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Excited Delirium Syndrome: Pseudo-Scientific Shield for Law Enforcement’s Violent Behavior

by Michael Fortino, Ph.D.

By the time Denver Police Department (“DPD”) officers handcuffed Anthony Sleets on July 7, 2021, he was already having a bad day. He had passed out in a hotel parking lot after what he thinks must have been an assault—he awoke to find he’d been sprayed in the face with mace.

Then a woman who found him and nudged him awake with her foot told police that he “lunged” at her. DPD cops found Sleets in his car changing his shirt and said they were going to take him to a detox unit. Insisting he was merely dehydrated and not intoxicated, Sleets resisted, and ended up in handcuffs, waiting for paramedics to arrive.

When they did, one of them injected Sleets with ketamine, a powerful veterinary sedative, because, as police body-worn camera footage recorded a cop explaining, he was “trying to assault some paramedics.”

“We’ve got to keep you calm,” the officer added.

Sleets denies assaulting anyone. More importantly, the incident occurred one day after Colorado House Bill 21-1251 took effect, which prohibits the use of ketamine “to subdue, sedate or chemically incapacitate an individual for alleged or suspected criminal, delinquent, or suspicious conduct.”

That law represents a sea-change in the way law enforcement and emergency medical personnel have responded to the allegedly excited state that the Denver cop referred to. Called Excited Delirium Syndrome (“ExDS”), it has now been used for decades to justify violence against criminal suspects like Sleets, who end up brutalized at the hands of the very people serving to (purportedly) protect them.

In defense of these egregious acts, and specifically, those that have resulted in a suspect’s death while in police custody, law enforcement has offered a myriad of different explanations, including:

• deterring an excessive threat to an officer’s physical safety

• safeguarding the public from a violent perpetrator, or

• attempting to subdue a rebellious and non-compliant suspect.

Unfortunately for the police public relations department, bodycam footage and eyewitness video now render many of those excuses implausible. But there is still another explanation to defend these worthy warriors.

In what looks like an effort to fortify the ranks and to assuage the court of public opinion, a controversial term salvaged from the dustbin of the 1980s has become ubiquitous in its justification for every form of police abuse, from baton beatings to a barrage of bullets levied against an unarmed suspect. That term is ExDS.

This allegedly temporary form of psychosis has been blamed for over 1,000 fatal police encounters with uncooperative suspects, and even some who are cooperative, who “had to” be tasered because they were suffering this still-mysterious brain-chemical episode—likely caused, the theory goes, by an overindulgence in illicit drug use.

A May 13, 2021, article in Psychiatric Times reported on a recently concluded conference meeting to discuss different views of ExDS. It explained that the term is recognized by the American College of Emergency Physicians and the National Association of Medical Examiners—but not by the American Medical Association, the American Psychiatric Association (“APA”), or the World Health Organization, nor does it exist in the Diagnostic and Statistical Manual of Mental Disorders (which recognizes only delirium). In fact, APA took a position against ExDS as a diagnosis in December 2020.

Nevertheless, proponents of this syndrome insist it results in a super-human delirium in which the perpetrator might be foaming at the mouth, flailing arms and legs, biting at officers, growling uncontrollably, and able to endure excessive punishment and restraint without any sense of pain.

By pointing to ExDS as justification for excessive force against a suspect, police officers, and even prison guards, often claim that they had no choice but to kneel on the neck of an assailant, shoot an unarmed suspect in the back, or inject him with potentially fatal amounts of ketamine to render comatose an emotional person who might merely be suffering autism.

If ExDS is real, then it offers a potentially viable excuse for these police responses. It’s also reasonable to believe that the definition would simply be forever expanded by police to cover all scenarios involving abuse of force.

Consider the autistic man in Aurora, Colorado, 23-year-old Elijah McClain. While walking home from the store in 2019, he politely told police who stopped him that he was highly sensitive about his ‘personal space’—a condition of his autism. Yet strangleholds were administered by police, followed by massive doses of ketamine, after which he subsequently died. Could this young man have been suffering with Excited Sensitivity Syndrome?

Maybe society needs to consider an entirely new syndrome when it comes to police abuse of force—Excited Warrior Syndrome?

Before we may diagnose each of these possible syndromes, though, let us explore the origin of ExDS to better understand how we came to such a quixotic and dysfunctional point.

