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The Therapeutic Culture

Editor's Note: Should Seung-Hui Cho be classified as "evil," "disturbed," or both? This article, originally published on makes an attempt to examine Cho through the lens of psychology--and to predict whether or not our approach to mental illness in America can prevent tragedies of this kind in the future. It is followed by a selection of commenter responses by readers of

Many years ago--before the sixties, when activist reformers discovered the notion that mentally ill patients were an oppressed people, like Negroes (as blacks preferred to be called then), women, and homosexuals (as gay men were identified then), and decided that they must be set free from their sadistic doctors and nurses (deinstitutionalized) in order to become independent (homeless)--I was a resident physician studying psychiatry at Bellevue Psychiatric Hospital.

As first-year residents, I and my colleagues spent many long and interesting hours in the admitting office seeing hundreds of men and women like Mr. Cho, the psychotic killer at Virginia Tech, to determine whether they were an imminent danger to themselves or others. The admitting office was the point of triage in the hospital. Because the hospital was designed to hold 350 patients, and our usual daily census was about 700, the critical clinical decision to be made in that office was whether the patient needed to be admitted for further study and treatment.

On a summer Saturday night the two or three residents on duty there might see a hundred or more patients between 10:00 p.m. and 1:00 a.m., so we didn't have much time to waste. Almost every patient was brought in by a pair of policemen, and on a hot weekend night there were as many as 40 or 50 policemen milling about in the waiting room. One of the things I discovered quickly was that it wasn't easy to get sent to our admitting office. In a tough and apathetic city like New York, you really had to behave in an extreme or bizarre manner to get a New York City cop, who, they like to say, has seen everything, to escort a patient to the Bellevue admitting office. And I found out that their clinical judgment was pretty sharp. It was rare that a patient escorted by a policeman was not admitted.

Usually I'd see the patient alone and perform what is called the Mental Status Examination, which assesses all of the patient's mental functioning. Usually, the exam revealed quickly that the patient's everyday judgment was so impaired--was so out of touch with reality--that he was a candidate for admission. But there were occasions when it was difficult to tell the degree of impaired reality testing and this required a report of the patient's recent behavior. And since the only sources available were the patient and the policeman who brought him, I would have to call in the policeman. Sometimes the cop would not know anything but sketchy and unreliable information. At other times he would wearily pull out his black leather notebook and start to report extensive descriptions of the patient's behavior, which the patient was reluctant to share but would more or less acknowledge when he was confronted.

The patients who were most reluctant to share their thoughts with me and who were most evasive about the details of their everyday life were patients like Cho--seriously paranoid: They knew that their thinking was weird or bizarre, and they didn't want others to know. But their evasiveness gave them away, and usually I would admit such individuals. At first, when I was new to the work, I felt that I was on shaky ground and worried about such admissions. But after a number of them I discovered that the patterns of mental functioning are extremely reliable, and that if a patient behaves evasively and is uncommunicative about himself, there is usually a good reason. After admitting such cases I would follow up by speaking to their families and their friends--if they had any--and inevitably found that there was evidence of much psychotic behavior during the recent and distant past.

Common sense is one of the rarest of commodities these days. And it has been made rarer by the gradual transformation of our society, in the past half century, into a "therapeutic culture." There does not seem to be right or wrong anymore, no good or bad behavior, no problems that cannot be cured, no complications that cannot be solved, no flaws that cannot be removed, and no flawed people who cannot be made perfect. Freud cannot be blamed for all of this; after all, he warned that all that psychoanalysis could do at best was to change neurotic misery into everyday unhappiness. It was those social reformers who came after him, in the twenties and thirties, who took his ideas and ran with them, too far, too fast, and with too much arrogance. Philosophers like John Dewey, progressive educators, the Child Guidance Movement, and social work schools.

Unfortunately, the dynamics of the therapeutic culture were at work at Virginia Tech during the last couple of years and have contributed to the deaths of 33 people. Benedict Carey, a New York Times writer, describes these dynamics: "Seung-Hui Cho seemed indifferent to every small act of human kindness, any effort to connect. According to classmates of Mr. Cho ... one student made several attempts to speak to him, even after reading his frightening writings. Mr. Cho's suitemates, and some teachers, too, made an effort to engage him. And there were undoubtedly others. Maybe they signaled their openness with a slight nod, a friendly widening of the eyes. Those acts of genuine decency failed to prevent Mr. Cho's rampage on Monday." Why? The unintended consequences of the therapeutic culture.

The three basic values of the therapeutic culture are tolerance of aberrant behavior, a non-judgmental attitude, and a sense of understanding for the suffering patient. This is what Cho was being offered by the community at Virginia Tech. Their response goes against the commonest of common sense and only served to protect Cho's illness from being acknowledged, diagnosed, and treated. It only enabled him only to continue his psychotic existence and get worse. During his last two years at Virginia Tech there is no doubt that he was severely, psychotically ill. What is the evidence?

