Workplace Violence III
Dealing with NEW High Impact Incidents

April 20, 2023

Speakers and Reactors:

Dr. Charles Denham – Moderator
Chief Bill Adcox
Assistant Chief Vicki King
John Nance, JD
Randy Styner
Jennifer Dingman

Dr. Charles Denham:  Hello, we’d like to welcome you to our Workplace Violence III Program today. Our topic is threat scenarios, and we look forward to having you join us. I am Charles Denham. I will be your MC today and take you through what we’re doing. This is our 202nd webinar, the 202nd sequential month of webinars that we offer. And in this particular topic, it’s really, really critical, and we look forward to sharing it with you. We want to remind everyone that is listening today or watching that we offer this program both as a video streaming from our website and on a podcast. And so, we hope you can take advantage of that, those that are watching on demand at a later date. You can go to our website at and download the slides and watch the content.

Just to set the context, in about 2015, we started a program called Med Tac, focusing on bystander rescue care. And then we launched before Covid, an emerging threats community of practice for major medical centers. Basically, the things that keep people up at night, keeping leaders up at night. We’ve expanded it to higher education and schools K through 12. Both the visible and invisible threats that we run into. And workplace violence is one of the major one of these major threats. There are, are 30 of them that we’re focused on. And we’ll give you an opportunity here in a moment to remind you. And those of you that are listening to the podcast can go to www.safetyleaders.or. Those of you watching live may go to our website, and those watching the video on demand may go to the website.

The 30 areas that we have on the screen for those in the podcast right now are the 30 areas of focus of this thing we call a community of practice. And one of them is workplace violence, but we have a number of violent threats, workplace violence threats, and threats covered. We have what we call a widget, a box at the bottom of the webpage for this webinar. And for those of you that qualify, we’d like to invite you to join our community of practice. We will be covering in private sessions a lot more detail about workplace violence, and active shooter events targeted lethal leader force incidents, but we don’t want to give bad guys that detail. And so we will have people who wish to join us.

Please go to the bottom of the webpage where you have joined us today. And those on the podcast and, and the on-demand video, you may enter, but you’re going to have to tell us the organization you’re with. We’d like to know the topics of interest that you’d like us to cover, both in our general sessions for the public, as well as those that are in the private sessions where we cover a lot more detail. Active shooters spend between a hundred to 150 hours of preparation before they go on a killing spree at a school, a church university, or a business. The Joint Commission on Accreditation has expanded the definition of workplace violence from purely physical to now an act or threat occurring at the workplace.

That can include verbal, non-verbal, written, or physical aggression, threatening, intimidating, harassing, or humiliating words or actions, bullying, sabotage, sexual harassment, physical assaults, or other behaviors of concern involving staff, licensed practitioners, patients, or visitors. We are applying this principle to higher education. We’re delighted to have Randy Steiner with us, who is an expert in this field, and is one of our leading directors of emergency response at one of our major universities. We’d like to draw those that are watching the video and watch it or watching live. We have a slide that addresses our prior 2023 Workplace Violence series. We started with work our workplace violence one and we ex we covered this new definition of not only physical but then the non-physical. And then, we have expanded more detail regarding the non-physical in our last webinar.

Today, we’re talking about the high-impact threat scenarios that our organizations are facing. We’ve also had previous webinars in prior years. So, this has been a topic of critical concern to all of us over the past years. And we’d like to draw your attention to a number of those prior 90-minute programs, which we have also converted to podcasts that may have a little dated material if they’re from a year ago or the year before. But a lot of the frequency and severity of these issues are picking up speed. And we believe that they’re critically important. So, for those who have not been with us before, we always start these webinars. These are now over 200 monthly webinars that we provide for free by setting our course with focus on patients and families, and now students and educators that are not professionals in threat safety. And we’d like to have Jeni Dingman open for us. She is a longstanding patient safety advocate, having had a patient safety event in her home. She has been a steadfast supporter for over a decade of this area. She was a winner of the Peak Conrad Global Patient Safety Award. And she has been a major contributor to a number of areas. And so we’ll ask Jeni to open for us.

Jennifer Dingman:  Thank you, Dr. Denham, for your kind introduction. I’m really looking forward to today’s program on workplace violence. This series is very, very important, and we all need to learn more and more about this, as it’s happening too many times in our country. I want to thank everyone for being here today, and I encourage you to share the recording with your family, friends, and colleagues. I’m anxious to get started, so I’ll hand it back to you, Dr. Denham.

Dr. Charles Denham:  Thank you, Jeni. And Jeni will be on with us at the end of the program to help us with our reactions. So, on our slide, for those of you on the podcast, we have a number of experts that have contributed to this series and are either recorded because they’re very active in their jobs at the front line or live – you’ve heard from Jeni, Vicki King will speak a little bit later. Assistant Police Chief at MD Anderson and the University of Texas Police Department; John Nance, who is a long-standing aviation safety, patient safety, and now higher ed safety leader, who’s also an ABC journalist on safety with Good Morning America; Randy Styner, who’s on with us live. We’re grateful to Randy to have you here to kind of help us sum up with our reactions, she’s a long-standing leader in this, a best-selling author, and a fantastic community leader here in Orange County and with the University of California Irvine.

We have Dr. Casey Clements in our prior webinars who is not only the Director of Clinical Practice for Mayo Clinic in Rochester, but he’s also in charge of safety and occupational safety for the Mayo Clinic, both an MD and a Ph.D. who we’ve called on previously to help us with the topics of sepsis as he is also as he says a recovering researcher – so he is an emergency medicine doctor; and with great scientific grounding, we have Chief Bill Adcock, who has been named number a number of times as one of our leading national security leaders. He’s the Chief of police at the University of Texas Police Department at Houston, but he’s also the Chief Security Officer for MD Anderson Cancer Center, where I have the honor of having some of my training.

We have Dr. Gregory Botz, who is our clinical leader for what we call our Med Tac program on bystander rescue care. He has dual appointments as a full professor at both University of Texas at MD Anderson as a critical care doctor, and as in, in the Department of Critical Care and Anesthesia, as well as a full adjunct professorship at the Stanford Medical Center, where he did a fellowship in simulation. He’s also the medical director for the police department of the University of Texas and has been actively innovating in that space in this area. We just want to draw your attention to our social media which we will be doing a lot more within the next year. And we have that on one of our slides. So, before we get started, we have a full program, and we’re going to just move on and get me out of the way very quickly.

We just want to remind you of our purpose, mission, and values for those of you that have not been with us before. The purpose of TMIT Global in our global research test bed, in our multiple programs, it will measure our success by how we protect and enrich the lives of families, patients, and caregivers. We’ve expanded to higher ed, so it’s staff members, educators, the community, and our major universities and small colleges. We also work very closely with the rural and small hospitals. Our mission is to accelerate performance solutions that save lives, save money, and create value in the communities we serve, and the ventures we undertake. We always try to monetize the impact so our CFOs and COOs can justify adopting new innovations. So, it’s important to really know the cost of innovating.

Our core values are iCare. The “i c a r e” stands for integrity, compassion, accountability, reliability, and entrepreneurship. We try to live those values. Our disclosure statement, for those of you on the podcast, we have, none of our speakers have anything to disclose. And for those that are, are reading it, you’ll see our leaders of the entire series have nothing to disclose. Also, TMIT Global High Performer Webinar Series has received no direct, indirect, or affiliated financial support. And we’ve never received any, or, and never will we receive any from healthcare, pharmaceutical, or device companies. Conflicts of interest, those of you that are in higher ED may not realize how critically important disclosure is, but we want to really make sure that everyone knows that we have received no money from those industries.

The TMIT Global Research Test Bed is comprised of 3,100 hospitals in 3000 communities. We have about 500 subject matter experts that have worked with us over the last 39 years. This happened because we have continued to put on educational programs, and those that are contributors join us. And almost everybody we’ve ever worked with has joined our community of practice, which is really an honor to have them work with us. Over the 33 or 36 months of the Coronavirus crisis, we developed safety programs for families and for major universities that couldn’t move as quickly as we could on putting the science together for the 17 industry sectors named by Homeland Security to have to keep working during lockdowns. And so our global research test bed has just grown over that period of time. And we have partners in every state and union.

During the Covid crisis, we undertook a thousand workers study focusing on response, rescue, recovery, resilience, and readiness. We’ve expanded this to focus on safety, including workplace violence and family safety. And then finally, we have had a number of articles in Campus Safety Magazine pertinent to this effort. And we’ll be posting these articles on the web, on the page for the webinar. For those in the podcast, we have written articles in Campus Safety on active shooter events, rapid response teams to such events, AED, and bleeding control gear that may be placed there. And also a Family Safety Plan article. We’ve got four articles coming in future issues of Campus Safety Magazine. The problem we identified in 2015 for our MedTech program was failure to rescue, and we won’t belabor it.

Those that are on the webinar and on-demand may see the leading causes of death for which good Samaritans can save lives. Before EMS arrives, they include sudden cardiac arrest, opioid poisoning, and a number of issues. And our program to deliver continuing education is through what we call Care University. It’s not an accredited university. It’s our learning management system. And we provide Stop the Bleed training and a number of training modules to schools, universities, major medical centers, and families. And so, our strategy is to build a community of practice and then develop courses that allow us to identify competencies people need to learn and then help certify those that can benefit from certification. We’re working with the insurance industry now to help reduce the cost of premiums and have people have an on-ramp to have insurance for some of these really bad events.

