One Size Does Not Fit All; Violent Extremism and Clinical Service Utilization

One Size Does Not Fit All; Violent Extremism and Clinical Service Utilization

Featured Article

Featured Article | International Journal of Forensic Mental Health  | 2023 Vol. 22, No. 3, 222-232

Article Title

Clinical Services Addressing Violent Extremism: The Quebec Model


Cecile Rousseau; Division of Social and Cultural Psychiatry, McGill University, Montreal, Canada

Rochelle Frounfelker; Department of Community and Population Health, Lehigh University, Bethlehem, PA, United States

Cindy Ngov; Sherpa University Institute, Montreal, Canada

Anne Crocker; Department of Psychiatry and Addictology, University of Montreal, Montreal, Canada


The association of ideologically motivated violence with mental health disorders raises specific challenges for security agencies and clinical services. The aim of this paper is to describe the clientele of a specialized intervention program based in Montreal, Quebec, in terms of type of violent ideology and clinical presentation. We conducted a retrospective chart review of 156 individuals referred for violent extremism who received clinical services between 2016 and 2021. Univariate statistics were used to present a description of client sociodemographic and clinical characteristics. Roughly a third of clients referred for violent extremism presented non-ideologically based violence (32.6%), followed by 31.4% affiliated with far-right extremist ideology and over a quarter (25.6%) holding extremist views on gender. Over a third of these individuals had a stress-related (35.7%) and/or mood and anxiety disorder (36.9%), followed by 28% with an autism spectrum disorder diagnosis. The majority had some previous contact with mental health services. A significant number of clients displaying extremist discourses and/or actions needed psychiatric services but often failed to receive them because of the reluctance of clinicians to work with individuals perceived as high risk; in addition, individuals may be reluctant to engage in services perceived to be part of a socio-political system they reject. Specialized services are important as a means to provide mental health care to this group and also to develop knowledge and best practices for working with this clientele and provide consultation to mainstream mental health service providers.


Violent extremism; clinical services; mental health care; specialized intervention

Summary of Research

“…While violent extremism has recently begun to be considered a significant public health issue requiring prevention programs…it is a field which remains relatively unknown to clinicians, who nonetheless may increasingly encounter patients adhering to their hate discourses or to ideologies legitimizing violence…For lone actors and those individuals that do have a psychiatric problem, therapeutic clinical interventions may offer more relevant risk reduction strategies than security-oriented approaches, such as incarceration, which permeate the field of violent extremism…Overall, most violent extremism intervention programs were developed as a response to a particular threat, and very few address violent extremism in both lone actors as well as socialized actors…This paper describes the characteristics of patients receiving services from a specialized clinical team addressing violent extremism in Quebec (Canada)…The research questions are: How many individuals have received services? What were the socio-demographic characteristics of individuals receiving services? What were their clinical characteristics? What forms of psychosocial adversity did they report? What were the sources of referrals and the pattern of service utilization of these patients?” (p. 223-226).

“The results suggest that circulating extremist ideologies in our society are inspiring idioms of distress and behaviors in a sub-group of patients with mental health disorders, and that this constitutes a challenging presentation which clinicians may have to address…The extremist ideologies of patients are aligned with violent extremism sociopolitical trends in the last decade…The relatively large group of patients referred for what proved to be non-ideological forms of violence reflects the growing attraction to mass killers and school shooters by youth…Finally, more recently, the referral of individuals for extremist behaviors (threats and violent acts) related to conspiratorial and anti-system beliefs may be related to the effects of the pandemic on violence…Our findings converge with a study of active shooters in the US [United States], with and without ideological motives…in which the most frequent diagnosis encountered were mood disorders, followed by stress related disorders. The high number of ASD [autism spectrum disorder] diagnoses among clients is also noteworthy and has been reported in the violent extremism literature (Faccini & Allely, 2017)…Overall, the clientele served by the team is clearly a psychiatric population in need of mental health services and cannot be characterized only as a forensic population. Notably, for many of our patients, distress was often increased by the involvement of security forces that infrequently recognized the severity of patient mental health problems (except in cases of psychosis)…” (p. 229).

“Results show that patients referred for violent extremism report multiple social grievances…Issues related to social isolation and family conflict, which affect half of our patients, are frequently found among extremists…The low community engagement and the high internet use complete the picture of individuals who are generally in the margins of society and may project onto this society (and too often onto their family) the responsibility for the perceived injustices they suffer. The internet plays a well-recognized role of echo chamber which confirms the legitimacy of these grievances largely shared by a resentful community…These grievances are, however, also common in psychiatric patients, and it is not possible to determine if social grievances have a causal role for our patient population, or if violent extremism rather constitute[s] a new way to express distress for patients who would have channeled their despair and rage differently in the past…” (p. 229).

Translating Research into Practice

“…A number of factors may contribute to this finding: ASD clients may be over-referred because they are perceived as odd and not acting as expected. Their level of compliance with services tends to be better than the compliance of clients with other diagnoses, and their experiences of exclusion and isolation makes them more prone to be attracted to extremist discourse (Walter et al., 2021). Overall, caution is required in interpreting this finding, as the patients suffering from these diagnoses may experience a high level of distress that may lead them to accept services more readily than others” (p. 229).

“In terms of service delivery pathways, the unsurprising importance of security services as a source of referral emphasizes the need to establish firewalls and mandates around this clientele (Rousseau et al., 2017, 2019). The high number of clinicians involved per patient (almost always more than 2) may be an indication of the burden associated not only with risk perception but also with the continuous exposure to hate discourses. These are the main reasons evoked by mental health practitioners to refuse this clientele, often considered ‘unmotivated’ and ‘scary.’ According to team clinicians, active outreach, suspension of judgment, and teamwork are key elements for successful services (Rousseau et al., 2021)” (p. 229-230).

Other Interesting Tidbits for Researchers and Clinicians

“An emerging literature on the relationship between mental disorders and violent extremism emphasizes the similarities between the profiles and trajectories of active shooters and radicalized lone actors (Gill et al., 2014). In both cases, personal and collective grievances often play a key role, and a history of diagnosed mental disorder is present in 35% to 30% of perpetrators…The presumption of a direct, causal relationship between mental disorder and lone actor attacks is premature…and may be deleterious as it may stigmatize persons with lived experience of mental illness and run the risk of amalgamating social and political dissent with mental illness and criminal tendencies…” (p. 223).

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