First and foremost he isolated himself socially almost completely. He had no friends at all and permitted little or no communication with anyone. This in itself is characteristic of psychosis. The individual doesn't realize how bizarre such behavior appears to others. But when he does communicate his thinking is also strange and dominated by unrealistic ideas. In his junior year, Mr. Cho told his then-roommates that he had a girlfriend named Jelly. She was a supermodel who lived in outer space and traveled by spaceship.

In that same year his roommates mostly ignored him because he was so withdrawn. If he said something, it was weird. During Thanksgiving break, Mr. Cho called his roommate to report that he was vacationing in North Carolina with Vladimir Putin, the Russian president.

In class, he sat hunched behind sunglasses with a baseball cap yanked tight over his head. Sometimes he introduced himself as "Question Mark," saying it was the persona of a man who lived on Mars and journeyed to Jupiter.

In a poetry class in his junior year, women said he would snap pictures of them with his cell phone beneath his desk. Several stopped coming to class. English teachers were disturbed by his angry writings and oddness. According to The New York Times, "Lucinda Roy, then head of the English Department at Virginia Tech, began to tutor him privately. She, too, was unnerved. She brought him to the attention of the counseling service and the campus police because she thought he was so miserable he might kill himself."

Even his classmates sensed his underlying psychosis. One of them said that after he finished reading one of Cho's weird plays one night, he turned to his roommate and said, "This is the kind of guy who is going to walk into a classroom and start shooting people."

Late in 2005 he became fixated on several real female students. Two of them complained to the police that he was calling them, showing up at their rooms, and bombarding them with instant messages. After the second complaint against him in December 2005, the police came by and told him to stop.

A few hours after they left, The New York Times reported, "he sent an instant message to one of his roommates suggesting he might as well kill himself."

All of this added up to an individual who was significantly out of touch with reality. Like most psychotic people he was a quiet "loner" who avoided social relations, afraid of other people finding out how fantastic his thoughts were. The point is that he should have been under psychiatric care and close observation at least from December of 2005. That he was not is partly the result of the dominant attitude at Virginia Tech and most other schools--the therapeutic culture's requirement that bizarrely behaving students be "tolerated," handled with kid gloves, and that the offending behavior be treated as though it does not exist--pretending that there is no elephant in the room. Unfortunately, the laws enacted since the seventies protect this state of things. A school may not suspend or expel a student with mental illness who is or becomes psychotic--more absence of common sense. And further, the school may not share any information about the student and his aberrant behavior with anyone, even if such information might be helpful in the patient's treatment.

This is what happened in Cho's case. After he threatened suicide the campus police were called, and Mr. Cho was sent to an off-campus mental health facility. After a counselor recommended involuntary commitment, a judge signed an order deeming him a danger and he was sent for evaluation to Carilion St. Albans Psychiatric Hospital in Radford, Virginia. A doctor there wrote a cursory report: "Oriented X4. Affect is flat. Mood is depressed. He denies suicidal ideation. He does not acknowledge symptoms of a thought disorder. His insight and judgment are normal." The doctor who wrote that Cho had normal judgment and insight--insight in this case meaning the capacity to understand how sick he was--was either quite inexperienced or incompetent if he could not see what so many of Cho's classmates and teachers could see. In any case, if the examining psychiatrist had been informed that Cho had been behaving in ways that suggested that his reality testing and judgment were impaired, he might have required that the patient spend a couple of weeks being observed on an inpatient unit. While there, the degree of his psychopathology would have been ascertained and realistic treatment plans might have been formulated.

But the system failed Cho and the university. And although the judge ordered him to undergo outpatient treatment, as far as we know he never even tried and 33 people died.

The forces that can be unleashed in severe mental illness--psychosis--are very powerful. And of course it is a mistake to focus on Cho's guns. As his videos show, he could have killed with a hammer or a hunting knife, and he could have become a serial killer with these. The gun was only more effective and dramatic. Psychotic killers can use anything as a weapon. A distraught mother can kill her five children by drowning them in a river or the bathtub. Or he could have become a "Unabomber" like Theodore Kaczynski, another psychotic loner whose final score was three killed and 23 mutilated.

The most important thing is to see aberrant behavior realistically as a sign of a possible psychosis and deal with it realistically--not tolerate it as an aspect of the individual's "creativity" or politely ascribe it to simple shyness, in accord with the attitudes of the therapeutic culture.

The attitudes and techniques of the therapeutic culture--non-judgmental toward behavior (moral neutrality), empathic, understanding--have only one useful and proper place--a treatment venue: a consulting room or hospital. There is no place for these in schools or in any other life situations. Their use outside of clinical situations can only result in a perversion of normal guidelines for social behavior, confusion for teachers and students, and ultimately resentment and mischief.