So now, let’s talk about these threat scenarios. For those on the podcast, we have 30 categories for which we’re focused on our threats, and a number of them include some of the recent ones, pandemic readiness brand damage. But workplace violence is a critical issue. So, a couple of operational definitions describe inside and outside threats as those that we’re subject to. We talk about reducing our vulnerability to threats because a threat times the vulnerability equals the risk for harm. We can’t accept the fact that, oh, we’re just going to be harmed and not prepare for that risk. So, our strategy is to rebuild resilience. How do we build resilience, and what can we learn about that? So, for those that are on the podcast, I have a slide up where we’ve taken the topics of the 30 areas we’re focused on in emerging threats, and we’ve identified those and put them on a graphic so that then we can look at how many of them might be connected to each other.

And in the old days, workplace violence. And Randy, I know when you get to speak, we used to think about workplace violence being only physical violence, but now we’re seeing an enormous uptick in verbal and the expanded definition of the Joint Commission. And if we really look at that expanded definition for those in the podcast, we’ve highlighted in yellow, those that aren’t physical. And the expansion of this definition that we now are applying to higher education is an enormous group of additional incidents that aren’t just physical violence. And so, when we look at workplace violence now with this new definition, we’re talking about violent acts against the leadership. In a future webinar, we’ll talk in more detail about the stalking of leaders and, and protective details, insider threats, those from the inside that have intentions to have impact.

We are seeing a lot of corporate espionage. We’re seeing nation-state espionage that’s going on. It’s harming our organizations, and it’s harming our safety, intentional harm of patients or students or staff and financial harm to those that we serve. Defamation or unfair press, preventive and then preventable death or severe injury that could be far beyond just physical violence. So now let’s talk about our topic today. We’re talking about impact scenarios. We have been working for 39 years in the area of patient safety and quality and aviation safety. And if you were to be able to look at impact on one axis and volume on the other axis, and if you were to look at and segregate these into categories, those that really grabbing a lot of press attention or the high impact, low volume active shooter events, the lethal force incidents, there are high impact, high volume events, and we really focus on those.

But then the sneaky ones are the low-impact, high-volume things that are happening all the time that have minimal impact for the one incident. But suddenly, you start to wake up to the fact that you’ve got behaviors of concern that can lead to active shooter events and leader stocking events and other things. So, when we drill down, and we’re not going to, I’m not going to read everything for the podcast, and for those that are viewing, we have a, a number of scenarios, a huge group, in the high impact, low volume – the active shooter events, the terrorism events, leader, targeted events, suicide, insider threat, et cetera. The high impact, high volume events – domestic violence that can occur and spill over into the workplace, which is happening all the time. And a number of very, very serious high volume, high impact events, but the low impact high volume scenarios with behaviors of concern, disruptive behavior and a lot of stuff now leaking into social media.

And then when we look back at an active shooter event, we see that a number of those really need to be understood because they can convert to a lethal force incident, which will be covered in detail today. We’ve asked Chief Adcox, who was actually leading a program today and couldn’t be on, to really talk about these issues.  And then we’ll hear from John Nance regarding this topic as well. So, let’s hear from Chief Bill Adcox. He is the current Chief Security Officer and Chief of Police at MD Anderson Cancer Center and is really a pathfinder in this threat safety science. So, Bill, thank you very much for being such a great leader in threat safety science, and you’ve frequently been named as one of our top security leaders and really be becoming a pathfinder for the rest of us. We’d like to have you just give your message to organizations about the fact that this is really evolving, and collaboration is critical.

Chief Bill Adcox:  Well, thank you very much Dr. Denham for doing this, and again, having me on the program. Let me first say that collaboration is critical. Partnerships and collaboration are critical. There is no one size fits all. There is not one simple program that you can put in place and you’re going to solve all your problems. Every organization is different. The culture’s different. The size is different. The complexity is different. Operations are different. And as healthcare is an accumulation of many, many systems And it’s very tough when you’re trying to integrate those systems. You’re looking at the recent laws and changes, Accountability Care Act and et cetera. But when you’re looking at all these things, you’ve got to have collaboration, and you have to have people engaged and involved. The key is to commit to getting in front of problems early, utilizing the threat safety science information, and utilizing this threat assessment and mitigation approach. You do that through multidisciplinary teams, cross-functional groups. You do that with people talking to each other. You do it with both internal resources as well as external resources. You get, you get professionals together, you talk about it and making sure everybody is in tune with the fact that you’re going to be looking at prevention first, and you’re going to be paying attention to the clues.

Dr. Charles Denham:  So, we’re so appreciative that you’ve expanded and that our team and our community of practice and emerging threats have expanded from medicine and from healthcare and medical centers to higher education colleges, universities, and actually schools K through 12. Are you surprised at how many common denominators occur in those environments?

Chief Bill Adcox:  Not really surprised. I mean, there’s a lot going on in our world today. Sadly, not all good. And we’re seeing a lot of, a lot of stressors and a lot of things happening, A lot of copycats. A lot of people are angry. That’s why we always tell people, , we use the term giving individuals a soft landing. Never take your fellow human being for granted, just because you have the authority to, for example, terminate someone’s employment for cause. Don’t take it lightly. Making sure that person’s whole when they leave your organization is critical. Remember, you are dealing with human beings that are on the very stressed today. And when you look at these horrible events that are going on, and you dig into those, you can see that there’s some considerable areas in which we could have had a different intervention than May.

And I state that may have changed that trajectory. And that’s what we have to be real careful with. And I’ve got tell you that there are times when there’s grievance collectors, and there’s people that hang on to grievances. And we’ve had cases that we’ve looked at that are 20 plus years later when the person acted out committed a terrible, horrible, tragedy. So yeah, you, you have to be real careful that you’re, that you’re looking at all the different points of information and who’s doing what and making sure that you’re really treating every human being you come in contact with, with a great deal of respect. And you still do your job, but you do it in such a manner that everybody remains whole.

Dr. Charles Denham:  Well, Bill, thank you so much. We have the graphic of the evolving set of scenarios, the impact scenarios before us. It’s growing. The definition of workplace violence is expanding. And now, as we’re expanding from higher Ed to schools, et cetera, it’s critical, isn’t it, that we keep watching each of these quadrants and that they can evolve?

Chief Bill Adcox:  It is critical. What we do know is that we’ve worked on this for a number of years, Chuck, and it’s important that we look at these and continuously get better at dealing with them. The real critical quadrant obviously is the top left quad quadrant, and about half that quadrant you can really have an impact on. But if you spend your time in that high impact, low volume area, because things that you look at very infrequently, you’re not dealing with very often, you probably are not going to be very well adept at dealing with it. If you get into that quadrant and you get very good at it, and you have the right processes and the right procedures and systems in place, you can pretty much deal with the rest of those, those quadrants which at any given time, things can move from one quadrant to another, just depending on what’s going on.

But really, your top left quadrant is where you need to get really attuned at dealing with those. Because in anything that’s low volume, you’re not doing it repetition. And in life, when you’re doing something, a lot of times you generally get pretty good at it, and it’s, and if you’re seeing something over and over, you’re going to get adept at it. So if you have a really high-impact event, but doesn’t happen very often, just be prepared for it. And if you do that, you can, you’re more than likely going to have a better ability to prevent it. And if you cannot prevent it, you’re going to go to your secondary prevention, which is to reduce the damage.

Dr. Charles Denham:  Bill, you’ve given us some really practical advice about what a medical center or a university might do at their local police force, perhaps of a grant to help develop competencies in the local police force. Do you want to expand on that?

Chief Bill Adcox:  Certainly.  When we talk about every organization different and different size and capabilities there are smaller medical operations that, might consider giving a grant to the local law enforcement that they’re teaming up with. And in that grant, they get training, whether it’s Homeland Security Department, or go off to the Association of Threat Assessment Professionals and get certified at threat management to be able to look at these things. And then you have somebody out in the community that you can pull upon as part of your team. You’ll enter into local agreements, whether it’s an inter-local government agreement, whatever it takes. And then you bring the right people together and you have a multidisciplinary cross-functional team, a behavioral dimension team, and you’re working together, and you’ve got your outside resources. Because remember, every hospital, every business, every organization is akin to be in a city of its own.

I mean, you have your internal functions, your internal databases, your internal stimulus that’s going on, your internal culture, different levels of information. HR has a set of information. Management has information, stuff is coming up in your IT security, stuff is coming up in your risk area. There’s all these different areas that you see different information. And if all those disparate points of information are not correlated and are not looked at, so that you can, what we call connecting the dots, so that you can get out in front of a potential problem.  You could have a tragedy waiting to happen. So again, having the external expertise, whether it’s your local law enforcement, your local government entities, as well as internally, having your multi-disciplinary team together and working together with the right agreements in place is the absolute starting point in order to get in front of these problems.

