4. Clarifying Questions - RonaldMah

Ronald Mah, M.A., Ph.D.
Licensed Marriage & Family Therapist,
Consultant/Trainer/Author
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 How Dangerous is this Person? Assessing Danger & Violence Potential Before Tragedy Strikes
Chapter 4: CLARIFYING QUESTIONS


Chapter 4: CLARIFYING QUESTIONS
The therapist or professional is often presented with difficult clients to treat in individual, couples, and family therapy- also group therapy.  Or a concerned person may run into a very difficult individual in his or her life at work, in the community, or in the family.  Among the presenting issues are aggressive, impulsive, and violent behaviors.  Or, there may also be aggressive, obsessive, and violent thoughts or writings.  Sometimes, they are all present. How dangerous is this person?  Is there a likelihood of physical assault on another individual?  Or is there "only" a potential for emotional or psychological abuse?  Dealing with emotional or psychological abuse lies squarely within the domain of therapy, with the qualifying requirements of mandated reporting to authorities where it constitutes child, elder, or dependent adult abuse.  Potential for physical assault is both a therapeutic responsibility and a legal and ethical responsibility for therapists.  It is a major responsibility for many professionals depending on their mandated roles.  On the other hand, it is a moral responsibility for members of a community.  There are often complex issues and circumstances that make a child or teen or adult "act out" or become moody.  Effective treatment or intervention comes from appropriate assessments of individual personality, issues, and circumstances that lead to clarity.  Conceptual clarity subsequently implies treatment approaches and interventions.   The therapist and professional needs, while others often want to differentiate among three categories of people:

1. Individuals with challenging behaviors that are however relatively simple and benign to deal with (low potential for aggression and/or violence),
2. Individuals with more problematic transitory or episodic and/or more intense behaviors (moderate potential for aggression and/or violence),
3. And individuals with high potential for aggression and/or violence.

There are seventeen specific criteria to consider for assisting the therapist, other professional, or concerned people differentiate danger potential and direct treatment and intervention processes.  This information gives guidance for both treatment and preventative work for children, teens, and adults.  It applies to parenting, teaching, and facilitating emotional, psychological, and social development. This information is applicable for assessing for potential for couples and domestic violence, child abuse, physical assault, and emotional, psychological, economic, financial, and social attacks by teenagers and adults in a variety of situations from the family, school, neighborhood or “hood,” at work, and other communities.  It may also be applicable to suicide- aggression or violence against oneself and elder abuse.  In the sense that self-harming or self-destructive behaviors are violence against oneself, these principles may also be relevant to examine alcohol and drug abuse, behavioral addictions, and compulsive behavior.

Eight of the seventeen criteria are highly compelling for an individual such as Seung-Hui Cho, the killer at Virginia Tech.  These are

1. Self-Righteousness Attitude
2. Entitlement
3. Ego-syntonic Perception
4. Intense Emotional Arousal
5. Resentment
6. Characterlogical Nature
7. Isolation/Avoidance Behavior
8. Lack of Remorse

I have not, and in all probability, the therapist, another professional, or reader has not undertaken an intensive formal evaluation of Cho's developmental, psychological, social, academic histories- nor is the information readily available.  Others have attempted to reconstruct his personal history to venture how he came to his violent outburst. Nevertheless, these issues remain highly suggestive from the media information that has been available.  

Cho had an intensive sense of self-righteousness that fed into deep resentment from being ostracized and bullied throughout his school career.  The self-righteousness and resentment translated into an intense entitlement to have vengeance, which created a complete lack of remorse for actions to be taken.  It is clear that he deeply believed that his victims or targets deserved to be killed.  He was also living up to the powerful and vengeful persona that he believed in.  There was no conflict within himself regarding who he was and his eventual violent behavior; his violence was ego-syntonic.  His issues and emotional state were not transitory, but rather seemed to be deeply embedded into his personality.  His perception and relationship to others and the world appears characterlogical.  His inability and difficulty in social relationships led to deep isolation and a lack of relationships or community to give him any kind of feedback or reality check or testing of his perceptions.  While his lack of remorse would seem to suggest being a sociopath, his writings and his videos demonstrate intense emotional arousal unlike that of a sociopath who tends to have flat emotional affect.  In addition, it appeared that he intended to commit suicide or go down in a blaze of glory.  Sociopaths or individuals with antisocial personality disorder are highly manipulative and can be extremely dangerous, but they also normally fully intend to survive their behavior.  In other words, they do not want to go down in a blaze of glory, but to survive and to do it again in some other form to some other people.  A possible diagnosis from afar is that Cho had paranoid personality disorder or some other issue that results in significant paranoia.  Paranoid personality disorder can be the source of intense violence.  For example, Gregory Lester, Ph.D., trainer and therapist who specializes working with personality disorders identified the Columbine killers as having paranoid personality disorders (CAMFT, 2004).  