ExDS is at best a confluence of various diagnoses, some rooted in traditional psychological observations, others of more recent vintage. It is also a convenient and euphemistic multi-purpose term, like the gun placed at a crime scene in the pre-bodycam days, providing a plausible explanation when situations go south, and there is nothing else but official misconduct left as an explanation.

Even so, the world has only just awakened to the abuse and injustice that led to the death of George Floyd. The fact remains that many of today’s criminal courts continue to tolerate police misbehavior. Rodney King was brutally beaten nearly to death in full view of the entire world as the incident was captured on videotape, yet the officers involved walked away ‘scot-free.’ That was 29 years ago. It seems the more things change, the more they stay the same.

Excited Excuse Syndrome

In 2020, the American Psychiatric Association noted, “[ExDS] is too non-specific to meaningfully describe and convey information about a person.” The conclusion was that ‘excited delirium’ should not be used until a clear set of diagnostic criteria are validated.

Law enforcement, however, backed by the American College of Emergency Physicians, maintains that there are specific similarities between certain belligerent, non-compliant suspects—those difficult to control or subdue—that makes the ExDS label attractive when defining violent encounters, regardless of who may be expressing violence. In other words, and according to police, the suspect acting out under the spell of ExDS is both violent and requiring violent countermeasures in order to apprehend, control, and contain him.

ExDS, the phrase and definition, was coined by Drs. Charles Wetli and David Fishbain in 1985, coincidentally at precisely the time of a surge in the war on crime and drugs initiated by then-President Ronald Reagan. Other doctors chimed in, notably Dr. Vincent DiMaio and Theresa DiMaio, who claimed that the symptoms of ExDS are “almost always” triggered by use of illegal or therapeutic drugs (reflecting shades of Reefer Madness, the 1936 anti-marijuana propaganda film).

Wetli identified symptoms of the syndrome as follows:

• behaviors of “intense paranoia, extreme agitation, rapid emotional changes, delusions and hallucinations”;

•“intermittent grunting” and “incoherently screaming for no apparent reason,” along with “religious or racial epithets, pleas for protection (‘don’t let them kill me’), or calls for police despite the presence of several uniformed officers”;

• elevated core body temperature up to 105 °F, “dilated pupils, skin discoloration, foaming at the mouth and respiratory distress may also be present”; and

• physical behaviors such as striking objects, running “wildly into oncoming traffic,” or “disrobing and nudity,” and “apparent ‘superhuman strength.’”

The cause of death, he concluded, could be attributed to “an overdose of adrenalin, which, when combined with drug use and pre-existing conditions can result in systematic organ failure.”

Dr. Wetli came up with this originally to explain away the deaths of seven men and 32 women from an area of Miami popular with sex workers and drug traffickers. But Wetli ignored the fact that police had used restraints on five of the men. As for the women, he believed they all died from the effects of drug-induced stress during sex.

In fact, by 1992, most of the deaths of the women had been attributed to a convicted rapist and suspected serial killer, Charles Henry Williams, after Wetli’s boss, Miami-Dade County Chief Medical Examiner Joseph Davis, had all of the bodies exhumed for re-examination and found evidence of strangulation, which Wetli also ignored.

Williams wasn’t officially determined to be the killer, as he died of AIDS while awaiting trial for the murder of one of the women. In the years surrounding the killings, he had accumulated seven allegations of rape, with three leading to convictions. Despite all of this, Wetli never retracted his position on ExDS in the cases.

On the contrary, in a 2010 interview with Miami New Times, Wetli, who was in private practice in New Jersey at the time, indicated that he still believed “death-by-sex might have killed those women,” saying it was “certainly a possibility.”

“The guy never went to trial, so we’ll never know.… But believing in something, and proving it, is another story,” continued Wetli.

As far as the symptoms Wetli defined, the degree to which they rely on subjective interpretation is obvious—a point University of Miami brain researcher Deborah Mash admits. Like Wetli, she is also a frequent provider of paid expert testimony on ExDS for TASER International. She also insists that science supports the diagnosis of ExDS despite the fact that it relies on eliminating other possible causes of death and on then examining second-hand evidence of symptoms through police testimony and reports.

