by Ronald Mah
for "Learning" in
by Ronald Mah
on Children's Behavior,
Discipline, and Child
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Dangerous is My Client?
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following e-mail arrived in my Inbox in late April 2007.
have a young Korean-American client who is a college graduate student in
literature. He’s a writer. I'll call him Jim. His initial presenting issues were dealing
with a sense of isolation and his long-term resentment and anger from
being misunderstood and bullied throughout his school career. This young
man felt very alone and angry when he was younger.
Jim wanted to work on this because he was concerned it might
eventually affect his relationships and career.
He is clearly exceptionally intelligent, and perhaps even brilliant
in his work. He has been
recognized for his writing and received awards since high school.
He has been involved in an internship with one of his instructors,
an editor for a literary magazine. He
finds that very stimulating although he is doing somewhat menial work as a
talked about working on a graphic novel where the protagonist is dealing
with anger over rejection, "and being invisible" with the themes
of justice, compassion, violence, suffering, victimization and bullying,
and redemption. It is very
clear, that the novel is semi-autobiographical and that he identifies with
the main character. The plot
of the novel culminates with an intense massive act of vengeance upon the
main character’s abusers. I
don't want to be simplistic, and really don't want to be stereotypical or
even worse, racist, so I need to be more clear if there is potential for
violence with him. The conversation was disturbing to me after the recent
violence at Virginia Tech. To
be more blunt, my question is, how dangerous is my client?” (Details
have been altered to protect the confidentiality of the client.)
than two weeks earlier, at Virginia Tech
on April 16, 2007, on the campus in Blacksburg, Virginia, a student,
Seung-Hui Cho killed 32 people and wounded many more, before committing
suicide. This was the
deadliest school shooting in U.S. history.
Only eight years before on April 20, 1999 at Columbine High School,
two students, Eric Harris and Dylan Klebold, killed 12 students and a
teacher, as well as wounding 24 others.
They also committed suicide before they could be captured.
Seung-Hui Cho was of Korean ancestry having moved here as a young
child. Cho left behind angry and vengeful writings and videotapes
chronicling a long history of mistreatment by others. His intense resentment seemed to motivate his homicidal
actions. After the fact,
laypeople and professionals have struggled to figure out the cause and
origins of his violence, as was done after the killings at Columbine High.
For some, this is to understand the tragedy.
For others, it is also to understand, anticipate, and hopefully
prevent similar explosions in the future.
Unfortunately, examining prior episodes of violence by others such
as the Columbine killers did not prevent Cho's outburst. “With his
sadistic creative writing, contempt for snotty rich kids, militaristic
posing, and heavily plotted revenge fantasy, Virginia Tech killer Cho
Seung-Hui has eerily reminded many Americans of Columbine murderers Eric
Harris and Dylan Klebold. Cho apparently saw Klebold and Harris as kindred
martyrs, giving the boys two separate shout-outs in his suicide
manifesto” (Cullen). None
of us as therapists wish to be similarly reminded of Cho, Harris, or
Klebold as we may fail to recognize a client’s potential for violence.
e-mail I received shortly after the shootings, posted a question that was
not hypothetical or academic. Television
and other media analysts (the Today Show, NBC Nightly News with Larry King
among others) have argued as to whether Cho was an angry depressive, a
psychopath, a schizophrenic, or a psychotic among other diagnoses.
Several resources, including Time (Veale) quoted family members
saying that he had been diagnosed with autism when very young. This
brought a quick response from AutismLink and Autism Center of Pittsburgh
Director Cindy Waeltermann that it was "unfair to blame Cho’s
actions on autism." As
mental health clinicians, it is hard not to speculate on the evolution and
causes of Cho's violence. Speculation
however can be beneficial if it serves us to assess other individuals,
such as our clients or our clients’ intimate relationships for the
potential of violence. The
therapist who wrote the e-mail was concerned because there were elements
in her client that were similar to Cho and his history.