Consensus may never be reached regarding Cho’s diagnosis or the diagnoses of other killers.  Interestingly the paranoid personality disorder diagnosis has not been mentioned often in reading of the media literature about Cho.  Whether or not others agree with this diagnosis does not serve Cho or the many victims at Virginia Tech.  However, the criteria noted are compelling and can lead to this diagnosis.  This can be further useful in assessing the violence or danger potential of others, hopefully before violence occurs or so that intervention can be made.  The therapist can consider the eight criteria relevant to Cho: self-righteousness attitude, entitlement, ego-syntonic perception, intense emotional arousal, resentment, characterlogical nature, isolation/avoidance behavior, and lack of remorse.  These criteria or elements along with others can be applied to the client, Jim that the therapist was concerned about in the e-mail.  The therapist will find that there are important distinctions between homicidal Cho and Jim.  In addition, if the therapist considers the full constellation of criteria (another eight found to be important), the therapist can gain even greater clarity for diagnosis.  Some of the criteria or elements give clear indication of a more stable and less violence-prone individual.  Others guide the therapist in clinical inquiry with relevant clarifying questions.  

The first major characteristic difference between Jim and the shooter at Virginia Tech is that Jim voluntarily sought out therapy from Sandra.  He sought help from another person- a professional.  He was not mandated or forced into therapy.  Cho was a social isolate and unable to maintain social relationships.  He had difficulty maintaining even formal relationships with teachers.  He internalized his process and did not have any social context for reality checks.  Jim uses therapy with Sandra for this process, and may also use other reliable people to examine his perspectives, process, and choices.  In contrast to Cho, Jim is successful socially.  He seeks out social contact and interaction.  Also, Jim was not comfortable with his own anger and resentment.  It was ego-dystonic for him, because he did not want to be an angry or resentful individual.  He could see how it would harm his relationships.  Jim is not deeply resentful, although he could have cause for resentment in being a gofer for his instructor at the internship.  Instead he appreciated the opportunity to experience the work despite his menial responsibilities.  The judgment regarding the other criteria and elements were not immediately clear to the therapist for Jim, but could be pursued through the therapeutic process.  The following are questions I suggested Sandra, as the therapist should explore to get more information and clarity.  Some are specific for Jim, while others would be useful in general to examine other individuals.

a) Are there any aspects of paranoid personality disorder or other paranoid thinking?  This can also be from paranoid schizophrenia or stimulant drug abuse (cocaine, crack, crank, methampethamine).

b) Is there a long held resentment and self-righteousness for past wrongs done to him?  Or, is the upset or anger transitory?  Intense feelings that are released through cathartic processes are less likely to erupt into violence.

c) Does he/she have mechanisms to self-soothe distress or other negative emotions (other than with drugs and alcohol or other dysfunctional behavior)?  Does he/she activate them effectively or readily?  Individuals, who can self-soothe to any significant degree, are more likely to keep bitterness and resentment under the threshold that ignites destructive behavior.

d) Is there any underlying Asperger's disorder (high functioning autism) that may be indicative of missing social cues?  Does Jim give appropriate non-verbal social cues in the therapeutic interaction?  Not only do many individuals in the autistic spectrum not recognize social cues, they may also not give appropriate social cues.

e) Does he/she present as "odd"?  Mismatch between emotional content and non-verbal cues (eye contact, facial expressions, body movements, voice tone, etc.) may indicate autistic issues, or may indicate disconnection due to intense uncomfortable emotions.  In addition, any individual perceived as different is more prone to being targeted for victimization by bullies.

f) Is his or her presentation that of a “normal neurotic?”  “Normal neurotics” may have an intense presentation at the high or low end of the normal spectrum of emotions.  However, they tend to be available to processing their emotions in therapy.

g) What is the energy of the graphic novel for Jim? The writing Jim is doing may be cathartic and serves to mollify his resentment.  It may keep him from possibly exploding violently into reality.  

h) How does Jim feel about his recognition?  Does he feel the recognition is deserved?  Appreciation is the normal reaction to recognition.  High fragile self-esteem or entitlement would be characteristic of narcissist individuals.  Failure to get recognition can result in narcissistic rage and transitory aggression.

i) Does Jim feel that despite the awards that others still don't understand or value him?  That he has gotten recognition and awards from others from his work would seem indicative of gaining positive social validation.  Thus, he would be less likely to be dangerous.  If he thought that the recognition and awards come from stupid people that he feels superior to... that getting the awards are just signs of their ignorance, stupidity, perverted values, that he's fooling them, then there should be more concern.

j) Does he/she feel understood by anyone?  By the therapist?  Individuals often seek validation from their therapist, after many life experiences of invalidation.  They normally appreciate and respond positively to the validation.  If the client cannot feel understood or appreciated, or dismisses validation, it would be of concern.