For first responders, of course, it might be easier to swallow the notion, since it is difficult to differentiate between, say, a person suffering from an epileptic seizure or other psychotic episode. It provides a way to “explain the unexplainable,” in the words of a 2012 St. Louis University Law Review article on the topic, much the way we chalked up the violent behavior on display during the January 6, 2021 insurrection at the U.S. Capitol to “mob mentality,” another pseudo-scientific concept.

Just since the onset of the COVID-19 pandemic, we have witnessed a rash of violent eruptions on our airlines when a passenger is confronted for not wearing a mask—4,365 as of this writing. Are we suffering from Extreme Mask Syndrome?

ExDS is rooted in a mid-19th century diagnosis by a Massachusetts doctor, Luther Bell, who observed an extremely delirious state in some of his psychotic patients that sometimes ended in death. Others made similar observations over the next century, until the post-WWII revolution in pharmacology provided new sedatives to counteract these extreme psychotic states. Then came the liberalization of the 1960s, which led to a re-examination of laws allowing involuntary commitment. By the 1980s, there were more police encounters involving people suffering a mental health crisis, and law enforcement and emergency responders began regularly tapping into the arsenal of “calming” psychotropic drugs to deal with them. Into this environment was born the diagnosis of ExDS.

From the civilian perspective, aren’t there other factors to be considered? In reviewing such violent police interactions, we should also consider:

  • the impatience of the officers involved;
  • the impersonal treatment of their subjects;
  • the pragmatic and often frantic desire by police to subdue a non-compliant actor at any cost, including the taking of life; as well as
  • the over use of lethal force against unarmed or submissive captives.

In cases like that of Elijah McClain, and countless others, death resulted soon after police arrived on scene. Bullets, Tasers, chokeholds, and the use of volatile and unpredictable “calming drugs” were all elements in these confrontations, and all resulted in needless death.

These encounters resemble not so much an attempt to restore safety and security as a clash between war combatants. Our streets have become a one-sided gladiatorial event where the victors in their uniforms represent the sacred social order and the hapless, beaten, tasered, and drugged victims represent the unwashed, the misfit, the barbarian, the outsider, the “them” that must be removed from society. This lack of humanity and compassion pervades the entire criminal legal system, which camouflages and excuses its naked violence in palatable sounding terms like “proper procedure,” “harmless error,” “qualified immunity,” or euphemistic psycho-babble such as ExDS.

Excited Sedation Syndrome

Known as “sedation agents,” drugs used to subdue individuals (aside from pepper spray and other irritants), include;

• Midazolam, a sedative marketed under the brand name Versed;

  • Lorazepan (Ativan);
  • Diazepan (Valium);
  • Haloperidol (Haldol);
  • Droperidol (Inapsine);
  • Ziprasidone (Geodon);
  • Olanzapine (Zyprexa); and last but not least
  • Ketamine (Ketaset/Ketalar).

Of these, ketamine is the most favored because of its short onset period—just one minute to take effect. Other agents can also be sprayed nasally, but an injection is easier to administer on a restrained subject during a struggle. Unfortunately for the subject, ketamine has some very nasty side effects, such as choking, vomiting, and difficulty breathing. Sedating agents, however, are only one element of scene control.

A myriad of other products was developed with the intention of subduing a non-compliant person through, what was promoted as, non-lethal technology. One of those so-called “non-lethal” technologies developed in the late 1960s, and requiring a great deal of creative marketing in order to find its home with law enforcement, was the Taser.

The inventor of the trademarked device, “TASER,” was Jack Cover, who named his 1969 invention after the 1911 young adult sci-fi novel, Tom Swift [and His] Electric Rifle, (using the initials TSER and adding an “A” to facilitate pronunciation). The weapon is also reminiscent of that famous gadget from the Star Trek television series, the phaser, and the famous line by Captain Kirk, “Set phasers to stun.”

Cover’s concept was to create a non-lethal weapon, one that tamed instead of destroyed, one that subdued instead of neutralized its intended prey. But federal regulators classified the device a firearm, since it relied on gunpowder to propel a pair of copper wires that delivered a non-lethal electrical charge.

The idea finally got the refinement it needed from Rick Smith, who founded TASER International in 1993 to market a new version of the device that relied on compressed air to direct energy to the wires and—more importantly—was not classified as a firearm.