However, there were also distinct elements once identified that
allowed her to have confidence that her client was unlikely to erupt into
violence. These elements also help direct the therapeutic process.
are fifteen criteria or elements to aid determination of the violence
potential of children and teens. The
concepts should also be applicable to adults.
Eight of the fifteen criteria are highly compelling for an
individual such as Seung-Hui Cho.
into consideration, that I have not, and in all probability, you have not
undertaken an intensive formal evaluation of Cho's developmental,
psychological, social, academic histories, these issues are highly
suggestive from the media information that has been available.
He had an intensive sense of self-righteousness
that fed into deep resentment from
his years of 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 sociopath.
In addition, it appeared that he intended to commit suicide or go
down in a blaze of glory. Sociopaths
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.
My best guess diagnosis from afar, is that Cho had paranoid
personality disorder or some other issue that results in significant
paranoia. Gregory Lester,
Ph.D., trainer and therapist who specializes working with personality
disorders identified the Columbine killers as having paranoid personality
my clinical experience with young children, pre-teens, and a few adults
with high functioning autism or Asperger's Syndrome, I have seen a
developmental progression that can lead in some cases to a paranoid
personality disorder. This is
by no means, the normal or only outcome.
With early intervention and skillful education and care, children
with Asperger’s Syndrome or other high functioning autism can be highly
successful in all aspects of life. Dr.
Temple Grandin is one example of a very respected author with autism.
She is an expert on cattle handling, and has written and spoken
often from her experiences and insights as an autistic individual,
including many television appearances.
Unfortunately, with inadequate caregiving and/or highly negative
social experiences, there can be extremely problematic outcomes for some
individuals. Autism or
Asperger's Syndrome does not cause violence.
However, one of the major challenges for individuals within the
autistic spectrum is the difficulty in reading social cues, especially
nonverbal cues. Individuals within the autistic spectrum are also often more
sensitive to environmental stimulation.
These combine to make social interactions often extremely
challenging for such a child. In
communities such as classrooms or the playground, other children often
identify such children as being different, and subsequently a target for
teasing and victimization. The
childhood history of Cho reports that he was brutally teased and bullied
in school. Depending on the
individual temperament or personality of the child, as well as the
environmental and interventions support (or lack of) from caregivers such
as teachers, children with these issues respond differently.
It seems that Cho did not get the appropriate support or
intervention, and with his intense personality suffered greatly and became
ever more resentful. Another person with more positive support, with a similar
intense personality may become a very attractive passionate individual.
Because of the difficulty in understanding social cues, Cho may not
have understood how he was perceived, or why others treated him so badly.
This may have exacerbated his growing isolation, emotional trauma,
and increasing resentment. Unable
to identify why others were so abusive to him for seemingly no logical
reason, a hypervigilance and hypersensitivity leading to paranoia may have
resulted. Over the years, a
paranoid personality disorder may have developed.
Waeltermann is alluding to such destructive dynamics, when she
says, "This is a wake-up call that stresses the importance of early
intervention, research, and appropriate treatment strategies.... research
has consistently shown that when children receive the help that they need
early on they are more likely to become more adept at social and
communication skills." Cho
did not receive this intervention or treatment.
It appears that his challenging dynamics (which I believe may have
been undiagnosed Asperger's Syndrome or other autistic spectrum issue),
while observed, were never accurately diagnosed and most importantly,
never treated appropriately. The
consequence to him was his lonely enduring deep dark world of anger and
resentment that subsequently erupted to darken the lives of so many
may never be reached regarding Cho’s diagnosis.
Interestingly the paranoid personality disorder diagnosis has not
been mentioned in my reading of the media literature. Whether or not, others agree with this diagnosis, does not
serve Cho or the many victims at Virginia Tech.