Dr. Charles Denham:  Well, thank you, Bill. We really appreciate the great work you all are doing and your readiness to share with others and to keep this community growing and helping protect those we serve and those that serve as well. So, thank you very much for all you do.

Chief Bill Adcox:  Thank you very much.

Dr. Charles Denham:  So, we really appreciate Bill and the concept of the transition from some of these low-frequency events to the high-impact events is critical now. John Nance has been a longstanding patient safety, aviation safety, and now school and university safety expert. His expertise really helps motivate, move, and inspire boards of directors. John was in the military, and we always have fun talking. He was a colonel in the Air Force, as my dad, was. He was a pilot in the Air Force. He then flew for Brane Airlines. And then when Brane went under, he went to a law school and then he topped off his aviation career as a captain with the Alaskan Airlines. He’s written over 20 books, both non-fiction and fiction books. One of the most articulate people who really understands the processes in place. The, combination of having his law degree, and his deep appreciation of the systemness of patient safety, aviation safety, and school safety really brings us an opportunity to share some of their important and critical issues. And he as well, was tied up today. And so yesterday, we recorded him for you.

John, thank you so much for sharing time with us today. You truly are one of the greatest assets in our country, because you understand patient safety, aviation safety, and now we’re looking at not only medical centers but we’re looking at schools and we’re looking at higher education and protecting those who serve and those they serve. John, I know it’s your belief that governance boards need to be educated and well-informed. Do you want to address that?

John Nance:  Yes, absolutely. One of the things that we have learned in all aspects of safety involving carbon-based human beings, that’s us, is that you have to have a pretty good grasp on what could happen and the magnitude of those things. And unfortunately, we have too many boards that do not get involved until it is in a reactive status. I think we use the analogy of the old game, whack-a-mole, , something pops up and you go attack it, and then you think everything’s all right. No, in fact, until you have a pretty good idea of what human nature can cause, and the places that they can go, for instance, one disgruntled individual who has not listened to who’s been disruptive on the campus or in some other way you can’t make the assumption that you’ve got it contained. If there are elements of precedence in the past, not just for that individual, but otherwise that this could escalate, then all of a sudden now you’re whacking a mole. It’s a much more serious situation. Boards absolutely have to get behind this. They have to understand the level of the threat, they have to understand the escalating part of that, and they have to understand that the one thing we want to avoid at all costs is surprise. In other words, we don’t want to hear, “well, we didn’t see that coming.”

Dr. Charles Denham:  So, John, as we think about the impact scenarios of those that are high impact, high volume, we know that those are really critical. It’s the low-impact, high volume that could convert into some of those low-volume, high-impact scenarios that we’re seeing now at schools and at medical centers, and all over with active shooter events. But they’re a lot more and it’s critical that everybody really understand the relationship between frequency and volume, so they don’t get caught off guard, as you’ve said or get surprised.  John, can you comment regarding these scenarios and from a board perspective, why it’s so critical to understand these and relate it to what you’ve seen in patient safety and in aviation safety?

John Nance:  Yes. I think the assumption that you’ve got things contained in any particular area is one of the operative problems here, because whether it’s the board or whether it’s C-suite, the idea is, well, what are we doing to contain this? What are we doing to identify, for instance, disruptive behavior, mental health issues? And too often, because there is no carrier wave of momentary attention put on it, in other words, nothing’s happening, right? Then the assumption is made that we’ve got it contained. That’s, that’s where you get into massive trouble, and you end up with one of these things accelerating up into a high impact, high volume scenario, or even worse an active shooter event or something of that nature. It really comes down to human nature. It comes down to having an institutional ability to say, we don’t have these things contained. If there is one single solitary possibility that somebody has not been handled appropriately, or some situation has been handled appropriately, I’m talking in generalities. But this particular graph has some very good specifics in it, and every one of the ones in low impact and high volume could easily escalate, if not watched, not just contained, but watched.

Dr. Charles Denham:  So, John, in the article that you and I wrote with Sully Sullenberger and Dennis Quaid, we talked about an N T S B for healthcare. And in that article, we talked about the successes in aviation and why an interdisciplinary approach where multiple players from multiple domains have to work together to tackle threats and reduce risk. Why that’s so important now. 

John Nance:  In higher ed and in our medical centers, when we look at violence, it’s Incredibly important because it’s a process basically of weaving together the entire human experience for a particular area, whether it’s a business, whether it’s medical, et cetera. And, being realistic the thing that changed us completely in the aviation business and enabled us to get to zero, or at least as close as you humanly can in terms of zero accidents, was realizing that we could not just basically tell people to be safe. We could not direct it. We couldn’t do it just one time with training courses. We had to have an omnibus approach to it. And that approach is never finished. It is always an ongoing process. And this is one of the things that is characteristic of what we call a high reliability organization, is one that is always willing to say, well, there are things we screw up every day, but we’re going to put every one of them on the table. Consider them as messages from the underlying system, and we’re going to deal with them and get better and better and better without that approach on an omnibus basis with the approach in the old way, we got this contained. We have a committee over here, we got a committee over there, you’re never going to get there.

Dr. Charles Denham:  So, John when the aviation industry looked at the forecast of future total losses of an airliner going down, they were shocked to realize how frequent that was going to be. And that really is a low frequency or a low volume, but a high impact event. Tell us how focusing on that made everything else safer and operations got a lot better. Just as a byproduct

About 1988, there was a major meeting in Washington, DC, I won’t belabor it other to say that the fellow who was kind of our GU roof or human factors Dr. John Lauber got up and said, I’m throwing away my speech, because I heard three different conversations that were identical coming up here today. And they really disturbed me. Three different people were saying, , this is such a complex industry, we’ve done great in improving safety, but we’re always going to have a few accidents. There’s going to be a continuous noise level. He said, guys, if we don’t believe in zero, we’ll never get close. And that was so true. That was actually the key to what changed in commercial aviation, was the idea as we have been trying to put it into medicine, that if you don’t believe that we can get to zero, you’re, you’re going to always tolerate too much. And there was always going to be a background of accidents. Well, in the case of aviation, you ramp that up over 30 years, and that’s what they knew in 1988, and you’re dropping a 747 every other day. We couldn’t do that type of impact would simply destroy the industry.

Dr. Charles Denham:  Well, fantastic. John, thank you for your continued focus on threats, harm, and risk, now expanding it to higher education and more broadly to schools. We are so grateful for your expertise and your insights.

Thank you, John.

So, we’re appreciative of John’s insights, and John will be covering some of these other topics at a later date. As an NTSB is being considered now, the topic keeps popping up. We’ll have our article from 2012 posted on the webpage for those who want to read it. But the issue was the industry got together and focused on safety and quality, using an interdisciplinary approach multiple industries, and had an enormous impact on safety. And we today are at just an amazing six Sigma safety in airlines. Now, our bags are not six Sigma performance, but definitely our flights are. So, for those of you that are with us live, we want to let you know that this is an extended session because Vicki King will go for over an hour on a very detailed scenario.

This is one that evolved from the lower right quadrant of our impact scenarios where someone was complaining, someone was concerned about their parent, and escalated and could potentially have escalated to a very high-impact low-frequency event. She’s going to take you through it. It was such an amazing talk that she gave that Netflix picked up on it and thought it was terrific. There may be a future film that’ll come out, and embodied in the film and in her presentation are segments from the film that actually prompted focus by someone who could have turned into an active shooter. And at the end, for those of you that can’t watch for the entire session, what happened was this appeared to be someone who had a lot of mental problems and difficulties. However, when they went to his home, he had a virtual armory at his home.

And this was so a major active shooter event was averted. And she will tell that story. Vicki is the Assistant Police Chief at the University of Texas Police Department at MD Anderson. They protect not only those at MD Anderson, but the University of Texas Health Science Center. There are about 160,000 doctors, nurses, students, caregivers and staff within walking distance at Texas Medical Center. I had the honor of training at five out of the six main hospitals there, and then had the opportunity of collaborating with them. And we’ve been working in this area of threat safety science since 2015. So, we’ve had a lot of time to think about it and work on it. Vicki is probably one of the leaders in the world in threat safety science, in threat management. And we’re collaborating on a book that’ll be coming out shortly that will put into context the future of threat safety science and call on looking at the past. And that’ll be out in the next three to six months. And this is not to generate revenue. All proceeds will be donated to patient safety and quality programs. So, everyone knows there’s no intention other than to share information. And we’ll be sharing the book actually through these series of webinars for free. So we’ll hear now from Vicki King. And we recorded her day before yesterday, as she also is speaking on threat safety science today in another city. So we’re so grateful to have her speak today, and we’ll be playing her recording. And for those of you that are online live because of internet speed today, you might see a few glitches and interruptions, but when you go back to our website, you’ll be able to see it in entirety. And for those that are on the podcast, sorry that you’re not seeing the visuals, but you can go to our website to watch the program again. So, without further ado, we’ll have Vicki King speak, and then we’ll have Randy Styner be a reactor to her comments.

Vicki, we thank you so much for sharing your time with us today. You’ve always been such a tremendous speaker in this topic, as I know very close to your heart and ours. And the protection of everyone at the workplace is so critical. Thank you so much for sharing this set. Talk with us.

