Violence is not simply a mental health issue. It is, and has always been, a societal one shaped by culture, institutions, access, and the stories we tell about harm and power. Still, mental health professionals encounter violence clinically, not only in the aftermath of trauma, but in the intimate moments when people disclose fear, rage, or violent fantasies that alarm them.
We are called to receive the minds and bodies of people within the context of the society they live in, and as American clinicians working in a country plagued by gun violence, we must hold those disclosures responsibly while avoiding turning patients into suspects.
In outpatient psychiatric practice, violence sometimes enters clinical encounters not through action, but through disclosure. As an outpatient evaluator working primarily with early psychosis and depression, I sometimes encounter patients deeply distressed by violent thoughts toward others.
Recently, during a virtual psychosis evaluation, a young man described urges to commit mass violence. He was disorganized, frightened, and clearly tormented by what was occurring in his mind, but not beyond intent or potential. What stood out most was not bravado or threat, but anguish. He seemed afraid of himself and was actively seeking help.
With support from colleagues and the patient’s cooperation, I petitioned for hospitalization. His family became involved and arrangements were made for him to be admitted. The patient himself was fully willing to go.
From a macro perspective, this would likely be considered good care. There was reasonable evidence of imminent harm to others and the person disclosing the thoughts felt seen, cared for, and collaborated with in planning for a higher level of care.
Still, in the wake of this success, I cannot shake the sense that it was largely the result of improvisational instinct rather than training. Much of what guided me felt relational and intuitive and, in retrospect, uncomfortably lucky.
The intervention worked because the patient disclosed what he was thinking. It worked because there was enough alliance for the conversation to continue. It worked because the patient ultimately agreed to hospitalization. But I keep returning to the question of what might have happened if those conditions had not been present.
What if the alliance had not been established? What if the patient had been less willing to disclose his thoughts? What if his family had refused involvement?
In a virtual visit, what exactly would escalation have looked like? Would I have been sending an ambulance to his home? A police vehicle? Where is the line between preventing harm and creating new harm through the response itself?
When Violent Thoughts Enter the Room
Later, when discussing the case in a team meeting, I was struck by the tone of the conversation. There was a curiosity that reflected my own mixture of shock and relief. My colleagues wanted to understand what had happened and how I knew what to do. They were looking for what might be replicated, how we might recognize a similar situation sooner, and whether there was some way to formalize the decision making.
Implicitly, we were looking for a kind of standard operating procedure for assessment, escalation, and follow up. The realization that stayed with me was that there is not one specific to homicidal ideation. Not really. Not outside forensic contexts.
In everyday outpatient psychiatry, when a patient discloses violent thoughts, the response often unfolds in a loosely improvised way. Clinicians rely on consultation with colleagues, general risk assessment principles, local legal requirements, and the strength of the therapeutic alliance. Sometimes this leads to hospitalization. Sometimes it leads to closer follow up, family involvement, or safety planning. Sometimes clinicians simply monitor the situation over time.
In other words, the response is often reactive and individualized rather than structured or widely taught.
When violent thoughts emerge in treatment, many clinicians feel unprepared. There is little shared language for discussing homicidal ideation with patients. There are few widely used outpatient frameworks for assessing it. Training in violence risk assessment is often limited to forensic settings.
In practice, this uncertainty can lead to two opposite risks. Underreaction or overreaction.
Some clinicians may avoid probing the topic directly because they fear stigmatizing patients or triggering legal obligations they do not fully understand. Others may escalate quickly to hospitalization or law enforcement involvement because they lack intermediate tools for managing uncertainty. Neither outcome is ideal for patients or clinicians.
Suicide Assessment as the Only Comparison
The contrast with suicidal ideation is striking.
When it comes to suicide, we talk about it constantly. We train for it. Most clinicians can readily name several evidence based assessment tools and are comfortable using cumulative questions to understand intent and risk. We learn how to ask directly and indirectly. Have you thought about going to sleep and not waking up? Have you found yourself wondering what the point of continuing is? Do you know how you would do it?
Over time these conversations develop a rhythm. We learn language that is direct but collaborative, serious without being alarmed. That language creates a kind of clinical confidence that patients can feel.
In the rare cases where I recommend hospitalization for suicide prevention, I have a sort of speech I give patients. I tell them something like this. I cannot guarantee this will be therapeutic. It might be frightening or frustrating. What I can say is that we are trying to keep you alive. That is my goal here.
Similarly, when someone is exhibiting symptoms of early or unrelenting psychosis, I might add that hospitalization can help us figure out what is going on.
I never promise that hospitalization will be especially healing. Short term psychiatric admissions are, frankly, a gamble in terms of therapeutic benefit. But I can usually tell patients what to reasonably expect next.
