Behavioral Threat Assessment with Dr. Jack Rozel

Hello, I'm Captain Matthew Turner, and welcome to

another episode of the GSA Set podcast. In this episode, we

will be interviewing Dr. John Jack Rozell.

Dr. Roselle has been working in emergency mental health since

1990, and currently serves as the medical director of Resolve

Crisis Services and the clinical chief of crisis services at UPMC

Western Behavioral Health.

He is also the founder and co-director of the UPMC

Systemwide Threat Assessment and Response Team. Dr. Roselle

divides his time between emergency psychiatry and

violence work, and is a past president of the American

Association for Emergency Psychiatry. Dr. Roselle trains

and consults with teams across UPMC and the world on projects

related to violence and threat management, staff injury

prevention, firearm injury prevention, and crisis and

emergency psychiatry. He has served as an incident commander

for mass shootings and been involved in the behavioral

health response to several mass casualty events.

You began working in emergency mental health more than three

decades ago. What initially drew you into this sort of crisis

psychiatry?

When I was in high school, you know, I had a couple friends who

were doing the EMT thing, and I really sort of got into that

space and had a chance to volunteer in a local emergency

department. And as I hit college, I I thought I knew it

was going into medicine, and I thought it was going to be

either emergency medicine or or maybe critical care, and by pure

dumb luck and and a little bit of privilege, I had enough

bandwidth and ability to do some volunteer work when I was in

college, and because

the sign on the bulletin board nearest my freshman dorm room in

college said, "Answer the call, volunteer for the Samaritans,

which was a local suicide crisis line.

That's sort of what I signed myself up for,

and I remember sitting there and and sort of falling in love with

the process and being astounded by

how much of an impact we could make. With I don't want to say

no training. There was a fair bit of training as a volunteer,

relatively little training compared to the rest of my

training. And same thing, like, oh my gosh, here I am making

such a difference in someone's life with relatively little

training. Like imagine if, like, I really went through a lot of

training and knew what I was doing, and here I am, you know,

a lifetime later realizing that the basics of being present in

the moment with someone in crisis and listening to them

with compassion and letting them tell their story is one

of the most important and essential things we can do in

that work.

Oh, absolutely! It can be huge. Kind of pivoting towards the

military side of things, military emergency physicians.

We're increasingly encountering this sort of behavioral health

crisis situation. What similarities do you see between

civilian emergency psychiatry and military emergency medicine?

Think of almost three spaces, right? We have traditional

clinical civilian emergency psychiatry. Someone is coming to

an emergency department, and kind of like the sign next to

the roller coaster, we have to decide: Is this person tall

enough to ride this ride? Right? Is this person lethal enough,

suicidal enough, homicidal enough to justify an admission?

And if they are, if they have the right diagnosis, the right

amount of dangerousness, then in that traditional emergency

psychiatry model, it's all right. We're going to send them

to inpatient, or if we're lucky, maybe they don't need inpatient,

and we can find the the right sort of box for them someplace

else. What we do in crisis centers is actually a little bit

different, and and maybe in some ways a little bit more hint to

to what might happen in a military setting where the

application of a diagnosis can be

complex and nuanced,

and the impact of a psychiatric diagnosis on you know mission

readiness, on security clearances, et cetera, I know is

a very complex topic. But what we do in crisis psychiatry is,

what does this person need? And I always say that you know, to

go to an emergency room, just like with a medical thing, it's

either someone has a medical need or a reasonable question of

a medical need that is so significant that if a really

smart person, a doctor, or or the right kind of APP isn't

there to make the assessment and interventions, serious injury or

death is going to come next. Right. Same thing in emergency

psychiatric. Like you need a psychiatrist or you need a

really skilled mental health professional. Say this person's

suicidal. They're psychotic. They're homicidal. To sort of

make that that determination about what happens next. Crisis

work is about this person is feeling overwhelmed. They're

either feeling like they're coping, their resources, their

support network is maxed out, or it's pretty clearly on a

trajectory that they're going to be maxing out sooner rather than

later, and they don't know what to do next. Right. So we always

sort of say dangerousness plus diagnosis equals admission on

the emergency side, but distress and dialog means assistance on

the crisis side. And in some ways, you know, I think military

psychiatry and military emergency psychiatry really has

to sort of be in both of those spaces at once, and as does any

good crisis psychiatrists or emergency.

Psychiatrists as well, right? It's these are not discrete

silos, right? It's

you know there's a ton of overlap, and you've got to be

ready to pivot on an instant. So pivoting a little bit, you

helped establish one of the country's leading hospital-based

threat assessment teams. Could you tell us some more about this

sort of behavioral threat assessment?

