GermanWings Airline Disaster: Thoughts on self-disclosure of mental illness and workplace violence.

Petra Kottsieper, Ph.D.

Almost everyone has likely heard about the air crash of a Germanwings flight 9525 en route from Barcelona to Duesseldort that occurred on March 24, 2015. It is now clear that the co-pilot deliberately steered the plane into the French Alps in order to kill himself and the other 149 passengers on board.  This has obviously resulted in frenzied search for a motive, which may at least explain what would bring a person to the point of committing such a heinous act.

Recently we have learned that the First Officer Andreas Lubitz had received treatment for possibly serious depression, suicidality and anxiety issues in 2009, resulting in a time of absence in his flight training.  He was subsequently declared fit for duty, resumed his very rigorous training and had passed all fitness tests since.  This has caused a lot of speculation about his mental health and a possible recurrence of more acute symptoms, as well as calls for more screening of mental health issues in pilots and flight crew.

As the investigation continues, we have learned that Mr. Lubitz had undergone diagnostic testing at a hospital for vision problems. This problem seems to have been diagnosed by one physician as psychosomatic, likely related to experienced stress and some underlying mental health concerns and/or psychological problems. Of course a vision problem, both medically based and psychologically based could be a major career ending problem. Doctors may have declared him unfit for duty at the time of the crash, however this information was neither passed on by Mr. Lubitz to his employer nor did he apparently follow the instructions of physicians.  Of course this would have required Mr. Lubitz to disclose to his employer that he was “stressed”, had vision problems that were thought psychological in origin, and had been declared unfit to fly.  His decision not to follow any of these recommendations had horrendous consequences. The research and opinions presented in the rest of this blog is not presented to excuse his behavior or decisions, but attempts  to highlight some of  the complex issues that surround this tragedy and think about ways to proactively respond to one of the larger issues at hand in this tragedy, the issue of self-disclosure at work . 

Why do people not disclose at work?

A review of the academic literature indicated that disclosure of mental health concerns in the workplace is most often associated with wanting to be a role model for others, requiring accommodations, a need to be authentic and honest (especially with coworkers), and to reduce the stress of concealing important parts of one’s identity. However, individuals who disclose are a minority.  A large majority of employees across various employment sectors do not disclose their mental health concerns and/or histories. Employees report fearing discrimination such as losing their jobs, being treated differently by employers and colleagues, having their competency questioned, being gossiped about and rejected due to being perceived as “different.” Sadly, there are good reasons for this fear, as 7 out of 9 research studies revealed discriminating hiring practices against people with mental health problems. For example one study cited, showed how applicants with a diagnosis of depression and anxiety were rated as significantly less desirable for hire when compared to people with disclosed medical disabilities and no disabilities.

 In the US and Europe legislation exists to protect people with mental health concerns from workplace discrimination. However, many people do not believe, apparently accurately, that these protections, will protect them.  So many employees choose to not disclose or to more actively conceal their “hidden” or “invisible” identities. This is an identity management strategy, very much the same as the strategies  used by people for other identities that can be kept “hidden, such as one’s sexual identity or HIV status. 

National rates of Depression and suicide:

It has been estimated that in 2002 the lifetime prevalence of major depressive disorder was 16.2% (32.6-35.1 million US adults) and for 12-month was 6.6% (13.1-14.2 million US adults). The same study noted that 10.4% of these individuals reported mild, 38.6% moderate, 38.0% severe, and 12.9% very severe symptoms. Respondents in the severe and very severe symptom categories reported that they were impaired in both their social roles (43.4% severe or very severe) and less so in their abilities to carry out their jobs (28.1% severe or very severe reported work domain problems).

It is know that approximately 90% of individuals who commit suicide either have been treated or could have been treated for some mental health condition, most often depression. Factors that increase suicide risk are the experience of desperation, hopelessness, anxiety, or rage.

Murder -suicide and workplace violence:

The Violence Policy Center (VPC) reported that in a six month period in 2011 approximately 313 murder-suicide events were reported in the media , resulting in 691 murder-suicide deaths, of which 313 were suicides and 378 were homicides. The majority of the perpetrators were male and their victims’ intimate female partners.  Often murder-suicide seems to occur after a breakdown in the relationship and/or within a framework of domestic violence. The media has reported that Mr. Lubitz long time off and on again girlfriend was not only pregnant but may have also broken off the relationship with him just a day prior to his actions.

What is clear and has not been talked about a lot in the media is that Mr. Lubitz actions constitute workplace violence, or a so called workplace rampage incident.  He committed it while employed, during his work hours and against his coworkers and employer, in addition to the many other victims on the plane. The main difference is that workplace rampage events are usually committed with firearms and not an airplane.  It has been pointed out by scholars that workplace shooters not only target individual people but also institutions, just as a school shooter does. A comparative case study pointed to similarities between suicide terrorists and rampage, workplace, and school shooters who also attempt or commit suicide. Rather than finding large differences between these groups, he found many similarities of risk factors between these groups, albeit to differing degrees. Preceding the attacks, these individuals experienced personal problems, including social, family problems, work or school problems, and precipitating crisis events. Workplace shooters were the most different from the other groups in that they experienced fewer family problems prior to their attacks. Their attacks were also more often linked to specific trigger or crisis events such as being fired, or reprimanded by their employers. Suicide notes were less often present in this group and Lankford suggests that the workplace shooter “may be the most normal of the four types of attackers in this study, from a cultural, motivational, and behavioral standpoint.”

What does all of this have to do with the GermanWings Disaster?

Suicidal individuals who commit workplace or other rampage killings may not fit into what many people typically think of when they think of a depressed person.  While an underlying or more acute depression may very well be present in some of the people and then obviously plays some role, it is not the only causative explanation as outlined previously.  Work problems such as a loss of work or in Mr. Lubitz case a fear of losing his job over his eye condition or having to reveal his recurrent psychological problems may have been a contributing factor. He may have also experienced a significant interpersonal problem if his girlfriend dissolved their relationship. Trigger events are one of the hallmarks (and few) predictors in rampage and workplace violence murder-suicides. These trigger events may also increase hopelessness and increases in anger or rage, and/or a need to make some kind of statement in order to gain some type of notoriety.