I do not have the same language for homicidal ideation.
In examining this evaluation, I realized this clarity was missing. I assessed risk and insisted on hospitalization, but I did not have the same language for explaining what would happen next or why that pathway made sense beyond joining with the patient’s fear.
Ironically, while I want to insist that suicidal ideation and homicidal ideation are different phenomena, they arise from different experiences, carry different meanings, and lead to very different ethical questions. Yet suicide assessment and prevention remain my only real point of comparison.
Why the Conversation Is Hard to Have
Psychiatry has become deeply preoccupied with avoiding the implication that mental illness causes violence. In clinical training, this concern often translates into caution around asking direct questions about violent thoughts at all.
The unintended consequence is that conversations about violent ideation may be avoided rather than examined. In trying not to reinforce harmful narratives about mental illness and violence, we may sometimes trip over ourselves in avoiding the subject altogether.
The clinical reality remains. Violent thoughts do appear in treatment. When those disclosures occur, clinicians are expected to respond responsibly even though many of us have received relatively little structured training in how to assess or respond to violent ideation outside forensic settings.
Toward a More Prepared Response
If psychiatry were to approach homicidal ideation with the same seriousness it applies to suicidal ideation, several possibilities come to mind.
Clinicians might receive more explicit training in how to ask about violent thoughts in ways that are direct but not accusatory. Outpatient practice might develop clearer frameworks for distinguishing between intrusive thoughts, emotional fantasies, grievance driven rumination, and situations where someone is moving toward planning or preparation.
Just as suicide assessment includes a spectrum of responses from monitoring to safety planning to hospitalization, approaches to violent ideation could involve graduated responses rather than a binary choice between ignoring the issue and escalating to emergency intervention.
The goal would not be to treat patients as potential criminals, but to treat violent thoughts as clinically meaningful experiences that deserve careful exploration.
If such an approach existed, the experience of disclosure could look very different for patients.
Patients who are frightened by their own thoughts might encounter clinicians who are prepared to ask about those thoughts calmly and directly. They might receive explanations about how clinicians evaluate risk and what different responses mean.
Most importantly, they might be able to disclose disturbing thoughts earlier, before those thoughts become more organized, more secretive, or more dangerous.
If patients are willing to bring these thoughts into treatment, psychiatry should be better prepared to receive them. Not because violence is a psychiatric problem alone, but because these moments still fall within the scope of clinical care.
Silence and improvisation are not sufficient responses when the stakes are this high.
I appreciate your article and that you address the topic of talking about the experience of violent thoughts with clients. I worry though that, beyond this important conversation, professionals don’t really have many clearly helpful responses. Hospitalization may feel safer, but is it, as it functions in western medical model psychiatry really safer?
Many factors contribute to both having violent thoughts and best preventing harm. Unfortunately, most are not well studied or considered within our system of care. These include – how isolation itself and our daily cultural context contributes to extreme experiences of a felt sense of a lack of physical and emotional safety and the development of reactive states in response, how the experience of hospitalization may be deeply disorienting and leave a person more vulnerable and further disconnected from personal support and how both side and withdrawal effects from prescribed medications also often trigger or add to violent thoughts.
Close and caring relationships are helpful for sure. I wonder if a dialogic approach such as Peer Supported Open Dialogue (POD) with people and their support network may better help address the ongoing complexities of both the causes of and best responses to violent thoughts.
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Hi there!
This is a good point where hospitalization is a complicated and conflicting intervention, especially in situations like this where the stakes are so high. It can feel like the safest option in the moment, but as you point out, there are real risks in how it’s practiced.
I love the mention of Peer Supported Open Dialogue. There is this vacuum of understanding what these thoughts are like and what actually helps. I think we are really missing the voices of lived experience here.
Thank you again for engaging with this so thoughtfully.
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Interesting points and responses. One thing I would say is that if the focus becomes the violence or violent thoughts and keeping a person safe, similar to suicidal thinking, then we are missing the point. Maybe its more about being curious about why someone feels this way, or voices tormenting them in this way. Personal experience is that there was a time I was so distraught by what I was hearing and psychiatry didn’t listen just told me I had insight and if I acted on my thoughts I would end up in secure care. Knowing what I know now, these voices were linked to unprocessed trauma and needed to be listened to and understood. I could have ruined lives, including mine, because of limited thinking (medicalised) of psychosis.
Oh and I wouldn’t have said that I had a great therapeutic alliance with the psychiatrist’s I told – I was very very frightened and scared. I thought and understood that people with schizophrenia were not responsible for their actions and were violent – I did not want to be that person.