The Taser is emblematic of America’s thirst for social control and purification but done so with an emphasis on being “humane.” With it, law enforcement now possesses the weapon of choice for non-lethal confrontations. And with ExDS, they have found the condition upon which to apply the Taser’s punishing spell. TASER International needed a condition like ExDS upon which to “stun” then rescue a victim from the syndrome’s wrath. It all sounded so noble.

Before Smith came along, Cover’s company went in and out of bankruptcy before it was sold and renamed Tasertron. It soon won a contract with the Los Angeles Police Department (“LAPD”). But then came the notorious beating in 1991 of Rodney King at the hands of nine LAPD officers, who had tried and failed to subdue him with their Tasertron.

After that failure, the parent company wanted to distance itself from the name Tasertron. Meanwhile, Smith met with Cover in 1993 and worked out the new propulsion system that remade the Taser. But the next concern was that it sometimes worked too well, i.e., not as intended.

A key problem for TASER International was the inconvenient fact that its product was not exactly “non-lethal.” Instead, it was so effective at knocking suspects off their feet that some were simply unable to get back up—ever again. Reports began to surface of subsequent deaths from organ shutdown following excessive exposure to Taser applications.

To overcome this negative image, savvy marketing strategies propelled the growth of TASER International by deploying an arsenal of police spokespeople and sales representatives in order to expand market share by reaching out to police departments nationwide.

By 1999, when the Taser M-26 was introduced, the company was reaping significant financial success. It filed for an IPO in 2001 and went public on NASDAQ, where it raised additional funding from a public that was all too eager to benefit from the expanded use of weaponry to be deployed against the masses. Unfortunately, the masses, it turns out, are us. By 2008, TASER International was registering $93 million in sales.

As the death count resulting from Taser use by police continued to climb, the company began to add medical experts and high-powered attorneys to its payroll. The company still pays a team of doctors and researchers to provide expert testimony in the courtroom as well as through published articles and white papers. Their strategy involves elaborating on an alleged epidemic sweeping the nation—ExDS—which they promote as an alternative explanation for Taser-related deaths.

Wetli, the DiMaios, and Mash have all been used by the company on its team of ExDS experts, each paid hefty fees for their promotional work and expert testimony. The strategy has worked well. Of 59 separate wrongful death lawsuits filed between 2004 and 2010, the company prevailed in all but two. The reason, as expressed by Vincent DiMaio: “There is no concrete evidence that tasers can kill you.”

“Of all in-custody deaths (not involving firearms), excited delirium syndrome is the most common form,” he concluded instead.

The watershed moment for TASER International was reached in 2009, when the U.S. Court of Appeals for the Eleventh Circuit ruled that the company was not liable for an in-custody death in Georgia where it could not be ruled out that the cause of death was ExDS. See Mann v. Taser International, Inc., 588 F.3d 1291 (11th Cir. 2009).

Now it was simply up to TASER International to make sure that every police officer with a Taser knew what ExDS was. And its team of experts—Wetli, the DiMaios, and Mash—were already on the job. The company also changed its name to Axon in 2017.

In this way, Axon/TASER has succeeded in making the ExDS diagnosis nominally valid, even in cases where Taser application is not directly the cause of death. The ExDS explanation makes the suspect guilty for his own demise, and it overrules all other factors associated with over-use of force or violent police confrontation. ExDS became the perfect scapegoat in nearly every questionable death, including that of George Floyd, as will be explored later.

One particularly troubling example is the case of Tony Timpa, a 32-year old man who died in August 2016 in the custody of Dallas police. According to news reports, “Three officers [caught on bodycam video] laugh(ed) and joke(d) as they restrain(ed) Timpa on the ground” for almost 14 minutes. When he became unresponsive, “with his face in the grass, officers joke(d) that he (had) fallen asleep.”

Tragically, it was Timpa who had called the police on himself. He had gone off his medication for schizophrenia and needed assistance. Unfortunately, this was not the kind of assistance Timpa had anticipated when he reached out to police for help. His death, though directly attributed to excessive force, was blamed on ExDS, which necessitated police interaction.

In March 2019, Dallas County District Attorney John Creuzot dismissed charges against the officers in the Timpa incident. Even though the suspect had already been put in handcuffs by a security guard when police arrived on scene, officers still subjected Timpa to brutal restraint. His death was nevertheless recorded as “sudden cardiac death” due to “the toxic effects of cocaine and the stress associated with physical restraint.” A federal judge tossed a civil lawsuit filed over the killing against the officers involved, a ruling based on their “qualified immunity,” wrote the Dallas Morning News. All officers involved kept their jobs.