These attitudes and the clinical techniques based on them emerged out of the practice of psychoanalysis in the early part of the century to deal with clinical problems unique to analysis but with no other application outside of analytic therapy. This came to be misunderstood by those who fell under the influence of psychoanalysis either as patients or students in schools of education and social work. Aping their analysts or teachers, they came to believe that these attitudes were in and of themselves therapeutic. And over the years these misunderstandings have gained ground and replaced reality--and common sense--as the guiding principles of education and social work.

It would be highly desirable to change the laws that stress the "civil rights" of the mentally ill in schools and that encourage the view that the privacy of the mentally ill individual trumps his health and well-being to laws that support early recognition of severe mental illness so that he may be helped to treatment and management of his psychosis in a timely way, and prevented from doing serious harm to the innocent.


Irwin Savodnik:

Perhaps the most shocking fact of the Virginia Tech tragedy is not the deaths that spewed out of a gun, not the devastating perplexity of a nation, and not the realization that there likely are other Seung-Hui Chos among us. The most shocking fact is the national conversation that has taken place in the wake of the worst such disaster in our recent history. It is a conversation that tells us more about ourselves than it does about the murderer or his victims, a conversation of political perversity and moral vacuity. Worst of all, the strangeness of this discourse seems to have escaped everyone's notice.

In the past week, we've heard about what a shock to the Korean-American community the news of Cho's act has been. Inevitably we've been served up the usual litany of psychiatric diagnoses, each with their attached warning about the potential of mental illness to terrify 300 million of us. Then there were those on both sides of the Fourth Amendment issue, each one offering, Hegelian style, their favored theses and antitheses. According to John Velleco of Gun Owners of America: "If there were no guns, there'd be no killing," or, as reported by Brian Ross of ABC News, "if students had been armed, they could have stopped the shootings sooner." These accounts all have one thing in common. They all point to something outside of Cho, some toxic element that drove him to end the lives of people he barely knew.

Yes, he was odd, given to fantasy, taken with an imaginary female companion named Jelly. But William Blake, Jackson Pollack, Jack Kerouac, and the Beatles were also odd. They didn't kill anybody. And yes, he was a first-generation Korean-American from a struggling family, hardly a distinctive feature of immigrant life in America. Of course, his family was as horrified by what Cho did as was the rest of the country, but so what? For a family not to be shocked by his actions would suggest they had relinquished any claim to sentience. When we subtract the cross-cultural theses, the various proposed mental illnesses and the gun issue, we are back at home plate without a clue.

Our conversation has left something out, an explanatory piece of the puzzle that has been relegated to one or another dustbin of our contemporary existence. Of all the explanations for Cho's actions, no one seems to have mentioned that he was an evil man--deeply evil, uncaring, morbidly self-centered, lost in a world he built and from which he launched his attack. Instead of looking evil in the eye, instead of asking about the whys surrounding his contempt for the lives of others, we have sought causes outside Cho, propellants that made him pull the trigger 175 times, killing 32 people in just minutes. What we have not heard or read is a simple, brute fact. Seung-Hui Cho killed all those people because of who he was. He was Seung-Hui Cho and he was evil to his core.

In the simplicity of this idea resides the source of public perplexity. We have abandoned the idea of evil, and that change in our view of the world makes it impossible for us to understand who Cho was. Cho insisted he was a victim, someone whose soul had been raped, whose blood had been spilled. Anyone who has worked in a prison will tell you they've heard all this before. Steven Sondheim put it perfectly a half-century ago in West Side Story when members of the Jets intoned, "We're depraved on account of we're deprived." For such people, there's always someone or something out there to explain why they committed such an egregious act. Today, sadly, Sondheim's irony is lost on the American public, not to mention its attendant "intellectuals".

Instead of evil, Americans see illness. Everyone seems to be trying to figure out why Cho was so "sick," why he couldn't control himself, talk out his problems with a therapist or someone who would understand him. No one seems able to acknowledge that an evil person commits evil acts. The idea of an evil character, of a lethal kind of person, one who has no regard for others, explains who Cho was. It helps us to understand why he had no hesitation about murdering all those people.

Cho is not a new phenomenon. What is new is the altered landscape of our collective imagination. In supplanting moral judgment with clinical diagnosis we undermine the fabric of our lives together, the threads that tie us together as a people and diminish an understanding of each other that took three thousand years to develop. An account of Cho in terms of his pernicious character is more penetrating than a psychiatric diagnosis.

Anyone who has read Thomas Hardy or Henry James understands this point. It is about time we jettisoned psychobabbling pseudo-morality and recovered a sense of ourselves as moral beings.

Jane Hall:

In his passionate letter, Irwin Savodnik says: "It is about time we jettisoned psychobabbling pseudo-morality and recovered a sense of ourselves as moral beings." And he asserts that Cho was "evil to the core."

