Mclean Hospital

Podcast: Forensic Psychiatry and Terrorism

January 21, 2020

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Trevor talks to Jacob Holzer, MD, a clinical staff associate in McLean’s Geriatric Psychiatry Outpatient Services and a forensic psychiatrist.

Forensic psychiatry is a branch of psychiatry that deals with the assessment and treatment of mentally disordered offenders in prisons, secure hospitals, and the community.

Episode Highlights

  • Dr. Holzer discusses the mental illnesses that can be involved in lone actor terrorism (27:10)
  • Dr. Holzer discusses the case of Anders Breivik, a far right terrorist who committed the 2011 Norway attacks (29:40)

Relevant Content

Episode Transcript

Jake: So being pulled in different directions for me is probably a good thing.

Trevor: Yeah?

Jake: Because I enjoy that part of it around forensic work.

Trevor: So, you enjoy the versatility of it all?

Jake: Yes. So, there’s really a balance. The cases that I get involved in doing clinically. You know, are interesting to do. So that variance I think adds to it, adds to the quality, instead of doing one specific thing. So, in DMH—

Trevor: What is DMH?

Jake: Department of Mental Health. Yeah. There’s sort of a forensic division there, and they oversee all these criminal evaluations that are referred from the courts into that system. So those evaluations are really pretty narrow. If you’ve done one, you’ve done a hundred already.

Trevor: And just generally, what are you evaluating specifically?

Jake: So, in that context, with the criminal evaluations, so there’s really three main types of evaluations. Again, there’s sort of other things that can be done. These are through the courts. So, this is something that a judge in one of the jurisdictions, depends on the area; they’re sort of divided up within the State, and every State’s going to be a little bit different on how they manage these things. But a judge will order through a statute, so it’s part of the Massachusetts general laws, will order evaluations. So, an evaluation, it depends a little bit, sort of the number of variables, but it depends on the complexities, what’s going on, the charges. The defendant may be evaluated in the court there, by a court clinician, usually psychologist, maybe right at the court or the defendant may be referred for an outpatient evaluation; they’re released on bond or whatever and told to come back for the evaluation.

Or they may be admitted into the hospital. It’s a department of mental health facility for the forensic evaluation. So, it’s a different context. Now again, most of what I focused on in this area with the criminal evaluations, it’s in the inpatient setting. Where the patient, defendant, he or she’s really not a patient, it’s a different status, but they’re referred over, they’re not kind of released into the community. They go from the court directly to the hospital. So that really was my work within DMH.

Trevor: Did you enjoy it?

Jake: Ah, yeah, it was interesting to a degree, within some obvious limits. I think part of the issue is it’s very circumscribed. So those sorts of evaluations, there’s really a pretty rigid format that you follow and there’s areas that you need to assess and address and you generate a report based on the evaluation. So, it’s really pretty rote, going through that and the reports go back to the court for the judge and both sides to review.

But again, once you start doing that work, the cases vary. What the crimes are, the individuals who are involved. But the evaluation is the same. It’s like one after another. Same sort of evaluations. So, there’s an evaluation for competence to stand trial. So that’s one area. And a clinician doesn’t actually rule on competence; that’s something the judge will decide based on all the information.

Trevor: That you provide?

Jake: That I provide. There may be other sources too. The judge may have other pieces of information to make that decision.

Another evaluation is criminal responsibility, so it’s separate. So if you see this, the competence to stand trial is looking at a person stability sort of right there, how they’re doing at that point to work with his or her attorney and sit in the courtroom and absorb everything and participate in the trial. Criminal responsibility is looking at the process. Going back to the time the person allegedly committed the crime and whether they were responsible in a legal sense, for the behavior they did. So, this gets really tricky. It varies State to State.

Trevor: Wait, they’re responsible for their actions or their behavior?

Jake: Well, both.

Trevor: Both. Okay.

Jake: At the time of committing the crime, so for instance, and again it varies a little bit State to State but lets get sort of technical; two areas that are looked at, and it’s by State law. One is whether a defendant knows what he or she did was within the confines of what the law says. So, if they were breaking the law that they knew, or in the case of being not criminally responsible, that they didn’t realize cognitively that they were going outside of the law.