Use of a Taser has been involved in many of the cases where ExDS was later invoked as the cause of death, despite the fact that excessive shock-stimulation resulting from multiple Taser applications eventually led to respiratory or heart failure. Nevertheless, police continue to use the weapon and continue to rely on “qualified immunity” as the virtually impenetrable shield against any accountability when death results.

What happened to Natasha McKenna provides another typical example of such abuse. The 130 pound, 37-year-old mom suffered with schizophrenia from the age of 12. In February 2015, after accusations that she assaulted an officer, she was taken to the Fairfax County Jail in Virginia. When guards tried to transfer her to a jail in Alexandria where she could receive psychiatric treatment, it was alleged that she became irrationally combative. She was subsequently tasered four times. According to Reuters “after the fourth shock, McKenna stopped breathing.” She was pronounced dead at a hospital three days later.

Police managed to guide the autopsy report toward a cause of death citing “Excited Delirium.” It described McKenna’s demise as an “accident.” But the county paid $750,000 in 2018 to settle a lawsuit filed by her family, and yet still prosecutors declined to charge any of the guards involved.

A database maintained by Reuters counts 1,081 Taser-related deaths as of November 2021, occurring at a rate that appears from other sources to remain fairly steady. According to Amnesty International, there were more than 500 Taser-related deaths in the U.S. between 2001 and 2012, while USA Today reported at least 513 from 2010 to April 2021. Of all fatal Taser incidents, less than 10 percent—103—have involved armed suspects. The exact count of such cases may not be known (or be made public) because a significant number are simply never adjudicated.

Recently, as a result of the Black Lives Matter protests in the COVID-19 summer of 2020, the issue has come to be front and center in the glare of media attention. The death of George Floyd, caught not just on one video, but on several, an incident visible in multiple dimensions and witnessed by a multitude of bystanders, presents American society with the obvious hard evidence of violent police behavior.

The trial of Floyd’s killer, Minneapolis policeman Derek Chauvin, also brought public attention to draconian police methods, inadequate training, and failed protocols. It is not merely systemic racism but systemic paranoia. Police are programmed to believe they are fighting a war, and as a condition of war, civilian casualties abound. What we are seeing is not about a few bad apples, it is about entire venomous orchards that we have seeded, managed, and maintained for decades in this country.

George Floyd and many others flashing across our news screen are just the visible tip of a much larger iceberg, symptoms of a larger “syndrome”—one which cannot be neatly packaged under the heading of ExDS.

Excited Pandemic Syndrome

The COVID-19 pandemic has exposed weaknesses in the social structure of the U.S., cracks in our foundation that have persisted from the Founding Fathers to the present. These were elements already present, but it took a global crisis to bring them into full view. Increasingly, there is a lack of civility that threatens the orderly day-to-day processes of our social structure, a lack of dialogue, a tone-deafness.

We have become harshly divided, strident, and politicized, driven to senseless extremes. Wearing a mask to ward off viral infection and propagation has inexplicably become an issue provoking grave and violent confrontation, as have vaccinations. Passengers on airlines have acted out irrationally in their refusal to follow common sense or civility guidelines. The decision to receive the vaccination, or not, to wear a mask, or not, to protect each other through compliance or defiance, regardless of our position, may have reached a level of hysteria. Could this also be “Excited Delirium Syndrome?”

The defense in the Floyd case made an issue of his health, his addiction to drugs, his heart condition, his resistance to arrest. They stopped short of formally claiming Excited Delirium Syndrome, but the idea was introduced by one of the officers, heard in video evidence while holding Floyd down, commenting to the other officers, “Do we have Excited Delirium here?” This seemed to follow all the familiar talking points created over many years of marketing and messaging by Axon/Taser in its effort to spur corporate growth and law enforcement acceptance.

It should be obvious that men like George Floyd may naturally react with fear and reticence to law enforcement in high-stress situations. How many such individuals, unarmed, even initially cooperative, end up dead in the process of police intervention?