Others have applauded his reminder that people are evil and agree that the idea of mental illness skirts the issue. This idea does not comfort me. To the contrary, this attitude perplexes and even frightens me as a citizen and a psychoanalyst. To speak of evil as if it were a metaphysical substance is not acceptable, Reagan's "Empire of Evil" speech 25 years ago not withstanding.

We know hardly anything about the early lives of murderers. Although some research has been done and there is evidence that some male criminals have chromosomal abnormalities, this hardly justifies using the label: evil. What if there is a genetic anomaly or a severely traumatic childhood that caused abnormal brain development? Is that person evil or is he damaged? And, are we average citizens willing to be seen as evil when we tolerate governments that torture those who don't agree with their policies and beliefs. If we are going to "recover a sense of ourselves as moral beings," mustn't we go all the way by condemning in both words and actions our leaders who are blatantly behaving in evil ways? Are we all not evil as we sit comfortably by while Darfur disappears? The entire world has had to build defenses against seeing the so-called evilness that pervades all our lives.

But is it good enough to name it evil? Is not evil another diagnosis? Do we call people with perversions evil? Do we not treat people who engage in sado-masochistic behavior? Not if we call them evil. We try to understand behavior even when it is unfathomable. We are not the clergy.

I will never know what made Cho act so violently. Was he genetically predisposed to violence? Was nurture mixed in? How did society effect his delusions? Was his brain damaged by an injury none of us knows about? Was his pain so unimaginable that he had to show it to us? Do any of us really know what we might do if armed. A brief temper tantrum is ugly--but what if a gun was involved? Using the concept of evil does not explain the Cho's in our world. His actions need to be looked at with a different lens if we are to learn anything about our civilization. Are we content to say "Cho had the devil in him?"

If truth be told and if it all boils down to good and evil, we are all guilty of evil. We may not kill 33 people, but we are responsible for far many more deaths and far more torture. Where is our responsibility. Is it not a possible that we live vicariously in this dangerous world? Shocking idea!

Even within organizations, sports, playgrounds, board rooms, and churches we behave with disguised murderous intent every day. Less and less do our kindnesses conceal our (what I believe to be) hatred due to growing helplessness. We pass prejudices on to our children. Is this motivated by fear or evil? Is evil really fear? I do not know the answers to these questions but as a psychoanalyst I must think about these things. To hide behind morality is worse than diagnosis.

Chalking horrific crime up to evil seems to miss the mark, at least for me.

Arthur T. Meyerson, M.D.:

There is no diagnostic system of behavioral disorders, psychiatric, psychoanalytic or otherwise that describes a single disorder that is universally or even largely associated with murder and in particular, random violence. This includes paranoid schizophrenia, paranoid personality, delusional disorder, psychopathy, etc. All of those diagnoses being thrown about by analytic colleagues on this list are a result of fear and ignorance, otherwise called prejudice, in this case by folks who should know better.

Most people with these diagnoses, by that I mean the vast majority, do not commit any violent act. What distinguishes these few from the majority? Clearly not social isolation, delusions, hallucinations (even command hallucinations) none of which occurs in any of the diagnoses mentionned without being characteristic of a huge majority of persons who do nothing but suffer.

The difference between the ones who are violent, who like Mr. Cho murder in individual cases or in a mass murder spree is that they are or have become something that can be characterized as "bad" or "evil". Many have been such before the onset of their formal diagnosis and those that haven't may have the illness as a contributing or precipitating factor but they are different from the mass of their illness-suffering co-diagnostic brothers and sisters.

When my colleagues throw diagnoses and sympathy at these folks who kill without conscious remorse they are in the throws of a psychocentric or analytic-centric, grandiose mental schema which ignores both morality and evolution. Good to evil, well socialized to guiltlessly violent-these are axes along a natural distribution, whether genetically determined or not and as such to confuse these with "mental illness" is plain ignorance. Rogue apes, lions and elephants are well known phenomena in the mammalian world.

There may well be some delusional persons who kill out of a false belief they are justified in doing so, but there are others with the same disorder and delusion, the vast majority in fact, who never do so. Dynamics may be determinative in some cases but no one has ever demonstrated that in any systematic way and to act with so little conscience in such an extreme fashion is not a good indicator of the ability to form a therapeutic alliance with Alice, Zev, Elio or anyone else. My best wishes in your attempts.

I've worked in a prison, run all the psychiatric services in the five Phillie jails, and wrote my first paper on women who killed their kids. The only thing I've learned that is well supported by the literature is that mental illness nor dynamics distinguish between killers and non killers. They offer, at best partial hypotheses and something else, evil or badness or moral deficiency, or brain disease (see the work of M Lewis or the Texas Tower killer) or that old saw, superego lacunae (in this case Grand Canyons) offer far more compelling hypotheses.