In addition to undisclosed and likely untreated (current) depression, an inability to tolerate a fear of failure or handle rejections from significant trigger events, people that commit acts of rampage killings or workplace rampages may also have certain personality dispositions in addition to all the other risk factors. They may be more self-centered, display a lack of empathy for others, or at times even evidence some paranoid thinking.  We just do not know enough about Mr. Lubitz’s personality disposition, except unconfirmed reports that he was very controlling with his girlfriend.  

What does this mean for employers and people with depression and other mental illnesses?

This is an unspeakable tragedy which will warrant a response for how workplaces handle employees with mental illness. We need to remember that events like workplace rampages are still very rare, especially in European countries.  We also need to remember that depression, anxiety or even suicidality alone may result at times in a need to take time off from work when someone’s competency is affected, but that violent actions will not be prevented by an increased focus on dangers of “mental Illnesses.”  If we want to increase our screenings to better predict or prevent workplace rampage or workplace violence incidents we need to screen for the risk factors of the specific and diverse types of workplace violence that exist, and not just increase general screens for depression and anxiety. 

We want to encourage more individuals TO disclose their mental health problems to their employers in order to receive support, accommodations or time of if needed. Similar to when someone with an acute flare-up of a chronic medical illness can take off without fear of losing their job or having their competency questioned. We will only reduce passive and active concealment if we reduce stigma against these conditions and not when we increase it. Successful murder-suicide prevention, or in this case a rampage killing, relies to a very large degree on knowing what is going on with the person in their workplace, and personal life domains. Increases in non-disclosure are neither helpful nor desirable. 

Final thoughts

I have obviously no idea what Mr. Lubitz was thinking that drove him to such a terrible conclusion to his young life.  I cannot imagine the anguish, pain and anger of the families of the people that were killed by him and likely the parents and/or other family members of Mr. Lubitz. I hope there will be more answers for the families and all of us in the days to come, but I doubt those answers will be straightforward and not multiply determined.   I also hope that employers will continue to work on creating more welcoming workplace environments for people with mental health problems by actively promoting the inclusions of individuals with mental health issues into their workforces and providing support when needed or requested. 

Understanding Anorexia

Stacey C. Cahn, PhD explores causes and treatment of anorexia nervosa, the most dangerous eating disorder.

Eating disorders are serious, debilitating conditions associated with significant morbidity and mortality, and distress. Anorexia nervosa, in particular, is associated with the highest mortality and suicide rates;  compared to healthy peers, women with anorexia are up to 12 times more likely to die of any cause, and approximately 57 times more likely to die from suicide, over the same period of time. 

The best predictor of positive treatment outcome in anorexia nervosa is early detection and intervention. Those suffering from eating disorders often feel shame, isolation, and face stigma. Children who experience anorexia may have difficulty understanding, much less explaining, their symptoms.  Others may not want to let go of perceived “benefits” of their eating behavior. So, for a variety of reasons, many suffer in silence and secrecy, which can serve to dangerously delay intervention. 

What causes some people to develop anorexia?

First, it's important to recognize that there is a genetic component to anorexia.  Someone with a first-degree relative who's had anorexia is at much greater risk for anorexia than someone without a family history.  So individuals have varying levels of biological "predisposition" to anorexia.  Other risk factors fall into two categories:  1) risk factors for psychiatric problems in general, including anorexia; and 2) risk factors specific to anorexia.  

General risk factors include low mood, a history of physical and sexual trauma, general family problems, and a parent with a psychiatric disorder.  These all appear to increase one’s risk for later mental health problems, including eating disorders.  

Specific risk factors for anorexia include: being female, age (early-mid adolescence is the prime time for onset), perfectionism, and concerns about shape and weight (and subsequent dieting).  Shape and weight concerns may be intensified by participation in competitive sports such as gymnastics, track, swimming or dance, where shape and weight are often related to performance.

Why is anorexia more prevalent in women? 

We don't really know for sure. Anorexia is relatively uncommon—historically, only about 0.3 percent of the population suffer from anorexia.  (Recently, however, the American Psychiatric Association has broadened the diagnostic criteria for anorexia nervosa slightly, so the official prevalence will likely rise somewhat.) Of those who suffer from anorexia, only about 10 percent are male; it's hard to get good data on a population that small. It does seem that cultural factors at least partially explain this gender discrepancy; thinness is more central to our culture’s “feminine beauty ideal;” there’s not an equivalent standard for men. Accordingly, men, overall, have less dissatisfaction with their bodies, and are therefore less likely than females to diet for weight loss, even if they are overweight. This disparity is significant because body dissatisfaction and dieting are risk factors for anorexia.

Are there any promising new treatments in development? 

Anorexia nervosa is notoriously difficult to research and treat. Treatment effectiveness has generally been disappointing due to a host of factors including the ambivalence about recovery intrinsic to the disorder.  

One psychological treatment that seems particularly promising is Enhanced Cognitive-Behavioral Therapy (CBT-E). Oxford University psychologist Christopher Fairburn and his colleagues have made impressive strides with their recent treatment research in Europe; they’ve conducted rigorous clinical trials testing CBT-E for adolescents and adults with anorexia. Compared to earlier treatment outcome studies, a remarkable number of those who completed the treatment had maintained their gains sixty weeks after treatment. Still, the most important predictor of positive outcome in anorexia is early identification and intervention. In general, the longer the duration of illness before treatment, the worse the prognosis.

Understanding that vaccines do not cause illness

Jessica Glass Kendorski, Ph.D., NCSP, BCBA-D

Vaccination—the word has become quite divisive. On both sides, we find well-meaning, intelligent, good parents who just want what is best for their children, and to protect them from harm. The science behind the benefits of vaccinating are clear (see this Healthy Kids blog about the importance of herd immunity), and the recent measles outbreak shows the consequences when individuals do not vaccinate. The total number of cases is up to at least 155 cases in 16 states. Over the weekend, New Jersey became the latest state to join the list.

So why are well-meaning, intelligent, parents, putting themselves and their children at risk? Part of the reason is because many people have not personally experienced the devastation of some of these viruses for which we now have vaccines, causing them to underestimate the seriousness of illnesses like measles. But there’s another factor in play: a natural, predictable bias in the way humans are wired to think, a bias known as the post hoc fallacy--the natural tendency for us to see causation in two events that co-occur in time.