So behavioral threat assessment and management, and there's a

lot of variations on that terminology. I won't vary with

the nomenclature discussions, but the core idea here is that

we look at people who may be at risk for violence not by drawing

a circle around some group of people because of ideology,

because of diagnosis, because of race, ethnicity. You know, I

always say, like, I don't care if someone goes home at night

and watches MSNBC or Fox News. I care if they want to hurt

someone. And to sort of get yourself brought into our

scrutiny, it's because of a behavior you did that was very

obviously threatening, or a communication you made that that

was threatening, right? And we look at the lots of aspects of

those folks through a multidisciplinary lens, so it's

not just that sort of half-assed behavioral health

multidisciplinary approach of "Ooh, we have a psychiatrist and

a psychologist. No disrespect to the psychologist, I love me a

great psychologist, but like I'm a psychiatrist, I work alongside

law enforcement, legal risk management professionals, HR

professionals in an internal organization, physical security

specialists, intelligence folks-like there's a lot of

folks brought together to look from as many different angles as

possible at this person of interest to better understand

what's going on in their lives, why they might be wanting to

engage in violence, what their risk factors are, what their

stressors are, and most critically, what can we do to

intervene? Right? What can we do before it gets to the use of, to

be blunt, kinetic intervention? Right? I've seen really awful

events made less awful because someone shot and killed the

assailant. I would much rather get to them way upstream when

they're just pissed off, when they just have agreements, when

they're just angry about

whatever issue they might have, and in healthcare settings, we

look at this through a lot of different lenses. Sometimes we

are concerned about patients or patients' family members who are

upset about an issue around treatment. Sometimes there's

employee-on-employee conflict. You know, we we see this in in

any you know anytime you have more than one person in an

organization, it sooner or later conflict may well arise, and and

you know it certainly happens in medical settings as well.

Sometimes we have what we call in a short way intimate partner

violence over spill, but maybe more accurately described as

someone is pissed off at me,

and they know me from something that's not related to work. And

as I come into work, I bring that zone of danger with me, and

that zone of danger is now impacting my coworkers and and

the workplace safety issues. And so that that that's a big issue

as well. And then also we have some ideologically motivated

attacks because people don't like the type of healthcare that

might be provided, and also we have other risks facing

healthcare facilities as well. They are, to be perfectly blunt,

a very soft target, a very appealing target, and starting

to be a little bit more thoughtful about what that looks

like from a counterterrorism and also a warfare lens. And and and

we're lucky on the continental U.S. that we sort of have some

fewer concerns of that, but we certainly don't have zero

concerns of that, and it's definitely something on our

radar.

So, looking at it from like an emergency physician lens,

how would you recommend EM physicians distinguish between

someone who's just pissed off making alarming statements, and

someone who's actually progressing towards this

targeted violence. Yeah. So the first thing I want to do is I

want to dispel the notion that emergency medicines can't do an

amazing job at this. You absolutely can't. I've seen this

over and over again. I know officially the the training

standards are that emergency medicine physicians don't

actually require, you know, the training points don't include

behavioral health stuff. Which, okay, that's weird, but you

know, you know, not my thing to maybe quibble on today. But

also, you get exposed to a lot of it, and just about every

residency training program I've seen does a pretty good job

teaching it. And I wish I knew who I heard say this because

it's such a good concept, but emergency medicine is the first

15 minutes of every other specialty, right? You can

stabilize an open globe, right? You can drop in the I/O line,

you intubate, you do you do major trauma resuscitations, you

do

everything, you know, from tap and a knee and and suturing up a

wound to everything else, right? And you don't have to do all of

it, right? You know,

you hit someone with sort of the the first round of

anticoagulants after a cardiac event, but you hand them off to

interventional cardiology, and you know the person that's up to

the cathode. But you do that first 15 minutes. I don't

necessarily need emergency medicine physicians to be the

world's best.

Managers, but we need them to do the first 15 minutes of that,

and part of that is recognizing, like, ooh, this is a threat

issue. This isn't just some ornery person in my ear. This is

someone that that you know we we need to look at more closely.

