Clinical Services Addressing Violent Extremism: The Quebec Model

Abstract

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.

Keywords:

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

Introduction

The relative importance and manifestations of ideologically motivated violence vary with distinct sociopolitical contexts. Its association with mental health problems is a controversial topic. While violent extremism has recently begun to be considered a significant public health issue requiring prevention programs (Bhui & Bhugra, 2021; Eisenman et al., 2006) it is a field which remains relatively unknown to clinicians, who nonetheless may increasingly encounter patients adhering to hate discourses or to ideologies legitimizing violence (Rousseau, Aggarwal, et al., 2021). According to UNESCO, violent extremism “refers to the beliefs and actions of people who support or use violence to achieve ideological, religious or political goals" (UNESCO, 2017). This can include "terrorism and other forms of politically motivated violence" (UNESCO, 2017). Violent extremism is associated with individual and social psychological processes both in local communities and larger networks. Integrative models distinguish between macro- (national and international), meso- (school, community) and micro-level risk and protective factors (life experiences, mental health) (Adam-Troian et al., 2021; Bhui & Bhugra, 2021; Rousseau et al., 2020). The association between mental health problems and violent extremism is complex: although engaging with an extremist group is not associated with psychiatric problems, this is not the case for lone actors, who may perpetrate violence in the name of a violent ideology (Gill et al., 2017; Silver et al., 2018). 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 (Hassan, Brouillette-Alarie, et al., 2021). Unfortunately, clinical intervention programs specifically designed to work with and address the needs of individuals defined as violent extremists are rare, and little is known about their effectiveness (Rousseau, Savard, et al., 2021). Intervention programs are distributed along a continuum with, on the one end, models focusing on psychosocial interventions to increase social integration without addressing mental health issues and, on the other end, programs inspired by forensic psychiatric approaches. As an example of the former, in Aarhus (Denmark), a psychosocial model of mentorship, formulated to address the social crisis around the departure of youth toward Syria to join ISIS, emphasizes the acquisition of life skills and the consolidation of a social network (Agerschou, 2014). On the side of specialized forensic interventions, in the UK, a service model developed by James et al. (2010) addresses the risk posed by lone individuals with intense pathological fixations, which constitute a sub-group of the subjects identified as violent extremists having mental health problems. A joint initiative of the police and the UK National Health Services, the Fixated Threat Assessment Services has been shown to reduce risk of violence in up to 80% of cases (James et al., 2010).

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. As countering violent extremism becomes a global priority, with mounting public and political pressure to prevent acts of terrorism (National Security Council, 2021), the relative lack of information on evidence-based programs and services that address both violent extremism and mental health is a major shortcoming. This paper describes the characteristics of patients receiving services from a specialized clinical team addressing violent extremism in Quebec (Canada) (National Security Council, 2021). We describe clinical presentations related to violent extremism to foster discussion as to the relevance of mental health services in a domain that remains relatively unknown to psychiatrists and other mental health professionals.

Violent extremism and mental health interventions

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 25% to 30% of perpetrators (Gill et al., 2021). In a study of pre-attack behaviors of active shooters in the US, the most frequent diagnoses were mood disorders, followed by anxiety disorder, psychotic disorder, personality disorder and autism spectrum disorder (ASD) (Silver et al., 2018). These findings align with results on preexisting psychopathology in lone actors, emphasizing the often neglected relationship between depression and violence and the association of suicidal and homicidal behaviors with social and cultural factors (Misiak et al., 2019; Trimbur et al., 2021). The work of James et al. (2010) on individuals who have pathological fixation on public figures suggest that most of them (86%) suffer from psychotic disorders, and raise important questions about the need to identify the factors that may be related to the actual level of risk (Gill et al., 2021). In the U.S. a study by Gruenewald et al. (2013) illustrates particularly vividly the differences in mental health diagnosis between U.S. Far-Right Group Terrorists, with 7.6% of perpetrators having a confirmed mental health diagnosis, and U.S. Far-Right Lone-Actor Terrorists, reaching 40.4%. Summarizing the available evidence through a systematic review of the field literature, Gill et al. (2021) converge with Misiak et al. (2019) in concluding that lone- and group- terrorists are two distinct profiles in terms of their motivations, psychopathological constitution and criminogenic needs. The presumption of a direct, causal relationship between mental disorder and lone actor attacks is premature (Gill et al., 2021) 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. Finally, the authors emphasize that mental health problems are rarely the sole issue and insist that interventions should consider the heterogeneity of the population and favor tailored interventions rather than broad based policies.