Thankfully I moved past that period, and now in very different position as i rejected a medicalised/biological understanding for a trauma one after listening to others who had made sense of their voice hearing and traumas.
I have held a full time job for 20 years now. I no longer take medications when I used to be on large doses and warned that I may not live outside a hospital setting. Learning from others with lived experience helped me understand myself and find ways to help myself, all be it with numerous people who believed in and supported me.
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Thank you for sharing this Wes. Really important point about getting to underlying issues and an inspiring story. I wonder if you’d enjoy Michael Garrett’s writing on psychosis. He explores it psychodynamically. I certainly find in my work that focusing on “symptom presentation” can leave much unresolved. I have been moved by his work alongside stories like yours where people find healing in depth.
Best wishes,
Jordyn
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Has it never occurred to American psychiatrists dealing with patients whose mental health is threatened by living in “a country plagued by gun violence” that the best advice that they could give would be for their clients to move to a less violent country? The author lives in Michigan, which is right next to Canada. The homicide rate using fiearms is four times higher in the USA than in Canada. Certainly emigration to Canada could bring relief for people terrorized by American violence.
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Oh sure, that totally works for my clients who have lots of financial resources, no real need or desire to stay close to established support networks of friends and family, and no DUIs or other legal history which would bar their entry into another country.
So, like, that one guy.
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Unless there is a concept and actuality of a therapeutic miliue hospitalization of now and more times in the past than not is not really that helpful.. The question is with violence how did the. voices if there are voices begin and what does that mean and people in the Hearing Voices movement would know better than. We are besieged and have been for along time with violence so unless there is a community movement in all areas similar but different from John Bowlby and Anna Freud and Bion and Winncott works then an hospitalized intervention on a locked unit with no alternative therapies or in depth clinical therapy not all that helpful. It is. a public health issue that because of NDAs and gag orders and corporate greed not able to evolve like polio which also had its big issues but ultimately one saving for many many children.
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“He was disorganized, frightened, and clearly tormented by what was occurring in his mind, but not beyond intent or potential. What stood out most was not bravado or threat, but anguish.”
This type of AI slop/prose is aggravating as hell. It’s not beyond your intent or potential to write better.
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You are a social worker
Psychiatrists do not think like social workers
Telling a psychiatrist of homicidal ideation or plans has them reeling in their seats with laughter
Telling a psychiatrist of any other ideations does not garner a better response than silence
Are you qualified to make diagnoses ?
Are you qualified to provide psychotherapy ?
Maybe in the country and jurisdiction that you work, what you do is permissible. ?
Most people get therapy and treatment according to their ability to pay. Absolutely nothing to do with their needs in general or immediate needs
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I would like to see “professionals” off this platform unless they have something really innovative to share!
I see this site degrading into a chat room between LMSWs, LCSWs and psychologists sharing their pathetic horror stories. Don’t they see that they have FUNDAMENTAL MISUNDERSTANDINGS about people, who they really are, how they really operate, and what the mind really is? Meanwhile, psychologists with innovative ideas that are working, like Steve Burgess, aren’t allowed to have a voice here. What the heck is going on?
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Coming from someone who has worked in psych, homicidal thoughts are part of individual lived experiences. Sometimes individuals feel completely let down by their environment and then they change. What do you mean by this you ask? I’m not talking about rumination as a starting point. As a healthcare worker myself, some of my most memorable encounters were by other healthcare workers. Highlights were gaslighting, manipulation, intimidation, threats, power games, sexual harassment, harassing people with disabilities, all while try to work. These things lead to rumination, but not just in me. Instead feeling defeated and ending my time or someone else’s after multiple failed attempts, I vow to continue to protest for representation and advocacy. I will study subjects to objectively render my time as I see best. I see the good in the system AND when the media says someone violent did something, I will always remember the flaws of it can be too much for some to live with and I must do better for them and others. I respect the individual experience. I will not be defined by social violence.
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“When Violent Thoughts Enter The Room: –
Surely assessment and differential diagnosis must include a comprehensive prescription drug history? Especially if the person is experiencing overwhelmingly agitation and restlessness (to the point of writhing-restlessness).
? New Drug Induction, Change within Class, Drug Withdrawal, Dose Modification. Poly-pharmacy?
Unless psychotropic drug-induced AKATHISIA, with its disinhibition and emotional lability, is correctly and promptly diagnosed, people who have NO MENTAL ILLNESS whatsoever may be left vulnerable to iatrogenic violence against self and/or others.
