Special Report

Thirty-Three Dead

Unintended consequences of the therapeutic culture.

By 4.27.07

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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 ten p.m. and one 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 forty or fifty 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 thirty-three 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 (according to the major piece in the New York Times last Sunday from which these facts and those below are drawn), 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 reports, "...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 thirty-three 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 3 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.

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About the Author

Yale Kramer is a psychiatrist and essayist for Horsefeathers, the blog that fights folly, ignorance, and cant.