When a client discloses homicidal ideation, three questions take over the rest of the session.
How serious is the risk? What do you need to do about it? And what will your note show?
The answers tend to live in the specifics. A fleeting image after a fight with a sibling and a plan to confront a coworker with a gun sit at opposite ends of the same term, and they call for very different responses and documentation.
Key Takeaways
- Homicidal ideation is a symptom that can appear with many conditions, or with none, and it ranges from a passing wish to a detailed plan.
- OCD harm obsessions are often unwanted and frightening to the client, and they need a different response than ideation a client endorses.
- Ask about the target/victim, plan, intent, timing, access to weapons and past violence in plain, direct language.
- Screen for suicide in the same session, since the two can show up together.
- Duty to warn rules differ by state, so learn your state's law and licensing board guidance before a crisis.
- A safety plan for violence risk often adds distance from the person at risk and tends to include secure storage of weapons.
- Your note should show what you asked, what you found, how you weighed it, what you did and why.
What Is Homicidal Ideation?
Homicidal ideation is the experience of thoughts, wishes or plans about killing another person.
It's a symptom that can show up with psychosis, mood disorders, substance use and personality patterns. It also shows up in clients with no diagnosable condition who are furious at one specific person or injustice.
Severity runs along a range:
- Passive homicidal ideation: a wish that someone were dead or gone, with no thought of causing it
- Active ideation without a plan: thoughts of killing someone, with no method or timeline
- Active ideation with a plan: a chosen method, place or time
- Plan with intent or preparation: the client means to act or has taken steps, like getting a weapon
Clients also say "I could kill him" when they mean they're angry. Take the words seriously enough to ask follow-up questions, then let the answers set your level of concern.
Homicidal Thoughts or Intrusive Thoughts?
A client who's terrified they might hurt their partner may have a very different problem than a client who wants to. That is often the difference between a harm obsession vs. a homicidal thought.
In Obsessive-Compulsive Disorder (OCD), harm obsessions are unwanted, intrusive thoughts or images about losing control and hurting someone, and they cause real distress. Blueprint's guide to impulsive thoughts vs intrusive thoughts goes deeper on telling these apart.
Homicidal ideation, OCD harm obsessions and the routine angry vent session can all sound similar in the beginning. Differentiating between them will require important follow-up questions. To better understand which assessments or questions to ask, consider the following table:
Medical, Substance and Psychiatric Causes to Rule Out
Therapists know that most violence isn't driven by mental illness, and still, a medical or psychiatric driver can change your treatment and/or crisis plan, so it’s important to screen across various categories.
Below is a rule-out checklist for you to use when the ideation is new, sudden or out of character for your client.
Because antisocial personality disorder is the personality disorder most often linked with violence, consider risk management (versus traditional symptom management) to be a significant driver for treatment.
How to Do a Homicidal Ideation Assessment
A structured approach to a homicidal ideation assessment can help you catch risk factors that have nothing to do with mental illness. Do your best to cover the same ground every time, establishing a baseline, and adjusting the depth of the assessment to what is shared by your client.
Ask direct, specific questions
Clients tend to directly answer questions asked, so be specific with your language. Use words like "kill" and "hurt" instead of softer, less direct phrases like "dark thoughts" if it allows for a more accurate assessment.
- Target/victim: "Who are you thinking about hurting?"
- Frequency: "How often do these thoughts come up, and how long do they last?"
- Plan: "Have you thought about how or where you'd do it?"
- Intent: "Do you think you'll act on this? What's stopped you so far?"
- Timing: Ask whether the threat depends on what the other person does next, or if there’s a specific time they’d choose to act regardless
- Means: "Do you have access to a gun or any other weapons?"
- Past violence: "Do you have a history of violence? What's the most violent thing you've ever done, and what set it off?"
- Perceptions: "Does it feel like this person is threatening or controlling you?"
Weigh what raises and lowers violence risk
The following factors carry the most weight in a violence risk assessment.
Note what's holding the client back from acting on these urges, too. What reasons do they give for not acting? Who are the people they don't want to lose? How engaged are they in treatment? These are considered protective factors that can give you a lot of important information about the client and the situation.
Screen for suicide in the same session
Homicidal thoughts are correlated with suicidality. In a 2022 study of nearly 19,000 US adolescents hospitalized with homicidal ideation, 66.9% also had suicidality. That doesn't mean most clients with suicidal thoughts also have homicidal ideation.
Asking about suicide doesn't increase suicide risk, so ask directly, honestly, and as often as needed to make a full assessment. The Columbia Suicide Severity Rating Scale (C-SSRS), developed by researchers at Columbia University, the University of Pennsylvania and the University of Pittsburgh with National Institute of Mental Health support, encourages consistency in asking.
Bring in collateral and consultation
Review collateral sources, such as records, prior treaters or family, with consent where it's required. Then talk the case through. Peer consultation or a second opinion can surface risk management ideas you hadn't considered.
Safety Plan for Homicidal Ideation
Barbara Stanley and Gregory Brown developed the Stanley-Brown Safety Plan for suicide risk. You can borrow its structure for violence risk, with a few changes. Blueprint's guide to using a safety plan template walks through the standard steps.
Here's how each step can look when the risk is to someone else.
Build the plan with the client during the same visit, and ask family or other supports to help limit access to weapons when the client agrees. Keep the plan in the client's words.
A safety plan never replaces a risk assessment. When risk is high, move to emergency evaluation, hospitalization or more frequent contact, and follow your state's duty to warn requirements.
What Duty to Warn Means and Why Your State Decides
The general principle
Duty to warn traces back to Tarasoff v. Regents of the University of California, the 1976 case in which the California Supreme Court held that therapists have a legal duty toward third parties their clients threaten. That case set off duty to warn or duty to protect laws in almost every state.
Today, most states either require or permit you to take reasonable steps to protect a potential victim. The state-by-state duty to warn laws also differ on what triggers the duty, such as whether the victim must be identifiable and how soon harm could happen. Some states even set different rules for different license types.
Duty to protect is the broader idea. Depending on your state, you might meet it by warning the person, notifying police, arranging hospitalization or stepping up treatment.
What HIPAA and ethics codes add
The Health Insurance Portability and Accountability Act (HIPAA) has a serious threat exception. It lets you share the information needed, without the client's permission, with people who can help prevent the harm, such as family, caregivers or law enforcement, when the threat is serious and imminent.
The Department of Health and Human Services defers to your good-faith professional judgment on that call. HIPAA permits the disclosure; your state law decides whether you must make it.
Ethics codes surrounding these situations help add guardrails. The National Association of Social Workers Code of Ethics asks social workers to share the least information necessary, tell clients about a disclosure beforehand when feasible and explain the limits of confidentiality early in treatment. Blueprint's overview of when therapists have to report covers the other exceptions.
How to find your state's rule
- Read your state's statute or case law, and treat any summary table as a starting point
- Check your licensing board's rules and guidance
- Call your professional association or your malpractice carrier's risk management line
- Ask a health care attorney about gray areas
It’s important to prepare for situations like these before you need to manage them, and put what you learn in your practice policies.
Documenting Violence Risk in Your Notes
Your record should show a thoughtful risk assessment and the steps you took to reduce the risk. A reviewer reading it later should be able to follow how you got from the client's words to your set of decisions.
What to include
- What the client said, in their own words where it matters
- Target, plan, intent, timing, means and past violence, including what the client denied
- Suicide screening results
- Risk and protective factors, assessed risk level and the reasoning behind it
- Actions taken, including why you did or didn't take other steps (like a warning)
- Any disclosure: who you contacted, when, what you shared and whether you told the client
- Consultation and the follow-up plan
Sample note language
Here's an example with made-up details:
"Client reported thoughts of killing former business partner over a lawsuit, several times daily for 2 weeks. Client denied plan, intent or timeline and denied access to firearms; spouse confirmed no weapons in the home by phone, with client's consent. No history of violence reported. Client denied suicidal ideation; C-SSRS screener negative. Risk assessed as low to moderate given frequency and a specific target, weighed against no plan, intent, means or violence history. Completed safety plan, including avoiding contact with former partner. Consulted with colleague on 10/14/2026; agreed state duty to warn criteria were not met. Next session in 3 days."
Homicidal Ideation FAQ
What is homicidal ideation a symptom of?
It isn't tied to one condition. It can show up with psychosis, mood disorders, substance use, delirium, brain injury or personality patterns, and in clients with no diagnosis who are angry at someone. Rule out medical and substance causes when it's new or out of character.
What is the relationship between depression and homicidal ideation?
In the 2022 adolescent study, teens hospitalized with homicidal ideation were more likely than other adolescent inpatients to have major depression. Depression can also bring suicidal thoughts, so screen for both when either one appears.
Can homicidal ideation be treated?
Yes, by treating what drives it. Psychosis, substance use, OCD and problem anger can all respond to treatment, and changeable risk factors like substance use can shift with intervention.
Do you have to report homicidal ideation?
Not automatically. Whether you have to warn or protect depends on your state's law and the facts, such as how serious the threat is and whether there's an identifiable victim. Past crimes follow different rules; see whether therapists have to report crimes.
Does 988 help with homicidal ideation?
The 988 Suicide & Crisis Lifeline is for anyone dealing with mental health struggles, emotional distress or alcohol or drug concerns, and clients can call, text or chat. If anyone is in immediate danger, call 911.