That we maybe we need to either develop our own personal

resource toolkit for it, or maybe we need to figure out who

the right folks are to bring in. And if you like mnemonics, I

want to give you a mnemonic, right? Threats. Take all threats

seriously. So threats, either a direct threat, I'm going to kill

you. Don't worry, I'm not going to kill any of you. Versus

leakage, hey, I'm going to go kill so and so, right? And by

the way, we hear a lot of that in the ER, and sometimes it's,

I'm pissed off at that person in the community. I'm pissed off at

my ex. I'm pissed off at my commanding officer or someone

I've got to work with. Right, a history of violence, especially

with the same or similar targets. Right, violence once,

violent once, violent again. Just like on the other side, you

know, my trauma surgery colleagues say, you know, shot

once, shot twice. One of the best best risk factors for

getting shot is that you've already been shot once. One of

the best risk factors for you being violent against someone

else is you've already been violent, and the magnitude of

violence in a military medicine setting is a little bit

different than it is in a lot of civilian settings. Because

Uncle Sam spent a lot of money to train you and all of your

teammates to do some very dangerous things, hopefully in

very controlled circumstances under very specific criteria.

But you know a little bit more about how to kill other people

than the average civilian, and so that sort of changes the

magnitude. Maybe not the frequency, but it certainly can

change the magnitude. R recent stressors, relationships are a

big one. Money, housing, employment, right? They might be

coming up on you know an Article 15 or court martial, or there's

no that they're having a lot of conflict with SEO, health stuff,

which can both be I'm having more medical issues, I'm having

problems paying for my medical stuff, or my loved one just had

a major medical emergency, and victimization is one of these

other acute recent stressors we worry about. I got someone beat

the crap out of me last night. My risk for violence goes way

up. Abuse as a kid, I've got some elevated risk, but it's

acute and recent stuff. E. Ethanol or other drug use.

A. Agitated or annoyed easily. You know, you jack. I'll keep

asking me all this stuff. You know, you always ask me my name

and date of birth. You idiots talk to each other. That's

right. That's what we do in a healthcare setting. But if

they're that bristly, that they have that hostile attributional

style, we get more worried about them. T takes no responsibility.

They project. They minimize suicidality, suicide risk

factors, violence risk factors, tightly linked symptomatic

psychiatric illnesses, especially psychotic diseases

like schizophrenia and schizoaffective disorder.

Finally, specific target access needs and plan. Right? Someone

tells me, you know, I'm I'm at the University of Pittsburgh, so

someone tells me they're going to go, you know, down on such

and such street and kill the next Pitt student they see. I'm

a little bit concerned. Professor Plum and the library

at 2p.m. because she grades on a curve with a wrench. I'm a lot

more concerned. They've thought through how they're going to do

it, and so that investigate all threats isn't just sort of a

nice way to remember it. And if you do a Google search, and

maybe you can drop in the link. There's an open access article

by the wonderful Dr. Amy Barnhorst and myself that that

sort of goes through this. We wrote it up initially for some

crisis line work, but it's it's intended for that oh crap moment

of someone's in chairs or someone's just been triaged, and

then there says this person made a threat in the workplace or

this person posted on Facebook that they're coming back with a

gun and people are worried. This is intended to walk you through

that first 15 minutes, whether you take the 10 minutes to read

the article, or you dump it on your heads and say, "Hey, read

this and come back and tell me what to do. However, you need to

do it, right? It's intended to be that that open access, quick

deployable, you know, rapid access, right?

Nice, and we'll definitely be putting that down in the show

notes for our audience.

Actually, you answered like my next like three questions really

well, actually.

So I guess something that is always interesting to me

is where exactly we draw the line on interventions. So is

there a point when clinicians should involve a behavioral

threat assessment team versus straight up law enforcement?

Right. We talk about this concept of a pathway to

violence.

That we know that most of the times when we think about

targeted violence, which is I am pissed off at that person or

that type of person or that group of people for whatever

reason, and I'm going to go hunting for them. Again, maybe

it's the person who stole my, you know, ruined my last

relationship, or the boss, or you know, the the bank executive

who I don't like. It starts off with grievance, right? It me.

I'll get annoyed by stuff, right? But these people get

fixated on it. It pivots to ideation. You know what? I can

do something about the way this person's wronged me, humiliated

me, shamed me. By the way, a humility stressor is a really

powerful acute risk factor.

For engaging in violence, people start researching and planning,

but then they get to

actual preparation. Right? They've actually done some

physical behavior to get more ready, acquiring a weapon, cased

out a location, things like that. When you've reached an

actual physical behavior,

then a couple things can be significant. In some

jurisdictions, that may justify an involuntary hospitalization.

