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My first trip to a psychiatric hospital was in 1978. I was a first-year college student, and one of my classes toured a state-run hospital. Like my classmates, I’d seen plenty of movies about a scary “crazy” person who escaped from a hospital and terrorized the community. But I learned on that trip — and my career experience has shown it to be true — that most people in hospitals like that came in on their own accord for help.

Our guide, the director of the facility, noted that the fence around the gigantic property was not there to keep the patients in, but rather it was there to keep others out. In fact, many of the patients in that facility could have walked out the front door any time they wanted. But they didn’t want to. They wanted help.

This trip reaffirmed what I have found to be true in my work with clients throughout my career: Most people with a mental illness are not dangerous. In fact, they are often more of a danger to themselves than others. But there are a few mental illnesses that can have potentially dangerous outcomes for others.

Three disorders associated with an increased risk of violence

Research is weak regarding which mental illnesses are correlated with dangerous behaviors. I’ve researched this area for close to 40 years, and I can assure you there is no simple answer. But here are three disorders that have the potential for dangerous outcomes and always give me cause for concern.

Reactive attachment disorder. In terms of dangerousness, reactive attachment disorder is the king. This disorder, which affects children, is one of the scariest due to the developmental limitations in children in terms of coping skills and problem-solving. I’ve seen these children cut, pinch, hit, and even kill infants and young children.

I’ve seen cases in which children as young as five years old have threatened their guardians with knives. I’ve had clients under the age of seven sexually assault younger children, and I’ve seen older children with this disorder kill family pets as well as rape adult women. Children with this diagnosis need 24/7 supervision along with intensive treatment plans.

Antisocial personality disorder. Antisocial personality disorder is the adult cousin of reactive attachment disorder. Clients with this disorder can exhibit their dysfunction in several ways. One key characteristic is that people with this disorder manipulate people. They can do this in a variety of ways, some of which don’t include violence.

But clients who choose to manipulate others physically or sexually can be dangerous. They have little compunction regarding the injury they cause others. The desire to manipulate others and see pain can lead to horrifying behaviors. These patients will attack staff or fellow patients in hospital settings, and they can easily attack therapists in outpatient settings. Individuals with this disorder are often the characters many of us know of as serial killers and serial rapists. Much of what I’ve seen of these individuals over my career is not far flung from the movies.

(For more on this disorder, see my article “Counseling encounters with the puppet masters,” which was published in the February 2019 issue of Counseling Today.)

Delusional disorders. My wife and I visited a restaurant in downtown Atlanta recently. As we approached the restaurant, I saw a man pacing back and forth on the sidewalk in front of us near the front door. He was clearly homeless and suffering from delusions. We gave a wide berth to the guy as we entered, but from our table, I could still him through the window. It grieved me to watch this gentleman outside the restaurant suffering in front of me.

As with antisocial personality disorder, individuals with delusional disorders exhibit their symptoms in a variety of ways. Only some of their expressions are dangerous. The sensory hallucinations (auditory, tactile, visual, etc.) that these clients experience are absolutely real to them.

But unlike antisocial personality disorder, these individuals are not dangerous out of spite or cruelty. Instead, the delusions they experience and the chaotic worlds in which they live can cause them to feel threatened and, in response, act out. This is why I steered clear of the homeless man as I entered the restaurant.

In other cases, their delusions lead them to think they are helping when they are doing the opposite. For example, Russell Weston, a 42-year-old man with schizophrenia, killed two Capitol police officers in 1998. He believed he was saving the world from aliens and was trying to access the “ruby satellite” he believed to be housed in the U.S. Capitol.

Violence risk assessment tools

Assessing dangerousness is a complicated process and an inexact science, and this can cause some mental health professionals to worry about assessing and treating clients with these disorders. But there are clinical tools that can help clinicians better assess the risk of potential violence.

I developed the Violence Risk Assessment Checklist in the 1990s (available at gregmoffatt.com) and have used it for years in businesses. This hierarchical checklist, like a suicidal ideation checklist, helps counselors evaluate for increased or decreased risk of potential violence. It contains twenty-eight items. Of the top eight, the more items the counselor checks when assessing the client, the higher the risk of violence.

The National Institute for Occupational Safety and Health provides a list of violence risk assessment tools that have been developed specifically for determining a person’s potential for violence to themselves or others. This list includes the Dangerousness Assessment Tool, which is a quick assessment scale clinicians can use to determine if an individual who is displaying signs of potentially dangerous behavior is a risk to others.

Clinicians need to realize, however, that just like assessing for risk of suicide, these instruments are only guides for decision-making and intervention, not precision tools.

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Next month, I’ll address who isn’t dangerous and how I know.  

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.

The views expressed in Counseling Today are those of the authors and contributors and may not reflect the official policies or positions of the editors or the American Counseling Association.