How Dangerous is My Client - RonaldMah

Ronald Mah, M.A., Ph.D.
Licensed Marriage & Family Therapist,
Consultant/Trainer/Author
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How Dangerous is My Client?

The following e-mail arrived in my Inbox in late April 2007.  

“I 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 "gofer."   

He 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.)

Less 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.  

The 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.

Here 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.  These are
• Self-Righteousness Attitude
• Entitlement
• Ego-syntonic Perception
• Intense Emotional Arousal
• Resentment
• Characterlogical Nature
• Isolation/Avoidance Behavior
• Lack of Remorse

Taking 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 disorders.

In 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 others.

Consensus 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 responsibilities.  The 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.
• 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, methamphetamine).
• 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.
• 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.

• 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.
• 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.
• Is 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 in therapy.

• What 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.  

• How 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 aggression.
• Does 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.
• Does 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.
• Does 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?

• How 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.
• 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 is a self-prophecy of hope as opposed to a story of doom.

• 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.
• What are his/her parents like?  This is a basic psychodynamic exploration- an examination of the family of origin, attachment relationships, validation, nurturing, etc.

• Does 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.
• 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.
• Are there class issues that may also apply?  Class is an often forgotten discriminatory issue.

• 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.
• 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.

• You 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 role.

There 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,

“From 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 stressful.”

The larger list of criteria or elements to use for assessment for violence or danger potential is:
1. Specific Triggering Event
2. Opportunistic Behavior

3. Sense of Entitlement
4. Self-Righteous Attitude
5. Ego-syntonic Perception

6. Self-Esteem Gain or Loss

7. Intense Emotional Arousal
8. Pleasure
9. Resentment

10. Functional Reinforcement (Positive or Negative)

11. Characterlogical Behavior or Perceptions
12. Transitory Behavior or Perceptions

13. Isolation/Avoidance Behavior
14. Social

15. Presence or Lack of Remorse

In addition, nine types or origins of violent or aggressive behavior may be characterized:
1. frustration
2. cultural issues
3. bullying
4. borderline behavior
5. narcissistic behavior
6. paranoid behavior
7. sociopathic behavior
8. psychotic violence
9. substance abuse ignited aggression  

Which 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:
• dealing with specific triggering events,
• likelihood of engaging in opportunistic behavior,
• sense of entitlement,
• origins and the consequences of a self-righteous attitude,
• development and consequences of ego-syntonic perception,
• how self-esteem is gained or lost with the behavior,
• dealing with intense emotional arousal that affects the behavior,
• pleasure versus displeasure of the negative behavior,
• development of and intensity of resentment,
• degree of functional reinforcement from the behavior (positive or negative),
• how established or characterlogical is the behavior or perceptions,
• whether the behavior or perceptions are transitory, and how to get past them successfully if they are transitory,
• degree of isolation/avoidance behavior,
• need for and success at social relationships and interactions,
• presence or lack of remorse

For 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  
• lack of remorse,
• pleasure in the violent behavior,
• absence of intense emotional arousal,
• ego-syntonic nature of the behavior,
• lack of resentment fueling the behavior,
• opportunistic nature of getting away with the behavior,
• disinterest in social sanctions,
• characterlogical nature of the behavior

Given 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
• potential functional gain in self-esteem and social status within the gang for the high risk behavior,
• need to arouse intense anger in order to be violent,
• lack of motivating resentment against a target,
• displeasure in the act,
• ego-dystonic experience
• remorse for harming someone.

For 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.

I have been contemplating, developing, using, and sharing this conceptualization with other therapists and human services professionals for several years.  It has developed and grown with input from others, and has proved to be a useful tool in clinical work.  I am extending this work including reference to more current violence in our society for a book "How Dangerous is This Person" which I will be self-publishing as an e-book.  You can contact me by e-mail at Ronald@RonaldMah.com or through my website www.RonaldMah.com.

References:
AutismLink Reacts to Diagnosis of Autism in Virginia Tech Shooter, AutismLink, PR Newswire Association LLC, www.prnewswire.com/cgi-bin/stories.pl.

Professor: Shooter’s writing dripped with anger, 2007 Cable News Network, CNN.usnews/2007/US/04/17/vetch.shhting/index.html.

“The 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, 2004.

Psychopath? 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.

A Family’s Shame in Korea, Jennifer Veale/Seoul, Time in Partnership with CNN, www.time.com/time/worls/article/0,8599,1613417,00.html.

http://www.templegrandin.com, website of Temple Grandin, Ph.D.
ADDRESS:
433 Estudillo Ave., #305
San Leandro, CA 94577-4915
Ronald Mah, M.A., Ph.D.
Licensed Marriage & Family Therapist, MFT32136
CONTACT INFORMATION:
phone: (510) 614-5641
fax: (510) 889-6553
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