Currently, there is little data available to develop best practices for clinical programs addressing violent extremism (Hassan, Brouillette-Alarie, et al., 2021; Hassan, Rousseau, et al., 2021). Systematic reviews show some promising evidence for primary and secondary prevention programs that address social integration factors such as vocational and educational training, civic engagement and cognitive complexity (Hassan, Brouillette-Alarie, et al., 2021). In tertiary programs, evidence points to the relative failure of de-radicalization initiatives and better success of disengagement and reintegration programs that include a wraparound approach (Hassan, Rousseau, et al., 2021). It is to be noted that all programs included in this systematic review target group extremism rather than individual with a lone actor profile, a sub-group of the the latter being found in targeted programs for stalking (James et al., 2010), or in case management programs (Cherney & Belton, 2021). The evaluation of the case management program highlights the positive effects of psychosocial support including psychotherapy on disengagement (Cherney & Belton, 2021). However, the field is fraught with methodological limitations. For example, most de-radicalization and disengagement programs are tailored for justice-involved individuals and thus do not represent voluntary participation in services. Program components are often not described in sufficient detail for reproducibility and lack clear data on participant outcomes (Gielen, 2019). Without such information, government and health institutions cannot train practitioners and provide services to appropriately assess and provide interventions with violently radicalized individuals presenting mental health problems who may be vulnerable and at high risk of violence, which is primarily the case of lone actors.

The Quebec model of clinical services to address violent extremism

Starting in July 2016, following recommendations from the 2015–2018 Québec governmental action plan, a network of specialized clinical services was commissioned to target violent extremism (Kirmayer et al., 2014; Rousseau, Savard, et al., 2021). This multidisciplinary team of experts, attached to a mental health and primary care institution (Centre Intégré Universitaire de Santé et Services Sociaux du Centre- Ouest-de l’île de Montréal), was established to offer consultation services to health, education and security partners across the province. This ecosystemic, intersectoral, and interdisciplinary intervention model aims to maximize outreach and develop specialized clinical and community services. The service model is structured around three pillars: 1) multiple access points to facilitate outreach and decrease stigma; 2) specialized teams to assess and formulate treatment plans based on existing best evidence in forensic, social and cultural psychiatry; and 3) collaborative involvement with proximity services responsible for social integration and long-term management.

Multiple access points

Specialized services can be accessed through different channels to offer rapid access and facilitate outreach and collaboration between relevant partners (individuals, families, communities as well as health, education, and security institutions). The intention behind multiple access points is to reduce stigma as, in Canada (and Quebec is no exception), mental health services, psychiatry, and forensic psychiatry are often perceived by individuals and families as an indication of “madness”. Primary care services and community organizations that provide services for a wide range of problems are often seen as less threatening. These entry points consist of two modalities: The first, Info-Social (811), is a free and confidential province-wide telephone consultation service that provides the general public with 24-hour-a-day advice, support and orientation for psychosocial issues. The second is a specialized Partner Consultation Line, operated by the Montreal Polarization Team, 7 days a week from 8am to 10 pm; calls are answered within 2 hours, and an in-person assessment is offered in the following week if required.

The clinical team generally receives three types of referrals: 1) extremist individuals (most often with a lone actor profile), with a suspected or proven risk of violence; after assessment, the team may consider that ideology (single or multiple) is not a driver of patient behavior. Violence is considered “non-ideological” if the patient consumes crude-horrific images (videos) or uses them indiscriminately in interpersonal relations to incite reactions without adhering to an underlying ideology. For example, adolescents may be referred to the team because they circulate DAESH decapitation videos, second world war atrocities films and/or glorify school shooters. Often, these youth, while presenting various degree of risk, do not adhere to a political or religious rhetoric, but use graphic images to express and feed their rage and fantasies and to provoke fear and horror around them; 2) families and significant others of radical individuals: this includes children from extremist parents (DAESH returnees and children of publicly known attackers adhering to extreme-right, Neo-Nazi or masculinist ideologies). They present significant distress and are often caught in a loyalty conflict between the school and home. The team provides them with individual and family services. In the last few years, the team has also organized group interventions for family members of ASD extremists (psychoeducation) and for significant others of anti-system and conspiracy theory adherents legitimizing violence, and 3) other individuals or groups affected in some way by violent extremism, usually as victims. Most of the victims that the team works with (often for a short period of time) have stress-related symptoms and disorders. The latter group also includes individuals or families who have been targeted as “radicals” because of prejudice and associated religious- or racial- profiling.