Trevor: So, the court’s trying to determine whether this person has an awareness of, not just what the law is, but how their actions went outside the boundaries of the law and whether they’re even aware of that. I know you said cognizant, but—

Jake: So, yeah, this is more of a cognitive, so they really understand what they did was outside of, kind of the legal framework, legal limits. I’m trying to think of a good example here. If someone is actively pretty seriously mentally ill and let’s say based on delusions, or hallucinations, they’re sort of responding to those and it’s pretty clear based on their history, that’s what’s going on, then that may make a case that because of the illness, they were acting in response to that and just mentally didn’t realize they were violating, sort of legal limits around their behavior. If that makes sense? That’s sort of a cognitive arm to that. So, it’s really understanding, appreciating the law and sort of stepping outside of it, if a person doesn’t understand that at the time, that may make a case for being not criminally responsible.

Trevor: Do you get a lot of criticism for doing this work?

Jake: Oh, actually no, not really criticism.

Trevor: I mean that wasn’t to imply that you’re helping putting guilty people on the street; I’m just imagining that there’s probably some people or families or some people from the prosecution that want things a little bit more cut and dry, and this acknowledges that there’s a gray area, and it’s legitimate and it needs to be entered into not even this dialogue, it needs to be entered into this trial. It does play a factor into it. And when family members of victims, they want to see justice, and this gray area that gets introduced kind of changes all of that.

Jake: Right. Absolutely. So, I think where it gets played out is that it can be controversial in some settings. So, part of the issue, and this has to do with, again, there’s a variability between different States as far as State charges go and at the federal level. So, here’s sort of probably the best example of this. That when President Reagan was shot, right at that time, there was really a more liberal application of what we’re talking about, at the federal level around criminal responsibility and being adjudicated for that.

Trevor: Didn’t I read somewhere in your presentation that the insanity defense or the insanity plea was kind of altered or changed around the time Reagan was shot in order to get a conviction? Am I out of line saying that?

Jake: No. So, well it was after, but you’re on the right track. Because in that finding the person, Hinkley, who did the shooting was found criminally not responsible at that time because of mental illness and he was sent to St. Elizabeth’s Hospital, at that point. But there was a huge outcry and it was very controversial and I think because in Washington, at the federal level, it was sort of a loose application of that, which meant many more people, for different crimes, it was easier to be found not criminally responsible or it’s also referred to as the insanity defense.

Trevor: You seem to have an issue with it being called that, should it not be called the insanity defense?

Jake: Yes, it’s referred to as that. Yeah, I mean just technically it’s more the jargon. “Criminal responsibility,” is sort of the academic.

Trevor: I mean, that’s really getting down to the core of it.

Jake: Yeah, right; it’s the responsibility for one’s behavior, actions. But State by State, things vary. And part of this, which I think is a little bit interesting, is that there’s some link, if this makes sense, I’m not sure I’m presenting this totally clearly. But there’s some link between this area of criminal responsibility and how easy or hard it is to get a finding of not responsible.

Trevor: I’m sorry, say it again, but in a different way. I’m not with you.

Jake: No, I understand. It’s technically called NGRI. So, “Not Guilty by Reason of Insanity,” that area. So, someone being found not criminally responsible, having that NGRI defense, and that that is found by the court. Some States it’s easier to do, and in other States it’s next to impossible. And there’s one or two States where it’s not even recognized; they don’t allow that sort of defense. There is some link between whether it’s easy or hard to get that defense, and within a State, societal values. And so, sounds a little crazy, but there’s a little bit of association with whether it’s a red state or a blue state, whether it’s more liberal leaning or conservative leaning.

Trevor: Okay. So how about this, what about New Hampshire, which has a very strong Libertarian Population? New Hampshire has that whole, “Live free or die,” thing. I grew up in New Hampshire and once I started leaving New Hampshire and I mean I’ve driven across country four times, and you experience different States. I understand New England’s different from Southern California, but New Hampshire has its own strange little thing. Are you talking like that? Like States have different values.

Jake: Yes. So I’d have to look this up, I’m not sure specifically about New Hampshire, but in general in the Northeast area, so potentially New York, Massachusetts, Connecticut, there’s a little bit of a looser definition, or should I say a little broader application of this NGRI defense.

Trevor: But let’s say Kentucky?

Jake: Compared with, I like to use Texas.

Trevor: That’s usually the standard; I wanted to try something different, but let’s go with Texas.

Jake: But there’s other States, so I don’t mean to pick on Texas, but there’s other States where there’s a really much more narrow and a higher threshold for finding of NGRI. If that makes sense. And I think in part that’s based on sort of different values and political viewpoints, State to State. But a generalized statement around all of this is that overall, an insanity defense is still very hard to prove.

And so my experience, getting back, working in the Department of Mental Health, I would do a ton of these evaluations and I shouldn’t say a ton, but let’s say a couple hundred evaluations. And in those numbers, I think not one defendant was found, not criminally responsible, none. All of them were found responsible, and then would need to stand trial based on that.

Trevor: And are you asked from different courts, from different States that were where this NGRI may be applied differently? Do you go and work in different States? Are you mostly working New England or specifically Massachusetts?

Jake: Right. And I’m sort of talking about, this is pretty narrow within the Massachusetts Department of Mental Health. I don’t do those evaluations anymore, but I used to do a lot of them within Massachusetts. So, every State has its own Department of Mental Health or it may be called something a little bit different, every State would do these sorts of evaluations. How they’re managed maybe totally different between States. You know how they’re applied within the court. So that’s going to really vary. But that work kept me within Massachusetts. I trained, I did some forensic work training in Connecticut and went to court there a few times. From what I remember, that was pretty similar. There weren’t lot of differences there, between those two States. I’m sure if I went to some other State, some specific States will be different.

Trevor: Well let’s change gears completely and get some really exciting stuff. You’re writing a book on the lone actor terrorism?

Jake: Oh yes. So that’s a project that I and some colleagues started in the past year.

Trevor: And you’ve been doing presentations on it and you sent me over an amazing PowerPoint presentation that I was both unable to understand and actually got some really good information from, because it’s so dense. What led you into this direction? Were you called into this direction? Did somebody contact you and be like, “Listen you and these people, you’re the guy for this and we need to know about this.”

Jake: Right. That would have been nice. That’s not what happened.

Trevor: No?

Jake: Yeah. Basically, I think I came about so years ago. So, within forensic mental health, I’ve talked about the clinical work, all those evaluations. And then really since I started doing that work, I was also interested in very specific areas involving forensics that it’s based more on research and literature. There’s sort of a lot of writings, so it’s really a pretty broad area. There’s a lot of research and academic work and lectures, presentations, books within forensic psychiatry.

Several years ago, I really shifted into an interest in kind of looking at the relationship between forensic mental health and different areas of national security. And I think that came about, I mean I sort of know this because I’ve always been interested in politics and international relations sort of a number of areas. And I keep thinking, had I not made that fateful move to apply to Medical School, I probably would have been doing something more in this area.

Trevor: You served in the Air Force. Yes?

Jake: I was in the Air Force. Yeah. Before Medical School, that’s right. So, I got interested in that area, that was unrelated to anything with medicine anyway. I was in the military, but I always maintained an interest in international relations and politics, geography, a number of areas. So I would keep up with reading and basically, within this area that I’m talking about with mental health issues, there’s sort of a small handful of people who are specialized in that area and they have worked on sort of a number of different projects, different areas within this. So, one example would be looking at terrorism more broadly, as one category, areas around threat assessment, threat analysis, working with law enforcement locally or the State or the FBI. There’s some mental health professionals, psychology, social work, psychiatry that may consult with different agencies, the military or Department of Justice or something. And so, this is sort of a small subgroup of people who do this work. And basically, as I was reading about it and I started to look into the literature more, I really got into it and I thought, it’s sort of a really interesting area to pursue.

So, what I found as I got into these different areas, I thought this whole area of lone actor terrorism is really very interesting and evolving. And very unfortunately, these cases keep happening periodically. So, they’re really pretty destructive when they occur. And so I got really interested in ... And I sort of knew, these are complicated areas, but almost all of these cases have some mental health component to them. But that’s not sort of, it; it’s not just based on mental health. There’s a lot of other issues involved. And so, really out of interest, I started reading a lot more about this and that led to doing some research, putting together material, and then doing posters, presentations. And that led to us developing this idea to work on this book.

Trevor: I can tell you right away, just speaking for myself, somebody who suffers from narcissistic personality disorder is that from all the information that you’ve sent me, and I watched your presentation and I’ve been reading about this lone actor terrorism, is that there is a narcissistic need to be doing this on your own and I recognize the behavior. It’s a bit of, “I just don’t trust anybody,” to like, “I want to be the singular symbol or beacon that people are going to look at when whatever I do is done.”

Ana: Notoriety.

Jake: So that’s interesting. I think Trevor, you’re getting into the whole area that is being hotly researched that people don’t have a good grasp of, around, what’s driving this? So, there’s a major interest in that and I think there’s a subgroup of people who ... I think really, it’s based more on personality or needs, where narcissism may play a role. I think that truly is part of it. What I found out in doing this work is that, we’ve got potentially hundreds of case examples and there’s some trends that we’re really tracking. And there’s a lot in the literature on this already. This is what we’re developing in the book as part of this.

So, one of the trends is that there’s a presence in probably, almost every case that I’ve already reviewed, of something clinical going on. But those clinical things are really varied. It’s all over the spectrum. So, it’s not just a personality disorder, or personality, some people it’s not a condition or anything, but they have certain personality traits. But there’s a lot of examples of substance abuse and major mental illness, schizophrenia and mood disorders and anxiety disorders and traumatic brain injury and “anti-sociative” disorders. Autism spectrum seems to be coming up in a number of these cases.

So that was sort of an interesting finding that when you look at, these cases, just clinical load seems to be there in a lot of the people who do this. There’s been research to show that there’s been some, again, not a lot of people are doing this, but there’s sort of a small group of people who have done research in this area. One guy who’s one of the world authorities in this area actually is collaborating with us on the book.

Trevor: Oh, that’s fantastic.

Jake: —Okay. So, he’s done a lot of research. His area is focused on terrorism, so that’s his whole area. But basically, he’s found, it’s fascinating when you compare people who were lone actors or you know, lone actors, so they work with one other personal off-site. There’s examples of that, and people who join organized groups; there’s a much higher rate of mental illness in the lone actor group, compared to the people who go off and join Al Qaeda or ISIS or something like that.

Trevor: Well, a group has to have a team. You have to have trust, you have to work together, you have to be organized, you have to be able to accept your place in the group, accept your position and work within those parameters. And I’ve always assumed, whenever I’ve worked with a group that we’re working towards a goal where, and I can say this as a narcissist, when I’ve decided to go it alone; the result doesn’t get pushed to the side, but the fact that I’m going to be the symbol for the result, weighs just as much. Whereas if I’m working in a group that really doesn’t even matter because, we’re the group.

Jake: Yep. No, exactly. So, there’s individuals who just wouldn’t make it in a group. And with this research that I was talking about these groups, as crazy as it sounds, so groups like ISIS, big terrorist groups, they’re pretty well organized, and they have recruiters and they look for people who would fit in, and they’re trying to weed people out who are potential trouble, they don’t want. So, some of these people who act individually, and we can go over individual cases. A lot of those people, they wouldn’t want in the group because it could jeopardize their group. So, it’s sort of interesting; I think part of it is these individuals will act, I mean it may or may not be narcissism, for some of these people they want to join the group and they get kicked out.

Trevor: Right. I’ve heard of that; they wanted to be a part of the group, they get pushed out, and so, “Now I’m going to do something that’s going to one up what you’re doing.”

Jake: Right. Well that could be to out-do—

Trevor: But now it becomes, there’s a competitive nature about it that’s strange.

Jake: Or to make a name for themselves. And that could be really worrisome too. So, there’s sort of a number of people who do these manifestos, that seems to come up a lot. Probably a really good example of this is Anders Breivik. So, he was the guy who committed the major atrocity in Norway where he set off bombs in Oslo and then he went to an Island and killed a number of teenagers in this camp, on this island in Norway. But Breivik, sort of a whole interesting history; there’s a lot, just to his case. He was ultimately found responsible and serving, but the legal system in Norway is much different. But it really turns out, and maybe it has to do with a really severe narcissism, but something was going on where he really wanted to make a name for himself and he wanted people to remember him.

He sort of represented kind of extremist, right wing nationalist views, that was his political view. But you know, he wrote this manifesto from what I read, he cut and paste a lot of stuff from other people’s manifestos and he actually had said, this is in the newspaper, something to the effect that what he did, that mass shooting, was basically a publicity move so he could sell his book. Which is quite remarkable. If you think about a number of people he murdered, but he wanted to do that in order to guarantee that he’ll have sales for his future book.

Trevor: Which I guess happened?

Jake: I don’t think he actually wrote a book.

Trevor: Oh, I thought that the book had been published or was about to be published and he was like, “Oh, this will get me number one on Amazon.”

Jake: Or I think maybe he was talking about his manifesto, maybe hoping his manifesto would be published and he’d make money out of it. He’s incarcerated and he’ll remain incarcerated, hopefully forever. So that’s him. I think I was getting off a little bit on a sidetrack around discussing them, but I think the point is that within this group of lone actors, there’s a wide range of clinical issues, but there’s a number of other variables that seem to pop up more in these patterns. That’s sort of what I found, and some other people have found this. So really interesting, kind of a number of things that are really quite interesting.

One thing that I found in looking at kind of a subgroup of people is, and again, it’s not going to be everybody, but there’s sort of a subgroup that have been in the military. There was some association with people who were in the military who just didn’t function well, didn’t make it. And something happened where they either got kicked out or their career trajectory took a turn for the worse, or they failed somehow. That pattern seemed to come up in a number of these cases. So, Timothy McVeigh.

Trevor: Yeah, I’m glad you’re bringing him up.

Jake: Yeah. He’s sort of an example where, there’s this whole literature, so he was in Desert Storm. He actually, I think fought in Desert Storm. He won awards.

Trevor: And correct me if I’m wrong; Terry McVeigh was involved with the Oklahoma City Bombing.

Jake: Timothy McVeigh, Oklahoma City Bombing, yeah in the mid-90s. So, early nineties I guess ‘90, ‘91, around that period was Desert Shield, Desert Storm. He was involved in that. He functioned well at that point. He then wanted to go on as a career in the Special Forces and failed out of that, and then got out of the army afterwards and then he got tangled up in extremism. I mean, he may have had some of those beliefs early on, but then after the military, he started to get involved in the militia movement.

But there’s something I always wonder about; had he not failed out of the army and he got on this path that he wanted to stay on, Oklahoma City may not have happened. And it’s hard to predict that. But it sort of shows this pattern, there’s other case examples here of people who were in the military or some occupation where things sort of deteriorated. They didn’t have sort of a productive career, getting promoted, but they failed out. And that seemed to be a little more prominent, as far as I could tell, no statistics on this, but it just seemed to be one of these variables that came up.

Trevor: Jake, I feel like we didn’t even scratch the surface. I feel like when you’re driving through the snow and the snow’s separating across the road ... I feel like that’s where we got, that’s as far as we got.

Jake: We’re approaching the surface.

Trevor: Yeah, right. Which is unfortunate, because this is insanely dense, and I mean insanely in the kindest way. This is like insanely dense material and it’s all fascinating. And I think what I’m going to request is that, given some time, we bring you back and we keep attacking this piece by piece and let’s really go through it. Because there’s incredible stuff in here and I feel like I personally, the narcissist that I am, has only the smallest grasp of it.

Jake: Happy to do it.

Trevor: That’d be great.

Jake: I’ll be happy to come back. Talk more about this. And I think there’s some important areas, you just touched on one area worth talking about more, it shouldn’t be a major problem.

Trevor: Thank you so very much.

Jake: Oh, you’re welcome. Thank you for having me here today.

Trevor: Okay.

Thank you for listening to Mindful Things. The official podcast of McLean Hospital. Please subscribe to us and rate us on iTunes or wherever you listen to podcasts. If you have any suggestions for special topics or future guests, email us at mindfulthings@mclean.org and don’t forget mental health is everyone’s responsibility; if you or a loved one are in crisis, the Samaritans are available 24 hours a day at 877.870.4673 again, that’s 877.870.4673.

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