The post hoc fallacy, fully named “post hoc ergo propter hoc” translates from the Latin “after this, therefore because of this.” It is an error in logic to assume that if event 1 occurs right before event 2, then event 1 necessarily caused event 2. As a personal example, my daughter received her booster MMR vaccination when she was 4 years old. The very next day she developed a rash and spiked a 104-degree temperature. I was scared, but, fortunately, it was clear to me that this probably wasn’t because of the vaccination; her 2-year old brother had had the same rash and high temperature a few days prior, and had been diagnosed with the Hand, Foot and Mouth virus. It would have been natural for me to blame the MMR vaccination for her illness (since one occurred right before the other), but I had the “benefit” of having another kid in the house with similar symptoms who 1) had been diagnosed with a highly contagious illness, and 2) had not been recently vaccinated.

Young kids get sick with regularity.  Young kids get vaccinated with regularity. Therefore, there is a reasonable chance that your child will get sick some time after receiving a vaccine, without the two events being related.  Similarly, with Autism Spectrum Disorder, symptoms begin to emerge around the same time that toddlers routinely receive the MMR vaccination. This timing predictably causes some parents to question whether the vaccination caused the disorder, when there is no evidence that suggests the two are related, and substantial evidence supporting that the two are unrelated.

This tendency to equate causality with timing has long been shown in the behavioral science literature. Take B.F. Skinner’s experiment with pigeons. The birds would receive a food pellet at random intervals from a machine. After a certain amount of time, they would perform whatever random activity they had done before receiving the pellet, as if that action would produce it. This is exactly why humans strive to understand what happened —what they did—to cause an event. And, it’s the reason why so many parents are convinced that a particular vaccination can cause an injury or disorder, when in reality, the two are unrelated.

If we want to increase the number of people who vaccinate their children, explaining the science is not enough. We must understand the natural tendency for people, all people, to equate coincidence with causality. We must recognize the stories that people tell about their child getting sick are very real, and very heartbreaking. We must help people understand the fallacy in their logic; that just because two things occur together does not mean that one caused the other. Any successful message has got to include real empathy.  Empathy for these very, well-intended parents, who have only the best interest of their beloved children at heart.  

Why we shouldn't physically punish our kids

Jessica Glass Kendorski, Ph.D.,NCSP, BCBA-D

The recent arrest of Minnesota Vikings Running Back Adrian Peterson has sparked a divided reaction within the NFL around the use of physical punishment with children.

Peterson’s lawyer, for example, said that Peterson “used the same kind of discipline…that he experienced as a child.” Former basketball player and current NBA analyst Charles Barkley also defended Peterson, while ESPN’s Chris Carter (a former Viking himself) noted, “You can't beat a kid to make them do what you want them to do." This range of reaction echoes the national debate surrounding physical punishment. But, existing research tells us that Carter is right.

Researchers define physical punishment as “the intentional infliction of pain and discomfort and/or the use of force to stop or change a behavior.” A 2008 study on the effectiveness of physical punishment on children in the U.S. found no long term effects on behavior change; essentially, when the threat of punishment was gone, the negative behavior returned.

Additionally, there is extensive research that physical punishment puts children at substantial risks for future defiant and aggressive behavior, increased mental health concerns, as well as greater risk of serious injury and abuse. Recent brain science research has shown that harsh physical punishment may actually have detrimental effects on the development of a child's brain.

The negative effect of punishment, physical or otherwise, extends to our schools as well. Many schools adopt “zero tolerance” policies, but in order for those to work, educators must discipline students in harsher ways, often with little effect. The US Department of Education reported in 2011 that there were more than 3 million suspensions per year and over 100,000 expulsions. What’s more, consistent use of punishment in schools causes children to become fearful and avoidant of school and teachers, and interferes with positive, pro-social relationships. Brain science is showing us that warmth and nurture are essential to brain development. Academic success—one of the best indicators of adult success—is best achieved in a school climate that is warm, welcoming, and promotes positive behavior and positive interactions with adults and peers.  In order to reduce the use of physical punishment, we must have other options.

Children learn to behave when their parents notice and respond to their behavior appropriately. When a child misbehaves, it is essential that parents remain calm (provide appropriate time outs if necessary) and communicate the appropriate way to get it right next time.  Techniques such as teaching behaviors that you want to see (keeping your hands to yourself and why); Reinforcing specific behaviors (keeping your hands to yourself); Modeling appropriate behavior (parents keep their hands to themselves); and reinforcing a low preferred behavior (doing homework) with a high preferred behavior (playing a game) are effective ways to encourage appropriate behavior.

The risks to physical punishment are huge and well outweigh the short term reduction of a negative behavior. It's time to change the culture of discipline in our country, and to show parents that there is a better way. Rather than debate its effectiveness (the research is clear on that), let’s educate on its tremendous risks, and on more positive approaches to discipline. It is not too late to change our educational and parental discipline practices. Our kids deserve better. 

Walk Out of the Darkness

Petra Kottsieper, Ph.D.

On October 5 the annual Walk Out of the Darkness, held by the American Foundation for Suicide Prevention will take place here in Philadelphia as well as many other cities around the country.

I will be walking in this walk as a person who came very close to losing a family member to suicide, know people who have successfully committed suicide, as someone who has a past history of mental health concerns,  and as a mental health professional.

"Suicide claimed 39,518 lives in 2011 in the United States alone, with someone dying by suicide every 13.3 minutes. A suicide attempt is made every minute of every day, resulting in nearly one million attempts made annually."

Losing someone to suicide is a profound event, sometimes not surprising to the families and friends of the person who choose to end his or her life, and sometimes it explodes into people’s lives completely unexpectedly. Many people who attempt or complete suicide experience extreme psychological pain and suffering and often see suicide as the only way out.  Often, people are unable to reach out in their darkest moments despite the relatively abundant resources that exist in the US. Why is this?

Stigma, fear, and hopelessness are all answers to this question. Stigma of mental illnesses remains a significant barrier to help seeking. Public stigma is not just grounded in the well documented beliefs and resulting stereotypes that people who are "crazy" are dangerous and unpredictable, but also in the fact that having "mental" problems is seen as something fundamentally different than having a "physical" problem. And while mental and physical illnesses may very well experientially vary, problems with mental health concerns are observed not only as different, but are also judged as worse. This is undoubtedly rooted in our perception of the superiority of the mind over our body; mind as the seat of our "rationality" and emotional balance.  In addition, some "mental health” problems, obviously due to their complexity, remain poorly understood.  In other cases we know a lot, have effective treatments, but these treatments are still not considered readily acceptable to be sought out.  Acknowledging that a family member, friend, or even oneself is having a mental health concern means that one has to accept this in the context of likely societal distancing and associated negative judgments.       