However, the criteria or elements that were compelling and led me
to this diagnosis can be useful in assessing the violence or danger
potential of others, hopefully before violence occurs or so that
intervention can be made. If
you consider the eight criteria or elements and apply them to the client,
Jim that the therapist was concerned about in the e-mail, you find that
there are important distinctions. In
addition, if you consider other criteria or elements (the other seven I
have found to be important), you can gain even greater clarity for
diagnosis. Some of the
criteria or elements give clear indication of a more stable and less
violently prone individual. Others
guide the therapist in clinical inquiry.
The first major difference between Jim and the shooter at Virginia
Tech is that Jim sought out 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 check. Jim uses
therapy for this process, and he 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 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
judgment regarding the other criteria and elements were not clear to the
therapist for Jim, but can be pursued through the therapeutic process.
The following are questions I suggested that the therapist explore
to get more information and clarity.
Some are specific for Jim, while others would be useful in general
to examine other individuals.
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, methamphetamine).
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.
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.
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.
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.
his/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
is the energy of the movie for Jim? The movie Jim is doing may be
cathartic and serves to mollify his resentment.
It may keep him from possibly exploding violently into reality.
does Jim feel about his recognition?
Does he feel them 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
Jim feel that despite the awards, that others still don't understand
or value him? That he has got 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.
he/she feel understood by anyone?
By you? 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.
he/she feel that he can be understood by anyone?
Who? Cho felt he
understood the Columbine killers.
Determine with whom the client identifies.
Who he/she understands. Are
they positive models or dangerous models?
does he/she see his/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, as both justifiable.
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 is a self-prophecy of hope as opposed to
a story of doom.
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.
are his/her parents like? This
is a basic psychodynamic exploration- an examination of the family of
origin, attachment relationships, validation, nurturing, etc.
he/she feel rejected now? Are
these feelings transitory or ongoing?
Transitory feelings come and go and are not likely to cause
distractive behavior, unless he/she is highly impulsive.
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.
there class issues that may also apply?
Class is an often forgotten discriminatory issue.
does Jim identify? As
American? As Korean? Internalized
self-hatred can have ethnic or cultural origins.
Internalized self-hatred can externalize into aggression
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.
could ask Jim directly about the shooter at Virginia Tech.
How much does he empathize versus identifies with Cho? Empathy might be indicative of understanding Cho’s
pain, while identification may be indicative of seeing himself in that
are lots of questions that can get greater information and insight.
What do your instincts say? Versus
your fears? In the short message from the therapist, there were
indications that were not consistent with Jim being a danger to others.
However, this therapist, just as you are, is the only one in the
room to make a final judgment and to do the interventions or therapy.
The therapist was able to take these questions and interact
purposefully with Jim. I
later received this wonderful note from the therapist,
the questions you prompted me with, even before seeing him again, I was
able to gather that my client 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.”
About four months later, I
received an additional communication from the therapist regarding her
client. “My former
Korean-American client 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
larger list of criteria or elements to use for assessment for violence or
danger potential is:
Gain or Loss
Reinforcement (Positive or Negative)
Behavior or Perceptions
Behavior or Perceptions
or Lack of Remorse
addition, nine types or origins of violent or aggressive behavior may be
abuse ignited aggression
and how the fifteen criteria or elements manifest indicate the core
etiology of the nine types of violent or aggressive behaviors.
Each of the nine types of violent or aggressive behavior has a
distinctive profile of the fifteen criteria or elements.
Explaining how each of the fifteen criteria or elements applies to
these nine types of violent or aggressive behaviors is beyond the capacity
of this article. In addition,
opinions may differ on the relevance of or how to apply these criteria or
elements. As you examine a
client for danger potential, including suicide, domestic violence, or
child abuse, using this process should conceptually confirm much of your
clinical instincts. I believe
that clinicians often do very good work based on instincts.
However, if it is good work, it also is conceptually sound work. As you understand the conceptual foundations to your
instincts, you go from good to often, great work.
In addition, instinctive work is largely reactive, but with
conceptual clarity you can be proactive.
This becomes especially important when there is a potential for
violence by or to our clients. The
first responsibility of a therapist is the safety of the client and the
safety of others in the greater community.