Alexandra K. Rolde, M.D.:

Arthur Myerson speaks of psychiatric diagnoses as being separate from what I would call "character." I am in complete agreement with him that evil as defined by total disregard for the morality of the act of murder in the case in question, is quite separate from psychotic diagnoses. It may be enhanced by the concomitant psychosis, but the superego lacunae are there regardless. My experience has been similar, and that is why it is important to hold patients who commit crimes accountable in the courts.

The above, however, does not preclude the idea that more attention needs to be paid to appropriate treatment for mental illness. Frequently a safe setting or medication, or a relationship with a therapeutic team, can augment the behavior which is likely to result from an unbridled lack of superego. Obviously the two are connected. We must not think, though, that a killer can always be stopped by mental health intervention. If that were so, we would not have murderers sitting on death row. I find it interesting that, in this discussion, no one has referred to those prisoners or called them mentally ill. Thus I concur with and thank Arthur for his post.

I would like to add, that in my opinion, there are degrees of this problem. I agree with Jane that as mental health professionals, it is not our domain to label people as "evil." However, I do think it is our duty when we analyze of treat patients in general, to not avoid analyzing super-ego lacunae and acts aggression in our patients. Many years ago, I heard a continuous case report of a long analysis or a man who had an infant child. The man broke the baby's clavicle two or three times in a rage, but this was never analyzed with the patient, who did not seem to show much remorse, only fear of consequence to him. There was no report made, no consequence occurred. After all these many years, I still feel that the case was mishandled. I think that this happens very often. A woman patient of mine took her roommate's cat one day and drove her to another part of town and let her lose because she did not like the cat. It was only my immediate response of "you did what?" that made her wonder if maybe she did something wrong.

Elio Frattaroli, M.D.

I have so far commented only about the "evil" issue because that one was immediately clear to me. I knew I was uncomfortable with the posts that talked about how Cho's paranoid psychosis should somehow be factored into the public discussion but I wasn't immediately clear what bothered me. I now realize it's exactly the same thing that bothers me about calling Cho evil. Either diagnosis--"evil" or "paranoid schizophrenia"--defines Cho as alien, different from you and me, and defines his behavior as something you and I can't possibly understand--in the sense of that introspective/empathic understanding that is the basis for ALL psychoanalytic knowledge of human nature--because it comes from this alien nature of his to which our ntrospective/empathic awareness has no access since we're not like that ourselves. It's similar to ascribing the behavior of suicide bombers and other terrorists to a religious delusion that puts them beyond the pale of any ordinary human understanding.

Contrast this with Bruno Bettelheim's recipe for understanding bizarre alien-seeming mentation and behavior. When a patient's words and actions make no sense, he said, simply ask yourself, "What would I have to be feeling to think and act in precisely that way?" Feeling--that's the key word. Behavior--and thinking--is motivated by emotional forces. All behavior, whether it is psychotic behavior or evil behavior or logic-defying behavior of any kind. Motivated by the same set of emotions we all have, possibly more intense than we are used to feeling them, possibly sensitized by environmental and chemical traumas we have never experienced ourselves, but the emotions are common to all of us. So one doesn't need to invoke evil or psychosis to understand and explain Cho's behavior. Many of my patients understood it immediately and intuitively and so did I. People who have been humiliated to an extreme that makes them feel they are viewed as subhuman, alien, more contemptible than excrement, and who feel irrevocably shunned and ostracized by the in-group that appears to have easy access to happiness, and who have this experience ongoing for years in their daily interactions with people tend to develop an intense hatred of those in-group people who make them feel this way (or who seem to) and of anyone they see as being in the same group or class (for terrorists the class may be all Jews or all Americans, for Cho it may have been all privileged carefree socially comfortable smug-and-uncaring students). And they want revenge. If those people have a genetic predisposition to a psychotic disorder, then this may all be experienced in the form of a paranoid psychosis, but the emotions that energize the psychosis are more or less the ones I have described, and it is the emotions that explain the behavior, not the psychosis (after all, most paranoid schizophrenics never hurt anybody and most mass murderers are not paranoid schizophrenics).

So to diagnose these people as evil and psychotic and essentially dismiss their emotional experience as irrelevant, is to retraumatize them exactly the way they have always felt traumatized by their designated in-group.

That doesn't mean that we don't need protection from these people. It doesn't mean that we don't need to act decisively to deal with them and the threat they pose to us. But diagnosing them isn't dealing with them--it's a way of not dealing with them.

Henry J. Friedman:

One benefit of NBC's controversial and often condemned decision to show the tape of the Virginia Tech mass murderer was that it allowed those of us trained in mental health to identify the clear cut paranoid psychotic rage demonstrated by Cho. The history of his behavior prior to this outburst of psychotic rage with its catastrophic outcome point clearly to a schizophrenic illness. While there has been much speculation by TV commentators that this was the act of a psychopath or sociopath this appears to be more a response to the horror of these multiple killings of innocent victims. It would reflect better on us as professionals if we stuck to terms like destructive or murderous rage rather than a term like evil which, despite its dramatic appeal is simply not a proper term for describing an incident such as the Virginia Tech multiple murders. It is possible to make a distinction between mental illness and its outcome in any disturbed individual. The belief that making a diagnosis, tentative at best, on someone like Cho means that all paranoid schizophrenics will be seen as potential mass murderers might lead some to feel it is best to avoid any diagnosis. This seems like an unfortunate conclusion because our refusal to recognize a psychiatric diagnosis then leads to speculations about evil that are in themselves misleading and unfortunate. ...

I wonder how many who have contributed to this discussion on the Virginia Tech massacre managed to watch the entire tape of Cho's ranting about what he was going to do and why he was right to do it. Despite the protests about NBC releasing it, the value seemed clear to me. It demonstrated how his thinking and feeling was going shortly before he went on the rampage that resulted in so many deaths of innocent individuals who in no way deserved the judgment he made or that I have seen repeated on this list. While exact diagnosis isn't possible the tape makes it clear that he was a paranoid psychotic. In his rantings about what others had done to him the delusional aspects were quite clear.

The strong arguments to the effect that labeling him as psychotic or paranoid or schizophrenic will give mental illness a bad name seem to me to miss the point. Art Myerson is correct when he insists that not all paranoid schizophrenics are violent. As he says most schizophrenics even in the midst of delusions and hallucinations don't injure anyone. On the other hand I doubt that many psychiatrists would disagree with the assertion that they aren't able to process reality effectively much of the time. If possible they need medication and treatment. Hopefully the influence of Thomas Szaz has faded so we no longer have to argue about the existence of illness or the need for the best possible treatments.

The attempt to understand the emotional state and status of all individuals whether patients or not is of course laudable and a definite part of what we do. I think, however, that the sentiments expressed to the effect that relying upon an empathic understanding of someone like Cho's suffering both from internal and external sources would have lead to a different outcome are unrealistic. His literature instructor, the poet Nikki Giovanni, said it best when she remarked that it was unbearable for her to be in his presence. I believe she was utilizing her empathy which informed her of his homicidal intent, maybe not a concrete plan at the time that she was his teacher, but rather a degree of hostility and destructiveness which made her fear for her life. When empathy is viewed only as a form of positive understanding and caring for a patient it blinds us to the important perception of dangerous intent in the patient. How often has this kind of empathic immersion aimed only at understanding the positive in the patient lead to a therapist being injured or killed? Why not leave room for the therapist's legitimate perception of something worth fearing in a patient? The belief that understanding will ameliorate everything including a desire to destroy the other out of paranoid envy will, in my experience, do more harm than good.

When we talk of evil vs. psychosis or mental illness we are talking in different worlds. Perhaps the divide on these worlds is determined by the setting in which a patient is being evaluated. If a patient is dangerous to himself or to others and we identify this in advance before anyone has been killed do we have to judge the patient to be evil? I hope not. I hope instead we would hospitalize, medicate, treat, etc. to a point of safety. If we fail as clinicians to act appropriately to contain such a patient as was the case in Virginia than we have to deal with the aftermath of murder. Then, the language of evil begins to evolve as we have seen it in this case but we can't abandon diagnoses even if we must stress to the public that schizophrenia or paranoid psychosis doesn't often lead to such an outcome. What we shouldn't do is insist that it wasn't involved in Cho's case or in the case of someone like Andrea Yates. We need to accept that our role is different than that of a commentator on TV or Depak Chopra when it comes to helping the public understand that some mentally ill patients are indeed violent in a very special way.

Deborah Hamm, M.D.:

Extreme violence remains part of the human condition, derived from our evolutionary heritage. An excellent read about this is The Origins of Virtue, Human Instincts and the Evolution of Cooperation by Matt Ridley:

Unless forcibly reminded of nature's cruelty, people tend to romanticize wildlife, seeing benevolence and overlooking viciousness. As George williams has emphasized, crimes at least equivalent in their effects (if not their motives) to murder, rape, cannibalism, infanticide, deception, theft, torture and genocide are not just committed by animals, but are almost ways of life. Ground squirrels routinely eat baby ground squirrels; mallard drakes routinely drown ducks during gang rape; parasitic wasps routinely eat their victims alive from the inside; chimpanzees--our nearest relatives--routinely pursue gang warfare. Yet, as supposedly objective television programmes about nature repeatedly demonstrate, human beings just do not want to know these facts. (p. 215)

Another excellent book on the subject is Hardwired Behavior: What Neuroscience Reveals about Morality by Laurence Tancredi.

I highly recommend both books.

Alexandra K. Rolde, M.D.:

Elio Frattelli and Jane Hall have asked about our understanding of, to coin a phrase, "the difference between US and people who commit atrocities".

Recently, an 11-year-old boy was admitted the residential therapeutic school where I consult. I was asked to see him because he is unremittingly hearing voices, despite antipsychotic medication (Risperdal). History revealed that his father physically abused him and his now 8-year-old sister, and also sexually abused the sister. He was witness to a lot of family violence and fighting between his parents. He and sister were placed in foster homes, his father is in jail, and his mother is deemed incompetent to take care of the children by DSS.

He has contact with his sister, but has had two hospitalizations because of impulsive, aggressive behavior and auditory hallucinations. He spent a few months in a group home, but was unable to be contained there, hence his admission to the current placement.

In the interview, he was rather monosyllabic, until I told him that I knew he had been hearing voices. He told me that he is still hearing them (no-one had really bothered to ask what they say). They are coming from inside his head, and he cannot say whether they are male, female or child voices. They tell him to either kill himself or kill other people. He says that he resists them all the time and works very hard at it. When I asked if he is tempted to do that, he said yes, but would never do that, so he tries hard all the time to focus on doing other things such as school work, or talking to people or reading, or sports. If he gets angry, he gives people three warnings that he will punch them if they continue saying or doing the thing that annoys him. He agrees with me that the thing that he dislikes most is to feel angry and hates to think about acting on it. He has set up these rules for himself. When asked, (presumably no-one else had) if he feels sad, he said that he feels unhappy a lot, especially when he is not doing anything, such as when he goes to bed at night. That's when the voices really bother him too, and he has trouble falling asleep.

He said that he has punched walls and broken things but has never hurt anyone and would not do that.

Apart from the fact that all his previous treaters ignored the fact that he has a Major Depression with psychotic overlay, and obvious PTSD, both of which have gone untreated , what interested me most was the fact that this child obviously has a very strong superego (our language), conscience (societal language), moral attitude (legal language?)

Now where did that come from? Given his history, how was he able to develop it? Do we think that Hitler et al did not have it? I think that is really the question. Why do some children develop conscience and empathy for others. Is it selective sometimes? I agree that the infamous individuals may have been products of their time, but in my opinion they used the climate to rationalize their private purposes and actions. Is the little boy that I saw going to grow up to be a mass murderer? Somehow I have a sense that he does not fit the same category as the others. The phrase that no-one has mentioned so far that comes to mind now is "the bad seed." In my opinion this child did not qualify. But am I right?

Do we really understand any of this? I have seen children who show no remorse, who have harmed themselves and others without the slightest hesitation. Do they qualify? Somehow, I think that maybe the time has come for some longitudinal studies of children who present with major psychiatric diagnoses but in groups of those who do exhibit a conscience and those who don't.

Having given individual examples of what we as psychoanalysts see in our work, I quite agree with Deborah Hamm, Art Myerson and Zvi Lothane that extrapolating from our theory to behavior of political mass murderers is a stretch we should not be making. Finally, the advances in our understanding of brain functioning from recent neurological research, as Deborah points out, should give us pause in assuming that nurture is responsible for all. Different deficits or neural pathways in different individuals need to be taken into account, and we are far from being able to categorize any of it as yet.

Steven S. Rolfe M.D.:

While I can understand that the general public as well as the general pundits have extreme difficulty coming to terms with psychosis and delusional thinking as contributing if not determining factors in cases like Cho I don't understand why analysts appear to have the same problem. Elio while I agree with much of what you wrote, when you say it's the "emotions not the psychosis that explain the behavior" I have to disagree-it is both the emotions and the psychosis-and of course neither fully explain it. However had Cho had been properly treated by a mental health system that hadn't denied his illness perhaps his evil behavior could have been prevented. That's what we should be emphasizing. And in order to do so we should distinguish between Bin Laden and Cho, which for some reason and much to my astonishment no one seems to want to do.

The argument that I keep seeing "all psychotics are not murderers and all murderers are not psychotics" is being used all over the place to say we can't say anything meaningful about inclination toward violent behavior in a given individual. That's an absurdity that is being used to justify our current politically correct mental health laws that don't permit involuntary treatment, and a managed care health system that doesn't allow for proper treatment. It's also an argument being used by the gun lobby to justify current gun laws; after all since we can't predict who will be violent we may as well arm everyone. To attribute Cho's illness to "evil" carries the same risk-since some people are just evil what can treatment accomplish?

So I completely agree with Henry that "our refusal to recognize a psychiatric diagnosis then leads to speculations about evil that are in themselves misleading and unfortunate". To say there is no link between the kind of paranoia Cho experienced and his violent behavior does a disservice to those patients who could be successfully treated. That is not to say of course all rage or psychosis can be successfully treated. Where the "rubber meets the road" would hopefully not be in court-the lawyers I'm afraid got us into this mess- but in a mental health treatment setting that would adequately treat this man's psychosis with medication that just possibly could alleviate his delusions , his sufferings, and his violent preoccupations enough for him to be engaged in a treatment process.

