[Assessment and intervention in the context of extremist violence]

Increasing social polarization and the growing normalization of violence have been accompanied by a rise in ideologically and nihilistically motivated violent discourses and behaviors. Although empirical data remain limited, mental health difficulties appear to be a significant risk factor in the adoption of extremist narratives. Clinicians are often left with few clinical tools to address such situations, caught between their caregiver role and their responsibility to protect the public. Using a clinical vignette based on composite cases drawn from a specialized team in violent extremism prevention, this article offers practical guidance for assessment and intervention when a patient presents with ideas of mass violence. It examines clinicians' emotional and countertransference reactions, the complexities arising from institutional requests for "risk assessment," and the importance of integrating both risk and protective factors into a nuanced clinical evaluation. The article also highlights the role of online environments in the dissemination of violent narratives, the value of systemic approaches, and the need to preserve the therapeutic alliance amid tensions between care and security. Finally, it emphasizes the importance of teamwork, supervision, and long-term follow-up in working with patients whose violent ideation may fluctuate over time.