This is where the annual walk comes in.  The walk addresses what is at the heart of the pervasive problem of stigma that continues to exist and makes it hard for many people to seek help for the problems they are experiencing. The walk is about "coming out," shining a light on the significant public health issues of suicide and having survivors come together being visible and open about having lost a family member without fear and embarrassment. Ending the taboo.

So what can we do as friends, family members, professionals, individuals who are struggling?

As a society we need to become so much more aware of what mental health problems really are. In addition to understanding their etiologies we also need to understand suicidal ideation as a phenomenological experience. This is especially important for professionals who need to work on gaining a better understanding of suicidal thoughts of his or her presenting patient.  We need to talk to people about suicide, and research indicates that even as professionals we are often not comfortable with this topic.[i]  We need to carefully examine our responses as professionals to suicidal talk of our patients and to carefully assess if hospitalization is necessary or not. In many cases it is not, but fears of liability and risk pervade our profession.

We need to continue to de-stigmatize mental health concerns and embrace the recovery framework that has become mental health policy in many parts of the US following the U.S. President's 2003 New Freedom Commission on Mental Health that emphasized the need for a transformation of our nation's mental health system.

We need to embrace the position that people generally can get better, provide hope and afford quality mental health care to everyone.  Recovery also does not always mean a return to baseline functioning. This means we all need to become more tolerant of mental health symptoms, as long as the individual chooses to live with these symptoms and the person is not endangering him/herself or others.  It means we need to treat everyone with respect, empathy, and compassion.  We need to make it acceptable for someone with an acute exacerbation of, for example, debilitating anxiety to take a sick day at work for self-care or an emergency appointment with their treatment professional, and not having to lie and call in with a cold.

If we lose someone to suicide we need to stop "forcing” survivors to talk about their grief behind 

closed doors. Research has shown that survivors of suicide are treated differently than survivors of other deaths by other causes.  Specifically, the "societal perception that the act of suicide is a failure by the victim and the family to deal with some emotional issue and ultimately society affixes blame for the loss on the survivors"  is something that we can all work on to combat in our own lives.[ii]

While I am not saying or arguing that everyone who attempts suicide has a mental illness or mental health concern, it is undoubtedly true that many people that attempt or successfully completely suicide, do.  It is time that we talk more openly and urgently about this public health crisis.  We need to end the stigma that prevents so many people from at least attempting to seek help, especially in light of the many available treatments and avenues for help that are available.  This help can be gotten from a lot of sources; families, friends, clergy, suicide hotlines, therapists, and medical professionals.  We all play a role in this.  If you know someone who is not doing well, or you suspect may not be doing well, ask them how they are really doing today.

**If you are someone you know is struggling with thoughts of suicide get help now. Contact

• http://www.suicide.org/hotlines/pennsylvania-suicide-hotlines.html
• https://www.afsp.org/preventing-suicide/find-help

**If you have lost someone to suicide, there is support. Contact

• http://www.suicide.org/support-groups/pennsylvania-suicide-support-groups.html

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[i] Walen, S.  (2002).  It’s a funny thing about suicide: a personal experience.  British Journal of Guidance & Counseling, 30, 4, 415-430.

[ii] Cvinar, G. J. (2005). Do Suicide Survivors Suffer Social Stigma: A Review of the Literature. Perspectives in Psychiatric Care, 41, 1, 14-21.

“Suicide by Cop” : What Do We Know About It and What Should We Do About It?

Petra Kottsieper Ph.D

A video has just surfaced of the events that lead to the shooting death of 25 year old Kajieme Powell in St. Louis. It is a very disturbing video to watch.  Initially, he is walking around the sidewalk seemingly muttering to himself, after he apparently stole two energy drinks from a convenience store that he had placed on the sidewalk. He ignores other people walking past him until the cops show up, who jump out of their car and very quickly draw their weapons. Mr. Powell is seen walking towards them and you can clearly hear him yelling at the police officers to shoot him, and they do. Apparently he was wielding a knife, which is not clearly visible in the video, and was threatening the officers.

People on the scene, as well as news writers, have been quick to call this a suicide by cop event. From what you can see and hear from the video, it could very well be. So what is suicide by cop? Suicide by cop (SBC) “ is a method of suicide that occurs when a subject engages in threatening behavior in an attempt to be killed by law enforcement” (Mohandie & Meloy, 2000). Usually this involves a subject brandishing a gun at police, both loaded and unloaded, which of course is an extremely dangerous situation for officers. 

SBC stats are not easy to come by, but several studies have attempted to arrive at some percentage of SBC of all police shootings.  One of the more recent studies published in 2009, found suicidal motivation accounted for 36 percent of more than 700 North American police shootings.[i]

These incidents have been around for a long time, but have not received scientific research attention until 1998.  Police departments and the FBI are also clearly aware of SBC, however, it is interesting to note that it was not until 1989 that the FBI began to track the number of justifiable homicides by police. Incidentally, a report from the Department of Criminal Justice, presents a large number of historical SBC case examples in their article.[ii]

Clearly calling a police shooting a SBC involves a clear and present danger to the responding officers. Most often this involves a firearm or what looks to be a firearm, but later turns out to have been a starter pistol or BB gun.  In the case of Mr. Powell; however, it was a knife.

It also requires the police to be aware that the person they are dealing with is actually suicidal and or mentally ill, and some kind of recognition of the behavioral or cognitive state of the person. This is of course not easy to tell, unless the person is yelling at the police to shoot them (which sadly occurred in the case at hand), or behaves in a very erratic manner.

Which brings me to one of my final points. Do police receive specialized training to deal with individuals who appear “erratic”, or may appear threatening either due to drug use or mental health problems?  And the answer is that indeed they do.

As early as 1974, forward thinking pioneers at Montgomery Country Emergency Service (MCES) in Norristown, PA started a training program where volunteer police officers were trained on mental illnesses and dual diagnosis (mental illness and substance abuse).[iii]  This was part of a pre-booking jail diversion training program.  This program was not started as a response to SBC, but rather as a response to the increasing arrest rates of people with mental illnesses for relatively low level offenses such as loitering, simple assault, trespassing etc. There are now numerous programs like this in the country, the best know being the Memphis CIT model (that is based on the local Montgomery Country, PA example). However, these programs fulfill the dual role of not only preventing unnecessary arrest and incarceration of individuals with mental illnesses, but also train officers of how to deal with individuals in crisis without resorting to force.