A lot of jurisdictions, and again, talk to your local legal

and subject matter experts about this. That that act of

furtherance may be that sufficient criteria to justify

that. It may also be what we call in legal settings the actus

reus or the guilty act that finally allows a charge to be

pressed. Now here's the thing:

if someone is going to get locked up for a long period of

time in the criminal justice system and the military justice

system in a psychiatric hospital, then either something

really bad just happened, or we got way too close to boom for my

comfort, right? I want to be way left of boom, right? I don't, I

don't want to get close to that. And I've had cases where you can

see, like, separated by a matter of you know yards, the distance

from the attacker and the target as the target's being escorted

out, and you know the attackers like entering the building, and

you sort of see everybody go, "Oh, that was way too close. And

also, thank goodness, right? I'll take it, right? But I, I

like to prevent things a little bit more upstream. You know, as

one of my bomb squad buddies says, they have a lot more tools

in the toolkit when you call them when the timer says six

hours than when it says 60 seconds. Same thing here. The

further upstream we can get, the better off we are. And

a good friend of mine, Beth Balgad, who's an attorney out in

Hawaii who does a lot of this threat work. One of the things

she said to me, and I'm paraphrasing, is that we make a

mistake when we call these threat programs because

we have primed our audience, our customers, as a threat program,

to wait until someone's making an obvious threat of "I'm going

to kill you" or "Don't show up to work tomorrow. I don't want

you to get in the way, or "You're going to get what's

coming to you. We prime them to wait until it's that bad, until

we're sort of at a breach situation or an overt threat,

rather than setting people up to say, "Hey, there's a conflict.

There's a grievance. Someone's upset about something here. How

can we do a better job problem solving? Or in a healthcare

setting, doing sort of that that service recovery, saying, "Ooh,

we we really did screw up. How how do we fix that for you?

Right. We we want to catch them downstream. We want to catch

them when the timer says six hours or six days, and not when

it says 60 seconds.

What do they say? Like an ounce of prevention is worth a pound

of cure. I think Ben Franklin said something like that. Yeah,

yeah. Going from that to unfortunately, sometimes things

do go boom. So you've served as the behavioral health response

to several mass casualty events. Could you tell us any more about

that?

Yeah.

So

I entered emergency psychiatry, and sometimes what we do is we

get involved in incident management, critical incident,

stress management type of work, as well as broader you know

emergency operations, and through that CISM and related

type of work, I've helped respond to or been an incident

commander for a number of incidents over

the years, including several mass casualty targeted attack

types of incidents, and I'll tell you, you know, one of the

things I've seen many times is, like the stuff. A lot of the

stuff that we do works, right? Run, hide, fight works. I I've

sat and and talked and and had really good interactions with

people who ran and who hit, right? And I can think of a

number of incidents where some of the first people who died

were the people who, by their wiring, by their compassion and

good hearts, frankly ran in the wrong direction because they

were running to help. Right, which it's a tough balance.

Right, we know stop the bleed works again. I've sat with

people whose lives were saved because of improvised wound

management in the midst of a real incident. We know that

TACMED works, right? I've seen what happens when we've got the

EM docs who've been embedded with the SWAT teams and been

able to go in and do really advanced trauma interventions in

the middle of a hot zone. I've seen all that work, right? We

know those are good interventions, and again, we

know that if we can prevent them, it's better. And we also

know that no prevention is perfect.

You know, we talk all the time about that metaphor of Swiss

cheese, right? You know, you have the the layers of Swiss

cheese sort of floating in space, and you have this sort of

laser beam coming through. And if all the holes line up just

right, then the beam hits the target, and the bad thing

happens. And we talk about this a lot in health quality. Of I

write the order of 10 grams of acetaminophen, and the nurse

doesn't think anything of it when she takes it off, and the

pharmacist doesn't notice it, and like all these sort of

errors have to happen for that accident to end up harming a

patient, right? And so a lot of things have to be lined up just

right. So a lot of little small errors have to happen, but

hopefully it gets caught well far upstream before it hits the

patient.

Same kind of thing here, right? We can put in different

measures. We can include things that address morale, things that

address insider threats. I was doing some stuff with you know

Ditmac and CDSE, you know, recently around insider threats

and targeted violence. We can put in you know physical

security measures. We can put in rapid response measures. But

here's

here's the other part of that metaphor. Well, violent behavior

has some properties that might make it kind of like that light

beam, or it might make it like a frankly a complex dynamic system

of human behavior. There's also something very intentional and

predatory about it, right? There are measures, there are

countermeasures, and I'm aware that there's someone like you

trying to get in between me and my target, so how do I go

around? How do I go, or how do I go through? Right. Sometimes

it's not a laser beam. Sometimes it's you know the very hungry

caterpillar who's going to eat their way through whatever

measures we put up. Good ID badging and access control and

security clearances helps. And also there are breaches all the

time, right? But we add layers and make it a little bit more

difficult. And we add enough of these layers, and it will

prevent a lot, but not all of it. Threat management adds a

couple layers to this, especially when you have a good

intake process so that people can make referrals. I'm

concerned about this person. I'm, you know, this is what they

said. This is what they did, and it's easy. It's accessible. It's

comfortable for me to raise my hand about this, right? Lots of

people know CPR, and there's a pretty good chance that if I go

to a bar, whether it's on a base or you know out in the

community, and I grab my chest and drop a stemmy, right?

