Wednesday, April 25, 2007

Face to Face

Reminder: Grand Rounds at Shrink Rap, BYOB, Submissions due by Saturday.

Sometimes, The Last Psychiatrist says things that make me want to scream. He did that the other day, in a post about the Virginia Tech shooter, he made the statement, and I quote:

"... Cho wasn't mentally ill. He was a sad, bad man who killed people because his life wasn't validated. There was no psychosis, there was no cognitive impairment, there was no psychiatric impairment in insight in judgment. There was a lack of sex, but that's not yet in the DSM. Not to reduce his life down to a soundbite, but he was a guy who thought he deserved better by virtue of his intelligence and suffering; found himself in a sea of mediocrity but couldn't understand why he couldn't therefore excel; and, worst of all, found that all the things he thought he deserved eluded him-- especially hot chicks, who not only dismissed him and found him creepy, but, worse, chose to be with the very men he thought were obviously inferior to him. "

Can I scream??? I don't want to defend this man, I haven't followed the news all that closely, and I watched one 3-minute video the killer made, though I will admit that statements he made along with some of his behaviors (for example, killing himself, or perhaps even the illogical thought process that might lead one to think that murdering innocent people makes one a martyr for one's nonexistant children) led me to think he might have a mental illness. On our podcast we talked about this in response to a reader's question and we didn't think a diagnosis of schizoid personality disorder was necessarily accurate or not, and we didn't think it was relevant to the act of mass murder.

I don't know how The Last Psychiatrist practices psychiatry. For me, when I do an evaluation of a new patient in my ideal bubble world private practice, I schedule 2 hours, I sometimes run a little over. I ask the patient about every aspect of their lives, including extended family history, descriptions of their parents' and siblings' personalities, detailed medical, occupational, romantic, legal, military, and habit histories. I ask about past episodes and treatment. I do a mental status exam. I request records, if someone accompanies the patient, I bring them in at the end of the interview to clarify history, get another perspective, talk about a plan. In less-than-ideal clinic world, I take a history and I often have extensive records from prior treatments.

I've never made a diagnosis based on a three-minute tape, one where I didn't get to ask questions.

How does The Last Psychiatrist know there was no impairment in insight or judgement (Give me a break, he thinks this guy had intact insight and judgement?) How does he know Cho didn't have sex? How does he know Cho was motivated by his anger about not getting the hot chicks?
Did I miss something here? The Last Psychiatrist seems to know an awful lot about the inner thought processes of a stranger.

Thanks for letting me scream. I'm done now.


ClinkShrink said...

I'll volunteer to share your scream. I didn't read the Last Psychiatrist's post and if I saw it was about the shooter I most definitely wouldn't. At this point I (and probably lots of other people) have heard enough speculation about the shooter, both educated/professional speculation and lay opinions. The bottom line is:

We just don't know.

I've only known two spree killers in my life, which is certainly not enough of a database to build an informed opinion on and regardless they were extraordinarily different (ie opposite from one another) people. The offenses themselves said very little about the person.

Random speculation is rarely helpful. And for certain events I think the only real appropriate response is solemn respectful silence.

And so I'll shut up now.

JR's Thumbprints said...

I'm not sure you could shrink rap Cho's problems into a neat little bundle.

Roy said...

I agree, TLP has over-extended h'self. But, Dinah, you have diagnosed someone on the basis of a thirty minute tape, with no opportunity to ask questions.

Part II of the Board exam. These are now four 12-minute videos.

Dinah said...

Actually, the videotape I was shown at boards had an interviewer who asked the same questions I would have asked. A little different, it's more contrived, and agreed upon acting session by all the individuals involved and where the examiners are aware that there is limited information available and the candidate is doing the best they can given what's available. And I didn't go on a public blog making a definative statement about a mass murderer's diagnosis, lack thereof, or the motivations behind his reprehensible actions.
I passed part 2 of the boards. And I've done quicky evals much faster at times I just don't blog about them.

DrivingMissMolly said...

You go girl!

I think he deliberately tries to be provocative, Dinah.