Assistant Chief, Vicki King:  Oh, thank you, Chuck. It’s a pleasure to be here. What we’re going to do is we’re going to explore a high-threat situation involving a self-proclaimed sovereign citizen. And the hospital’s need to provide lifesaving care, life-sustaining care to his 83-year-old mother. I will tell you that we have replaced the actual names with characters from a movie that our sovereign citizen identified with during the course of the investigation. So, what I wanted to do is frame this all the names except for the investigators. All those names have been changed, as Dragnet would say, to protect the innocent. So we’re going to explore this case together, and hopefully we can use the case to illustrate some of the investigative techniques of the threat assessment process that we use to combat workplace violence, especially with some of these more problematic individuals that are very difficult to work with within the context of the environment. So, we’re going to jump right in.

So, the title of our presentation is Hollywood Hospital and the Sovereign Citizen. This is a mixture of three different genres or three different aspects that played into the mindset of the sovereign citizen that our hospital officials had to deal with. So, we’re going to frame it in terms of trying to get you to see the world through his eyes a little bit, and then we can talk about some of the challenges we had in reaching him and trying to build a dialogue. Just a little bit about myself. Chuck went over my resume. I work with MD Anderson Cancer Center. I’ve been over their investigative operations now for eight years as well as UT Health. A little bit of background about both of those institutions. We also work with the Dunn Behavioral Health, which is a brand new state behavioral health hospital, and the Harris County Psychiatric Center, and the Harris County Psychiatric Center will play a small role in this case. So, to frame our discussion, the first thing I want to do is show you a trailer. And this trailer is important because our principal subject in this particular case was enamored with and identified with this movie. And we’ll talk to you a little bit about how he identified, and what aspects of the movie he found that paralleled his life so that you can understand where he is coming from. 

Let me just give you a little taste of this Netflix movie called I Care a Lot:

Movie clip:  Good morning, Ms. Peterson. I’m sorry to disturb you so early. The court has ruled that you require assistance in taking care of yourself.

 <Laugh>, I’m fine.  

I’m afraid it’s not up to you to decide. The court has appointed me to be your legal guardian. 


You have to come with me and remember, I’m here to help. My name is Marla Grayson. I’m just someone who cares.

Marla Grayson, you’ve had amazing success.  What’s your Secret? 

There is no secret, Peter. She forces them into the home, auctions off their house and uses the proceeds to pay herself…

Because caring is my job.

Well, big deal. Marla, I know what you do here, your hustle. Look at all these cash cows on your wall, just leaking money into your counter. Jennifer Peterson, she’s off limits. She has very powerful friends who can make life uncomfortable for you.

How uncomfortable are we talking?

Hello, Marla Grayson, I don’t like you,

You only just met me. 

There’s two types of people in this world, predators and prey. 

I don’t lose, I won’t lose. I’m never letting you go. Oh, you’re in trouble now. I am lion.

So that’s our story, and we’re going to begin with the real-life parallels that our hospital experienced. Lucy, that’s her fictitious name, is 84 years old. She’s the sole living relative of 57-year-old son James. She has advanced metastatic cancer, major cognitive disorder and dementia. She presents to our emergency department with a pulmonary embolism. She is also a named client in three Adult Protective Services investigations against her son James for neglect. And her son, h. He struggles with any type of authority and refuses to sign any admission documents that he perceives to be a contract between he and the hospital, where the hospital would have some measure of control or authority over him. And so he wants to remove her AMA now as her sole heir. He presents the hospital with a medical power of attorney that is signed and notarized by Lucy.

In the investigators are the hospital officials understand that he has removed his mother, Ana, a m a, from hospital care in the past because of the Open Adult Protective Services investigations that are there. So let me tell you a little bit about those. SoSo, on February 3rd, she presented to our hospital with difficulty breathing and required care, and James had taken her to Methodist Hospital, which is in the Texas Medical Center. He presented those medical and durable power of attorneys. She was diagnosed by Methodist with a pulmonary embolism and classified in critical condition. But again, James refused to sign any of the hospital paperwork and removes her AMA before Methodist can take any action to protect her, to protect Lucy from what they believe is medical neglect. They initiate an adult Protective Services investigation on that aspect.

And, but James, in the meantime, before they can gain the legal right to retain Lucy for stabilizing her and treating her pulmonary embolism James removes her on February 4th, she continued to struggle without treatment. So he brings her to MD Anderson. She had had been a previous patient with MD Anderson, and they immediately began to treat her acute symptoms andin James, again, refuses to sign any forms or allow his mother to sign any forms, but the hospital begins to treat her and are working with Adult Protective Services investigators just to get her the care that she needs. They go ahead. James is threatening to remove her, but the hospital staff work with him, do an amazing job of, of treating Lucy’s life-threatening situation while keeping him under wraps or keeping him satisfied for the moment. They work with protective services and psychiatry begins to evaluate both the mother and James.

So on February 8th, she’s admitted to the hospital and is being treated. The Anderson clinical team members find that Lucy is completely incapacitatedincapacitated, and her son is unable or unwilling to act in her best interest. SoSo,they petitioned for guardianship in Harris County probate Court. Number one, you can reflect back to our movie, that guardianship in the probate court in that court setting was a central theme of the Netflix movie. SoSo, the investigation was initiated into physical and medical and neglect by her son. And this incapacity was related to the inability to provide food, food, clothing, or shelter for themselves, care for their own physical health, or manage their own financial affairs. So, incapacity has a specific legal meeting within a Texas, so Adult Protective Services, they, they had three cases now pending. The first one was in 2018, James James’s mother had fallen in the home and broke her hip.

He tra he took her with a broken hip to three different hospitals for treatment each time. For the first two, he removed her ama AMA because he would not sign the the paperwork necessary for treatment. The third hospital treated her for her broken hip, and again, were able to assuage the concerns of James and just not worry so much about the paperwork, but worry about focus on the patient and her care and to, to try and get the  the hip issue resolved. She was released from the hospital to at-home physical therap therapy. But again, James refused to sign any documents pertaining to that care. He wouldn’t allow Lucy to speak to any of the care providers outside of his presence. He maintained complete control over her communications. And one of the things that the clinicians noted is that the patient appeared to be fearful to answer any of their questions.

With James interrupting frequently, she was afraid of giving going against himer. So, b the, because the home healthcare required some releases to enter the home they, they were unable to approve the, the home healthcare. They actually did have a home healthcare agent go out to the home and visit with Lucy and try and speak with her. But James would on, would not allow them inside the home, and would only allow Lucy to speak with the therapist in the backyard. So the therapist was unable to assess the home for fall risk or other important attributes to prevent a second fall or aggravation of her current injury. Now, James had been sending some interesting correspondence to some key figures, and in this particular case, he sent it to the sitting Secretary of State for the u for the United States. And so a special agent with Homeland Security began an investigation of James.

Due to this concerning correspondence that was sent to the US Secretary of State. They found that Lucy was locked in the home, appeared that the front doors were blocked, that she couldn’t get in or out of the home. And so they initiated their own adult protective services c. Concerns for Lucy. We interviewed her in 2021 when she was a patient of ours. We interviewed the doctor of psychiatry and, , found him her to be true, and incredible person. And they suspected physical and medical neglect by James. And so the investigators reviewed the guardianship referral and sent it over to the probate court. So in court, the investigator presented her findings. She documented Lucy’s recent hospitalizations, noting that the surrogate defic decision maker might not be suitable. The investigator provided the doctor’s assessment and found Lucy may not receive medication prescribed to treat the pulmonary embolism and D VT which would pose an imminent risk of life.

So the judge in this hearing in February, awarded Temporary Guardianship of Lucy to the Harris County Guardianship Program. Again, we’re gonnagoing to mirror back to our movie. And, and James saw this as the, the, the movie foreshadowing what was happening in his real life. James did get an opportunity to address the court but the judge affirmed temporary guardianship in on February 24th to the Harris County Guardianship Program. So what does that mean? Guardianship is one of the most restrictive and permanent solutions to incapacity. So a guardian who is appointed, has the authority to make all medical decisions, control all of the patients all of the wards, assets, movements and it’s very difficult. It’s not impossible, as we saw with some of our celebrities here recently. But not impossible to regain the rights once they’re taken away. So what the Guardian does is seizes control of all assets.

SoSo, any social security, any pensions, any investment income that you may have, and they take that the home, any cars, any anything of value that belonging to the ward and begins to use those assets, use those income streams for the benefit of the ward. Now, how does this play into James? Well, for us, it was extremely serious. SoSo, our first contact with him came at 10: 30 at night on the 24th of February in 2022 when James arrived at the hospital and he is denied entry. He wants to come visit his mother and he creates a bit of a disturbance. Officers respond, and he makes the claim that she’s being held against her will, and he wants to take her home. He meets with hospital officials and explains and, and the, and the hospitals explained to him, and James is well aware that guardianship has already been awarded to the Harris County Guardianship Program, and now they’re going to make all the medical decisions regarding his mother’s care.

And in fact, James has been so disruptive in the process that the guardians have denied any visitation that James would have with his mom. So now, again, in the movie James is just like the characters in the movie, James has been denied the ability even to visit his mother. SoSo, he calls the Houston Police Department to report a kidnapping. We, because it’s on our campus, the University of Texas police respond and they listen. And James presents paperwork. He says, look, this is my medical and durable power of attorney. They and that they need to explain to him. The officers on the scene explained, look, those documents have now been nullified by the court. When the court awarded guardianship and declared her award of the, of the, of Harris County, those documents in this possession were no longer valid.

James, at this time, begins to try and show officers what he calls his contracts, which prove that he, not the court has sole right to make decisions for his mother’s care. But interestingly enough, the officers didn’t pick up immediately that James also made the claim that his contracts gave him control over the courts. And that’s key to James’ mindset. He doesn’t create it; , he speaks loudly and demonstratively, but there’s no physical violence. He vows that he’ll be back and that people will be sorry. And he drives to a nearby police substation for the Houston Police Department to make a report for kidnapping and unlawful detention. So, we begin to look at his behavior. James obviously is not going to take no for an answer. He begins making repeated calls to his mom’s room each time he does.

He incites her. He creates extraordinary distress for her. So, they removed the phone from the mom’s room. Now he begins his calls to the nurse’s station. Eventually, we had to block the phone calls from his phone number to the nurse’s station, and then he began to deliver unsolicited care packages. And these are some of the items that he did. He loves his mother. He cannot understand how the government has seized control over not just her person but soon will be seizing control over everything that she owns and all of her income streams. So, James now begins to send, I mentioned some contracts, James begins to send some contracts as we begin to learn more about James and his way of thinking. James subscribes to a very infringed but is somewhat robust in terms of numbers.

They’re more than 300,000 people who ascribe to the sovereign citizen philosophy. And for those of you who are not familiar with it, sovereign citizens believe that government does not have an inherent right to control you or any of your actions through laws on the books. In fact, as we got to know James and got to understand more about his mindset, James believed that when you are born, you cannot immediately begin to be controlled by the government because you have a right, a human right to be free.  And that the laws that are in place were invented by what he calls dead men. So, laws enacted the Constitution and other provisions of government that were formed for the United States were inventions of dead men. And dead men can have no control over who you are and what you do. The only way you can have control over another person or thing is through a contract.

So, if you agree that this is how we’re going to interact, you agree that that is the only true and binding artifact that can control another human’s existence. So, there’s an interesting prospect. There’s a lot of literature on it. So, this is one of James’s contracts, and it’s a standard contract, but there’s some language in here I want to point to. And these are his words. “Me and my mother also have total immunity from Texas and the U.S. because there’s no contract.”  He has not accepted a contract; he talks about the US government. He talks about the state government, and city government as corporations. “Corporations can only have power over other functions and/or people by a contract to bind them to their will. To force my mother to be a hostage and take her assets and take over her life and mine, you have to have a contract.

My mother and me are both sovereign heads of state”. They believe that they are sovereign in their life and that they’re independent people, independent thinkers who are free from the constraints of society because they never signed a contract with society agreeing to abide by its laws and restrictions. And then James goes on in another section, He talks about, “my mom’s life is at risk because your agents want to show me that they have total power over my will and my mom’s life and assets. They don’t”. So, this is some of the rhetoric that we look at. And when we begin to examine from a threat assessment perspective, we look at the life of an individual. We look at their background, we look at their history, we look at their propensity for violence, but we want to understand where they are coming from what their thoughts are, and how they work.

And then, we want to establish their baseline is and see if there’s an escalation, a deviation from baseline. So, this is multiple pages. And these are some of the key provisions of his standard contracts. These are our baselines that you agree, you and all you have a duty to me, you agree to pay me any liability. I’m not going to go through all of these, but you can see how he begins to say that he now, by this contract, has control over everything you have and all of your assets. And his will is, is law. The key thing here is you agree that this contract is over everything and cannot be voided in any way or at any time, and never ends. So, you may be sitting there asking yourself, well, why would anybody ever sign that contract? Right? Well, see, James sees himself as being smarter than everyone else. So, he has a gotcha clause, and his gotcha clause says that you must disagree via certified mail within 24 hours of receipt, or the agreement and the contract are accepted. So, once you’ve done this, you have accepted the provisions of his contract because you’ve failed to disagree with the contract. So, this has no legal basis, obviously. But in James’s mind, he has outsmarted the world with these contracts so that he now has control over all of your value and net worth, and you are under his complete control. So, I said that that was our baseline. Those are basic contracts. Real quick, I’ll send it back. I want you to see that he writes in cursive here in his custom contracts. The handwriting is in a print format.  So again, we look at the context. So those cursive writings that we actually believe James’s mother may have written the cursive writings with him in these standard contracts that he drafted. So we start to evaluate this guy, is he a howler or a hunter? There are those people who, society has tagged, are sitting in their mother’s basement, pounding out emails, trying to inflict chaos on the world. They do something outrageous, and they get their satisfaction from watching the chaos that ensues from them dropping these really wild accusations and wild comments. So those are, we call those howlers, people who howl at the moon, and they’re really, there’s no direct correlation between a howler and an act of violence.

But a hunter is different. A hunter is someone who has a grievance. They have they want to exact revenge or create an act of targeted violence to address their grievance. And those kinds of folks are extraordinarily dangerous. And they may not telegraph exactly what they’re going to do, usually there are no direct threats, but you can see a building in their language as they prepare along what we call the pathway to violence as they proceed along that pathway. And there’s some seminal work. And we consulted with Frederick. He goes by Ted, Ted Calhoun and Steve Weston who actually wrote the book on threat assessment management strategies and identifying the difference between hunters and howlers. And they helped us assess some of the language used here. It would be a great read if you get an opportunity.

So, as we move into act two of our story, this is where the investigative process really begins, because we want to determine, as Reid Malloy in his seminal work talks about, is this a delusion, a fixation, or an overvalued belief? Because each one has a little bit different predicate toward an act of violence. So, we look at the special challenges in talking with James; his rigid thinking, and we talk in terms of conceptual complexity. And, and James is not conceptually complex. That means that he can only see the world in one way, and it is his way of viewing things. He cannot see alternatives. He cannot understand other more broad concepts. He is very rigid and very focused in his thinking, a completely non-rational framework that he works from. He’s also had negative prior experiences with authority.

And we’ll talk a little bit about those as we move forward. High situational stress. Let’s think about this high situational stress for James in James’ case. James has never held a job. He is 57 years old. He’s never had an intimate pair, bond with another human being. He is unable to form and maintain any, even superficial relationship with anyone beyond his mother. His world is his house that is owned by his mother, which is now owned or controlled, I should say, by the Harris County Guardianship Program. He has no income stream. Even though he could qualify for disability under his mental challenges that he has in his life, he would never sign up for social security or other benefits that would provide some sort of income stream for him. Because he is never going to sign the contracts. His income came from his mother, who was fairly successful in life. She had a pension. She had made some wise investments in her years, and so she had some investment income, social security, and a pension. His mother was his only income stream. So, when that is now taken away by the guardianship program for her medical care, not for the maintenance of the home, not for the maintenance of James and his needs, you can see how these high situational life stressors now begin to ramp up considerably. James, because he has never had a job or owned any property or anything of that nature, everything is in the name of his mother. The vehicle he drives, the furniture in the house, everything belongs to his mom in the lot. In reality, James owned nothing.

This isolation from others, the coexisting mental illness. We’ll talk a little bit as we move forward. So, we’ve talked a little bit about this. James’ parents were divorced when he was a child and his father reported in a police report in 2006 that James had suffered a psychiatric history assuming from the age of 12. He had one sibling, a brother, who predeceased him a number of years ago. He died from natural causes – open-source of his criminal history, which is what police investigators typically go to, showed to  have only one arrest. And that was for interference with public duties, a misdemeanor. That was in 2013. And that case was dismissed.  So, when you begin to look at some of this very limited information about James in open source, no social media profile, no history.

James shied away from the internet. He was afraid he was being spied on. That’s his paranoia coming to root. But his father talked about his psychiatric history. So, we have to dig deeper. We can’t just scratch the surface. We went in and looked at reports where James had not been arrested, but there was a police report, and we found some disturbing information. In July, 2006, he had been a named suspect in a family violence case involving his 71 year old father. Now, this is interesting. James had been estranged from his father since he was in his early teens. The father told investigators that James struggled with mental illness. He felt like his mother was an enabler. He couldn’t connect with James. He couldn’t get him the help he needed, and he hadn’t seen James for almost a decade.

When he showed up and his father opened the garage door, James was standing there, and James rushed his father and attacked him, and held him captive for 11 hours. His father believed he was in a mental health crisis. He was talking in circles. He was talking about how he had full control over his father, all of his father’s assets, all of his property, and that his father needed to pay him what he owed him. James’ father was able to escape after that 11 hour ordeal during which he was beaten by James. When police responded, James had left the area, but his father didn’t want to press charges. And so when his dad refused to cooperate with the investigation, saying, look, his son is mentally ill, he didn’t want to see him going to jail. He needed to get help.

