Hallucinations, Violence and a Closed-Ended Question

Last week was delusions. This week hallucinations.

The authors of the MacArthur Study of Mental Disorder and Violence write:

“The presumption of a link between hallucinations and violence is, if anything, even stronger than the supposition of a relationship between delusions and violence. Clinicians are taught uniformly during their training that patients experiencing command hallucinations, in particular voices commanding them to commit violent acts, are usually dangerous and in need of immediate hospitalization.”

So what did they find?

They conclude: “Our findings regarding the connection between command hallucinations and violence are somewhat more in keeping with conventional wisdom than were the results on delusions and violence. Although command hallucinations per se did not elevate violence risk, if the voices commanded violent acts, the likelihood of their occurrence over the subsequent year was significantly increased. These results should reinforce the tendency toward caution that clinicians have always had when dealing with patients who report voices commanding them to be violent.”

There you have it.


In the next section in Rethinking Risk Assessment (worth reading, as noted previously) they address “Violent Thoughts” and note:Rethinking Risk Assessment cover

“Have you recently been having thoughts of harming other people?” For as long as anyone can recall, this has been a standard question of clinicians’ mental status examinations for patients at admission and discharge from psychiatric facilities. Clinicians in training are taught routinely to make this inquiry. Indeed failure to ask the question could be considered negligent if the patient harmed someone soon after the examination and the victim claimed the injury could have been avoided with proper clinical inquiry about the patient’s thoughts of harming others.”

This question – “Have you recently been having thoughts of harming other people?” – isn’t one I would use or teach. It’s a closed-ended question that requires only a single word response. Does ‘yes’ or ‘no’ really provide the clinician the information they need?

While I’m not a forensic specialist, I’ve met many individuals struggling with paranoia. They have told me of feeling threatened, feeling unsafe, even fearing for their lives.  Their goal wasn’t to hurt someone; they wanted to feel safe themselves.  Thoughts of hurting others wasn’t about ‘hurting others’ it was about protecting themselves – it was defensive!

When I meet someone dealing with paranoid thoughts I ask them about their thoughts. I ask what steps they feel would be reasonable to take in order for them to feel safe, to deal with the ‘threat’ they perceive. Some individuals may take a passive stance – “There’s nothing I can do, they’re just too powerful ”, while others might say “I keep a machete under my bed all the time and if they try to come and get me I’ll get them first”.   In my view, this information is much more valuable than a yes/no response. It leads to problem solving.

Remember Shalom’s 3 favorite words “Tell me more.”

Shalom Coodin

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