From their website: “The Memphis Crisis Intervention Team (CIT) is an innovative police based first responder program: 'This program provides law enforcement based crisis intervention training for helping those individuals with mental illness. Involvement in CIT is voluntary and based in the patrol division of the police department. In addition, CIT works in partnership with those in mental health care to provide a system of services that is friendly to the individuals with mental illness, family members, and the police officers.”[iv]

I do not envy police officers for the many challenges they have to face on a daily basis and the often ambiguous and dangerous aspects of their jobs. However, I also believe that the law enforcement community in every single jurisdiction in this country has a responsibility to implement something akin to CIT programs and/or to train all of their officers in how to deal with individuals in the community who may be mentally ill or high on substances; including those wanting to die at the very hands of the people sworn to protect them.  According to a NAMI CIT fact sheet, 2000 communities in more than 40 states have implemented these kinds of trainings for their officers and we can only hope that training on how to deal with individuals in crisis (including those with a mental illnesses) will be provided to all law enforcement officers everywhere in this country for everyone’s safety.  It will not bring back Mr. Powell, but it may help others who are dealing with a crisis they think they cannot overcome. It will also help the officers who are often emotionally scarred when realizing they may have unnecessarily taken a person’s life, realizing that they were dealing with a person with serious mental health problems and could have possibly responded in a different manner.

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[i] https://www.valorforblue.org/Documents/Publications/Public/Suicide_by_Cop_Among_Officer-Involved_Shooting_Cases.pdf

[ii] http://www.forensiccriminology.com/pdf/Suicidebycop.pdf

[iii] http://journals.psychiatryonline.org/article.aspx?articleid=85518

[iv] http://cit.memphis.edu/aboutCIT.php

How Does It Feel To Be A Problem?”

by Celine I. Thompson, Ph.D.

It is hard to have completed at least one course in African American studies without hearing DuBois’ question posed from The Souls of Black Folk.  A century later this same question dominates my thoughts about the recent Michael Brown shooting.  I think about my own brothers and male cousins and am thankful that such violence has not claimed them.  Unfortunately, my hurt and rage are not assuaged, because even though the urban, young, Black males closest to me have managed to skirt violent ends, nearly all of them have had encounters with law enforcement and the justice system before the age of 25.

 Additionally, they have lost peers to violence, incarceration, and have vicariously (if not personally) experienced unwarranted police surveillance and brutality in addition to other forms of violence in their communities.  Every time the media covers the shooting of a young unarmed Black male, my own anxiety increases as well as my concern for the physical and mental welfare of my loved ones.  However, I do not have the exact same ominous thoughts about my young female relatives, or for myself, although being Black and female has its own experiences and challenges.  For the most part I maintain the privilege of being able to walk down and across the street and not fear if a rolling cruiser will stop me on my way, and what might happen if it does.

However, Arizona State professor Ersula Ore cannot do just that at the college campus where she works, so it would seem that I should add to my list of things to be mindful of as a young Black woman the prospect of being arrested for jaywalking.  Although, I think I would have handled the situation differently from Professor Ore.  I probably would have done everything the police officer asked of me, given my ID, thoroughly explained what I had been doing in that area, mentally rewind and scan my last steps and actions in order to build a credible defense for any possible trial coming against me. I would feel the need to prepare and present my whole life story just to persuade the police officer that I had done nothing wrong, or if I did do something unlawful that I was not aware it and would have apologized immensely.  That would be my totally “warranted” response… for jaywalking.  And whether I was allowed to continue on my way or if I found myself sitting in the back of a police cruiser on the way to jail, I would feel useless.  I would feel powerless and hurt and scared and uncertain of what to do, if I could do anything.  If I did not know that I was perceived as a problem before such an encounter, I would definitely know what it felt like to be one.

Many young men in our city know how it feels to be a “problem.”  Two months ago I had the opportunity to sit in the audience of Alice Goffman, the author of the recently published book, On the Run: Fugitive Life in an American City.  She read a selection from her ethnography detailing the vulnerability of young Black males in encounters with law enforcement and the justice system of our dear city of brotherly love.  While listening to the stories Goffman shared, I reflected on the experiences of my own young male relatives and heard in her words what many will view as legitimate recognition of what it means to be young, Black, and male in Philadelphia in the 21^st century.   Such vindication should be a relief, but in a room with a majority of educated women of color, you could feel tension and sorrow grow in our silence as Goffman spoke of the young men who were lost to violence and the struggles that many endure to try to steer clear of law enforcement for their own survival. 

It is the same tension and grief that I experienced in a conversation with a soon-to-be kindergartner. When I asked him if he was excited about going to a new school, he responded that he was a little “nervous.”   He continued to explain that “kids get locked up for fighting” at this school and if he was ever bullied, he was not sure if he could keep from fighting or getting into trouble.  I really wanted to tell him that he did not have to worry, but the most I felt that I could responsibly do was give him a few tips on how to deal with bullies.  The possibility of having to prepare a five year-old to deal with police officers is simultaneously distressing and surreal.

Perhaps these same emotions fuel the ongoing protests and riots in Ferguson as well as the peaceful protests observed throughout the country.  As psychologists experiencing such times and circumstances, we should be drawn to ask and search for answers to the following questions:  

• How do developing young men manage these disproportionate and unfair experiences?
• What “healthy” forms of parenting can take place under the threat of raising children so  undervalued in our society? 
• And these captive young men, what can motivate them to strive for success under the     inescapable reality of how the world will view and treat them?

Charles Blow in a recent NY Times op-ed piece captured this sentiment in an equally poignant version of the question posed by DuBois:“What psychic damage does it do to the black mind when one must come to own and manage the fear of the black body? The burden of bias isn’t borne by the person in possession of it, but by the person who is the subject of it.”

My mentor, Dr. Howard Stevenson, Constance E. Clayton Professor at Penn, has worked to help Black families manage this misplaced burden.  His work helping Black boys manage anger and racial stress in schools and to help African American families raise children in an environment affected by racism has brought attention to these issues and provides families with information and guidance on promoting resilience in our youth.  As mental health professionals, we need to be aware of and familiar with research literature and resources available to guide our understanding and treatment of the issues that affect vulnerable youth and those who are responsible for their care and survival.  For a soon-to-be kindergartner it cannot begin soon enough.