So unable to pursue it criminally, the case was closed. Then just a few months later, James returned again. He held his father captive. This time he extorted $75,000 forcing his father to turn in CDs and get money. He held his dad for four days. And again, escape. His father escaped this time and James ran, and the police were unable to find him. And that case was unfortunately never pursued. We don’t have a disposition on it. It wasn’t from our agency. It was another agency. The 2013 case was an interesting case. James believed that the smart meter that had been installed by CenterPoint Energy was collecting data on him and creating an inability for him to sleep and that it was sending electrodes and harming both he and his mother. So, James disconnected it. Centerpoint Energy went out to reinstall it.  And James ordered them from the property saying that, no they were trespassing on his property. And the police were called. And officers took James into custody for interfering with the ability of CenterPoint energy to reinstall the smart meter. It was a misdemeanor, and it was presented to criminal court. And that brings us to yet another interesting aspect for those who have dealt with the sovereign citizen philosophy in the past. You begin to see how they weaponize the civil process. Now, for someone who doesn’t believe in laws and constraints, James, among many others, was very selective in what laws they tried to use to their benefit.  So let me walk you through this a little bit. It’s an interesting journey that happened. 

So, in May, 2013, James was charged with interference with public duties and sent to court. He sent the criminal court judge one of his standard contracts where he controls the court. He controls the judge. He controls everything they say, the court pays.  From those communications, they order a competency hearing for James. And James was found incompetent to stand trial, unlikely to recover. And so the criminal case against James was dismissed on competency issues. Once the case was dismissed, this is the only time James actually ever engaged with legal representation. He hired an attorney to expunge his criminal court record. He didn’t want the courts having any record of him. And so this attorney begins to file paperwork. Of course, James wasn’t upfront with him about the rationale and reasoning for the court dismissal which plays a role, a significant role as we move forward.

His attorney filed for pro permission. So here again, I told you that James uses contracts to his benefit, and he had provided a contract on the criminal court judge when the judge did not comply. The criminal court judge did not comply with the provisions of James’ contract. He filed civil suit against the judge with the 125th Judicial District, that’s a civil court. And so in 2016, he filed suit against the state of Texas and the court judge for unlawful prosecution. And a crazy cacophony threaded together. It’s really interesting, but hard to follow. When you try and understand his cause of action and how he uses some of Texas laws, but also in the same breath, refute that he is beholden to any of those laws.

It’s very interesting. But he uses his contract as the legal basis for his control over the court and their failure to do what he wanted them to do. So after he filed that suit, then he presents a contract to the  125th judge. So to the civil court judge, he says that if the judge does anything that James disagrees with, he’s going to impose penalties for failure to comply with the contract. And the penalty is 999 trillion tons of gold, trillion tons of gold. James clearly has no concept of what that means or where it is,  he gives this court judge this contract, again, it’s not worth the paper it’s printed on. The judge doesn’t pay any attention to it just carries on with his duties to adjudicate the claim against the criminal court judge.

And then, lo and behold, James goes to the 129th judicial district and filed suits against the 125th judge for failure, for breach of contract – failure to pay the fines and fees that James has imposed as a result of his contract. Of course, he’s not going to be remiss. He also places the 129th judge under a contract imposing fines and fees and penalties for failure to rule in his favor. So, we see this, this network, it takes a while. The 125th court gets their case dismissed in April of the of that year. The criminal court judge similarly gets her case dismissed in 2018 on sovereign immunity. James is incensed about all this. So, he goes back to the 125th and filed suit against the attorney who was supposed to file his expungement paperwork and secure his expungement.  But that didn’t occur, and that case was finally dismissed in October of 2018. So, you see this journey from May 2013 to the final dismissal in October 2018. A lot of work was done by the Texas State Attorney General in the preparation of these documents, and the time that was taken up by the courts in these frivolous lawsuits by a man who clearly is struggling with mental illness. But this is the weaponization process. So, again, we go back and we look – okay – we can see the contracts that James has written in the past. We have those previous writings form our baseline. He sent these contracts to the Secretary of State, the US Secretary of State, as I told you earlier, but he also sent them to the Texas governor, the Houston Mayor, the CEO of CenterPoint, and the Texas Attorney General.

All of these judges’ contracts may have varied in length in grievance, but they presented the same conceptual rhetoric and the same concept that you have to reject the contract within his timeframe, or it is accepted. And the only violence that we saw in those contracts was centered around the encounter with the CenterPoint tech technician. James talks about how his pen was his weapon. So in looking at the documents, those formed our baseline. Well, in March of 2021 we began to receive different types of contracts, not the nice smooth penmanship or the cursive writing that you saw in his routine contracts. These began to have more of a staccato feel. He was writing in the margins. There as a thought word progress, he would insert those thoughts.  And so we began to see that his threats became increasingly more direct, more personal, and most important for us, emotionally charged. So, we looked at one of the biggest things, was this March 23rd, 2021. It was a 14-page document filed with the probate court. James began to target the probate court for their stance on the guardianship of his mother. And you can see some of the language that we pulled out here. And he begins to look to frame his argument as being unlawful, and what was being done to him was evil and that it was a declaration of war. And he frames himself as a justice warrior, someone who abides by the law, but now he is being targeted by the government. And, this last statement particularly stood out to us, it said, judge, when I said, I would not fight back, what you are to understand is that I will not kill you for this evil you’re doing to my family. I fight with my pen and always work to be peaceful, but murder my mother as I am next to her, and I will kill that person, kill the person that did this. So now he is personalizing it. He’s telling us what his planned to action is, ill will. And he finishes this document with Obey or Die. That is much different rhetoric than what we saw on the others. So we began – this is one of our investigators who worked on this case, and did a fantastic job. His name is Carlos Guzman. And we began to look at the escalation factors. So, he’s restricted from all contact with his mom, his mom’s bank counselor, seized by the guardian to pay for her care. The court ordered him to surrender his mother’s vehicle and vacate the home, notice of intent to seize that home, acknowledging that his mother is dying.

And time is running out. Now, we use structured judgment tools like the Waiver 21 that was developed by Dr. Reed Malloy and Dr. Steven White, and they help us frame and try and eliminate some of the confirmation bias that sometimes creeps up when someone is especially difficult to deal with. These are structured judgment tools that have specific behaviors that can be documented that tell us whether or not someone is on the pathway to violence. And our assessment of James was at this point, he showed 15 of 21 risk factors. We also use experts. We have our multidisciplinary team on the left as Dr. Georgia Thomas. And the center is Alvis Reiss, the chair of our behavioral intervention team at the hospital. And Inspector Mary Linsky, who heads up our threat management unit.  We used that. We obviously consulted with Dr. Weston Calhoun. And then we also worked with Dr. Reed Malloy and developed another structured judgment tool, the trap 18. And these are for people on the pathway to violence who have grievances against government and/or government officials. And when he talks about the extreme overvalued belief, their key aspects that we take into consideration, one is that others share their belief. And James is part of this sovereign citizen movement. So, they get reinforced by this negative literature and information that keeps coming their way.  Their belief system is relished, amplified, and defended by these folks. James’ view is simplistic, binary, and absolute. There’s an intense emotional commitment to it. And all of these factors may lead to the pathway to violence.

So we’re assessing this, and then boom, we get some more concerning contract language that James is sending. And again, first sentence to all agents, “I just saw the movie I Care a Lot.” And so he talks about how the doctors are working in the movie, how the guardians see all the assets of this person who is perfectly able of making their own decisions about their care and welfare. And for family members who are engaged and want to help. They take all that away from the family. And, so James says, “I ask and order the judge in this case and all agents to see this movie as soon as they can. As soon as you get this affidavit, Judge, you’re part of this evil. Let’s clear it up for the court and all. And then if you will not stop this evil madness on me and my mother, men and women will kill you for this kind of evil and rightly so, I will give you no tears. When they do Judge, see the movie I Care a Lot.  In the movie, they show the judge to be non-evil. And the judge is at the heart of these laws and evil. And if I can see it and know it, so can many others. 

So, let’s look at what James was seeing in the movie and what his thoughts were.  You think you’re good people, you’re not good people. Trust me, there’s no such thing as good people. I used to be like you, thinking that working hard and playing fair would lead to success and happiness. It doesn’t. Playing fair is a joke invented by rich people to keep the rest of us poor. And I’ve been poor. It doesn’t agree with me.  Because there’s two types of people in this world, the people who take and those getting took – predators and prey, lions and lambs. My name is Marla Grayson, and I’m not a Lamb. I am a lion.

She’s my mother. I should be able to see her whenever I want. She doesn’t need to be in a care facility. She doesn’t need a court appointed guardian. She has a loving son to take care of her. And I just don’t understand how the court can entrust my mother to this stranger. Ms. Grayson forced my mother into the home when she made it very clear that she didn’t want to go. And now she has auctioned off my mother’s house, her car, her personal belongings, and she uses the proceeds to pay herself. And now, Ms. Grayson has barred me from seeing my mother at all. She has kidnapped my mother.

So, our third act – our third and final act, obey or die. So, we have this new contract. We have specific actionable threats that we’ve pulled out and we confer with the probate court. They haven’t read any of this. These filings are coming in and we talk about approach behaviors. James is going to the court in the middle of the night and slipping these in the Dropbox. And they’re appearing the next day. And James is telling us in his contract filings, judge, I have a contract with you now enforced. It’s a safe bet. You do not like this. You steal our life. And I’m thinking of this all the time and every day.