The threat of harm to others, suicide, child abuse, and domestic
violence constitute fundamental legal and ethical requirements for all
mental health professionals. The
first assessment of violence or danger potential serves the choice of
action to that first responsibility.
The subsequent assessment serves our therapeutic responsibility to
address the client’s emotional and psychology process.
Whether or not you operate clinically using DSM terminology and
diagnoses, assessing for and addressing relevant criteria or elements from
the following list can serve therapy:
with specific triggering
of engaging in opportunistic behavior,
and the consequences of a self-righteous attitude,
and consequences of ego-syntonic perception,
self-esteem is gained or lost with the behavior,
with intense emotional arousal that affects the behavior,
versus displeasure of the negative behavior,
of and intensity of resentment,
of functional reinforcement from the behavior (positive or negative),
established or characterlogical is the behavior or perceptions,
the behavior or perceptions are transitory, and how to get past them
successfully if they are transitory,
of isolation/avoidance behavior,
for and success at social relationships and interactions,
or lack of remorse
example, the violence potential of one adolescent gangbanger versus
another gangbanger can be differentiated in seeing how one individual's
potential aggression may come from the cultural framework of the gang,
while the other’s significantly greater potential for violence and
danger to individuals and society may come from a sociopathic energy
within the cultural framework of the gang.
Differentiating criteria or elements for the sociopath would be
in the violent behavior,
of intense emotional arousal,
nature of the behavior,
of resentment fueling the behavior,
nature of getting away with the behavior,
in social sanctions,
nature of the behavior
the psychological profile of the sociopath, emphasizing or creating
significant negative consequences for the violent behavior would be the
most effective approach for change. Appealing
to remorse would be completely ineffective, among many other approaches.
For the gangbanger who may be asked to or does engage in aggressive
behavior primarily because of the culture of the gang, the differentiating
criteria or elements would be
functional gain in self-esteem and social status within the gang for
the high risk behavior,
to arouse intense anger in order to be violent,
of motivating resentment against a target,
in the act,
for harming someone.
this gangbanger, challenging the cruelty of the act, the dystonic identity
of being a violent person, the gangbanger’s remorse from harming
someone, while also addressing and offering alternatives to gain
self-esteem and status would be more effective therapeutically.
This approach would have little or no effect on the sociopathic
gangbanger. Can we absolutely
be sure about a client’s potential for violence?
Probably not, but we are nevertheless responsible to do the best
that we can. Applying these
criteria or elements to other clients could provide diagnoses, assessment
for violence potential, and direct treatment differentially.
And, give us greater confidence for our clinical judgments.
have been contemplating, developing, using, and sharing this
conceptualization with other therapists and human services professionals
for the past three years. It
has developed and grown with input from others, and has proved to be a
useful tool in clinical work. I
invite you to participate in the conceptualization and use of this
process. Your feedback,
commentary, and ideas would be very welcome.
You can contact me by e-mail at
You can contact me by e-mail at
or through my website www.RonaldMah.com.
Reacts to Diagnosis of Autism in Virginia Tech Shooter, AutismLink, PR
Newswire Association LLC, http://www.dailykos.com/story/2007/04/19/325287/-The-Killer-Who-Could-Not-Speak-Autism-Link-Update#
Shooter’s writing dripped with anger, 2007 Cable News Network,
Ones Who Make You Mad and Drive You Crazy: Personality Disorders For The
Marriage and Family Therapist,” presentation by Gregory Lester, Ph.D. at
the 2004 CAMFT 40th Annual Conference in Los Angeles, May 2,
Depressive? Schizophrenic? Was Cho Seung-Hui really like the Columbine
killers?, Dave Cullen, April 20, 2007, Slate Medical Examiner,
Washingtonpost.Newsweek Interactive Co. LLC, www.slate.com/id/2164757.
Family’s Shame in Korea, Jennifer Veale/Seoul, Time in Partnership with
website of Temple Grandin, Ph.D.
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