Dr. Celine Thompson is an Assistant Professor in the Clinical PsyD program.  Dr. Thompson obtained her PhD in Interdisciplinary Studies in Human Development from University of Pennsylvania Graduate School of Education, where she also completed her Master’s degree in Psychological Services (currently known as Counseling and Mental Health Services).  Her dissertation research focused on understanding “racially-gendered” identity development processes in Black adolescent females.

Not Sorry I'm Not Sorry

Jessica Glass Kendorski, Ph.D

Pantene's recent commercial depicting women apologizing for being assertive has been getting lots of attention from national media outlets such as Good Morning America and ABC News.  In the ad, several women are seen saying “I’m sorry” in situations that clearly don’t call for it—for example, one woman apologizes for interrupting a business meeting, and another apologizes for handing her husband their child after he comes home from work.

The ad comes at an opportune moment; this week, President Obama is hosting the first-ever White House Summit on Working Families, which will address improving gender equality on the workplace. In light of all of this, I wonder if gender differences in communication account for some of that disparity.

Women make up 47 percent of the work force. Working married women bring home 44 percent of their family’s income, and women make up 59 percent of the recipients of college degrees. Yet women only earn 77 cents for every dollar earned by men.  Could the tendency for women to constantly apologize, and engage in less assertive communication, be a possible contributor to this wage gap?

Expectations are key. Expectations guide communication in the workforce and also guide how adults communicate to impressionable children. Men are expected to ask for what they need and women are expected to apologize for asking. Fostering equal environments in the workforce begins with fostering equal expectations for men and women—starting in early childhood.

Early on, girls are taught to stifle displays of negative emotions such as anger and frustration, and often express the opposite of what they’re feeling, such as smiling even though they’re not happy—and apologizing when they’re not sorry.  On the other hand, it is more acceptable for boys to show evidence of anger and frustration. Because boys can externalize their feelings, they are able to learn to express these behaviors appropriately through assertive communication. If girls continuously suppress their emotions, then they may never learn how to truly be assertive.

Regardless of gender, children experience intense emotions and need to be supported and taught appropriate ways of dealing with these emotions. Adults should be aware of their expectations and the behavior these expectations foster in children.  Boys are expected and taught to grow up strong and assertive, but girls should be taught the same. And as the Pantene commercial shows, women can find strength in the ability to truly express their feelings.

http://workingfamiliessummit.org/

Chaplin, T.A., Aldao, A. (2013). Gender difference in Emotion Expression in Children: A Meta-Analytic Review. Psychological Bulletin, 139, 4, 735-765.

What Colors (are) Your Nation? Nationalism and the World Cup

Petra Kottsieper, Ph.D

A day after a vital soccer game where the US played Germany in the world cup (and thankfully both teams advanced into the next round), I have been thinking about soccer, the construct of pride and national identity.  As a native German who came to this country in 1991, I have been firmly rooting for Germany unless my adopted home team (USA) is playing. However, for yesterday’s game I went red, gold and black all the way. This raises the following question; what is it about the world cup, and soccer specifically, that has suddenly seemed to make it okay to me to paint my nails in the above colors, something I would have not been caught dead doing when younger?

This post is not about the merits of soccer, which I understand can be boring for people not raised on it. This post is about nationalism, pride and identity.  See, if you grew up German and were in my particular high school in the 1970's, your high school history curriculum consisted of pretty much the Third Reich and the Second World War.  We did not just learn “facts” but were asked questions such as “would you have sheltered a Jewish neighbor when they were in danger of being deported?” …… and the answers to these questions never came easy.  And they should have never come easily. Because how do you know for sure what you would do when your own life might be at stake? 

Grappling with my country’s WW2 history, similar to the generation before mine, left a shameful and horrible taste in our collective mouths. Were we guilty as a nation? Were we guilty as individuals?  The question of the condition under which people can commit terrible acts of torture and extermination, and if Germans had a special psychological or constitutional “propensity “ for this were investigated in social psychology research.  The famous Milgram experiments that started in 1961, uncomfortably demonstrated that “average” people administered at times deadly fake (unknown to them) shocks to others in a learning study. These experiments were some of the most famous investigations into the issue of conformity to authority.  Several other studies like this were conducted here in the US and these studies showed that under certain conditions a lot of people might do things that after the fact they themselves might be horrified by.

What does any of this have to do with soccer?  Soccer is one of the few team sports that is played all over the world. And, while of course it is as corporate as anything else these days, it can be played anywhere you can set up a goal and give people a ball. It makes people identify with their team, which really in the end for most people is about identifying with their city or town in league soccer, or their country in the case of the World Cup.  I also learned quickly, and to my utter amazement, that in the US seemingly few people have issues with showing their pride of being American at sporting events.

Just yesterday, an extremely vocal contingent of US fans had decided to watch the game in a German bar, which initially I thought would make watching the game even more fun.  However, it became clear very quickly that these particular fans seemed kind of oddly determined to drown out the Germans present, shouting them down with “USA USA” chants and “We believe we can win” (even when the game had 1 minute left and they were clearly losing). This had the rather odd effect of making the Germans become quiet instead of yelling back, and I observed several Germans in my vicinity shaking their heads at these fans, or just laughing at this very overt display of nationalism. 

You need to know, if you do not already, that draping yourself in flags and national colors and walking about the street chanting “Germany” is something you would have never seen when I grew up in Germany unless you had some kind of fascist tendencies. Nationalism, or national “pride” was often equated with fascism. And seeing this kind of display yesterday in the US carried out with such ease and apparent thoughtlessness, makes me uncomfortable....

However, as I think back to the World Cup in 2010, I see a change in the outward display of German nationalism.  I, for the first time, noted significant numbers of people carrying German flags (both here and in Germany) and wearing little cute face flag painting etc.  And I painted my nails for the first time. It was and remains odd for me to do, but I have come to realize that identifying with my heritage is not the same as thinking it is better than anyone else’s. I identify with being German, because I was raised on Rainer Fassbinder movies, read Herman Hesse, Boell, and Grass in high school, grew up on the humor of Loriot and Otto, love Broetchen and Nutella for breakfast and knew that when the bus schedule says the bus comes at 10:02 am and I showed up at 10:03 I was sheer out of luck.   

I watch World Cup soccer because I love the game. I wear the colors of the country that shaped me with joy, but also with a sharp awareness that we can and should never forget its victims;  and hope that our re-identification will never be equated with exceptionalism. 

