Wooden cubes in the form of a speedometer showing the risk assessment. Hand holding pencil is pointing toward medium to high risk.
Fida Olga/Shutterstock.com

Last month I addressed the topic of dangerousness in mental health. I noted that most people with mental illness are not dangerous and that, among those who are, they are more likely to be a risk to themselves than to others. In this month’s column, I focus on who isn’t dangerous and how our fears and stigmas can sometimes cause us to mistakenly perceive someone with a mental health disorder as a threat. 

Some years ago, an attorney in south Georgia called me and asked me to consider testifying in a murder case in which the attorney was counsel for the accused. The defendant had an IQ of just under 70 and he had allegedly killed his mother. The attorney wanted me to testify that the defendant’s IQ was responsible for his violent behavior.  

I had to decline that request, of course. While it is true that intellectual challenges may limit one’s problem-solving skills, there isn’t any evidence that indicates intellectual limitations “cause” one to be violent.  

Violence in psychiatric hospitals 

In psychiatric hospitals, patients can be aggressive with each other and with staff members, but there are reasons for this other than the psychiatric disorders themselves. Although mood disorders, anxiety disorders and even personality disorders (with the exception of those I addressed last month) may be contributing factors in aggressive acts, rarely do they directly cause violent behavior 

First of all, in hospitals, people with serious dysfunctions are concentrated together in a confined space. Therefore spats, disagreements and fighting are not unlikely in such environments.  

Second, these patients may be withdrawing from substances, managing complicated relationship issues and managing financial burdens all in the context of their mental health issues. These added stressors on top of their diagnoses can increase the probability of aggression. It is not caused by the diagnosis itself. 

Finally, some of the most aggressive individuals, as I addressed in last month’s column, can be found in hospitals, so it isn’t surprising that we see aggression in hospital settings.  

Misleading data 

Early research on violence and mental health was nearly all done within inpatient settings. John Monahan’s 1981 monograph was a classic example of this type of research. While it was an exceptional work, the research presented a skewed perspective on mental health in general. The findings of those early studies couldn’t reasonably be generalized to the population at large.  

I aimed to address this gap in the literature by exploring violence risk assessment in the general population in my first academic article, which was published in 1991. 

What we now know is that, excluding hospital practice, most of us in the mental health industry will never be assaulted by our clients, and most of our clients will never harm or attempt to harm anyone else. A widely cited study published in the American Psychological Association in 2008 indicates that 35% to 40% of psychologists are at “risk of being assaulted” by their patients. “At risk,” yes, but most of them aren’t. 

In a 2011 study, the National Institutes of Health (NIH) noted that 14% of patients admitted to a psychiatric hospital had been aggressive toward other individuals in the month prior to admission. Yet again, those who are hospitalized represent a narrow segment of the overall population.  

In another NIH study in 2019, researchers found that over half of the 470 clinicians in their study had been subjected to threats, verbal attacks or physical violence at some point in their career. While this is an astonishingly high percentage, we see again that “threats” are mixed in with the data of actual aggressive clients. The participants in the study reported confrontations by clients outside the office, harassing phone calls and other verbally aggressive behaviors that fell short of actual physical contact. Feeling threatened and actually being assaulted are not synonymous. 

Recognizing real vs. perceived threat  

I once consulted with a company that routinely hired housekeeping staff from an agency that worked with individuals on the autism spectrum as well as individuals with development disabilities. One adult male autistic worker had been working for the company for more than three years without incident even though he was on the severe end of the autism spectrum. 

As we know, people with autism often don’t handle changes well. Any disruption in their routine can cause them to be agitated. In this particular incident, this worker had gone to the maintenance area as he had done hundreds of times before, but for some reason the closet where his equipment was kept was locked.  

The worker became extremely agitated and was ranting in the hallway to himself, pacing back and forth. Another employee of the agency felt threatened by him, and he was eventually fired. It was a tragic end. The employee’s fear of the agitated worker is understandable, but he was no threat to the employee nor anyone else in the office.  

Recognizing who is actually a threat and who is not is a critical part of our work in mental health. Individuals who are not a threat, but inaccurately deemed to be so, can lose their jobs, custody of their children and potentially their freedom, among other things. There are also dire consequences in cases where people are a threat but inaccurately deemed not to be so, including the potential loss of life. 

My experience has shown me that most therapists are not well trained in distinguishing between the two. In a workshop some years ago where I presented a seminar on violence risk assessment and self-harm assessment, I asked the roomful of 100 or so clinicians how many of them worked with suicidal clients. Every hand went up. When I asked how many of them felt well trained in assessing risk, only two or three raised their hands. None of them had any significant training in their graduate programs on risk assessment. 

That leaves the responsibility for learning risk assessment to the clinician. We must stay current on the research on risk assessment, and we must interpret the data cautiously. 


Gregory K. Moffatt is a veteran counselor of more than 30 years and the dean of the College of Social and Behavioral Sciences at Point University. His monthly Voice of Experience column for CT Online seeks to share theory, ethics and practice lessons learned from his diverse career, as well as inspiration for today’s counseling professionals, whether they are just starting out or have been practicing for many years. His experience includes three decades of work with children, trauma and abuse, as well as a variety of other experiences, including work with schools, businesses and law enforcement. Contact him at Greg.Moffatt@point.edu.

Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.