Homicidal ideation in outpatients

[Attending1985]

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I saw an intake for a young adult patient with chronic homicidal ideation. Reports barrier as fear of legal consequences. I work in an outpatient clinic associated with a hospital and have no wraparound services. Now that I’ve seen the patient I know transfer of care gets more complex. Have any of you been in a situation like this where they’ve done an initial evaluation then recommended a community mental health clinic for wraparound services. What if the patient isn’t willing to go there?

 

[comp1]

Sure, this is kind of a bread and butter thing in SMI populations, whether that SMI is psychosis or personality pathology. Your specific state laws are going to determine what you have to do about HI (as with most things), but for MOST states, chronic HI without intent isn't something you legally must report to anyone. In terms of referring to community mental health...that's even more specific than state. That's getting down to the brass tacks of how your specific county works. If you aren't able to provide the level of care that the patient needs, then you do have an obligation to refer to the appropriate level of care. Ultimately unless the patient is conserved or otherwise deemed incompetent by your state laws, it's up to them whether they follow through on your referral. Do you mean do you have an obligation to keep seeing them if you can't provide the level of care they need and they aren't willing to go somewhere that can provide that level of care that you referred to? The answer to that is no.

 

[Attending1985]

I guess I’m a little confused on level of care. If I’m referring them to a county outpatient clinic. Is that considered a higher level of care?

 

[Sushirolls]

It can be, on paper.

Assuming the county community health agency is functioning well, well staffed. Which we all know they all function great, with low staff turnover, high employee retention/satisfaction, and just the right robust resources they need to best support their patients. A true testament to bureaucracy functioning well.

 

[Attending1985]

Question for those who work in the type of clinic that I do do you have screening processes to prevent things like this from happening?

 

[comp1]

This is unclear. What exactly are you trying to prevent? Seeing patients with homicidal ideation? Maybe if you have a cash based private practice you can somehow screen out patients like that, but I doubt most hospital attached practices are going to want to screen out what can be a core psychiatric complaint. If you mean prevent a patient from acting on homicidal ideation, that's a much more complex question and probably something to read books/literature on. Also, you often can't, which is why there are mandatory reporting rules in some state situations. And yes, county services CAN be a higher level care. They definitely aren't necessarily and can certainly be much worse/more limited than regular outpatient levels of care. You need to get familiar with what the services are in your county and if the patient has private insurance, what they cover.

 

[Attending1985]

This is unclear. What exactly are you trying to prevent? Seeing patients with homicidal ideation? Maybe if you have a cash based private practice you can somehow screen out patients like that, but I doubt most hospital attached practices are going to want to screen out what can be a core psychiatric complaint. If you mean prevent a patient from acting on homicidal ideation, that's a much more complex question and probably something to read books/literature on. Also, you often can't, which is why there are mandatory reporting rules in some state situations. And yes, county services CAN be a higher level care. They definitely aren't necessarily and can certainly be much worse/more limited than regular outpatient levels of care. You need to get familiar with what the services are in your county and if the patient has private insurance, what they cover.

How often are others seeing chronic homicidal ideation in their outpatient practice? I’ve been working ten years and this is my first case.

 

[splik]

Why does the pt need wraparound services? you haven't mentioned

 

[calvnandhobbs68]

Question for those who work in the type of clinic that I do do you have screening processes to prevent things like this from happening?

An outpatient clinic associated with a hospital?

I would assume the hospital system would have a policy about this if you're employed by the hospital system. I would bet you wouldn't necessarily be able to "screen" for this unless the system itself would allow it. In a private practice, sure you could try (ex. have some question about "do you now or have you ever had a serious intent to harm others?) but people can also just lie on their forms.

How often are others seeing chronic homicidal ideation in their outpatient practice? I’ve been working ten years and this is my first case.

I guess what do you mean by chronic homicidal ideation? Like towards who, because of what? Just everyone in general?Does it seem to be based in delusion, despair, antisocial personality traits, etc etc? Is there a violence history and any prior real threats of violence? It's the same thing as suicidal ideation there's quite a wide spectrum from "I think about dying sometimes" to "I'm going to kill myself tonight with this gun".

 

[lobstar]

Yeah agree with what specific wraparound services are needed? It kinda reads like you view all HI as something that needs to go anywhere else and needing "wraparound services" and "higher level of care" is a justification to get them out of your clinic asap. Like other people have pointed out, chronic HI doesn't necessarily need a higher level of care or wraparound services.