So, these are his provisions. You agree? I may use anything on you at any time in any way you agree, anyone can kill you on site. KOS. KOS stands for ‘kill on site’. You agree. You agreed to be killed. You agree. You judge or at war with the people of the USA and you and all may can kill you legally for this evil. You do the justice warrior. He has justified what he is doing, and it goes on for pages and pages. I’ve pulled out some key provisions. You agree that people will go after your family as you’ve done to the people, and it’s a very safe bet. Blood will be in order. You play, you pay. You agree. The evil agents will not stop until they’re a real cost to them. And KOS, kill on site is a real cost. KOS will work and might be the only way to stop the murder, fraud, lawless lawlessness, evil actions, violence, threats, rape, asset taking, and the list goes on and on. It’s a good fight and a lawful fight. You will be fighting all the time, but fighting for freedom is better than waiting for the people to kill you for all your sorry, evil actions.

So, page after page, after page, I’m not asking. I order all to obey. You agree? I’m peaceful and lawful. And so is anyone that kills you or anyone that lives with you. I’m mad as hell, and you have my mother and you are murdering her. These are for telling James’ philosophy and what his plans are. You agree, killing on site, KOS can only be stopped on you by returning all assets and cost and freeing my mother to me and making it known you have no jurisdiction and you have no jurisdiction on me and my mother have total immunity, and you work with me to try and make a real lawful system that all can use and get lawful benefits from. Only then can you not be KOS.  So, James has given his last chance, we talked about this last chance language in our field.

We look at ultimatums, and I think a reasonable person can infer that these are truly ultimatums. And we took these to the court, to the guardian, and to the county officials. We explained the threat assessment, the significant factors. No one had read the filings that we had. Nobody’s done an analysis on them. We raised their awareness, and we created safety plans for them. And the judge wanted to pursue the criminal charges. In the state of Texas, we have felony retaliation, and that protects courts and officials. Any public servant from an actor who wants to perpetrate an act of violence or retaliate against them for doing what they needed to do. We were able to get a pocket warrant. And because we were very concerned with James’s rhetoric and we know how the sovereign citizens work, we were concerned.

It appeared that at his home, he would be able to see the approach of law enforcement. We planned a tactical arrest using SWAT and bomb squad from Houston PD to help us with the arrest warrant and a search warrant of the residence. Of course, in police work, nothing ever goes to plan. James was actually encountered on one of the surveillance teams passes of the residence, and and he was taken into custody there. One of the key factors that we work on is, , in most law enforcement instances, you make an arrest, you take the person to jail, and that is the end of the case. Well, we recognize the ongoing potential for violence, should James win his freedom. And, and that’s highly likely since he’s entitled to a fair hearing about bail.

And a judge may hear his case and his pleadings and allow him to be released back into the community. So what we wanted to do is rehabilitate. Instead of taking James to jail on an arrest warrant, the first thing we did was take him to see his mom. Now, because James is under arrest and in our control, and we had some volunteer nurses who volunteered to take mom to a secure area of the hospital, they managed her care while James sat with his mom for more than two hours and said his goodbyes she was nearing the end of life. We supervised him and he got to spend time with his mom. Now, he railed and talked about the government and injustice and all those things, but he did spend some time talking to his mom, making those connections.

And once he was taken to jail, we followed up with some FaceTime visits on an iPad between James and his mom.  Of course, because her situation was so dire, she really couldn’t communicate with him. And she did pass away a few days after his arrest, and our investigator and the chaplain went and visited James and made the notification.  Even to this day, James does not believe that his mother is actually dead, which is concerning to us. He says she probably is, but he’s not gonna believe it until he sees her. Well, she passed away almost a year ago now. And she has long since been committed to one of our local cemeteries. But it’s important that we continue that. When the search warrant was executed it was done with care for concerns.

It took the bomb squad a long time to clear the residence. This is part one of the rooms of the residence that was lined with these thermal blankets made of aluminum foil. James did that to protect him against the smart meter on the side of the house. And from what he perceived to be probes that would try and monitor his movements. His kitchen was in disarray. He loved his mom, and he tried to care for her. He had on the kitchen table or I’m sorry, on the kitchen counter, a crock pot type of instrument that we were concerned might be the beginnings of making a bomb. But as it was analyzed by our experts, it was determined he was trying to cook up medications for his mom, homeopathic remedies to cure her.

He was a hoarder. This was his home. You see a lot of cat food boxes. He had some cats. We had to gain guardianship of the cats after his arrest. This was his mother’s room, and you can see how she was a fall risk. That’s her bed there. It’s easy to see how she could possibly trip and break her hip. This was James’ room. He did have some computer equipment. He would unplug it every night and keep it from being able to be accessed by the government remotely. But as we explored the pathway to violence, we looked for not only his plan to harm people, but his ability to carry it out. And in James’ case, he had a massive amount of firepower.  Of all these weapons he inherited one from his father.

But all of these weapons were in his mother’s name. This is a scar – an assault rifle that is extremely powerful. And it was ready to go. Massive amounts of ammunition. And this plate, I guess he has a whimsical side – winning plays well with others. I might have some evidence to dispute that, but nonetheless we look at does he have the ability to carry it out?  So we talk about grievance medication. One of the things we wanted to do in case he got out, is we repaired the damage to the home. The doors had been ripped off in order to gain entrance by squad and bomb squad. We had those repaired. We arranged for lawn care, one of his neighbors to mow his lawn.

We took custody of the family cat. We had to get guardianship of the cat through the court. James wanted us to just to lock the cat in the house. Well, you can imagine leaving a poor cat to its own devices for more than a year. That would be bad. And then we had those jailhouse visits that were arranged by Carlos Guzman, the lead investigator on this case. So, one of the things we wanted to do is get James his own income stream. And so, we talked with him about Social Security benefits. 

Where’s James now? Well, this is one of those cases where his psychosis actually worked for our benefit. He would’ve qualified for a bond, but he refused to sign any paperwork that was required for his release. He refused to accept any terms or conditions associated with a conditional release.

He’s continued to make multiple filings to the criminal court. He had refused court-appointed counsel. The, court ordered a mandatory competency hearing, and he was found incompetent to stand trial and now has a court appointed attorney. He was remanded from the jail to the Harris County Psychiatric Center, one of our hospitals. And we maintained regular visits with him over at HCPC. The lead investigator, he says that James calls him a Nazi, but a good Nazi. So maybe that’s progress. The case is still open and very active. I don’t know how the court will ultimately decide James’ fate but there seems to be no movement in his mental illness or his ability to understand what’s happened to him or prepare for a life outside of custody. And in an ironic move, James may become ward of the court and under the guardianship program of Harris County to bring it full circle. So, we talk in terms right now, there were no attacks upon the judges, the guardians, the doctors in our hospitals that received contracts. I received a contract myself from James in trying to manage his case early on. So, we talk about alternate endings. And in the movie there was no threat assessment of the characters in the movie that James identified with. There were no intervention strategies. There’s no coordinated approach. 

And so the alternate ending that took place in the movie, we are afraid could have been our ending.

Movie clip:  All it takes is hard work and the courage and determination to never give up.

So now you are a rich woman. Much. Are you worth? How much do you have in the bank?

You were great. My cheeks are aching from forcing that smile for so long. I haven’t counted recently.

Oh, but you are firmly in the top slice of the one for SES.  What should we do now? 

Whatever we want. Hey.

And you’re still only 39. That must feel good. 

Hey,<Laugh>. Oh, Listen, I don’t have time.


My mom died. Help. What? Hell she never let me see her, and she died in there alone. You, you’re gonna be baby, baby. Look at me. Look at me. Just you, you help Marla, Marla.

So with all the success, are you still ambitious? Are there dreams you still wanna achieve?

Peter, I am only just getting started.

Marla Grayson, CEO and founder of Grayson Guardianships. Thank you.

Thanks. It’s been fun.

And so, as we close our case review, our case study of James, our sovereign citizen, his connection to the movie and his view of the world, I offer you this cautionary tale: pay attention, listen, work toward a future resolution, and don’t rely on the fact that because the person is temporarily incapacitated, to put your mind at ease. Management of these cases extends far beyond an arrest. We continue to monitor James. We continue to work on his case, and should he ever be released, we will be reengaged with renewed safety plans for potential targets, and we’ll continue our efforts to connect with James. We may not be able to reach him completely, but either to neutralize, mitigate, or redirect his threat away from our officials and toward the law enforcement community if we can.

Dr. Charles Denham:  So, Vicki what a terrific presentation. And if I were running a 300-bed hospital, the average size hospital in America, or if I was running a major university, I would say, oh my gosh, you, all have such great competency and command of a very complicated body of information and had the resources to act. My first question really is your advice to this small hospital or the team very early in understanding threat management, any tips that you would recommend? The books, and you say other things that you would recommend for people that are getting started, and those many of them are joining our community of practice to focus on emerging threats,

Assistant Chief Vicki King:  Right. And I understand the resource challenges of some of the hospitals. But the most important thing you need to do is to educate yourself about what threat assessment is. And if someone is exhibiting these behaviors of concern, to begin to learn how to recognize them, many times in fact, there was an interesting study that I read that talked about your gut reaction to some of these cases or concerning individuals. Sometimes it’s spot on. And so, the question is not recognizing them, because most of us can recognize when somebody is so far afield, so much of an outlier that their behaviors indicate that they could become violent. So, what do you do? How do you, what actions are you going to take? Well, collaboration is probably the number one thing that you can do. If you have a local university, most of them have been trained in either the the structured judgment instrument or a similar device that helps you recognize individuals on the pathway to violence. Talk to them about their mitigation strategies.

How do you work to make contact with the person, not where you are, but at their level, and then work to either address their grievance in some way, or to construct what we call a soft landing. Is there some way that you can construct? Now, in James’s case, there was no soft landing to be had. So, neutralizing the threat was the only alternative we had. Then with our investigators connecting with him, we were able to redirect some of his attention away from the courts, away from the judges, away from the guardians, and most importantly, away from our doctors and onto our investigator. So, our investigator has a dialogue with him. Our investigator becomes the safety beacon to know when James is returned to somewhat of a baseline or when James is escalating and where he’s escalating. And then we can try and get ahead of the potential impact of a violent interaction with James, partnering with local law enforcement in your rural communities, in your small hospital settings.  The most important relationship you can have is with your law enforcement. Help the chief law enforcement officer understand that you are a critical infrastructure, and that the two of you need to partner on how to identify these problematic individuals.

How to address the behaviors and how to construct a coordinated response. Sometimes it requires the court, sometimes it requires mental health professionals to help. Sometimes it requires outside consultants who will come in and help you craft a mitigation strategy. You don’t have to have in-house folks like MD Anderson has with our team. You can reach out to professionals. The universities, they have a community aspect. Many of them are in the threat assessment space and understand it. There’s also an organization that I belong to, the Association of Threat Assessment Professionals. And it’s a nominal cost to become a member and to get free training from them to understand. But the networking that you receive with those threat assessment professionals gives you someone to call and to ask questions of someone, to help, to listen to where you are and help walk you through some strategies that may work.

And I will tell you, the strongest thing you can do is form a multidisciplinary team within your hospital. Get them some training, help educate them on this, on the research associated with threat assessment, as well as some of the strategic approaches to diminishing harm. And have them collaborate on safety planning strategies on mitigation working with law enforcement so that you can feed law enforcement the behaviors that indicate the persons on a pathway to violence and recommended pathways that you collaborate on to mitigate this threat. Those are things that don’t cost a lot. You don’t have to hire a whole staff of people, but if you build these relationships and work collaboratively, it is lower cost, but higher impact in terms of being able to address these behaviors of concern. And, in James’ case, we were collaborating with Homeland Security.

We were collaborating with the State Department, and we were collaborating with the Texas State Attorney General’s office to really look at the legal structure. And so that if we have to get into a neutralization with an arrest, which is not going to end the threat, but may keep people safe in the short term, then play long-term monitor. Are they getting out of jail? Are they going to get out on bond because when they come out, they may be more angry and more dedicated to their pathway toward violence than they ever were before. So, you’ve got to realize that that has some risk strategies and be ready for it. Ankle monitoring for those people who get out, request law enforcement assistance, do some target hardening, have some extra security in your hospital to deal with those particular cases. It’s not easy, but there are some solutions that are low cost if how to put them together and what strategy to use.

Dr. Charles Denham:  Such great advice. Thank you so much. I’ve put up our four quadrants of impact scenarios, and we had a wonderful discussion this week with you regarding the low-impact, high-volume issues that then can transition into a high impact low volume, where you really can see transitions from these. Do you wanna address why it’s so important to monitor the things that appear not to be really too threatening and then how they can evolve,

Assistant Chief Vicki King:  Right. When you have, and we all get patient complaints, we get family member complaints regarding care, it’s when those issues begin to solidify and focus on a specific person or organization when the language begins to be linked toward a justification for an act of violence, as we saw with James. James began to justify that if someone was killed on site, it was legal and justified. It was morally right. It was the only way to stop evil from being perpetrated. When someone starts to use language that you’re being evil, that this is a life-or-death situation, that you are committing an act of murder or you are harming someone, and they are justified in intervening. Those are specific languages that have a high correlation with a future act of violence. What you want to do is try and look at the grievance from their vantage point, not yours, not your policy, not how the attorneys are telling you.

What you want to do is try and listen to them. You don’t have to agree with them but let them vent and talk to them.  Okay, we seem to be at an impasse here. What can we do to work the problem? Let’s not add additional problems to this with threats or innuendos. Let’s see what we can do to work the problem. And taking it from that standpoint, trying to construct a face-saving opportunity for this person. Trying to construct a soft landing, trying to redirect their grievance into another area or to another person. Sometimes you can have positive results, but you look for those things that are changing away from a baseline complaint to a last chance. This is your last opportunity. This is life or death. You are evil, and now you have brought this on yourself. Whatever happens next. Those are key language factors that we look for in these kinds of instances. And engagement and collaboration really need to happen fairly quickly to try and get ahead of those situations.

Dr. Charles Denham:  Vicki, thank you so much for a terrific presentation. Great answers to these very difficult questions. And we really are at the beginning of the beginning of understanding threat safety science, and thank you for your work and being a pathfinder along with Chief Adcox and Dr. Botz, and so many others that are collaborating. Those from the Mayo Clinic, the Chief of Security at Mayo Clinic and Dr. Casey Clements. It is so critical that we really understand how to protect those we serve and those who serve together. So, you are really our hero. Thank you for all of what you have done and what you’re going to do in the future, especially as you now expanded to higher ed.

Assistant Chief Vicki King:  Right. Working with some of our sister institutions across the state of Texas and around the US to help them understand and apply some of these principles.  We’re really trying to pay it forward because that’s the best thing we can do, is contribute positively to this incredibly concerning trend that we’re seeing across the nation. Mass shootings occur, targeted violence is occurring at an increased cadence. So, anything that we can do to help those, our brethren we’re all about.

Dr. Charles Denham:  Fantastic.

Randy Styner is the Director of Emergency Preparedness at the University of California Irvine. He’s a best-selling author. He’s a wonderful community leader. And we really appreciate the fact that Randy can really help us kind of put into context his view from higher education and looking at a major area. We have a major medical center at the University of California Irvine as well as what we have with the University.  Randy, your thoughts on reacting, then we’ll go to Jennifer Dingman, and then we’ll close.

Randy Styner:  Yeah. Well, it’s a really interesting discussion. And it just got me thinking about some of the points that were made about not just the sovereign citizens, but the conspiracy, sort of world and, the need to take that into account when we’re looking at, preventing these things from turning into violence. It made me go back and look at an article that I read and a journal called Social Psychology. This was back in 2017, and it talks about the need for uniqueness as being this driving force behind the conspiracy theories, which the sovereign citizen movement is obviously a big part of, and what really stood out to me in this article was this and it’s titled that for everybody who wants to see it.

I know there are things they don’t know. It was published in 2017. There’s a, there’s a quote from a researcher named Billings who back in, or, I’m sorry 19, I believe 1986, talked about that and talked about this, that the role of the conspiracy theory, filling this need for uniqueness. And it gives the believer this sort of immediate knowledge of facts and makes them become the experts even knowing things that the actual experts don’t know And that’s a very <laugh> a hard thing to, to, to get ahead of. And it’s really an interesting point about the conspiracy theories. And, the internet as well, I think is just sort of amplified and become an amplification method of these beliefs for folks that sort of start into the idea of, of the conspiracies.

And it’s very easy, I think, for society in general to just kind of put those people in kind of a fringe category and say they’re just kind of kooky and those are weird beliefs and it’s not the mainstream. But,  there’s, I think that those that have need for uniqueness – a need to be seen as an expert. It can lead into these really dangerous situations for people, not just not from a mental health point of view, but for other people <laugh> around them. If they decide like this gentleman that all of a sudden because I disagree with you, I have the right to kill you to kill onsite and all that. So I think that a diagnostic tool to kind of help identify possible people who may commit these crimes or these acts of violence.

I don’t think that the conspiracy theory movement should be discounted. I think it’s a sort of a really good example of what could potentially happen. Not to say that we should round up conspiracy theorists or just do anything to someone when somebody hasn’t committed any kind of crime, but using that to kind of think, Hey, maybe it’s worth paying attention to…the poor kid who was shot through the door the other day. I can’t remember exactly where that happened off the top of my head. The shooter’s family coming back and saying in the last few years that he’s gone down these conspiracy theory halls and has really started embracing them.

So, I don’t want to just come right out and say that conspiracy theory subscription is an indicator of imminent violence. But I think that it shouldn’t be something that should be just absolutely ignored. And we’re turning it onto the college campus viewpoint, and from an emergency management standpoint and preparedness standpoint, it’s very difficult to do it because college campuses are designed to be these sort of free thought processes and find new things and, do research and embrace new ways of thinking, which can also lead to the, the embracing of conspiracy theory. So, it’s very difficult to really track that on a college campus and just the, the poorest nature of a college campus.

And it’s we’re a state agency. We are a public institution, anybody w