Individuals are either referred to the program by institutional or community partners, by family members, or by themselves, through a direct phone line which gives access to a team clinician (response in two hours maximum). The clinician performs a first assessment to confirm the relevance of the referral for the team and immediately proposes follow-up steps. Direct assessment is usually provided in the following week at the team’s office, in another institution (including schools, jails and health services), or at the client’s home.

Specialized clinics

Specialized consultation and supervision clinical teams are established in five regions of Quebec (Montreal, Laval, Québec City, Sherbrooke, and Gatineau). Team members, including experts in psychology and forensic psychiatry, are invited to discuss cases via monthly videoconferences. The team is composed of nine clinicians: six seniors and three juniors, four males and five females of different ethnic and religious identities, with two psychiatrists, four psychologists, two social workers and a psychoeducator. They combine special expertise in transcultural psychiatry, first episode psychosis, ASD, trauma treatment, and family and community interventions. They have all received specific training in violent extremism intervention and have continuing education in the field. They are regularly supported by clinicians with forensic psychiatry expertise.

The clinical team’s consultation model is inspired by the Cultural Consultation model developed and validated by the McGill Division of Social and Cultural Psychiatry (Kirmayer et al., 2014). The team offers clinical consultation to its partners as needed and provides primarily direct assessments and short-term follow-up.

The assessments are culturally sensitive and trauma informed. Risk is regularly assessed at intake and every six months (or more rapidly if necessary) using the Short Term Assessment of Risk and Treatability (START) (Webster et al., 2009). The START is used with mental health and criminal justice populations to assess risk across multiple risk domains (violence, self-harm, suicide, self-neglect, substance abuse, unauthorized leave and victimization…). It is a structured professional judgment scheme that assesses through clinical consensus among an interdisciplinary team the dynamic risk to predict short-term behavior. Because the START does not specifically target violent extremism, in some cases the Terrorist Radicalization Assessment Protocol-18 (TRAP-18), a structured professional judgment instrument for threat assessment of lone actor terrorists, is also used (Gill, Clemmow, et al., 2021; Goodwill & Meloy, 2019).

The team remains involved with proximal services when the perceived risk exceeds the comfort level of less specialized clinicians. In cases where a patient does not consent to personal clinical information being shared between professionals, confidentiality is maintained in line with the Canadian professional codes of ethics, with the exception of cases where risk is deemed to be too high and imminent, warranting an emergency intervention. Security agencies are aware of this and understand the importance for clinicians to develop and maintain collaboration and alliance with individuals, families and communities based on trust. Collaboration among staff and trust are critical factors in the success of violent extremism services (Hassan, Brouillette-Alarie, et al., 2021).

The central role of proximal services

While initial assessment, psychotherapy and/or psychiatric services can be offered by the clinical team, more proximal, community-based services such as frontline mental health, education and youth protection organizations are essential for promoting the social integration of patients. Such services include mental health follow-up in local primary-care clinics, intervention by readaptation centers for patients with intellectual delay or autism and community organizations services such as employment and education support, as well as mentorship (Aarhus, 2019). Artistic programs fostering self-expression and creativity are offered in partnership with community organizations. A multimedia pilot program involving young artists has shown to provide youth with alternative means of expression (Bourgeois-Guérin et al., 2021). These programs are particularly useful to reach out to socially isolated youth reticent to use healthcare services.

Objectives

The aim of this paper is to describe the patient profile of a specialized intervention model addressing situations referred for violent extremism in operation in Montreal since 2016. 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?

Methods

Participants

Participants were patients of the CIUSSS-CODIM Polarization team: 1) youth/young adults receiving clinical services, 2) family members of youth/young adults receiving clinical services (or departed to war zones), and 3) victims of hate crimes. The only inclusion criterion is having received services between January 1st, 2016, to December 31^st, 2021. A total of 156 individuals were included.

Procedures

Ethical approval for the study was obtained from the CIUSSS West-Central Montreal Research Ethics Board. Data from medical charts were extracted and transferred to REDCap by two research assistants (RAs) trained by a member of the clinical team. A research team member with experience in medical chart review extracted the data of five patients. To assess inter-rater reliability, two RAs independently extracted data from the same five medical charts and the results were compared. Results obtained from the RAs were compared with that of the more experienced team member. Disagreements were discussed and resolved with the experienced member of the research team and the process was repeated until the two RAs reached an 80% agreement on the extraction process.