Someone there's going to know CPR, right? And you know what?

Here's the thing: even if it's the hotel bar at a

conference for cardiothoracic surgeons. No one's grabbing a

knife and cutting me open there on the bar floor, right? They're

going to start with CPR, right? And we don't need a world filled

with cardiothoracic surgeons. We need a world filled with people

who recognize, I recognize that issue. I know what to do next. I

know how to activate the rest of the chain of response that's

around. And there's got to be a chain of response around you to

receive those threatening concerns, right? Need a

paramedic to show up and help get them to the hospital to, you

know, you and your colleagues to do the next step, and then

sometimes you hand them off to, you know, interventional or

whoever else needs to get involved,

right? Nice, I like that. You don't need a world of

cardiothoracic surgeons as an EM physician, I love to hear that.

As few surgeons as possible. No offense.

We're seeing a lot of different changing patterns of violence,

like nihilistic violent extremism. That's kind of like

the buzzword of the day. Yeah. Also, we're seeing artificial

intelligence, social media, online radicalization. Are there

any trends that are concerning you right now?

So here's the irony. On on top of my papers are are some notes

on some slides from a talk I did earlier this week on nihilistic

violent extremism or sadistic online exploitation or whatever

term of art you want to use for this. And sort of my opening

comments on literally on the piece of paper on top of one of

the several piles of papers on my desk is this: right, violent

and predatory behavior, like all human behavior, changes and

adapts over time. The collection of behaviors we're talking about

now that this you know NVE SOE stuff, it's generated from some

common environmental factors that have been around as long as

there as there's been human beings, but it's also evolving

very quickly now because of our modern environment, both in a

social sense and a technological sense.

And this thing specifically of NVE and SOE,

other terms people might have heard of, 764 CVLT pronounced

cult, but but spelled with a V, order of nine angles. You know

some of these other affiliated groups in this space, or the

COM, the community, they've been popping up like popcorn for the

past five to 10 years or so, and have a really big impact. And

they're probably continuing to evolve.

The concepts are dynamic and turbulent and kind of squishy,

right? Our social psychologists, our criminologists-they're

still trying to find the right nomenclature to describe this

thing that is distributed, that is

not completely disorganized, but not organized in the way that

you know the mafia used to be organized. Like, or there's the

don at the top who sort of gave all the orders right. But still,

there's there's influencers in this space. It's something that

you know is it's better for Substacks and symposia than the

peer-reviewed literature. But it's something that we're

starting to get our heads around, and it's very appealing.

You might have heard the metaphor of salad bar extremism,

where people sort of pick a few ideas from one extremist group,

a few ideas from another group. In some ways, that's a nice

metaphor because we're seeing blends of ideologies that we've

never seen before, like ISIS and Nazis and black supremacy all

mix together.

Seems like an odd combination to me, but we've seen it, right?

And also, it's not a passive process of someone picking

ideologies out of like this appeals to me, that appeals to

me, because some of these ideologies are being very

intentionally and very strategically pushed towards

these vulnerable people to bring them into these movements, and

so there's other processes at play, and what what I you know

one things I reflect back on this many years out of my

training is that if you told me in med school that foreign

intelligence organizations were going to be pushing propaganda

to increase violence towards different groups that I was

concerned with, including other clinical groups. Like

again, as a med student thinking that we're going into

psychiatry, I would have had a differential diagnosis going,

and yet here I am, you know, 35 years later, saying, "Ah, crap!

What's going on now? And how do I figure out this whole other

space that wasn't in the brochure when I was in training?

It's a bleak topic, but it is a fascinating

one. Yeah, I think we're actually running out of time. Do

you have any closing thoughts you'd like to leave us with?

So one of the groups I do a lot of work with it's called the

Eradicate Hate Global Summit, and and within that the

Prevention Practitioners Network. These are affiliated

groups that are working on providing good resources,

education, and training to folks like you and me, to our other

behavioral health colleagues in clinical settings, to our policy

leaders, to other interventionists, to help better

understand hate-based violent behavior, and to find the right

ways to reduce it and make our communities and our teams safer

from those attacks. And we're going to drop some of those

resources into the links here.

Absolutely.

Well, thank you so much for your time, sir. We really appreciate

having you on. All right. Thank you so much for having me.