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Tijdschrift voor Psychiatrie 60 (2018) 4, 241 - 249

Essay

How to act in case of a homicidal patient; a literature review and a practice guideline

B.S. Frelier, T.J. Holwerda

background Death threats are common in the therapist’s office. Many therapists don’t know how to handle these.
aim To provide background information and tools for the practitioner who receives a homicidal threat from a patient.
method A systematic literature review of the epidemiology, diagnostics, risk assessment and treatment of homicidal threats.
results During consultation, a death threat is not equatable with the announcement of murder. There are far more instances where the patient does not follow through with their threat. A psychotic disorder, an antisocial personality disorder, alcohol abuse, (bipolar) depression, long-existing (severe) domestic violence, possession of a weapon or a previous conviction for a death threat are important risk increasing factors. The risk assessment evaluates the motives and the proclivity to act. emdr and aggression regulation therapy appear to be effective treatments for underlying trauma and anger. However, psycho-dynamic aspects and feelings of countertransference should also be taken into account during therapy. Three Dutch guidelines about professional secrecy are important when making an assessment about whether or not one should break the rules of confidentiality.
conclusion Any practitioner who may be faced with a homicidal patient should have ready access to the relevant guidelines. Mental health institutions are encouraged to actively support this process.

keywords homicidal, professional secrecy, risk taxation, weapons