Measures

Violent extremism

Ideological categories included far right, far left, religious, gender, nationalism, conspiratorial, and non-ideologically based violence. Categories were chosen based on existing literature on categories of radical ideologies (Doosje et al., 2013) and the expertise of the clinical team. Individuals may align with one or more ideology (Doosje et al., 2013); for instance, a person associated with the far right can also support an anti-female ideology (gender extremist ideology). The number of types of extremism was calculated as a categorical variable.

Sociodemographic characteristics

Sociodemographic information included age (continuous variable), gender identity (male or female), marital status (single, married/has partner, separated/widowed) and highest level of education (high school or lower, college, university). Additional information includes school enrollment (yes/no), current employment (yes/no), and history of involvement in the criminal justice system (yes/no).

Social grievances and integration

There were eight social grievances, each measured as a categorical variable (yes/no). These included, for example, grievances caused by family dynamics, social isolation, and harassment and bullying. There were nine measures of social integration such as integration at work or school and involvement in a community, sports team, or place of worship. Eight were measured as a categorical variable (yes/no); one variable, friendships, was measured as a categorical variable with three response options—none, few, and many.

Clinical information

Any history of engagement in mental health treatment was documented as a binary variable (yes/no). Substance use or abuse in the period during which clients received services was also documented as yes/no. Diagnostic categories included ASD, intellectual disability, stress-related disorder, mood/anxiety disorder, psychotic disorder, and personality disorder, attention deficit hyperactivity disorder (ADHD), oppositional defiance disorder/conduct disorder, and other.

Clinical services

Service information included source of initial referral to the clinical team (categorical variable), number of clinical sessions with the care team (continuous variable), referral to other services (yes/no), and number of clinicians working with the patient (continuous variable).

Data analysis

We used univariate statistics to present a descriptive epidemiology of individuals engaged in violent extremism services. Means and standard deviations (SD) were reported for continuous outcomes, and frequencies and proportions for categorical variables.

Results

The majority of patients were enrolled in services because they were radicalized (N = 86, 55.1%). Common sources of referral included health services, security agencies, friends and family, and self-referral. Although the vast majority (82.7%) received individual services, over a third (34%) obtained family-level support. Treatment team size ranged from 1 to 8 clinicians (mean = 2.5). It is to be noted that, in spite of our efforts to involve local services from the beginning, the number referred to other services is low (24.4%). There are a few reasons for this: first, primary care clinicians are reluctant to engage with this clientele because they are often frightened and/or feel unequipped, and second, our patients are very distrustful and difficult to engage in the mainstream system. Clients have to show motivation and engagement in order to receive service; thus, very often, in spite of a personalized referral, lack of motivation is the main reason to close a case before any intervention takes place. The high mean number of interventions per client (26) reflects the fact that clients require intensive interventions and that clinicians never close the file in an at-risk case if appropriate follow-up is not ensured (see Table 1).

Table 1. Sociodemographic characteristics and clinical services profile of individuals engaged in services from 2016 to 2021 (N = 156).

Variable	Radicalized (N = 86)		Affected by violent extremism (N = 19)		Family member (N = 51)
Characteristic	M	SD	M	SD	M	SD
Age in years	25.3	13.2	35.6	19.4	41.9	17.7
Number of clinical sessions	26.1	39.3	8.84	8.41	15.7	19.7
Number of clinicians on care team	2.56	1.42	2.26	1.37	2.45	1.05
Characteristic	N	%	N	%	N	%
Gender identity
Man	81	94.2	9	47.4	23	45.1
Woman	5	5.8	10	52.6	28	54.9
Marital status
Single	70	81.4	13	68.4	13	25.5
Married/In a relationship	10	11.6	3	15.8	22	43.1
Separated/Widowed	6	7.0	3	15.8	16	31.4
Currently in school
Yes	45	52.3	5	26.3	12	23.5
No	41	47.7	14	73.7	39	76.5
Highest level of education
High school or under	42	48.8	6	31.6	14	27.5
College	16	18.6	3	15.8	7	13.7
University	15	17.4	7	36.8	13	25.5
Missing	13	15.1	3	15.8	17	33.3
Currently employed
Yes	18	36.0	4	25.0	22	52.4
No	32	64.0	12	75.0	20	47.6
Not applicable	36		3		9
Referral sources
Self-referral	13	15.1	5	26.3	19	37.3
Friends and family	15	17.4	4	21.1	19	37.3
Youth protection services	7	8.1	0	0	6	11.8
Community organization	6	7.0	3	15.8	1	2.0
Security agencies	23	26.7	3	15.8	12	23.5
School	12	14.0	2	10.5	0	0
Health services	25	29.1	4	21.1	8	15.7
Other	0	0	1	5.3	1	2.0
Number of referral sources
1	71	82.6	16	84.2	37	72.5
2	15	17.4	3	15.8	13	25.5
3	0	0	0	0	1	2.0
Modality of service delivery
Individual	81	94.2	18	94.7	30	58.8
Family	16	18.6	3	15.8	34	66.7
Mentorship	2	2.3	0	0	0	0
Number of types of modalities
1	74	86.0	17	89.5	38	74.5
2	11	12.8	2	10.5	13	25.5
3	1	1.2	0	0	0	0
Referred to other services
Yes	21	24.4	8	42.1	7	13.7
No	65	75.6	11	57.9	44	86.3

Of individuals that were radicalized, roughly a third 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 ASD diagnosis. The majority had some previous contact with mental health services (see Table 2). The majority of extremist individuals were characterized as being socially isolated (52.3%), with a high proportion reporting grievances related to their families (65.1%) and past experiences of trauma, discrimination and harassment/bullying. These patients were for the most part not integrated at work (73.7%) or school (77.9%) and were not involved in community settings (86.2%) (see Table 3).

Table 2. Psychiatric and extremist ideology profile of radicalized individuals engaged in clinical services from 2016 to 2021 (N = 86).

Characteristic	N	%
History of mental health service use
Yes	59	68.6
No	27	31.4
Criminal offense history
Yes	20	23.3
No	66	76.7
Substance use abuse
Yes	19	22.1
No	67	77.9
Extremist ideologies
Far right	27	31.4
Far left	3	3.5
Religious	18	20.9
Gender	22	25.6
Nationalism	5	5.8
Conspiratorial	11	12.8
Non-ideological violence	28	32.6
Number of extremist ideologies
1	67	77.9
2	10	11.6
3	9	10.5
Psychiatric diagnosis
Autisim spectrum disorder	24	28.6
Intellectual deficiency	5	6.0
Stress-related disorder	30	35.7
Mood & anxiety disorder	31	36.9
Psychotic disorder	9	10.7
Personality disorder	18	21.4
Attention deficit hyperactivity disorder	9	10.7
Oppositional/conduct disorder	7	8.3
Other	6	7.1
Not applicable	2
Number of psychiatric diagnoses
0	2	2.3
1	45	52.3
2	25	29.1
3	12	14.0
4	2	2.3

Table 3. Social integration and grievances of radicalized individuals engaged in clinical services from 2016 to 2021 (N = 86).

Item	N	%
Social grievances
Trauma
Yes	27	31.4
No	59	68.6
Discrimination
Yes	16	18.6
No	70	81.4
Harassment/bullying
Yes	37	43.0
No	49	57.0
Romantic relationship breakup
Yes	19	22.1
No	67	77.9
Social isolation
Yes	45	52.3
No	41	47.7
Family
Yes	56	65.1
No	30	34.9
Work
Yes	11	12.8
No	75	87.2
School
Yes	32	37.2
No	54	62.8
Social integration
Contact with family
Yes	77	89.5
No	9	10.5
Friendships
None	22	25.6
Few	46	53.5
Many	18	20.9
Romantic relationship
Yes	21	24.4
No	65	75.6
Work
Yes	14	16.3
No	72	73.7
School
Yes	19	22.1
No	67	77.9
Community involvement
Yes	7	8.0
No	75	86.2
Involvement in sports
Yes	7	8.1
No	79	91.9
Frequents place of worship
Yes	19	22.1
No	67	77.9
Use of internet/social media
Yes	77	89.5
No	9	10.5

Discussion

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. Results provide information about the types of violent extremism clinicians may encounter, the diagnostic profile of patients involved in violent extremism, the social grievances they report, and the services and role of a specialized team in the domain.

The extremist ideologies of patients are aligned with violent extremism sociopolitical trends in the last decade. From 2014 to 2018 the Caliphate and religious extremism was at the forefront of the news and concern of the Canadian government (Jensen & Larsen, 2021; Rousseau et al., 2019), while the threat posed by the extreme right and by anti-system and masculinist movements was characterized as the principal terrorist threats by policy makers in Canada more recently, since 2021 (Artz, 2022; Kelly et al., 2021; National Security Council, 2021; Perry & Scrivens, 2015; Rottweiler et al., 2021). 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 and the increase in online consumption and glorification of violence (Adam-Troian et al., 2021; Podoshen et al., 2014; Venkatesh et al., 2021). Many of these youth consume a wide range of graphic violent material, including violent pornography, independent of any associated extremist ideology. 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 (Pierre, 2020).

In line with a systematic review of mental health disorders and violent extremism (Gill, Clemmow, et al., 2021), results show high diversity in diagnosis in this clinical sample. Our findings converge with a study of active shooters in the US, with and without ideological motives, (Silver et al., 2018), in which the most frequent diagnosis encountered were mood disorders, followed by stress related disorders. The high number of ASD diagnoses among clients is also noteworthy and has been reported in the violent extremism literature (Faccini & Allely, 2017). 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.

Psychological autopsy studies of individuals who had committed violent attacks (Gill et al., 2022; Meloy et al., 2019) suggest that the risk associated with co-occurrence of mental health disorder and violent extremism should not be minimized. 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). The results should not be interpreted as evidence of over-representation of psychiatric disorders in individuals attracted by violent extremism (Gill, Clemmow, et al., 2021). This assumption, which may stigmatize unduly patients with mental disorders, as has been the case for violent extremism and Muslim heritage individuals, (Younis & Jadhav, 2020), is neither supported nor informed by the results which only show that there is a sizable group of special needs of individuals with psychiatric disorders and extremist discourses-actions who require services.

Results show that patients referred for violent extremism report multiple social grievances (Corner & Gill, 2021). This is aligned with the violent extremism literature that indicates social grievances play a major role as determinants not only of attitudes but also of behaviors related to violent extremism (Hassan, Brouillette-Alarie, et al., 2021). Issues related to social isolation and family conflict, which affect half of our patients, are frequently found among extremists (Bazex et al., 2017; Böckler et al., 2018; Knight et al., 2017; Sikkens et al., 2017) . 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 which justifies the use of violence to obtain reparation and recognition (Hassan et al., 2018). 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 a new way to express distress for patients who would have channeled their despair and rage differently in the past. This may in part reflect contagion and imitation phenomenon, associated with the extensive media coverage of extremist attacks (Poitras & Laforest, 2019).

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. This 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).

Limitations

Our study has some limitations which should be noted or addressed. The use of cross-sectional data obtained from a retrospective chart review precluded claims of causality regarding the relationships observed between certain variables. Although experimental study designs, in particular randomized controlled trials, would be ideal in order to evaluate program effectiveness, this is not possible given ethical issues around withholding much-needed services from at-risk individuals and lack of alternative evidence-based treatment. Case-control studies may also not be feasible given the challenges of identifying appropriate comparison groups. Additionally, relying on a chart review means that data is not based on self-report of patients engaged in services, who may have a different perspective on their experiences related to social grievances and social integration in particular. Finally, study findings are situated within the sociocultural context of Quebec and Canada, meaning that results may not be generalizable to populations in other settings.

Conclusion

Overall, our results show a high prevalence of mental health problems in individuals referred for potential violent extremism and suggest that these clients may benefit from clinical services. Although results of a formal longitudinal evaluation are not yet available, the positive client response to the proposed services highlight their potential usefulness. The results also suggest that these patients often fail to receive services because of the reluctance of clinicians to take on cases perceived as high risk and the fact that they may not easily engage with services that do not reach out to them and are perceived as part of a system they reject. Specialized services such as the Polarization team are important not only to provide direct services to this group, but also to develop knowledge and practices adapted to this clientele and provide consultation to mainstream mental health youth and adult services. They may fill the gap between forensic psychiatry services and more proximal services that may feel ill equipped to address violent extremism. More research is needed to describe this clinical phenomenon, document the efficiency of different model of service provision, and identify key elements that may be transferable across sociocultural contexts.

Ethics

This study was approved by the Psychosocial Research Ethics Committee (REC) of CIUSSS West-Central Montreal Research Ethics Board (REB). All data was carefully reviewed to ensure confidentiality.

Conflicts of interest

The author(s) declare no competing or potential conflicts of interest.

Additional information

Funding

This study is supported by Public Safety Canada’s Community Resilience Fund, Grant number 8000-21042.