Red Flags: Warnings Signs of Violence That You Should Know


(7-8-16) Dear Pete,  In your recent blog post, Violence and Mental Illness: An Uncomfortable Subject But A Grim Reality For Some Families,” there are frequent references to “warning signs.” Please tell us what all the warning signs are. –K. Y.

I passed this email request to  my friend and fellow advocate Doris Fuller, Chief of Research and Public Affairs at the Treatment Advocacy Center, who wrote poignantly and eloquently in the Washington Post about her own daughter’s illness and eventual suicide. Here is her thoughtful reply. 

Red Flags for Family Violence

Risk factors

Most people with serious mental illness are not violent. However, a small percentage not being treated may be violent toward family members or others. According to Surviving Schizophrenia: A Family Manual, the three most important predictors of violence are:

  • Past history or threats of violence, against family members or others;
  • Concurrent alcohol or drug abuse; and
  • Failure to take prescribed antipsychotic medications.

Additional risk factors that have been found to be significant are:

  • Being 20 to 35 years old
  • Delusions of being persecuted, watched or attacked (“paranoia”)
  • “Command hallucinations” that order the person to engage in a specific behavior (e.g., hearing a “voice” that orders the person to commit a violent act to end world hunger)

As the number of risk factors present increases, risk increases.

If you are worried about a loved one, but there appears to be no immediate danger, alerting the person’s psychiatrist, case worker, ACT team or other mental health provider to the situation ideally results in intervention before crisis develops.

However, it is critical not to underestimate the risk of danger in the presence of multiple risk factors, even from someone you know loves you deeply. People who are acutely psychotic – especially if also delusional and abusing alcohol or street drugs – may not be predictable and are capable of extreme violence. If your instincts tell you the situation is dangerous, it probably is.

Leave the scene if possible and/or call 911. Be sure to tell law enforcement you are calling about a psychiatric crisis and request first responders trained to respond to mental health emergencies.

It pays to be prepared. Keep crisis information current and readily available to give to first responders and hospital personnel. It should include the person’s name, age, diagnosis, treating psychiatrist or other providers, current medications and summary of past history of symptomatic and/or violent behavior.

Responding in a Crisis

Mental health and law enforcement experts offer the following tips for responding to a danger of assault. The list is by no means comprehensive and should not be taken as a substitute for leaving the scene or taking other potentially life-saving measures.

  • Speak in a calm, quiet voice. If it seems your loved one isn’t listening or can’t hear you, it is possible that auditory hallucinations (“voices”) are interfering. Don’t shout; raising your voice won’t help and may escalate tensions.
  • Avoid being trapped. Remain physically between the person and the open door. Maintain a safe room with a secure lock and telephone access where you can retreat in an emergency.
  • Respond to delusions by talking about the person’s feelings, not about the delusions – Say, “This must be frightening,” not “You shouldn’t be frightened – nobody’s going to hurt you.”
  • Don’t stare. Direct eye contact may be perceived as confrontational or threatening
  • Don’t touch unless absolutely necessary. Touch may be perceived as a threat and trigger a violent reaction
  • Remain physically distant. Anything that makes you appear threatening – like standing over a person who is seated – could heighten risk.
  • Don’t give multiple choices or ask multi-part questions. Choices can increase confusion.
  • Don’t correct, threaten or criticize. Acute mental illness is a medical emergency. Suggesting that the person has chosen to be in this condition won’t help and may escalate tension
  • Don’t argue with others on the scene. Conduct all discussion of the situation quietly and out of the person’s hearing
  • Don’t whisper, joke or laugh. This may increase agitation and/or trigger paranoia

The Treatment Advocacy Center hosts a psychiatric crisis smartphone app. Open this link on your smartphone to load the app.

No matter how prepared you are, it can be difficult to remember your preparations when you find yourself in an emergency. The app can be helpful.

The Treatment Advocacy Center provides additional tips on the Get Help section of its website.

About the author:

Pete Earley is the bestselling author of such books as The Hot House and Crazy. When he is not spending time with his family, he tours the globe advocating for mental health reform.

Learn more about Pete.