According to a March 2023 report from the U.S. Government Accountability Office, the FBI’s domestic terrorism investigations have “more than doubled since 2020” and the number of open FBI domestic terrorism investigations have more than quadrupled, climbing “from 1,981 in FY 2013 to 9,049 in FY 2021.” This significant rise in violence has led everyone from Congress to mental health clinicians to question what might be driving such spikes and whether there is a relationship between mental illness and such violent extremism. If there is, how can it be addressed clinically while ensuring patient safety and protecting the public?
What is violent extremism?
As you can imagine, most people aren't born extremists. The process of shifting into holding violent extremist beliefs and acting upon them is known as “radicalization,” which is defined by Błażej Misiak et al. in the European Psychiatry article “A systematic review on the relationship between mental health, radicalization and mass violence” as “a process by which individuals adopt extreme political, social, and religious ideation that leads to mass violence acts.” Some extremism grows from a belief in conspiracies, which Biljana Gjoneska describes in “Conspiratorial Beliefs and Cognitive Styles: An Integrated Look on Analytic Thinking, Critical Thinking, and Scientific Reasoning in Relation to (Dis)trust in Conspiracy Theories” as “implying secret and malevolent plots by scheming groups or individuals.” Gjoneska describes texts by conspiracy theorists as reflecting not the external world per se but rather internal worldviews,
"Offering a glimpse into the mental states of people with [a] pronounced tendency to endorse conspiratorial narratives as explanations for important events and cultivate persistent beliefs that powerful others are secretly plotting to harm them.”
Gjoneska points out that these kinds of beliefs are easily spread, often to the point of being referred to as “contagious” with negative repercussions towards the health of individuals worldwide. It can be helpful to think about the ways in which people's psychologies, personalities, and pre-existing psychiatric health conditions might make them protected from or predisposed to this contagion the way that a patient's immune system would make them more or less likely to catch a physical pathogen.
How health care professionals can recognize warning signs of mental illness colliding with extremism
It is important for clinicians to holistically recognize what could trigger at-risk patients with an eye towards escalating warning signs. Clinicians are encouraged to perform “threat assessments” in order to identify warning signs and accompanying levels of risk. In “The Role of Warning Behaviors in Threat Assessment: An Exploration and Suggested Typology,” Dr. J. Reid Meloy et al. define eight warning behaviors, or “particularly toxic changes in patterns of behavior which require an operational response,” for clinicians to identify and intervene in patients at risk of committing violence:
- Pathway behavior (planning, researching, or preparing an attack)
- Fixation (“any behavior that indicates an increasingly pathological preoccupation with a person or a cause [...] typically accompanied by social or occupational deterioration”)
- Identification with being an agent for a particular cause or the “psychological desire to be a 'pseudo-commando'”
- Novel acts of aggression or violence suggesting a “behavior tryout”
- An energy burst (“an increase in the frequency or variety of any noted activities related to the target”)
- Leakage (“communication to a third party of an intent to do harm to a target”)
- A direct threat to the target or police
- Last resort warning behaviors, indicating “in word or deed” that the patient sees violence as the only solution to “increasing desperation or distress”
In addition to looking out for warning signs, Dr. Meloy et al. also suggest assessing the likely severity and probability of outcome of violence as well as the “imminence of the behavior of concern, [including] brevity of time between the assessment and the act [and] an increasing probability of the act occurring within a specific time-frame.” This will help health care providers determine the necessary speed of intervention. Risk is dynamic by definition, however, and clinicians should not take an immediate lack of concern as an unchanging matter:
“It is necessary to repeat the [threat assessment] in the light of new information, as each occasion [is] simply a 'snapshot' of a moving scene - a still frame from a movie. Some [instruments] adapt such snapshots to the changing picture by the use of scenarios or scenario planning [including] constructing likely narratives of how things might change for the better or worse. [An] attempt is made to project the risk factors into the future and look at ways in which they might evolve, if certain changes [...] were to occur.”
Clinicians can encourage patients to take actionable steps to downgrade the likelihood of extremism, explain Arie W. Kruglanski et al. in “To the Fringe and Back: Violent Extremism and the Psychology of Deviance,” including making social changes and practicing resilience:
“A new friendship network may curb individuals' enthusiasm for extreme means and encourage her or him to embark on a renewed pursuit of mainstream activities. Similarly, extrication from the extremist network may facilitate leaving extremism behind just as immersion in that network may have previously fostered a movement to the fringe. [...] To leave the fringe behind, one may require the resolve and willpower to withstand the group pressure that often binds one to the extremist 'attractor,' and/or the competence to satisfy one's fundamental needs in the balanced ways prescribed by the mainstream. [For example,] in order to be reintegrated into the society, a criminal may need to receive the appropriate vocational training and education [or] the drug addict may need to learn to subjugate her or his destructive habit.”
Risk factors for conspiracy beliefs, radicalization, and violent extremism
Early literature on violent extremism gives little in the way of definitive answers about mental illnesses that might make people inclined to radicalization. Misiak et al. were careful to mention that “caution should be taken on how the association between 'mental health' and 'radicalization' is being claimed because of limited evidence so far, and a number of methodological limitations of studies addressing this issue.” It is also important to note that a belief in conspiracies, or even extremist beliefs as a whole, do not signify an inevitable move towards violence. However, a lack of consensus doesn't imply that clinicians shouldn't increase attention toward mentally ill patients with risk factors for violence who also display warning signs for increasing radicalization. Misiak et al. reviewed a number of studies before 2018 and found,
“Depressive symptoms might be associated with radicalization proneness [but] it remains unknown whether depressive symptoms are associated with resilience or vulnerability to radicalization. Another finding from our systematic review is that several personality traits might predispose [a person] to develop extreme ideation [and] lone-actors might represent a specific subgroup of subjects with extreme beliefs which can be characterized by high prevalence of psychotic and/or mood disorders.”
Meloy and the other authors acknowledge the prevalence of mental illnesses across perpetrators of different kinds of violent extremism. When it came to attackers of public figures, for example, they identified psychosis, delusions, and grandiosity as recurring themes, while adolescent mass murderers and school shooters displayed signs of suicidal ideation. A study cited by the authors on 15 current or ex-postal workers who committed workplace homicides mentioned past histories of substance abuse and mental health issues.
Misiak and the other authors make a point to distinguish between those who are radicalized into joining terrorist groups and those who perpetrate violence on their own, since,
“There is a limited body of evidence for high prevalence rates of mental disorders among terrorists. Terrorist groups might indeed be unlikely to wish to recruit individuals with mental disorders if this is perceived to risk their mission. Moreover, it has been suggested that lone-actors and group terrorists might differ in terms of radicalization pathways, group dynamics, and prevalence rates of mental disorders.”
Misiak et al. explain that radicalization “is a multi-step process with mutually reinforcing stages,” so it is crucial to be able to recognize a risk for violent extremism and intervene as early as possible. They mention several personal history risk factors to be mindful of,
“Including low cultural integration, discrimination with [a] subsequent sense of inequity and injustice, social disparities, and low social cohesion or gang violence [as well as] early experiences of abandonment, perceived injustice, personal uncertainty, family dysfunction, friendships with radicalized individuals, and social changes.”
Kruglanski et al. explain that people who demonstrate moderate (i.e., typical) behavior have motivational balance, avoiding satisfying one need at the detriment of another. They suggest that something sparks a motivational imbalance in an extremist individual, such as,
“When persons realize on their own or are persuaded by others that their important need [which is often social in nature] has been neglected, and [...] an opportunity presents itself to gratify it. Addressing the need in question may then assume high priority.”
Kruglanski and the other authors emphasize the importance of a social group in promoting or moderating extremist behavior while also suggesting that some psychological traits can be protective against extremism even in the midst of an influential social “network”:
“When a violent act is socially validated, people experience less guilt and distress than when it is questioned by important others[.] When the group constitutes an important part of the self-concept, individuals are more likely to engage in extreme pro-group behaviors. [However,] individuals with high confidence in their own judgment, or with high self-ascribed epistemic authority, may not depend as much on others for validation of their goals and means; they are less impacted by social networks and persuasive communicators, as they [...] are in no need of external validation.”
Kruglanski et al.'s emphasis that “high confidence in [one's] own judgment [or] authority” is protective against “persuasive communicators” and similar outside pressures suggests that, conversely, low self-confidence could be a risk factor for group-based radicalization. However, this can work in the opposite direction with “lone-actors” like Unabomber Ted Kaczynski or Anders Breivik, who killed 77 individuals in Oslo in 2011, “had no concrete network of social support [,] and constructed his own justificatory narrative for the massacre.” Other personality risk factors exist across both group and lone-wolf violent extremists, as Kruglanski et al. explain:
“Individuals who are chronically high on a given need (e.g., need for achievement, social approval, sensation-seeking) should be predisposed to privilege it over others. [...] Highly acquiescent individuals may be more readily convinced than others by extremism promoting narratives and networks, whereas individuals with a strong predisposition toward uniqueness may be more prepared than others to break out of the mainstream and explore the fringe regardless of social support. [...] Rejection-sensitive (vs. less sensitive) individuals may be more prone to radicalization. [...] Individuals who are high on the need for cognitive closure may find such [militant] ideologies more appealing, and hence are more likely to radicalize, than individuals who are low on the need for closure[.] Individuals who are dependent or conformist may be more attuned to the network pressures toward radicalization than individuals who are independent and nonconformists. [So, while] there may not be a unique personality profile that characterizes violent extremists prone to volunteer to extremist organizations, certain individual characteristics relevant to determinants of the radicalization process may certainly contribute to [their] likelihood of radicalizing under the proper circumstances.”
What creates these “proper circumstances” for radicalization? Kruglanski et al. suggest,
“Violence is often employed in the effort to restore one's compromised significance. Case studies of fifteen school shootings show that they often occurred in response to social rejection. [...] Humiliation of one's group offers the possibility to strike back at the culprits, [...] demonstrating one's power and hence significance. [...] The experience of significance loss was significantly related to expressed readiness to suffer pain and to sacrifice one's comfort for a significance-lending cause.”
Kruglanski and the other authors pointed to certain recurring “inciting incidents” across their sample of ideological extremists in America:
“Those who experienced abuse, social rejection, or failure were more likely to resort to ideologically directed violence [while] analyses of the motivational patterns of suicide attackers revealed that the degree of violence in an attack was correlated with indicators of the attacker's motivation to gain significance[.] Economic discrimination against minorities has been found to be a substantive predictor of domestic terrorism. [...] Many instances of significance loss are [seen as the] result of other people's actions [and perceived as] unfairness.”
Despite misconceptions, patients with mental illnesses are much more likely to be the victims of violence rather than the perpetrators, as Norman Ghiasi et al. explain in “Psychiatric Illness and Criminality.” It's crucial to understand that violent extremism is a complex phenomenon that cannot be explained with psychiatry alone. However, in the instances when someone with a mental illness is at risk of committing violent acts, an understanding of these risk factors and knowledge of how to assess for warning signs and de-escalate patients on the precipice of radicalization can make a significant impact on keeping people safe.
Continuing education on mental illness and extremism
Curious to learn more about helping patients who demonstrate risks for violent extremism? Head to AudioDigest to explore patient safety CME courses, including Conspiracy Theories and Violent Extremism, Part 1 and Conspiracy Theories and Violent Extremism, Part 2, to learn how to identify personality traits that predispose patients to violent extremism, implement strategies for managing psychiatric disorders in patients with extremist ideologies and conspiracy beliefs, and reduce the risk for associated violence.
