Developing Crisis Service Tools For Preventing Harm to Others

Written by: John Draper, Ph.D.

On a hot July evening in 2012, James Holmes lingered outside the cinema where the new Batman film, “A Dark Night Rises” was playing. He later testified that he pulled out his mobile phone and dialed the number to a crisis hotline, with the distant hope that he might hear words that would somehow stop him from carrying out his murderous plan. He waited, and the call disconnected.

A few things have changed since that night when twelve people fell victim to a mass shooting in an Aurora, Colorado theater.  Following this horrific incident, Colorado Governor John Hickenlooper signed a bill that created a statewide crisis call hub and comprehensive crisis care system. Most of the 988 calls to the Rocky Mountain Crisis Partners center are now connected to a counselor within 15 seconds. More people in desperate need to speak with a mental health crisis counselor can readily recall and dial a national 3-digit code, no matter where they are in the United States, and be connected to a counselor within 41 seconds. Another change, tragically, is the ubiquitous nature of mass shootings in this country, now numbering nearly two a day.

The Relationship Between Harming Oneself and Harming Others

In my prior role as Director of the National Suicide Prevention Lifeline, our primary mission and priority to prevent suicides was clear. Although it was not frequently discussed, the service’s potential for preventing harm to others was also apparent. In general, research has consistently shown that persons who are threatening others are more likely to die by suicide than commit homicide, and high risks of suicide are commonly seen in persons assessed to be a risk to others.

Specifically concerning mass shootings, University of Alabama expert Adam Lankford cited consensus research in 2018 indicating suicide and life indifference as one of three factors common to all perpetrators. Lankford’s review of these incidents further observed that—unlike most homicides—they are like suicides in that both are most frequently pre-meditated.

A 2004 report from the U.S. DOE and the Secret Services stated that 78% of school shooters were suicidal first, and psychiatrist Antonio Preti later described school shooters as “suicides with hostile intent.” These authors note that mass shooters expect one of two outcomes from their rampage: either life imprisonment or death (by law enforcement or their hand).

Dr. Thomas Joiner, an internationally renowned suicidologist who wrote a 2014 book on murder-suicides, theorized that all murder-suicides are homicides that are fundamentally driven by suicide and related “perverted virtues” of “mercy, justice, duty, and glory.”

Developing National Recommendations

In our efforts to prevent suicide, the data reminds us that our crisis counselors may also have an opportunity to prevent harm to others. However, crisis counselors must be intentional, capable, and caring in their efforts to assess individuals who could bring harm to themselves or others. The Lifeline/988 does have national standards to guide counselors in their assessment of persons who could be suicidal, however, no such standards are in place for violence assessment.

In 2018, when I was at the Lifeline, we worked with the National Center for Domestic Violence, Trauma, and Mental Health to develop national recommendations for crisis counselors working with persons threatened by violence in their intimate relationships. In 2019, we pivoted to working with experts to develop recommendations for Lifeline network centers for assessing callers’ potential harm to others. We worked with Dr. Jack Rozel from the University of Pittsburgh, past president of the American Association of Emergency Psychiatry, and current Medical Director of resolve Crisis Services, a Lifeline network center. Jack is a leading researcher and consultant on preventing violence in crisis work, and he advised a Lifeline workgroup on assessment for violence. The Lifeline later provided a tip sheet for Violence and Threat Management for network centers in 2022.

Building Expertise into a Practical Tool for Preventing Violence

Shortly after I joined Behavioral Health Link in October 2022, BHL’s Medical Director Dr. Chuck Browning and I began refining clinical elements of the BHL Platform. The Platform is our proprietary software that enables crisis call hubs, mobile teams, local clinics, and crisis-receiving facilities to coordinate personalized crisis care across the continuum. I continuously work with Chuck to make sure the Platform contains best practices in the assessment and care for all the people we serve, and this endeavor compelled us to continue the efforts begun at the Lifeline to expand the Platform’s risk assessment to include “harm to others.”