Many such individuals have already been on the wrong end of law enforcement—they have experienced the cruel and dehumanizing process of courts and prisons. Their reaction may seem foreign to those who have remained outside of the system. But for many confronted by police, fear overtakes them, and they respond with a fight-or-flight reflex rather than face the inevitable—a return to prison where every day is an act of survival within a world of people behaving as if they suffer ExDS.

Excited Spectrum Syndrome

Post-George Floyd, the public has finally begun to take a closer look at similar police and prison custody deaths where ExDS was cited as justification for seemingly excessive measures. Not all such measures, however, involve a Taser or gun. In the death of Elijah McClain, a more complex weapon was deployed to subdue this “suspicious looking” individual.

McClain, who had gone to a grocery store to purchase an iced tea, was seen departing the store wearing a ski mask and “moving his arms erratically.” His family later said that McClain was sensitive to cold and was prone to wearing the mask even during the summer months. Prompted by the eyewitness report, police were called, and McClain was accosted by officers with the Aurora, Colorado, police department at 10:30 p.m. on August 24, 2019.

When confronted, McClain explained to officers that he was an introvert and requested politely to be left alone and not have his personal space invaded. But one officer is seen on a body cam seizing McCain after saying, “You look suspicious.”

McClain panicked, and a struggle ensued. McClain was subsequently placed in a carotid chokehold by one officer while the others restrained him. Barely able to catch his breath, McClain attempted to reason with officers pleading, “I am not breathing correctly.”

EMS personnel were called to the scene to help further subdue the panicking suspect. McClain—a 5-foot, 7-inch tall individual, known by many as typically docile and kind, and diagnosed emotionally on the autism spectrum—was administered a dose of ketamine suitable for a 190 pound drug-affected man. McClain immediately began to choke and vomit, while attempting to apologize to officers for causing them trouble. This suspect could not have been more polite nor more vulnerable. McClain also suffered from a heart condition and eventually passed out at the scene, succumbing a week later. His death coming at the hands of the very people sworn to protect him.

Following the incident, three officers and two paramedics were charged with McClain’s death two years after the fact by State Attorney General Phil Weiser. In July 2020, one of the cops, Officer Jason Rosenblatt, was fired after “liking” and replying “ha-ha” to a social media posting by two of his fellow officers of a selfie at an Elijah McClain memorial site in a display of pride and taunting. Along with fellow officers Nathan Woodyard and Randy Roedema, Rosenblatt faces charges of manslaughter and criminally negligent homicide. Paramedics Jeremy Cooper and Peter Chichuniec also face the same charges as well as one count of assault for using ketamine for a purpose other than lawful, medical, or therapeutic.

Excited Warrior Syndrome

It is no surprise that encounters between law enforcement and the public are fraught with anxiety and danger, but can every case of police brutality be summed up under the convenient heading of “Excited Delirium Syndrome?”

Today, more than ever, we are experiencing extreme fault lines in society—racial, political, gender, socio-economic, and now, a pandemic-fueled fault line around science and trust. These fault lines end up culminating in more intense interactions between police and civilians. Delirium, it seems, is everywhere. Distrust, antipathy, and suspicion vibrate on both sides of the line.

Interestingly, only one side has not just the firepower but society’s approval. Minorities, social misfits, the psychologically-impaired, or the hopelessly drug-addicted all seem to end up on the losing side of any exchange with law enforcement. Such persons are mere “collateral damage” in our quixotic struggle to achieve the unachievable, a flawless social structure.

Law enforcement thrives on an “us versus them” esprit de corps. “They” have arrayed an impressive, well-equipped army composed of officers, agents, investigators, prosecutors, judges, and prison guards, and “they” seemed to have surreptitiously turned against “us.” “They” have taken on the role of warrior in a battle against a syndrome that they claim has afflicted “us.” Why this has become acceptable is because it is not “they,” the warriors, or “us,” the embattled, but rather, “all” who seem to suffer from “Excited Delirium Syndrome.” 

 

Sources: American College of Emergency Physicians, Excited Delirium Task Force; harvardcrcl.org; doi.org; psychnews.psychiatryonline.org; Forensic Science, Medicine and Pathology (Journal); Time Magazine, August 2021, KDVR, WHSV, New York Times, Washington Post, Denver Post, Dallas Morning News, Miami New Times, The Guardian, USA Today, Reuters, Mother Jones, Psychiatric Times, Police Magazine, Amnesty International

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