When Enough is Never Enough: The Psychology Behind Animal Hoarding.

Petra Kottsieper, Ph.D

If you have been following the regular Philadelphia evening news you may have come across one of the biggest recent animal hoarding cases in Philadelphia, which also made it into some international newspapers.  On March 26, some 239 cats were removed from a double row house in the Frankford section of Philadelphia, after the same person had previously surrendered about 40 of her cats voluntarily.  The woman who lived with and took care of the cats also officially ran an animal rescue group, a situation that very clearly got out of hand.   Hoarding has become popular in recent years with TV shows such as the now cancelled “Hoarders” on A&E, and “Hoarding: Buried Alive” on TLC.  I assume, and I am assuming because I have never watched them, most people watch these shows with a mixture of curiosity and disgust.  It seems, however, that animal hoarding presents its own unique challenges that, until very recently, have not been explored at all.

Hoarding is finally gaining its own entry as a diagnosis in the Diagnostic and Statistical Manual of the American Psychiatric Association, 5th Edition (DSM-5; 2013).   Hoarding disorder, as it is now called, appears to affect between 2-5% of the population.  It furthermore appears to be a distinct disorder and not just a symptom of Obsessive Compulsive Personality Disorder (OCPD) , or Obsessive Compulsive Disorder (OCD).  Hoarding has been referenced in the literature going back all the way to Dante, and was first discussed by psychoanalysts as one of the determinants of having an "anal personality."  In the 1980’s the anal personality construct (also containing orderliness and obstinacy) developed into Obsessive compulsive Personality Disorder.  To make things more difficult hoarding has also been thought and is still thought to be a part of Obsessive Compulsive Disorder.[i]

So now in essence we have 2 types of hoarding categorization. Hoarding disorder in itself and OCD with hoarding behaviors.  Differences between these two manifestations are that in hoarding disorder the accumulation and refusal to discard things (or animals) is often thought to be “normal” by the person and may even be associated with positive experiences. Whereas individuals with OCD who engage in hoarding are more likely to experience their behavior as distressing and not really part of their self-identity. Individuals who clutter are not necessarily hoarders, but individuals who hoard have excessively  cluttered and largely unusable work and living spaces, often resulting in serious health and safety concerns.

Why do people hoard compulsively? Many reasons have been put forth. One example is the belief that individuals who have grown up in poverty or serious deprivation may grow into someone who engages in hoarding.  This theory has not been substantiated by research. Hoarding has been thought of as a pathological excess of capitalism, and several psychoanalytic theories have conceptualized hoarding as a drive to acquire in one’s self-development for a variety of functions.  More recent research has begun to outline psychological and cognitive processes closely related to or may even causally related to some hoarding behavior.  For example, one recent study used functional magnetic resonance imaging to compare neural activity and self-reports in individuals with HD, OCD and individuals with no mental health diagnosis.   It was found that individuals who compulsively hoard exhibited very distinct neural activity in specific brain regions that mapped onto their self-reported and observable psychological states in response to specific stimuli.   Compared to the other two groups, the individuals with HD reported significantly more difficulty with decision making around personal objects they had brought to the study, especially around the emotional value they assign to the objects in question. In addition these same individuals reported experiencing significantly more sadness and anger when thinking about discarding any of these items.[ii]  

Other emerging theoretical approaches have pointed out the importance of a dysfunctional attachment style in individuals who hoard animals.[iii]   Even “normal” animal rescue behavior probably function as a means of deriving meaning and a sense of self as a “good” person. Additionally, rescuing an animal from a "kill shelter" or the streets, which may otherwise mean “death” for the animal, can afford the person a special feeling of control, a sense that individuals who develop hoarding behaviors may not experience in other areas of their lives. These individuals may have disrupted or dysfunctional attachments to other humans, and their attachment to the animals develops into their primary means to build and maintain a sense of self. The control experienced often becomes so extreme (and some have argued delusional) that these individuals believe that no one else can take care of the animals as well as they do, despite evidence of death , disease and squalor all around them.

What does this mean for the woman in our recent local animal hoarding case? Animal hoarding has been described as significantly more difficult to deal with for public health departments as compared to complaints about individuals with non-animal hoarding behaviors.  Individuals who hoard animals are much less willing to cooperate with authorities during the resolution of hoarding complaints leveled against them.  In a very comprehensive overview of animal hoarding, it was noted that animal hoarding largely overlaps with object focused hoarding, but it may constitute even more severe cases , especially as it is often associated with extremely squalid living conditions . 

Individuals who hoard animals often develop the hoarding behavior in middle or older age, as opposed to a younger age as seen in individuals who hoard objects, and they seem to be more often women.  Animal hoarding seems to also be associated with more dysfunctional beliefs and attachments to the animals they hoard as compared to other hoarding situations. Individuals are often unable to bury them or discard the animals even when they are deceased. Furthermore the extreme distress experienced when having to give up the hoarded animal might be greater in individuals who hoard animals as compared to object hoarding. [iv] 

Hoarding in general , but animal hoarding specifically, is in significant need of more research. Very little is known about animal hoarding and the etiology of this possible subtype of hoarding disorder (it is not mentioned as such in the DSM-V).  However, animal hoarding is not an infrequent occurrence, carries not only significant risks to the person and the animals involved but also the nearby community, and can be an expensive and frustrating problem to deal with.  Additionally, animal hoarding has an extremely high relapse rate, reportedly as much as 100% . Historically it has been left to be dealt with by predominantly animal control and law enforcement.  This is clearly an area in dire need of interdisciplinary collaborative efforts and attention from human welfare and mental health agencies. Maybe the inclusion of hoarding disorder as a separate category into the DSM-V will be one important step in this direction.  

In the future I hope to see not only the rescue of the animals from these terribly sad and awful situations, but also envision the provision of (either voluntary or court mandated) help and assistance to the people who very clearly are in need of treatment and relapse prevention.  

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[i] Mataix-Cols, D. et al. (2010). Hoarding Disorder: A new disordered for DMS-V?. Depression and Anxiety, 27,  556–572.

[ii] Tolin D.F., Stevens M.C., Villavicencio A.L., et al. (2012). Neural Mechanisms of Decision Making in Hoarding Disorder. Archives of  General  Psychiatry, 69, 832-841.

[iii] Nathanson, J.N. & Patronek, G.J. (2009). A theoretical perspective to inform assessment and treatment strategies for animal hoarders.  Clinical Psychology Review, 29, 274–281.