AKATHISIA – A common and life threatening Adverse Drug Reaction (ADR), then results in misdiagnosis of Serious Mental Illness, inappropriate, detention in an anti-threrapeutic institution, and enforced, further psychotropic drugging which intensifies both AKATHISIA and the risk of violence.
I have seen misdiagnosed, inappropriately prescribed, antidepressant induced ADR mismanaged this way. NO ADR information or advice given by the prescriber.
The outcome:-
Irreversible multi-systems, permanent psychotropic drug injury, economic devastation, emotional and psychological injury, societal rejection and the destruction of all life’s hopes, dreams and aspirations.
Psychiatric diagnoses and MISdiagnoses are Labels for Life.
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The current analysis being promoted by CCHR (in their most recent video) is that akathisia is the ADR most closely associated with subsequent violent behaviors.
Apparently this ADR is often much worse as a personal experience than what it is being described as. It will give you a sort of internal “itching” or “crawling” that makes it totally impossible to be comfortable, often for prolonged periods of time. It’s basically a form of torture. And some people get to the point where they are willing to do ANYTHING to end it.
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Hello! To you and Retired Physician, these factors were considered but not applicable in the reflected experience!
To the point about akathisia, I think this is especially relevant to consider when there’s an unfortunate quickness to interpret certain presentations of irritation as noncompliance, a deficit in coping skills, or an unmovable personality factor.
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I don’t understand this. What does “reflected experience” mean?
Does this mean you see no connection between the sometimes unbearable drug reactions known as “akathisia” and suicidal ideation?
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Sorry to be unclear. I meant that it was not a factor in the assessment I referenced and reflected on for this article!
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“To the point about akathisia, I think this is especially relevant to consider when there’s an unfortunate quickness to interpret certain presentations of irritation as noncompliance,”
The point being made by the very experienced retired doc is the most important comment here.
What is most relevant and difficult is being able to distinguish akathisia induced violent thoughts from non akathisia induced violent thoughts, because if you you send them to psychiatry the drugs they will be forced to take will without doubt make them much worse if it is akathisia. When I say that I have experienced it, only I wasn’t violent I had suicide ideation.
I’m wondering what do you do to work out this incredibly important distinction? Failure to understand this will lead to a horrific situation.
Do you ascertain if they are on medication, do you seek the help of a pharmacologist who could ascertain if they are more than likely toxic. Do a quick search to see if what ever medication drugs they are on or street drugs inhibit Cytochrome P450 3A4 and Cytochrome P450 2D6 also if they activate or inhibit Carbonic Anhydrase which maywell be a factor in akathisia.
And my experience in a psychiatric hospital tells me that Larry Cox is correct here:
“The current analysis being promoted by CCHR (in their most recent video) is that akathisia is the ADR most closely associated with subsequent violent behaviors.”
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Hi Chris!
We have a pharmacist take a med history prior to visits to reconcile what is otherwise outside of my scope. I do take a history of any involvement with psychiatry in these evaluations as well.
Also, the above point you mentioned about distinguishing akathisia was made by me 😉
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As a parent currently living with a son who just this week has had breakthrough psychosis emerge even though he receives his monthly injection and is now speaking about violence against me-which is a 360 from who he is normally, I want to say we need to intercede on behalf of people that experience this. Rural, open land nature, frequencies-music and its counterparts that we know affect emotion, mental states of being and behavior. Studies have been done regarding the impact of behavior modified by frequency. Something to bridge the selves within..?
Ibogane? Dancing around a fire? Something to stretch the fascia, yoga? Something to encourage connection and belonging, community living and therapy? Something to heighten and enliven the senses, a fresh fruit salad with crunchy apples and sweet & sour yogurt and nutmeg? Something to consider the needs of their individual biochemistry, mensahmedical. com.
Variety and caring are unnecessary in the sterile-clinical keep them alive through isolation and over drugging. It is uncharitable that the same approach continues to be used.
To be able to address the needs of people who live through this type of healthcare nightmare we need to seriously consider if treatments, ever cure?
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The ideas you had might all be helpful. Even the salad.
But if your son is like many others, past life trauma may also have to be addressed. And the only ones I know having success with that are Hubbard’s students and Steve Burgess’ group.
Don’t avoid the ideas being frowned upon. Question is: Exactly who is doing the frowning? Hubbard’s ideas have been around since 1950, and psychiatry has always frowned on them, though most of them I am quite sure have no idea what they are criticizing.
Everyone who can get educated about techniques that actually work will be helping to replace the current culture of harm. I hope your son can be saved. But if not, you can be pretty certain that he will come back and try again.
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Communities routinely deal with extreme states and violence without professional help and always have. Its only sunce the 1800’s that psychiatry took off as a response to the harsh conditions capitalism created which meant communities didn’t have the time to look after the severly distressed.