We engaged Dr. Jack Rozel and Dr. Thomas Joiner as expert consultants to advise on the harm-to-others screening, assessment framework, and content. In addition, we reviewed research in the area and common violence assessment scales, as well as interviewed national experts in threat assessment and violence prevention from the intelligence community. Consistent with our experience in developing the Lifeline suicide safety assessment, researchers and practitioners in violence assessment emphasized the need to focus on how assessments inform clinical interventions and treatment, as opposed to focusing on their ability to predict harm to self or others.

Extending the Lifeline’s Suicide Safety Assessment Framework to Violence Assessment

The BHL Platform applies Lifeline’s core principles from suicide to violence risk ratings, e.g., assessing an individual’s desire, intent, and capability for physically harming self/others. Experts consulting on this approach agreed this is an elegant framework for conceptualizing areas of risk and collaborative plans toward preventing suicide and violence. Some key distinctions in harm-to-others should be considered. For example, whereas one’s “desire for suicide” is specific and self-directed, one’s desire to harm others can be either a specific (e.g., a neighbor or the school across the street) or a non-specific individual or group (any person from a racial or ethnic group, etc.). A person’s “capability” for harming others can be readily affected by access to firearms, for example, as well as by their plausible access to the person or group they wish to harm (e.g., the person lives across the country as opposed to working in the same office space daily). As with suicidal intent, the degree to which one has clear intent to harm others is central to assessing their risk level, including any reported plans and preparatory behaviors for carrying out violent acts.

The vital fourth element of Lifeline’s risk assessment framework—buffers/reasons for not acting to cause harm—is essential to both violence and suicide risk prevention planning. Experts in violence behavior analysis emphasize prevention over prediction and focus on how clinicians can mitigate violence by identifying and leveraging the individual’s strengths and inhibiting factors. There are several “buffers” itemized in both Lifeline’s suicide safety assessment and the BHL Platform’s harm-to-others assessment, but one of the distinct areas relates to “a concern for consequences.” Certainly, a person may rule out suicide due to concerns about the would-be severe psychological consequences on their loved ones, but the consequences for violent acts on others may affect their loved ones as well as their own personal freedom, career, etc. In general, the platform’s harm-to-others assessment has both similar and distinct features related to the national standards for suicide risk assessment, but they are both designed to assist counselors in actively collaborating with persons in crisis to reduce their own risk and promote their continuing safety.

Future Implications for Better Violence Assessment Tools in Crisis Care

Preventing suicides and resolving behavioral health crises must be the priority for 988 crisis services, as most persons who are suicidal are a threat to themselves and not to others. Further, most persons in behavioral health crises are neither a danger to themselves nor others, and managing crises at the moment can prevent individuals from later placing themselves or others at risk. However, it is also true that if our counselors can identify behaviors in callers (chatters/texters) that could put others at risk, our crisis services could better promote both public health and safety. In addition, the better we are at identifying potentially harmful behaviors of all kinds, the more we can learn, develop, and innovate on effective approaches to preventing violence to self and others

In 2006, a popular television show for young people, One Tree Hill, planned to broadcast an episode where a high school student whose plans to shoot up his school were thwarted, ending in his suicide. Before broadcasting, the show’s publicists reached out to Lifeline to explore how they could include the Lifeline phone number in the episode as a public service for viewers. The PSA led to a spike in calls to the service, with one caller connecting to a crisis center in Colorado. The caller was a young man who reported that he planned to shoot up his school and kill himself. The responding counselor empathically engaged him, helped him feel less alone, and collaborated with him to agree to receive a visit from law enforcement. When police arrived, they discovered a store of firearms and ammunition and brought the young man into custody. The counselor later testified at his hearing, where the young man was remanded to a treatment facility to find hope for a better life.

It is not a stretch to say that the young man’s decision to reach out to the Lifeline in 2006 and the counselor’s outstanding work on that call made the difference in saving his life and the lives of several others. Could our crisis counselors be better trained and prepared to identify persons threatening harm to others as well as to themselves? And, if so, could we better collaborate to keep them and others safe? I believe lives are counting on us to do so.