[iv] Frost, R.O.,  Patronek, G. ,  and Rosenfield, E. (2011). Comparison of object and animal hoarding. Depression and Anxiety, 28, 885–891.

Returning to Life After the Olympics: Taking Home More Than the Gold?

Sarah Levin Allen Ph.D, CBIS

Within a minute, the life of Saraka Pancochova, a Czech Olympic snowboarder, went from smiles and High Fives to lying prone on the snow of Sochi. I counted the seconds wondering when the medical staff would arrive. Within minutes, Pancochova got up and was applauded for finishing her run. This was after a fall in which she lost consciousness and cracked her helmet down the back. USA Today[i] quoted Pancochava, “I didn't think I really got any concussion, maybe a tiny bit, but nobody told me…I just got really lucky. It could have been worse. I got knocked out, and that hasn't happened in a while, but I was lucky the snow was soft, and you know, it just happens sometime in snowboarding."

She got lucky? Let’s hope so. I would call it lucky if Pancochova could read this blog and respond to it tomorrow. My guess is that she, and the athletic community in Sochi, mean “lucky” in that she could compete in the next round. What about after that round? What about tomorrow when she attempts to read the articles about her?

“Luck” or “success” is not in finishing the race, but in protecting her brain from future injury and ensuring that she can function on a day-to-day basis. Just ask the students with whom I work. My job is helping students who have sustained brain injuries, desperately trying to succeed in the school setting.

As I reflect on these students, I think about what it takes for me to complete this passage. I am suddenly overwhelmed with understanding for students with concussions and other brain injuries. I’m sitting in front of the television dividing my attention, grasping ahold of all the ideas floating in my head, organizing those ideas, sequencing them, and pulling my attention toward my computer and away from the Olympic games. I’m doing all this while occasionally telling my 3 year old not to clobber her brother and telling my 2 year old to choose an activity other than throwing things down the stairs and sliding on his head to the bottom. 

Then I think about typical students. In high school, students must change classes a minimum of 6 times a day, switch their attention from one topic to another every 40 minutes, selectively attend to the teacher and not the Hottie in the front row; not to mention control their emotions which are triggered repeatedly as hormones reek havoc on their bodies. 

When school ends, they are expected to go to practice or debate team, collect coats for the homeless, and finish their homework preparing for 3 tests before falling asleep in front of the television and doing it all again the next day!  Then there is the socialization that is essential during all of this. Socialization that includes constant texting or group chats in which a significant amount of divided attention, focus, and exposure to stimuli is required, without which, a student would be isolated and lack an identity.

With all these daily requirements, my head is spinning. Yet, despite these demands in the setting in which these athletes are required to return, there hasn’t been much discussion about how to help these “typical” students return to full functioning.

There has been a significant amount of conversation about sports concussion. The NFL and NCAA have been in litigation accused of failing to educate athletes on concussions[ii]. Brain injury advocacy groups as well as the NFL have helped to increase awareness around the issue of brain injuries, specifically concussions. In 2011 and 2012, PA[iii] and NJ[iv] respectively passed a youth sports act that required schools to develop “return to play” rules for athletes who have sustained concussions. Once these laws were passed, identification of concussions increased along with the need to support these students once they return to school.

And it’s returning to school that becomes the most difficult. The supports that are typically in place to support students (i.e. 504 plans or IEPs) don’t happen fast enough or are too taxing on an already bleeding system. What do we do when a student shows up to school the next day or the next week and needs help? How do we tell all 6 teachers, physical education instructors, specials instructors, administrators, counselors, and nurses how to support this student? Who is responsible for identifying learning issues, monitoring the rehabilitation that is happening in the classroom, and helping the student gain some self-knowledge into their injury and recovery?

How do we avoid spending 2-4 weeks (up to ½ of a semester) allowing a student to flounder in a typical environment with no supports, before we put things in place to help him/her succeed? These are the questions that have now become the focus of school administrators as the awareness and identification of students with concussions increase.

So, where does that leave those like Pancochova or my high school students? Well, the majority of those with concussions will get better. They’ll need minimal supports for 2-3 weeks, and then they’ll begin to get back to their normal routine. Those with 2 or 3 concussions will struggle more, and those with more significant brain injuries will need even more assistance.  The minimal deficits I experience as a sleep deprived, working mother pales in comparison to the uphill battle these young athletes and students go through as they attempt to get their brains back to normal.

I’ll continue to think about them, and tighten the helmet I have decided to wear around 24 hours a day, as I finalize this blog, change the laundry, break up the wrestling match on the floor of my office, turn off the television, and start dinner. All the while, I’ll be hoping that I never get an injury that could make all these “other jobs” virtually impossible.

For more information on return to school programming for students with concussions see Dr. Allen’s webinar for the BIANJ at http://bianj.org/2013-concussion-in-the-classroom

See Pancochova’s fall here: http://www.nbcolympics.com/video/czech-snowboarder-sarka-pancochova-cracks-helmet-brutal-fall?ocid=yahoo&ctx=top-moments

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[i]http://www.usatoday.com/story/sports/olympics/sochi/2014/02/12/snowboarder-cracked-helmet-slopestyle-halfpipe/5414539/
[ii] http://www.usatoday.com/story/sports/college/2014/01/02/concussion-lawsuits-ncaa-consolidated-adrian-arrington/4293867/

[iii] http://www.epysa.org/assets/947/15/PA_Act_101.pdf

[iv] ftp://www.njleg.state.nj.us/20102011/PL10/94_.HTM

Hale, J.B., Metro, N., Kendorski, J.G., Hain, L.A., Whitaker, J., & Moldovan, J. (2009). Facilitating school reintegration for children with Traumatic Brain Injury. In A. Dvis (ed.), Handbook for Pediatric neuropsychology. Hoboken, NJ: John Wiley & Sons.

"Celebrity" Guest Blogger:
Sarah Levin Allen, Ph.D., CBIS is an Assistant Professor at the Philadelphia College of Osteopathic Medicine. She is a licensed pediatric neuropsychologist, certified school psychologist, and certified brain injury specialist, who specializes in the area of evidence based interventions for schools. Her passion is in promoting and integrating brain based learning approaches in the classroom. Dr. Allen consults with school districts on return to school programming for students with brain injuries and works closely with advocacy groups to promote awareness of concussions in the classroom.