For many years we have known that the content of psychotic delusions often mirror the cultural context. It used to be fears that the CIA or FBI was taping or following. It shouldn't be surprising that the content is now often much more violent and dangerous. Freud cautioned when he said, before the creative artist we must lay down our arms. The same must be said for the forms of mental illness we know relatively little about.

Deborah Hamm, M.D.:

There is no mind without brain.

I think it is problematic to "listen" to the minds of patients without some awareness of brain, chemistry, genetics, etc., the awareness of which need not distract from meaning and interpretation, but ideally should facilitate the richness of understanding and inform the treatment process. When I listen to music, my awareness of the relationship of melodies with harmony, and the mechanisms creating the music (musicians, conductor, instruments, concert hall) can actually enhance the experience, unless my attention to the music is in some way disrupted by it. Paying excessive attention to brain function is no more interfering when listening to patients than paying too much attention to theory or metapsychology, and when either occurs it can serve as a useful indicator that something is "off," which needs to be addressed. But if we don't know, at least minimally, about the possible contributing factors of brain (chemical imbalance, genetics, etc), options for more accurate, enriched understanding are lost, and effective intervention is needlessly restricted.

Charles Whitman, the mass murderer who shot 45 people (killed 14, wounded 38) from the University of Texas Tower in 1966, after viciously murdering his mother and wife, was suffering from a brain tumor. "Post-mortem autopsy of his brain revealed a glioblastoma multiforme tumor the size of a walnut, erupting from beneath the thalamus, impacting the hypothalamus, extending into the temporal lobe and compressing the amygdaloid nucleus (Charles J. Whitman Catastrophe, Medical Aspects. Report to Governor, 9/8/66)." The significance of the tumor as a causal factor is reported as controversial, which I don't understand. Whitman had a constellation of worsening symptoms implicating both hypothalamic and amygdaloid involvment: increasing hyperreligiosity, sleep-wake disturbance, increased appetite, hypergraphia, increasing frequency of rage attacks, and headaches. Because he started keeping a diary, his mental truggle with illness is poignant: "Control your anger ... don't be belligerent ... stop cursing ... control your passion." Days before he began his murder spree, he contacted police and requested to be arrested, but was referred for psychiatric evaluation, with which he complied. He reportedly complained about his symptoms and his family, including an abusive, demanding father.

Several days before climbing the tower, he wrote a letter to himself which included the following: "I consulted Dr. Cochrum at the University Health Center and asked him to recommend someone that I could consult with about some psychiatric disorders I felt I had. ... I talked to a doctor once for about two hours and tried to convey to him my fears that I felt overcome by overwhelming violent impulses. After one session I never saw the Doctor again, and since then I have been fighting my mental turmoil alone, and seemingly to no avail. After my death I wish that an autopsy would be performed to see if there is any visible physical disorder. I have had tremendous headaches in the past and have consumed two large bottles of Excedrin in the past three months." The note that he left with his mother's body included, "If my life insurance policy is valid please pay off my debts ... donate the rest anonymously to a mental health foundation. Maybe research can prevent further tragedies of this type."

Charles Whitman was highly communicative (unlike Cho), was clearly seeking help, and was not helped. In a quick look at Cho's background, I recall reading that he was silent for most of his life; his grandmother expressed early concern that he might be "autistic." His unwillingness and/or inability to communicate was recognized as an enduring problem. Even this minimal information points to some sort of genetic burden.

These are extreme cases, and not analytic. But the point I am trying to make is that mind and brain are exquisitely intertwined, and that although we, as psychoanalysts, often focus on mind, we cannot ignore brain, and knowing about brain function is not dismissive, even in patients appropriate for analysis. For example, including thinking about genetic influence enables me to expand the range of possibilities regarding intentionality ("can't" related to impossibility or degree of difficulty, "won't" because of conflict, et cetera).

With technology and knowledge, the gap between neurology and psychiatry is closing. There is no such thing as nature versus nurture. There is only an exquisitely, richly linked ongoing choreography that is epigenetic (environment-gene-gene-interactions) which should not detract, but rather enhance our appreciation of mind. I believe the average number of genetic mutations every individual statistically carries is somewhere around 10-12, so I don't consider genetic mutations as alien (no one escapes). Nor do I find myself on a slippery slope, abandoning mind, but rather listening more fully, and comprehensively, I hope.

Mindful of full disclosure regarding motivations for these recent posts, I'll add that I was visiting the U.T. campus for a routine college visit with my family on the same day as the V.Tech massacre. We were standing at the turtle pond memorial beneath the tower, on tour, learning about the Texas tragedy, when news about the Virginia Tech massacre began to circulate. We need to keep trying to do better.

By Yale Kramer