00:36:35.679 --> 00:36:40.480
I think those are the soft skills that all of us know how to practice.
00:36:40.480 --> 00:36:44.400
We just need to use that in this different context.
00:36:44.400 --> 00:36:46.320
So just use the soft skill.
00:36:46.559 --> 00:36:47.119
Non-judgment.
00:36:47.119 --> 00:36:51.119
It feels very mentalizing forward because it's like curiosity and non-judgment.
00:36:51.119 --> 00:36:56.079
And I think those are the things that so often open the doors to people saying, okay, I guess I'll share a little bit.
00:36:56.960 --> 00:36:58.800
This is so unusual in interactions.
00:36:58.800 --> 00:36:59.280
Yes.
00:36:59.280 --> 00:37:00.000
Yeah, right.
00:37:00.000 --> 00:37:03.840
It's it's very hard not to talk to someone who really wants to listen to you.
00:37:04.079 --> 00:37:04.400
Yes.
00:37:04.480 --> 00:37:04.719
Yeah.
00:37:05.039 --> 00:37:05.519
Well, Dr.
00:37:05.519 --> 00:37:10.159
Pedro, thank you so much for sharing and giving us an overview and to share some resources and tools that are out there.
00:37:10.159 --> 00:37:23.199
Again, I think one of the big takeaways I'm hearing from you is to try not to be so put off by this that we don't do something helpful when we encounter this when we do have skills as clinicians and as psychiatrists that we could do something helpful.
00:37:23.440 --> 00:37:24.239
That's very helpful.
00:37:24.480 --> 00:37:24.880
Well, Dr.
00:37:24.880 --> 00:37:27.039
Pedro, again, thank you for being here.
00:37:27.039 --> 00:37:29.599
Any last words for our listeners today?
00:37:29.840 --> 00:37:34.719
Yeah, I would say, you know, this is an area that kind of falls in all of our laps.
00:37:34.719 --> 00:37:42.000
So I would say if you if you hear threats or you feel that instinct in your gut that something's wrong, take that serious.
00:37:42.000 --> 00:37:49.519
Um, if you're interested in more learning more, definitely look at the terrorist radicalization assessment protocol by Dr.
00:37:49.519 --> 00:37:50.400
Malloy.
00:37:50.400 --> 00:37:51.679
Or you can read Dr.
00:37:51.679 --> 00:37:54.480
Rahman's book, Extreme Overvalued Beliefs.
00:37:54.480 --> 00:37:59.199
That's a good overview about this area and how it intersects with those changes in thinking and emotion.
00:37:59.199 --> 00:38:01.360
And talk about it in your institution.
00:38:01.360 --> 00:38:04.719
What do we do when we evaluate and see someone like this?
00:38:04.719 --> 00:38:18.079
Bring it up to the judges you work with regularly in courts, if you're an institution that involuntarily commits folks, if they understand what risk could look like if it was imminent, but not suicide risk.
00:38:18.079 --> 00:38:23.599
Um, and talk about those things as factors for why someone might need to be committed short term to understand what's going on.
00:38:23.599 --> 00:38:24.880
So that's what I would say.
00:38:24.880 --> 00:38:27.679
Learn as much as you can, talk about it openly.
00:38:27.679 --> 00:38:31.199
We all are scared by this stuff, all your colleagues.
00:38:31.199 --> 00:38:32.800
So definitely talk about it.
00:38:32.800 --> 00:38:35.440
Ask for help from a colleague if you ever feel lost.
00:38:35.679 --> 00:38:36.239
That's right.
00:38:36.239 --> 00:38:36.719
All right.
00:38:36.719 --> 00:38:38.800
So once again, you've been listening to Dr.
00:38:38.800 --> 00:38:42.239
Pedro Julness, and this is the Mind Dive Podcast.
00:38:42.239 --> 00:38:43.760
I'm your host, Bob Bowen.
00:38:43.920 --> 00:38:46.000
I'm Carrie Hurell, and thanks for diving in.
00:38:46.000 --> 00:38:50.239
The Mind Dive Podcast is presented by the Menninger Clinic.
00:38:50.239 --> 00:38:56.239
If you're curious about the professional experiences of mental health clinicians, make sure to subscribe wherever you listen.
00:38:56.559 --> 00:39:01.280
For more episodes like this, visit www.menningerclinic.org.
00:39:01.519 --> 00:39:06.960
To submit a topic for discussion, send us an email at podcast at meninger.edu.