k) Does he/she feel that he can be understood by anyone?  Who?  Cho felt he understood the Columbine killers. Cho identified with the Columbine killers.  Determine with whom the client identifies.  Who he/she understands.  Are they positive models or dangerous models?

l) How does he/she see his or her own anger and what does he/she do with it or in reaction to it?  Even when many individuals feel their anger is justifiable, they also understand it can be dysfunctional for them.  Of greater alarm, is when an individual sees the anger and the aggressive behavior that harms others is justified.

m) What is the ending of the novel?  Is there personal redemption or just vengeance?  Does the protagonist die (is doomed) or move on to "happily ever after?"  Does the character have hope?  Is it a transformative process for the character?  For example, from doing poorly to doing well, from being alone to having positive relationships?  A transformative story can be a self-prophecy of hope as opposed to a story of doom.

n) What generation is Jim?  Foreign-born, first American-born with immigrant parents, second generation, or third generation or beyond?  The less Americanized or closer to immigration generationally, the more likely an individual may have difficulty fitting in.  
o) What are his or her parents like?  This is a basic psychodynamic exploration- an examination of the family-of-origin, attachment relationships, validation, nurturing, etc.

p) Does he/she feel rejected now?  Are these feelings transitory or ongoing?  Transitory feelings come and go and are not as likely to cause destructive behavior, unless he/she is highly impulsive.

q) Was he/she referred or mandated to therapy?  Is he/she self-referred?  Self-referral is an act of hope and less likely to be indicative of desperation, and thus he/she is probably less likely to be dangerous.

r) Are there economic class issues that may also apply?  Class is an often forgotten discriminatory issue.
s) How does Jim identify?  As American?  As Korean?  Internalized self-hatred can have ethnic or cultural origins.  Internalized self-hatred can externalize into aggression against others.

t) Does he/she identify as normal?  As special? As different?  Misunderstood, etc.?  How does he/she identify relative to others, such as victim to bully, or superior to inferior?  The role dynamics can predict behavior at or to others.

u) Sandra could ask Jim directly about the shooter at Virginia Tech.  How much does he empathize and/or identify with Cho?  Empathy might be indicative of understanding Cho’s pain, while identification may be indicative of seeing himself in that role.

There are lots of questions that can get greater information and insight.  These questions served also to prompt Sandra organize and conceptualize what she already knew consciously and felt intuitively.  The therapist, professional, or concerned person needs to examine an individual not only from what he or she knows and heard from the individual, but from his or her own instincts.  These may be clinical instincts for the therapist, other instincts accrued through work experience and study for the professional, and for anyone whether holding a specific role to treat or intervene, personal instincts from life experiences.  What do they say?  Are they relevant and reasonable instincts versus the therapist, professional, or concerned person's anxieties and fears?  In the original short message from Sandra, there were indications that she already sensed were not consistent with Jim being a danger to others.  The questions helped bring what Sandra already sensed into sharper conceptual focus that she could recognize and articulate.  It remains important to know that this person, just as any therapist or professional or community member, is the only one there and with interactions with Jim or another individual to make a final judgment and to take action, do the interventions, or conduct therapy.  The inquiring therapist Sandra was able to take these questions for clarifying her collection of experiences, knowledge, and impressions.  They also directed her purposeful investigation and interaction with Jim.  I later received this wonderful note from Sandra,

“From the questions you prompted me with, even before seeing him again, I was able to gather that my client Jim was most probably needing affirmation and that his attitude is more hopeful.  It is clear that he was reaching out for some support and that his work most probably is cathartic. I feel empowered and will move forward in the therapy.  I will use the questions to further assess him, and whether my current sense of his low or non-propensity to violence is correct.” Several months close to a year later, I received an additional communication from Sandra regarding her client.  “My former client, the young Korean-American man Jim is doing a lot better.  He’s starting a paid post-graduate internship at the literary magazine this fall.  He won an award for one of his short stories that included a financial prize.  He has had a lot of support from his former instructors and myself. Although I haven't heard from him in a while, he usually contacts me for a few sessions when a crisis or he needs to work through something stressful.”  How dangerous is... was Jim?  Not very... whew!  How well did the Sandra assess Jim?  Very well.  How confident was Sandra that she was not missing something important and dangerous?  Very confident!  The process of assessment could when applied to another individual result in a more alarming interpretation of high violence potential.  Resultant findings may not be a relief but the therapist might be confident that he or she has identified something important and dangerous.  Accurate assessment as always should direct further treatment, action, and/or therapy.


ADDRESS:
433 Estudillo Ave., #305
San Leandro, CA 94577-4915
Ronald Mah, M.A., Ph.D.
Licensed Marriage & Family Therapist, MFT32136
CONTACT INFORMATION:
office: (510) 582-5788
fax: (510) 889-6553
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