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I disagree. Psychiatry, in some form, has been around for a very long time. And so has “capitalism.” The industrial age did allow for the expansion of the psychiatric profession. But I’m not sure it was there to treat people who were distressed by “harsh conditions.” It served as a new way for the ruling classes to get rid of political enemies, and people who learned their secrets. And it was just as popular in Russian as it was in America.
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Jennifer, thank you for sharing and I am sorry for this sudden change you and your son are experiencing.
I’m struck by how you’re thinking about “bridging the self within.” What a profound way to put it. There is some evidence for approaches that incorporate those elements: for example, horticultural therapy has shown some benefit for people living with schizophrenia, particularly around engagement and quality of life. But as you can imagine, they are less (if at all) supported by traditional healthcare settings.
I sincerely hope that you have care during this time where safety and stabilization really matter, for both of you.
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Thank you for your article. I have just two thoughts regarding issues that were not raised.
1) I know that in America, confidentiality can no longer be assumed to be operative in conversations with a “professional,” whether we’re talking about a conversation with a priest or a psychiatrist. This creates an uncertain climate for the “patient.” They will be less likely to be honest about their anger precisely to the extent that they “plan to do something about it.”
2) There are a class of drugs called entheogens, which includes MDMA. America has been too busy hating drugs to notice that such drugs help inspire compassion. In a sane world, surely we would be using entheogens in counseling sessions to help angry patients “feel” for their perceived enemies.
The use of Ecstasy (the street version of MDMA) in the British rave scene of the 1990s resulted in unprecedented peace on the dance floor. Unprecedented! But MPs cracked down on the drug, and dancers switched to alcohol, a drug that kills 178,000 a year in the US alone. After the crackdown, the dance floors erupted into violence, all “justified” by the fact that a few young people had died after using Ecstasy. Why? Because drug prohibition had denied them regulated product and information about safe use.
These are drugs that help people feel compassion! Surely, this is hugely relevant to the topic of counseling angry patients. Consider the following quotations from DJs in Britain, as they describe the peaceful 1990s rave scene that existed with the help of Ecstasy. The following quotes are from the 2020 documentary by Terry Stone entitled “United Nation: Three Decades of Drum & Bass.”
“It was the first time that black-and-white people had integrated on a level… and everybody was one.” — DJ Ray Keith.
“It was black and white, Asian, Chinese, all up in one building.” — DJ MC GQ.
“Everyone’s loving each other, man, they’re not hating.” – DJ Mampi Swift.
And MDMA is just one of endless phenethylamines that could exist in a free world. Chemist Alexander Shulgin had the rare freedom to synthesize hundreds of phenethylamines in the 1990s, resulting in user reports such as the following:
“The feeling was one of great camaraderie, and it was very easy to talk to people.”
“I was able to go through and resolve some judgments with particular persons.”
“No more axes to grind. I can be free.”
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Hey Brian!
1. Yes I agree confidentiality is a confused subject in our healthcare system! Where electronic health records can be accessed by other healthcare professionals, documents can be subpoenaed, and petitions for involuntarily hospitalization loom: the fear of disclosure makes so much sense.
2. I appreciate this consideration about accessing compassion through entheogens. However, as it applies to homicidal ideation, I am not certain that anger/hate are always at play. Still, I do wonder what it would be like to have better access to these treatments in mainstream psychiatry.
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Your observations may be accurate.
But drugs are not the path to any human virtue. Drugs can wear off and the body can wear out. The soul is eternal. And that should be the correct target of the “healer of souls” (psychiatrist).
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Larry, I’m with you! With so much research on neuroplasticity… we don’t give our amazing bodies half a chance to recover with good food, rest and exercise, quiet, and being around people who love us. Our tendency to medicate every “symptom” is hallmark of the reason for so much addiction. Too easy to look for the “high”. Peace doesn’t stand a chance.
In sincere gratitude to all struggling so hard and choosing meaningful life.
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My God! All you have to do is search on the words “suicidal” and “homicidal” on the website drugs.com. Up come a long list of drugs that have those “side” effects. Just stop prescribing all that cr@p. It doesnt take a rocket scientist. It just takes common sense and self-awareness of what you are doing. I thought you were in the self-awareness business. Only for your clients, not for you? Most of these drugs are no better than placebo for their indications. So find a better way. Stop experimenting on your patients.
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I was admitted inpatient with psychosis and homicidal ideation 2 years ago, and reading this article makes me extremely appreciative for the staff there because when I disclosed my HI to them not only did they take it seriously they seemed to ask all the right questions without putting me on the defensive, and I was able to get the care I needed
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