He's a pot stirrer and a habitual line stepper.

He revels in his anonymity and vents and just puts things out there. Let's face it, everyone is speculating about this murderer.


Dinah said...

I thought you were talking about Roy

Anonymous said...

I read that too.

I thought about your podcast that covered post-mortem psychiatric evaluations.

With those evaluations, at least the evaluator has access to comprehensive, relevant and in depth material (as opposed to only having access to the group-think coverage that the "Media-of-Fear-and-High-Drama" chooses to present).

Once a definitive and absolute statements is made without significant information I find myself partly dismissing the validity of the rest of the....pundit's assertion.

However, I still learn from The Last Psychiatrist, and his points of view are interesting. And I have to think that he was aware that such there were drawbacks in his choice to present a possibility as a fact, as well as holes in his data. He knows that he can't know any such thing about Mr. Cho.

So, I wonder why he chose to do it that way.

I think it may have been a more human, less professional (or perhaps, the human side of professional) response to the assumption that there is a mental illness (which is able to sponge up some of the culpability) in anyone who does such a terrible thing.

Bardiac said...

Um, nerd alert.

I think the link to the last psychiatrist at the top of your page is broken. You can fix it by deleting the part of the url that links to this blog, or by cutting it and pasting in the real url:

(That's two minutes of my life I'll never get back for following and figuring out the link, but I'm pretending to make it worthwhile by doing the nerdly thing and helping you with the link. Virtually altruistic?)

Midwife with a Knife said...

There are some things, like killing 33 people, that are so horrible, that it's hard for me to imagine that someone with an intact mind can do that.

Then again, string theory is hard for me to imagine, too, but that doesn't make it a poor model for the universe. The 64 tiny dimensions the mathematical foundations require are suspect, though...

Dinah said...

Bardiac, the link is fixed, I owe you two minutes, have it tacked on at the end.

Ania, one can be mentally ill and still be culpable. I can believe that a mental illness contributed to Cho's distortions, anger, whatever it was, and still think that someone who shoots up 32 people should go to jail forever.

Anonymous said...

Dear Dinah,

Yes, I agree. The parenthetical bit of my sentence was an extension of the assumption or belief that some people hold or rely on - especially in the face of events such as this.

I should have put,

"I think it may have been a more human, less professional (or perhaps, the human side of professional) response to the assumption that some people hold: that there is obviously a mental illness and that [said] mental illness sponges up some of the culpability in anyone who does such a terrible thing.

Is that clearer? Goodness, did I just muck it up more?

Sometimes, I don't get the form just right. I don't like that at all.

Also, I read everything here (almost everything), but don't comment much. But, since I seem to be on a roll today, I want to mention how much I appreciate your posts and pod-casts.

Thanks so much, you three.

Anonymous said...

(Did you see that^, Miss Dinah?

You don't know me from....well, let's say "Eve", but I feel unsettled when I think I've left someone with the wrong impression of me or my viewpoints.

Sooo, just checking.

Take care.)

TheLastPsychiatrist said...

Hi. I wrote the offending post that is making people scream, so I'll try to defend it:

Psychiatric pathology exists on a spectrum. There's no "ill" or "not ill," and impairment in one realm doesn't explain impairment elsewhere. A diagnosis does not explain your entire existence.

I should not have, therefore, said he wasn't "mentally ill." What I should have said was he was not insane: he knew what he was doing, he knew what he was doing was wrong, and he had the ability to control himself. So he is entirely to blame, i.e., the mental illness, even if substantial, is incidental.

Clearly, maladjusted and sexually frustrated college kids don't often go on rampages, so there was something in him that helped him choose this outlet. But add up the body counts in the past twenty years. What's in common in mass murderers isn't mental illness, but frustration, impotence (metaphorical) and anger. Or are all those suicide bombers in Israel bipolar?

But as a social question, (and the reason why I wrote that post in the first place (a reader had requested it)): why does everyone want him to have a mental illness? What's the societal benefit of this posture? The answer is that it explains and contains his behavior, and makes others safe by default. No blame falls on society, on upbringing, on anything else. "He was schizophrenic, that's why." Feel safer? Oh, what about the other 8 university shooters?