 

[Attending1985]

Can anyone recommend some resources. I’ve been looking and I just find stuff on management of acute homicidal risk but not chronic.

 

[calvnandhobbs68]

Can anyone recommend some resources. I’ve been looking and I just find stuff on management of acute homicidal risk but not chronic.

You seem fairly flustered by this....also why are you not just answering the questions here so people can actually give you advice? Saying someone has chronic HI is as meaningless as saying they have chronic SI, possibly moreso.

 

[aim-agm]

How often are others seeing chronic homicidal ideation in their outpatient practice? I’ve been working ten years and this is my first case.

It's really not that uncommon. I think I'm averaging a case of "chronic HI due to psychiatric condition with plan and intent that would be acted on given opportunity" as least every 1-2 years, and those were just the cases I was doing psychotherapy with.

 

[FatherPsychiatry]

It's really not that uncommon. I think I'm averaging a case of "chronic HI due to psychiatric condition with plan and intent that would be acted on given opportunity" as least every 1-2 years, and those were just the cases I was doing psychotherapy with.

What did you do with those cases?

 

[R. Matey]

How often are others seeing chronic homicidal ideation in their outpatient practice? I’ve been working ten years and this is my first case.

Questions off the top of my head: Are they expressing an imminent threat to harm someone? Do they have a plan? Do they have access to means? If yes, are they willing to part with those means? Are they willing to enlist support people to help them? If not, are they willing to distance themselves from those means as much as possible? Can they commit to a safety plan? Do they see this person often? Are they trying to see this person? They are afraid of legal consequences, sure, but how afraid are they? Do they worry about going to jail? What will they lose if they go to jail? What will they gain by not acting?

 

[aim-agm]

What did you do with those cases?

Fortunately the risk of the HI being acted on was quite limited in these cases, so they could continue to be (closely) managed outpatient. Only one patient had desire to actively seek out the object of the HI, but they were halfway across the country and that patient was married, so travel was unlikely to be undetected and adequate time for warning and response.
In these cases the HI was (in different ways) trauma-related and moral functioning (and personality function in general) was intact, so treatment was primarily psychotherapy which they responded well to.

 

[MatchVault]

On the resource question from #11 — for chronic (as opposed to acute) risk, the literature standard is structured professional judgment rather than trying to "predict" violence. The HCR-20 (version 3) manual is probably the single most useful resource: it walks through historical, clinical, and risk-management factors and how to build scenario-based risk formulations. The APA's resource document on assessing and managing violence risk is a good companion piece, and it is worth bookmarking your own state's duty-to-protect/warn statute, since the legal obligations vary widely by jurisdiction.

A framework often taught for keeping this straight: (1) Is there an imminent, identifiable threat with a plan and means right now? That question drives hospitalization and duty-to-protect decisions. (2) What are the modifiable drivers — active psychosis, substance use, access to weapons, interpersonal conflict — that become the treatment targets? (3) What is the monitoring and safety plan between visits? Documenting that structure explicitly also matters medicolegally.

One practical note: coordinating with other treaters and warning an identifiable potential victim are generally permitted disclosures, so the HIPAA barrier people worry about in these moments is usually lower than it feels. The key is documenting the clinical rationale at the time.

 

[clausewitz2]

On the resource question from #11 — for chronic (as opposed to acute) risk, the literature standard is structured professional judgment rather than trying to "predict" violence. The HCR-20 (version 3) manual is probably the single most useful resource: it walks through historical, clinical, and risk-management factors and how to build scenario-based risk formulations. The APA's resource document on assessing and managing violence risk is a good companion piece, and it is worth bookmarking your own state's duty-to-protect/warn statute, since the legal obligations vary widely by jurisdiction.

A framework often taught for keeping this straight: (1) Is there an imminent, identifiable threat with a plan and means right now? That question drives hospitalization and duty-to-protect decisions. (2) What are the modifiable drivers — active psychosis, substance use, access to weapons, interpersonal conflict — that become the treatment targets? (3) What is the monitoring and safety plan between visits? Documenting that structure explicitly also matters medicolegally.

One practical note: coordinating with other treaters and warning an identifiable potential victim are generally permitted disclosures, so the HIPAA barrier people worry about in these moments is usually lower than it feels. The key is documenting the clinical rationale at the time.