by Ronald Mah

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by Ronald Mah

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How Dangerous is My Client?

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

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

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.

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:

In addition, nine types or origins of violent or aggressive behavior may be characterized:

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:

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 

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

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 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 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 40^th 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.

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