And if it is mental illness, what do we intend on doing about it? My bias implies harsher sentences, societal changes, etc-- we can debate that later. But if it is all mental illness, then what? Do we lock up the "mentally ill" like we do pedophiles and terror suspects, before they even commit a crime, just on suspicion? And who decides who is suspicious? Us? Do you trust every psychiatrist to be good at this? Or should it be the government?

Would you have been happy-- I mean this in all seriousness-- if George Bush had Cho arrested last year for being a terror suspect? Which part of that bothers you? It would have been legitimate, because he was dangerous. So is it that he was arrested before he committed a crime, or that George Bush did it? Either way, that's what you're proposing we do all the time.

You want to make "treatment" mandatory? Great. Tell me _exactly_ who should decide who needs treatment, and for how long. And tell me how this treatment is going to prevent him from becoming violent, and for how long, and tell me what we should do when the treatment doesn't work.

We can turn Guantanamo into a massive psych hospital. Any takers?

Anonymous said...

To The Last Psychiatrist:

I agree that illness doesn't define a person's entire existance.

Regarding Cho, one could make inferences about his motives and behaviors, but there's just not enough information to make sweeping statements about his mental state, motives, intent. Perhaps the psychiatrist who examined him during his 2005 admission knows more, perhaps he had a diagnosis.

From what I saw, I thought it was possible that Cho was delusional, there just wasn't enough information. I don't know how you could know if he could control his actions.

Plenty of people feel frustrated, angry, and impotent--- most don't become killers.

Does everyone WANT Cho to have a mental illness? I don't think so, as a society we see mental illness as a mitigating factor, if it's bad enough the actions are not treated as crimes with the same degree-- had Cho lived, he would have needed to be pretty nuts to have escaped criminal prosecution.

I believe that Cho did have a mental illness-- it seems his behavior caused people to suggest he "get help," resulted in a hospitalization, inspired a professor to try to take him for treatment. I have no idea what that mental illness was, if it was chronic or persistent, or if the symptoms of that illness gave rise to his actions.

I never suggested pre-emptive treatment or shipping all would-be mentally ill criminals to Guantanamo, but it is an interesting thought.

I'm not sure there was a legally-sanctioned means to prevent what happened at Virginia Tech. As a Monday morning quarter-back, would you deny that Cho should have gotten treatment?

Perhaps the best we can hope for is that more troubled people will get help before they do awful things.

Unknown said...

Jason from Neurotransmission here. I share some of TLP's misgivings about reflexive attributions of mental illness to Cho.

Never having met Cho, I don't claim to know categorically that he wasn't mentally ill, but I'm equally sceptical of the commentary I've read that attempts to gloss what little we really know of Cho's inner world in diagnostic terms. To the extent that DSM terminology has genuine clinical or explanatory efficacy, it surely lies in providing clinicians with a mutually comprehensible framework to guide the psychiatric treatment of living patients over a therapeutically meaningful period of time-- not as a forensic postmortem of a killer-suicide of whose thoughts and behaviors only glimpses remain.

Mentally ill or not, the point raised of Cho by TLP that resonates from my perspective is the societal dimension of his actions. If neither psychosis, schizophrenia, romantic disappointment nor Glock 9mms by themselves (or even in combination) truly provide sufficient reason to render the massacre comprehensible, we're forced to consider wider factors. For me, one wider thought is that Cho perceived himself to be a loser in the starkly polarised winner/loser culture of American hyper-capitalism -- that his intrinsic sense of the social contract by which he determined the shape of his life's final act was harshly attenuated by longterm social isolation. Like Milton's Satan, Cho thus resolved that it was "better to reign in Hell than serve in Heaven."

I wonder if the challenge of acknowledging such deeper structural causes lies perhaps in our sense that reconfiguring the social contract more equitably amounts either to a discredited Marxist delusion or a potential threat to the status quo.

For more on this theme, see "Others Must Fail: Cho Seung-Hui and the bloody cost of American individualism" at: