Special Report: Thirty-Three Dead By Yale Kramer

Special Report
Thirty-Three Dead
By Yale Kramer
Published 4/27/2007 12:08:17 AM
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, 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.
Yale Kramer is a psychiatrist and essayist for Horsefeathers, the blog that fights folly, ignorance, and cant.

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103 Comments on “Special Report: Thirty-Three Dead By Yale Kramer”

  1. Tamar Schwartz Says:

    In a free society the problems of the mentally ill are extremely complex. I disagree with Dr. Kramer’s negative view of laws that protect the privacy and
    rights of all individuals, even those who are mentally ill. I also strongly disagree with his statement that the problem has nothing to do with gun
    control.

    We cannot stop all mentally distraught or mentally ill people from killing, though we must do everything legally and humanly possible to do so. Indeed there was a system failure with the VT gunman. That said efforts to frame and focus this tragedy on mental illness and explicitly state the problem isn’t gun control is absurd….. and in many cases has more to do with the long arm of the gun lobby than any real interest in mental health.

    I am not saying that this is Dr. Kramer’s interest.

    Joe Cronin
    Chicago

  2. Tamar Schwartz Says:

    05/02 9:57 PM
    It Goes Without Saying
    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 Jerry. 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.

  3. arolde Says:

    Response from 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 anamoly 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,” musn’t we go all the way by condemming 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 lense 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.

    Jane Hall

  4. Tamar Schwartz Says:

    Comment From Jane Walword:

    On the subject of gun control and the rights of the mentally ill, I’ll relate an event that took place two days ago at JFK. I had made it through security in plenty of time to have some dinner before I boarded a flight. While enjoying my dinner, deep in my thoughts I became aware of someone at the next table talking. I looked over andsaw a man, sitting alone talking to himself. At first I thought it was another instance of someone with an ear piece talking on the phone. Suddenly the man turned around (he had been sitting with his back to me) and addressing me he said, “Hey, what happened at Virginia Tech was wrong wasn’t it?” I responded that yes I thought it had been wrong.

    It was obvious to me right away that the man, no surprise to any reader of this list, was psychotic and paranoid. He began to address a very young woman at an adjacent table. He was calling her names with a fluent use of rofanity. He said, “You know I’ve been around, I’m not some 23 year old.”

    The young woman looked frightened and said, “Don’t talk to me.” I got up and went for the manager. The manager asked me if the man had been drinking. And I said, “I think he’s probably psychotic.” When the manager arrived the man turned to the young woman and said, “You told on me didn’t you? Even though I saw her [me] get up and walk back there. But I know it was you.” He then turned to me and said, “Did you tell on me? You did, didn’t you?” Eventually security was called and they took him away, to where I don’t know. But not before he had moved to the other side of the restaurant, upsetting people there.

    The incident was considerbly less frightening to me because we were on the other right of security and I thought it very unlikely that he could have a gun. The fact that he didn’t have a gun made me feel considerably more omfortable. In my opinion it makes a strong case for gun control. However I believe it also makes a strong case for the need to be rational in our problem solving about the complex issue of civil rights for the mentally ill. It seems to me that the young man in Virginia was abused by a blind and rigid adherence to the principle of civil rights. As a result, the young man has murdered 33 people, including himself, not to mention what must have been a torturous existence without adequate treatment and support. It’s an example of how it’s possible to do wrong by doing right. In public policy as well as within our own organization we should be guided by principle, not blinded by it.

    I worked at Long Island Jewish Hillside Hospital in New York during the early 70s and witnessed the mentally ill being denied threatment they needed in large numbers. David Berkowitz (Son of Sam) was one of those in New York who could not get what he needed. Over the years I’ve often thought that the issue of civil rights for the mentally ill received popular support more because of the cost of providing adequate treatment for the indigent mentally ill than a real concern for their civil rights.

    It also speaks for a need to educate the public about mental illness. No one, other than myself recognized the man was psychotic. Every one that made a comment to me was sure the guy had just had too much to drink and was a “jerk.” I was impressed by how little the general public knows about mental illness.

  5. Tamar Schwartz Says:

    Response from Zvi Lothane

    Does evil exist or is it merely a moral judgement? Is it God-made or man-made? Is it immoral or illegal? Should we punish evil or forgive it?

    The basic meaning of evil is injury. causing injury, death, or calamity. The cycles of nature include injury, death, and calamity. It is different when people do it to each other. Emanuel Kant called it radical evil: man-made evil for which we are held morally and legally responsible. Hitler and his henchmen were evil. We were clear about the evil of the Holocaust and felt we waged a morally justified war against the Nazis.

    Is Bush also evil because he waged war on a sovereign state? Was the Viet Nam war evil? Were the Russians and Chinese evil before we established relations with them? Was Saddam evil? Is Iran evil? Or are these various instances of lack of morality in politics? It used to be said that an erect penis knows no morals. The same can be said of militarism, conquest by force of arms, and lying in politics: all institutionalized activitivies in society. Our representatives in Congress vote for these activities and appropriate funds that come out of our pockets.

    Mr. Cho was responsible for his actions: but was he also forensically responsible or should have been judged not responsible by reason of insanity? Even if the judge has so ruled, based on forensic opinion, Cho still would have been punished: jailed for life.

    Morally speaking Jane is right in counting 33 not 32 victims. Mr. Cho was a victim of his own tortured soul and also of the loopholes in the systems that allowed him to slip through the holes in the net. I do not know if contacts were made with his family to ask them to compel him to be in treatment. I do know that the campus police was ineffectual in their surveillance of Cho and negligent in that it did not storm the rooms once the shooting started. I don’t know if the students could have fought back as the passengers did on one of the hijacked planes during 9/11.

    But I agree with Jane that Cho was not alone: he lived in a family, he lived in the society VTech. Everybody bears a measure of responsibility.

    Zvi Lothane

  6. Tamar Schwartz Says:

    Response from Henry 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.

    Henry J. Friedman

  7. Tamar Schwartz Says:

    Kramer the commonsense-man also makes the following assertions which has nothing to do his blaming psychoanalysis: 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 beh avior with anyone, even if such information might be helpful in the patient’s treatment.

    Yale, are you claiming that the policies at VTech were also a result of the therapeutic culture engendered by psychoanalysis? Where is you common sense here? You are also missing this essential ingredient: it is not enough to lock people up, you also have to involve the family in the treatment plan, as best exemplified by the young man who shot Reagan. The family would have been in a position, if properly guided, to compel their son to enter treatment.

    Another respondent to your post pointed out to me the following absence of common sense on your part when you write:

    “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.”

    Here your neocon ideology is in evidence: how could Cho have killed thirty two people with a hammer or hunting knife? This is sheer nonsense: he would have been overpowered by a few strong guys before he had any chance to kill as many as he did. (By the way, the state of shock was so enormous that there was no time for any resistance to be offered by the students who were being shot at. At the same time, strapping police fellows were seen standing behind a tree while the shots were ringing out without budging to go in and intervene, as they should have, were they properly trained.) I think this piece of nonsense about the hammer and knife shows that in having by and large identified with neo-con ideology you are also a staunch defender of the all-powerful NRA and gun lobby.

    Zvi Lothane

  8. Tamar Schwartz Says:

    Response from Zvi Lothane

    Kramer the commonsense-man also makes the following assertions which has nothing to do his blaming psychoanalysis: 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 beh avior with anyone, even if such information might be helpful in the patient’s treatment.

    Yale, are you claiming that the policies at VTech were also a result of the therapeutic culture engendered by psychoanalysis? Where is you common sense here? You are also missing this essential ingredient: it is not enough to lock people up, you also have to involve the family in the treatment plan, as best exemplified by the young man who shot Reagan. The family would have been in a position, if properly guided, to compel their son to enter treatment.

    Another respondent to your post pointed out to me the following absence of common sense on your part when you write:

    “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.”
    Here your neocon ideology is in evidence: how could Cho have killed thirty two people with a hammer or hunting knife? This is sheer nonsense: he would have been overpowered by a few strong guys before he had any chance to kill as many as he did. (By the way, the state of shock was so enormous that there was no time for any resistance to be offered by the students who were being shot at. At the same time, strapping police fellows were seen standing behind a tree while the shots were ringing out without budging to go in and intervene, as they should have, were they properly trained.) I think this piece of nonsense about the hammer and knife shows that in having by and large identified with neo-con ideology you are also a staunch defender of the all-powerful NRA and gun lobby.
    Zvi Lothane

  9. Tamar Schwartz Says:

    Response from 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 anamoly 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,” musn’t we go all the way by condemming 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 lense 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.

    Jane Hall

  10. Tamar Schwartz Says:

    Response from Alice Maher:

    Hi Elio, nice to hear your voice again.

    My position is somewhat different from Irwin’s, Jane’s and yours, I think. I actually don’t think of Cho as evil (maybe…) – I think of him as a paranoid schizophrenic, which is another concept that society should understand better than it does, as Jane W pointed out a few days ago. What I responded to in Irwin’s post, and Katherine’s response to it, was that it literally “reminded” me of the word; it brought the word “evil” to my consciousness. That doesn’t mean I flipped a switch and turned “paranoid schizophenic” into “evildoer.” Not at all… but it did reframe the problem in an intriguing way. It made me think of how words like “evil” and “altruism” weren’t used at all during my many decades in the analytic community, and I wondered why we had such a poor understanding of those concepts, or resistance to wrapping our minds around them.

    The fact is, the outside world DOES think in terms of good and evil (as Elio rightly points out, we’re generally the good ones and the people we oppose are the evil ones, except when we switch to “mea culpa” mode). And the outside world DOES need to know more about mental illness than they do now.

    One thing my analytic training taught me was to stay with the surface and work within the language frame that the patient is using, and move to the depths slowly, from that position. It occurs to me that we’re not doing that, so we’re not helping the non-analytic community understand the world, themselves, or psychoanalysis, any better than they already do.

    I saw a show on the VT massacre on CNN where they labeled Cho as suffering from “stress, depression and rage.” Nothing about paranoia, nothing about impaired reality testing, nothing about evil. All that does is blur the distinctions between him and the rest of the stressed out, sad and angry people with bad childhoods, and scare others without offering insight that might lead to directions for solutions. We can do better.

    Alice

  11. Tamar Schwartz Says:

    Response from Arthur Meyerson:

    There is no diagnosic 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 distrubution, 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.

    Arthur

    Arthur T. Meyerson, M.D.
    Cl. Professor of Psychiatry
    NYU School of Medicine

  12. Tamar Schwartz Says:

    Response from Frank Summers

    I agree with Jane, and I just want to add this: If Cho is evil for killing 33 people who did him no harm, is Bush not far, far more evil for killing thousands who did us no harm and were never any threat to us? Why is Cho labelled “evil” and not those who are responsible for far more deaths than he? And what about the torture of hundreds of others who were sold to us for bounty and did no harm? Frank Summers

  13. arolde Says:

    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 concommitant 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, noone 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 2 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.

    Sasha Rolde

    Alexandra K. Rolde, M.D.
    27 Fields Pond Rd.
    Weston, MA 02493

  14. Tamar Schwartz Says:

    Response from Elio Frattaroli

    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.

    Elio

    Elio Frattaroli, M.D.
    http://www.healingthesoul.net

  15. Tamar Schwartz Says:

    Response from Geof Margo:

    I don’t much like using the word “evil” because of it’s religious connotations, and because it is so subjective in its use. For example, how many people must one kill to be called “evil” rather than simply a murderer, an immoral person and so on? Or, is an adulterer “evil” or just immoral for breaching the marital trust?

    An important piece that we have left out of the discussion thus far is that evil-doing, immoral behavior, or whatever term we prefer, has to include the requirement that the doer knows that what he/she is doing is wrong, and that the consequences of that action will bring harm to others.

    It is for this reason, I think that political figures like Bush have made it into the discussion, not just because of the company some of us keep. Most people here and abroad seem to believe that the Iraq war has 1. caused many deaths, 2. that the instigators of this war knew that this was the likely result of their actions and 3. it is a
    war that could not be justified in an acceptable way, eg for self-defense.

    When it comes to the original topic, calling Cho “evil” is not an easily justified claim, and again not just because my friends are liberals, or some other ad hominem argument. What would make Cho immoral or evil, is not that his actions were wrong. They obviously were. What we don’t know is how well he understood the nature of his behavior. In other words, we get to the thorny business of diminished capacity. As a society we believe that if someone cannot fully appreciate the nature of their actions then that behavior is not called immoral, and is not punished, even though their liberty may be curtailed for the community’s protection.

    I don’t know if Cho had diminished capacity or not. There is evidence of deliberate planning and so on, but this is not in itself conclusive one way or the other. Similarly, he appeared to have significant mental illness, but again mental illness as a general category does not necessarily preclude capacity. So it gets down to a
    careful evaluation of all the evidence in a particular case, and often we are left puzzled. Without a thorough evaluation it is irresponsible to make a pronouncement.

    So maybe Cho was evil, maybe he was crazy and did not appreciate his actions, and maybe we will never know for sure.

    Geof Margo

  16. Tamar Schwartz Says:

    Response from Gerry Izenberg

    The relationship between therapy and moral judgment is a vital question, and more complex, I think, than the discussion so far has suggested.

    It is not a question of either/or. Analysts always make moral judgments about the behavior of their patients because they are also moral beings who act in the world. Many–all?–patients , for example, behave badly at times, sometimes very badly, towards their family, lovers, friends. But in therapy we bracket or suspend moral judgments in the belief that by doing so, we will eventually help change /ameliorate the underlying conflict/deficit that causes such behavior.

    It’s a kind of moral wager: we don’t make moral judgments in the short run because we hope in the longer run we won’t have to make them. To say that such bad behavior is neurotically, or even psychotically, caused, however, is not to excuse it or explain it away; it remains bad however it is caused. Our patients, by the way, know that very well, which is why it is often difficult to get them to suspend judgment on their own behavior long enough to try to understand its sources so that they can change it instead of oscillating continuously between bad behavior and guilt. And even then we know, and they often come to know, that even if they dochange, they have still to come to terms morally and psychologically with the bad things they did in the past.

    What we call evil is on the extreme end of the scale of moral badness. We mean two things when we use the term evil: we mean behavior that is so far along the scale of badness that we are not morally and emotionally willing to bracket or suspend moral judgment, and about which we have no confidence that even if we could, we would be able to change it, since we know nothing about what causes it. Those who balk at the use of “evil” I think do so because they don’t want to give up the hope of finding its psychological causes and changing it, and because they think that those who do use the term have essentially done so.

    They may be right, and certainly I don’t think we have reached the stage of knowledge where we can rule out the possibility of knowing the causes of, say, mass murder committed by individuals. As a historian I believe we actually do know something about the kinds of beliefs one has to have to participate in genocide. But no amount of knowledge that we might theoretically gain in the future will change the judgment that some forms of behavior are evil, or the judgment that the morally or socially appropriate way of dealing with people who commit evil is something other than therapy.

    Gerry Izenberg

  17. Tamar Schwartz Says:

    Response from Arthur Meyerson

    Freud and most analysts recognize that all behavior is a complex interaction of experience with the genetic and constitutional (a frequently used concept in Freud’s writings) predisposition of an individual. Some illnesses and personal characteristics may be entirely genetic (blue eyes, PKU) while others are interactions of genetic susceptibility with environmental factors (favism which only emerges if one eats fava beans). In the behavioral realm, with all the major mental illnesses on Axis I there appears to be a complex genetic (even poligenetic) predisposition which interacts with experience to produce illness or protect against it.

    Lack of empathy and guiltlessness appear, in some instances to be the results of genetically determined influences (bad seed), in some to be strongly influenced by experience (abuse leading to abuse) and in some is mysterious.

    What this list has been struggling with is the relationship between lack of empathy and guillessness as well as violence in those suffering from major mental illness. In Elio’s case, he tries to explain the violence by pointing to Cho’s social isolation and experience of rejection and analogize it to a suicide bombers experience in
    producing violent rage. However, all links between Cho’s mental illness, his life experience (largely a result of his paranoid position one would guess) and his violence are tendential. The acts he committed were bad, evil. He appears to be guiltless and lack empathy. Was this due to a biologically determined, gentetically patterned defect independent of his mental illness.
    Was it due to his mental illness. Was it due to some unrecognized experience or those factors Elio sites? We have no evidence that paranoid diagnosis per se produces violence. We have no evidence of his genes. We have evidence that his suspiciousness rendered him odd, isolated and frightening to others which may have feuled his paranoia but there are many who experience that without violence. In the case of political violence or religious violence such as Elio sites there is always group psychology at play and a strong identification with a real group to which the violent person belongs. This was not Cho’s position.

    Therefor in the absence of biologically, psychologically or social explanations that are compelling, we turn to the actions of the person in question and use the most traditional method of classification based on what some call morality but I, having an evolutionary bent, would think of as absolutely unacceptible in any group and therefore repulsive, bad, evil.

    Where the rubber hits the road is in court. If Cho had survived, psychiatries tradition under McNaughton, since the 19th century, might testify that his violence was a result of his inability to distingush right from wrong due to his paranoid delusions. However, on the other side would be someone like me saying that his mental illness touched thousands, even millions world wide, who are never violent and he is therefor to be held responsible for his actions. In a more rational system he would be
    found guilty but insane and sent for a life sentence to a treatment facitly/prison.

    We have to agree that there are many behaviors we simply can not understand as yet and in any individual cannot determine the extend of biological/genetic, enviornmental and social factors that may determine the behavior in question. When, as in this case, that is true, we like the rest of society should feel free to be
    citizens or members of a social group that considers Cho’s behavior evil and him evil for perpetrating his acts.

    Untill then, guesses as to the link between paranoia and violence, experience and violence in this case are mere speculation leading to a tendency to substitute falacious pseudopsych for any human’s right to judge such behavior and its perpetrators and evil.

    Arthur
    Arthur T. Meyerson, M.D.
    Cl. Professor of Psychiatry
    NYU School of Medicine

  18. Tamar Schwartz Says:

    Originally posted 05/04 8:10 AM
    Response from Ben Davidson:

    I agree that a mental illness, likely paranoid schizophrenia, describes an influence on Cho’s violence, it cannot be considered a full explanation of it. There is no question that his actions were evil, but how can evil be used as an explanatory concept in a way that is not tautological- i.e. Why did he do it? Because he is evil. How do we know he is evil? Becaus he did it. It seems to me that evil is important for us to discuss, because it is relevant, but also sorely needs clarification in terms of its intrapsychic dimensions. What does it mean psychologically to be evil? How do we differentiate it from psychopathy, if we do. Clearly capacity is highly relevant, but for arguments sake, let us say that Cho did have capacity to understand that what he did was wrong. What would an evaluation need to demonstrate to diagnose evil? It seems to me that to be useful we cannot define evil simply on the basis of specific behaviors. This is especially relevant to Irwin Savodnik’s hope that early detection of evil could have prevented this. It is easy to say that Cho was evil now that we know what he did. But what if we only had his previous bizarre behavior, his stalking, or his writings? All very alarming, but was it evil? How should we assess this?
    -Ben Davidman, M.D.

  19. Tamar Schwartz Says:

    Originally posted 05/04 8:50AM
    Response from Thomas Bartlett:

    Ben Davidman points out the tautology involved in using “evil” as an explanatory concept, and asks: “What would an evaluation need to demonstrate to diagnose evil? It seems to me that to be useful we cannot define evil simply on the basis of specific behaviors. ”

    As it happens, an attempt to do just this was made in the 15th century, in perhaps a predecessor of the DSM (and the PDM), … the Malleus Maleficarum.
    Check it out.

    http://www.malleusmaleficarum.org/

    Tom Bartlett
    thomasabartlett@comcast.net

  20. Tamar Schwartz Says:

    05/04 9:32 Am
    Response from Arthur Meyerson

    Freud and most analysts recognize that all behavior is a complex interaction of experience with the genetic and constitutional (a frequently used concept in Freud’s writings) predisposition of an individual. Some illnesses and personal characteristics may be entirely genetic (blue eyes, PKU) while others are interactions of genetic susceptibility with environmental factors (favism which only emerges if one eats fava beans). In the behavioral realm, with all the major mental illnesses on Axis I there appears to be a complex genetic (even poligenetic) predisposition which interacts with experience to produce illness or protect against it.

    Lack of empathy and guiltlessness appear, in some instances to be the results of genetically determined influences (bad seed), in some to be strongly influenced by experience (abuse leading to abuse) and in some is mysterious.

    What this list has been struggling with is the relationship between lack of empathy and guillessness as well as violence in those suffering from major mental illness. In Elio’s case, he tries to explain the violence by pointing to Cho’s social isolation and experience of rejection and analogize it to a suicide bombers experience in producing violent rage. However, all links between Cho’s mental illness, his life experience (largely a result of his paranoid position one would guess) and his violence are tendential. The acts he committed were bad, evil. He appears to be guiltless and lack empathy. Was this due to a biologically determined, gentetically patterned defect independent of his mental illness.

    Was it due to his mental illness. Was it due to some unrecognized experience or those factors Elio sites? We have no evidence that paranoid diagnosis per se produces violence. We have no evidence of his genes. We have evidence that his suspiciousness rendered him odd, isolated and frightening to others which may have feuled his paranoia but there are many who experience that without violence. In the case of political violence or religious violence such as Elio sites there is always group psychology at play and a strong identification with a real group to which the violent person belongs. This was not Cho’s position.

    Therefor in the absence of biologically, psychologically or social explanations that are compelling, we turn to the actions of the person in question and use the most traditional method of classification based on what some call morality but I, having an evolutionary bent, would think of as absolutely unacceptible in any group and therefore repulsive, bad, evil.

    Where the rubber hits the road is in court. If Cho had survived, psychiatries tradition under McNaughton, since the 19th century, might testify that his violence was a result of his inability to distingush right from wrong due to his paranoid delusions. However, on the other side would be someone like me saying that his mental illness touched thousands, even millions world wide, who are never violent and he is therefor to be held responsible for his actions. In a more rational system he would be
    found guilty but insane and sent for a life sentence to a treatment facitly/prison.

    We have to agree that there are many behaviors we simply can not understand as yet and in any individual cannot determine the extend of biological/genetic, enviornmental and social factors that may determine the behavior in question. When, as in this case, that is true, we like the rest of society should feel free to becitizens or members of a social group that considers Cho’s behavior evil and him evil for perpetrating his acts.

    Untill then, guesses as to the link between paranoia and violence, experience and violence in this case are mere speculation leading to a tendency to substitute falacious pseudopsych for any human’s right to judge such behavior and its perpetrators and evil.

    Arthur
    Arthur T. Meyerson, M.D.
    Cl. Professor of Psychiatry
    NYU School of Medicine

  21. Tamar Schwartz Says:

    Originally posted: 05/04 9:40 AM
    Response from Henry Kaminer:

    This discussion has been very interesting and productive. I recall a lecture by the forensic psychiatrist hired by the prosecution in the famous Son of Sam murder cases. The nfortunate young man had a clear diagnosis of schizophrenia, paranoid type- he heard voices telling him to go out and kill the couples he found snuggling, in their cars, in deserted parking areas. He admitted that he know it was wrong for him to kill them but that he had to obey the voices. The psychiatrist went over the details of the sequence of murders. It came out that one night, even though the voices told him to go out and shoot people, he stayed home. Why? It was raining and he didn’t want to get cold and wet. This convinced the jury that he could resist the voices.

    Similarly, someone who is not schizophrenic, but suffering from what Kernberg calls alignant Narcissism can feel so frustrated, humiliated, and angry that he or she will ignore “common sense” or the Voice of Reason and give in to the emotion. Forensic Psychiatric practice has to deal with different issues, (including intrapsychic ones) than does office therapy.

    henry kaminer md

  22. Tamar Schwartz Says:

    Originally posted 05/04 12:50 PM
    Response from Thomas Bartlett

    Art Meyerson took me to task, as it turned out, offline, for my comparison of the DSM to the Malleus Maleficarum. Rightly, I thought.

    The reply I wrote to him was also meant as a contribution to this discussion, so I am passing it along.

    In a message dated 5/4/2007 9:11:46 A.M. Eastern Daylight Time, meyera03@med.nyu.edu writes:

    “All moral judgements are not religious ones and your argument is as tendentious as many of the others in this case. ”

    Arthur,

    I suppose I asked for that, by being lazily cryptic and provocative. I was just so taken by the actual witches hammer once I found it online that I didn’t do the work of stating what I really think.

    I am more in sympathy with the points originally raised by Irwin Savodnik than came across, and I recognize completely that his and your use of the term “evil” is based in an entirely different understanding from that of the Inquisitors. I agree entirely when you write “The delusion on this list is that all bad behavior is explicable in psychobiosocial terms.” The perennial skeptic in me would also be wary were we now to replace our “expertise” on “mental illness” with some new one on “evil”…though it is good to gain the kind of conceptual clarity people on this list are working toward.

    I share what I take to be Irwin Savodnik’s Szasz-ian skepticism about the encroachment of psychopathologizing explanations into political discourse, at the expense of moral judgment and commonsense. (I do not really believe we HAVE any special ‘knowledge’, as analysts, so much as a skill at a method that has to do with the unconscious.)

    I think it was by writing that Cho was “evil to the core” that Irwin drew the strong reaction that he did, in me, no doubt Elio, and others. It came off as bizarre and chilling. His later explanations were more careful and on point. Somehow, calling an act evil, or the product of evil, is clarifying, while calling a person evil in an encompassing way seems to stop understanding short.

    That initial comment had reminded me of Szasz himself, who sometimes let his libertarian opposition to psychiatric labelling box him in a corner, in effect saying of the ‘psychotic’, “If my patient tells me he is Napoleon, I would say he is lying.” This struck me as combating one oversimplification with another. At the very least, it came off a bit heartless.

    So if there was any point in likening the Witches Hammer to the DSM, however glib you might find it, it was that I believe, as Elio pointed out, that we often use diagnoses (“evil to the core”, “paranoid schizophrenic”) to define an abyss that separates us from the “other” and assures us we are not like them. But it stops short our understanding, rather than freeing it. Irwin Z. Hoffman has recently criticized the PDM on similar grounds.

    As to Cho, for my part, I could not help but feel sympathy for him when I heard the story. Not because he was “sick” or because he was “evil”, whatever saying these might add to our understanding, but because life must have been truly wretched in the ways Elio described, to bring him to such an act of rage. This does not mean that what he did was not bad or evil. I suppose I should be angrier at him, and if I were a parent of a college age child, that reaction would probably be much stronger in me. But this was my honest reaction… it was harder to feel anger than to feel pity and a sense of tragedy, whereas with some evil acts, the reverse is true. I try to set aside all I supposedly have learned about psychopathology and morality, and make sense from there.

  23. Tamar Schwartz Says:

    Originally posted 04/05 11:48 AM
    Response from Alice Maher

    I fully agree with those of you who say that, in an ideal world, Cho should have been understood as a human being with emotions before, or instead of,
    diagnosing him as either “paranoid schizophrenic” or “evil.” However, I don’t believe that a kid like Cho, with a history like his, would have been able to trust a therapist, or a teacher, or the kids around him, or his family, or his society, or the mental health community, enough to embark on the development of a working alliance that included commitment to medication and psychotherapy. That’s why I advocate for better education about mental illness, even if that education initially includes language that we’d prefer to change, like “paranoid schizophrenia.” If the people around Cho had had a better understanding of the nature, origin and meaning of his disorder, the possible directions it could take, and how different situations might be handled, that might have resulted in him having an ever-so-slightly greater feeling of trust – trust that the environment around him could tolerate him, and that his feelings had meaning that could potentially be understood over
    time. And that slightly greater sense of trust might have helped him choose a different path.

    (Terrific discussion!)

    Regards to all,
    Alice

  24. Tamar Schwartz Says:

    Originally 04/05 12:36 PM
    Response from Dan Coleman
    Elio, I agree with you. Years ago I worked both in my psychiatric office, in
    the county jail, and in the state hospital. I heard about the patient feeling
    humiliation/shame which lead to feeling rage and wanting to do envious revenge
    acts. This was in jail. In the state hospital and in my office I dealt with
    people who carried the diagnosis of paranoid schizophrenia. These people were
    not driven by their emotions and had not, for the most part, carried out
    revenge acts.
    P.S. Yes, Arthur, I was and am speculating, but we didn’t call Susie
    Sidesaddle who had shot her abusing doctor, evil. Don Coleman

  25. Tamar Schwartz Says:

    Response from Sasha Rolde:

    Upon reading Henry Kaminer’s comments to Yale Kramer’s posting, I am reminded of my residency years at the Mass. General and McLean Hospitals in Boston. I recall that antisocial behavior often resulting in criminal charges accompanied many patients admitted to both hospitals for evaluation and treatment. We frequently discussed whether these patients, usually either Schizophrenic or Manic-Depressive, frequently quite paranoid and admitted against their will, should be held responsible for their actions in court. In almost every case, it was felt that the diagnosis should not excuse a patient from prosecution, because it was important both for society and for the patients to recognize that they did something WRONG. I think the discussion here has to do with the superego position, often lacking in patients who both deny that they are sick and that they did anything wrong. The main thrust of Yale Kramer’s message, although I do not agree with some aspects of it, is that “societal tolerance” undermines the very foundations of our laws, which, from our psychoanalytic point of view, are there to uphold the values of conscience and superego–i.e. of ”right and wrong.” This is what would protect both the patient and society from the carnage which we are seeing. I am not talking about a fundamentalist position – but rather about issues such as : 1)it is wrong to not protect people from harm – be it to themselves or to other people (mental health professionals do have a “duty to inform” under certain circumstances). I am frequently suprised how often this does not happen in an appropriate way. I do think that the idea of protecting people refers tangentially to people carryng loaded guns, but it really encompases a far greater area of potential harm than that. 2) It is also wrong for people not to be held accountable.

    Having said that, I would add to Henry’s and Harvey’s comments that it is my impression that most analysts are comfortable with analysis of “internal conflict” but not with confrontation of superego lacunae in their patients. This may be the message that we have given the public and we need to look at that.

    Added to the above is of course the fact that due to managed care and the closing of faciltities for long term severely ill patients (i.e the state hospitals as well as many private psychiatric hospitals) the remaining few places are overcrowded and can keep patients for very short periods of time, allowing the return to the community of disturbed and often dangerous individuals without any adequate follow up, especially if these patients refuse to be treated after discharge.

    Sasha Rolde

  26. art lynch Says:

    The realm of evil seems to be a religious one and using that lens takes us far beyond violence. Using a clinical lens may actually be more helpful. If we try to understand the violent behavior as a symptom, in addition to the moral agency component, we need to consider the motivating factors. Why do people do what they do? All this, of course, has been said. Like Art Meyerson, I have spent my time in jail (working). In running the mental health service for the new york city jails, I participated in most critical incidents including: homicide, suicide and acts of violence. For me the crucial question in determining a level of service was motivation: why did the person do this? This is not a diagnostic issue as Meyerson points out. We do not find violence as a diagnostic criteria and associating it to shocking behavior brings the danger of further stigmatizing a burdened group. Empirically some studies suggest there is little difference in violent incident rates between seriously mentally ill and non mentally ill persons(see the MacArthur Study – 1998). A more suitable distinguishing variable is substance abuse.
    When looked at motivation, as most of the responders have pointed out, we see a full array of possibilities: some engaged in this behavior impulsively without clear intention, others are quite calculatedly with full intent to do harm without remorse, others still have murdered brutally in the midst of acute psychotic states responding to command hallucinations, persecutory delusion or other psychotic symptoms and some stay home because its raining. There is some evidence that violence for mentally ill persons can be stimulated from a different source than non mentally ill persons. Bruce Link found violence as a response different for psychotic individuals than for non-psychotic subjects. The psychotic patients were responding to what he labeled as “thought control over-ride” variables and included: command hallucinations, thought insertion, thought broadcasting, persecutory delusions. Still no generalizations can be made because these same psychic states do not eventuate in dangerous behavior for all or most. These findings can, however, can help us in developing programs for individual’s who are potentially violent and who are stimulated by these kinds of variables. Assisted Outpatient treatment, as poorly conceived as it was, is an attempt at this kind of programmatic response.
    Ultimately though, the law and the courts are ill equipped to provide guidance even with psychiatric evaluation services available. Art Meyerson’s point that “In a more rational system he would be found guilty but insane and sent for a life sentence to a treatment facility/prison” is very appealing but this kind of mindful system is not available and with competing resources liked homeland security it does not seem like it will be available any time soon. The incident was tragic but the problem has a much greater social dimension. This to me was best stated by Jane Walword and Zvi Lothane: We all need to bear a measure of responsibility.

    Steadman, H., Mulvey, E., Monahan, J., Robbins, P., Appelbaum, P., Grisso, T., Roth, L., & Silver, E. (1998). “Violence by people discharged from acute psychiatric inpatient facilities and by others in the same neighborhoods.” Archives of General Psychiatry, 55, 393-401).

  27. Tamar Schwartz Says:

    05/05 12:30 PM
    Response from John Leonard

    I heard a radio report that a self appointed spokesperson for Christianity stated yesterday that Congress’ act to add sexual preferences as right that would be protected under the non-discriminatory laws, represented an action that was antiChristian and perhaps_evil_ in its intent. The use of “evil” has many meanings to many different peoples. This thread continues to be very engaging and so far continues to move me away from the use of “evil” as an explanatory or therapeutically useful concept. My desire is to stop executions so that those interested can have subjects to work with in order to develop our understandings. Regards,

    John F. Leonard, M. D.
    leonardj@ucla.edu

  28. Tamar Schwartz Says:

    05/02/07 11:08 AM
    Response from Heney 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.

    Henry J. Friedman

  29. Tamar Schwartz Says:

    05/05 7:44 PM
    Response from Henry Friedman:

    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 judgement 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 he 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
    souces 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 therapists 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 orDepak Chopra when it comes to helping the public understand that some mentally ill patients are indeed violent in a very special way.

    Henry J. Friedman

  30. Tamar Schwartz Says:

    Response from Fred Sander:
    Dear Elio, Arthur, Tom, Don, Arnie et al.

    Perhaps Freud was wise to stay away from “evil” as a useful concept. The only reference to it in the Standard Edition alludes to the
    Wolf-Man who, speculating on the origin of evil, found God the almighty responsible since He had to power to make man good. Actually the word “evil” does not actually appear in that passage. It was in the eye of the indexer.

    It does remind me of the remark made by Supreme Court Justice Potter Stewart when deciding what was pornographic. He said something like “I know it when I see it.” Which further reminds me of the umpire who said its not a strike until he calls it. So here we are now in the post-modern world of “subjectivity as the almighty” but nonetheless with aggression often winning out over eros.

    Or we could turn to the poets – Sartre’s “Hell is Other People” (in “No Exit”) to which Eliot responded “Hell is oneself” (in “The Cocktail Party”)

    What a nice break from issues of governance….or are we engaged in intellectualizing defenses?

    Fred

  31. Tamar Schwartz Says:

    05/04 12:40 PM
    Response from Fred Sander:

    Henry,

    I guess the reconciliation of your take and that of Elio’s depends on where the evaluator is sitting and where on the slope of psychotic
    disorder the psychotic is sliding and the context of community standards for hospitalization. That is sometimes difficult to evaluate and is not necessarily an objective assessment. I once treated a “paranoid schizophrenic” seeing him on park benches, frightened when he sent food to my family’s apt., involved the police when I felt he may
    be a danger to self or others -he owned a gun. It was virtually impossible to hospitalize him until the leverage of his relationship to
    me got him to agree to go into a hospital. Years later I was called by the FBI and told he was hospitalized in another state when he
    threatened the President of the US. Perhaps these days hospitalization may be easier than then. Only a verbal threat to kill the President was a ticket of admission.
    Who knows where he is now? But the treatment required both some attempts at empathy with its attendant risks plus firm attempts to
    prevent danger to self and others. It is not always a case of either/or.

    Fred

  32. Tamar Schwartz Says:

    05/04 8:44 PM

    Reponse by Elaine Zickler

    It was clear to me that Cho was living in hell–his own mind was hellish; when he threatened his retaliation on the indefinite ‘you’ he was also speaking to himself, to his own inner tormenting. Milton has Satan observe this about his own mind in Paradise Lost, as well. I think it is very difficult to abstain from this ‘othering’ of evil, as Tom points out. There are many things beyond our understanding and beyond our ability to help, but I don’t think we have reached these limits yet. It has always been my understanding that what psychoanalysis can offer is not personal salvation or a cure for all evil or even a definition of it, but perhaps a way for people to come to an ethical position regarding others, whom they cannot ever totally understand, but whom they cannot either totally disavow. It has been my understanding that what we do in analysis, one person at a time, is to avow more and more of what is human and humiliating and therefore humbling about ourselves. While we may not be espousing any religious doctrines of forgiveness, I do think, as Julia Kristeva asserts, that there is a forgiveness implicit in psychoanalytic discourse, in the exchange of fantasy and action for speech, in the attempt to verbalize our desires in the presence of a benign other. Not everyone can avail themselves of this, obviously, and unfortunately. Cho was failed by any number of systems, despite the best efforts of many people to get help for him, or at least restraint. What we most often call evil seems to me to be a product of a certain synergistic effect, a collision of personality and opportunity and sometimes social and cultural forces–as with the example of Hitler that Irwin makes. Hitler is a kind of synecdoche, a part for the whole; when we say his name, we refer, in fact, to thousands of people, to legal policies, to an entire governmental and technological system that, altogether, I would not hesitate to call evil. At the same time, I do not think it was sui generis, or that it required a special category of ‘evil’ persons to take place. Everyone did their part, some by doing nothing. The last six years have made me understand what it might have been like to have been an ordinary German at that time, being an ordinary American now when who knows what ‘evil’ is being done in my name, and legally.

    Elaine Zickler

  33. Tamar Schwartz Says:

    05/05 8:09 AM
    Response from Herbert Gross:

    We are a wordy bunch and more comfortable than we should be behind the torrents of words we can express and debate. Mr. Cho was primarily non-verbal and when he used words he scared those around him. In the “good old days” when I could commit a patient that scared me because society gave me the power I could use the information that patients communicated in non-verbal channels. Today we can’t; we have lost society’s trust.

    The more we learn about how much is learned before children have words the more glaring is the gap in our clinical skills with regard to the non-verbal or implicit or procedural domain. If our clinical settings are our laboratories, what are we doing to pioneer the use of non-verbal domains therapeutically?

    We have exported many of our ideas to the culture at large who now seem comfortable or at least familiar with our techniques based on words. Many successful brands of talk therapy have been psychoanalytically spawned Perhaps it is time to reconsider what we do in order to make room for disorders that can only be communicated non-verbally.

    I don’t know if we can develop techniques for using non-verbal information therapeutically, when working with adults but if we can we might regain the trust of the society around us. We also might be more in-touch than the students and teachers Mr. Cho frightened for four years before he went on his killing spree.

    Herbert S. Gross, M.D.
    Clinical Professor of Psychiatry

  34. Tamar Schwartz Says:

    05/05 2:55 PM
    Response from Fred Sander:

    Dear Arthur,

    With your “evolutionary bent” would you opine about the behavior of chimpanzees in the wild? They, apparently for purposes of territoriality, will bash a rival male’s skull to smitherines. Not so the bonobos…at least that is what I have gleaned from the media, not from first hand observation. Would that count as a forme fruste of evil? Does “survival of the fittest” become a “moral” issue with the arrival of homo “sapiens?” Are Darwinian theory, and Freudian theory and Physics, for that matter, amoral sciences? I agree we probably can’t answer these questions without more knowledge especially of the contexts in which they become manifest.

    Fred

  35. Tamar Schwartz Says:

    05/05 3:29 PM
    Response from Fred Sander

    Dear Henry
    You make a distinction between what we deal with in office practice vs what is addressed by forensic psychiatry. It’s not that simple; as, for example, in the case of Bernard Goetz, the New York subway vigilante, in the 1980’s.

    This man shot four young black men, who were allegedly trying to rob him, in the back. The NY Times family history included his father being indicted for sodomy when Bernard, I think, was 13. He and his sister were sent to boarding school in Switzerland. I don’t know whether his case involved forensic exams, though I would imagine it did. He also had been “mugged” a few years before. So I suppose we must rely here on multiple factors including a community at the time fed up with NY street crime, so he became a hero to many. I don’t recall any diagnoses bandied about, but he served 8-9 months of jail time and I assume is living out his life in relative obscurity.

    I guess this case illustrates how hard it is to generalize and certainly makes diagnosis by itself, as many have suggested, of questionable value.

    Fred

  36. Tamar Schwartz Says:

    05/06 3:55 AM
    Response from Irwin Savodnik:

    The issue of schizophrenia and violence is of considerable interest. Most studies reveal that such people do have a higher rate of violence, up to four times higher, but the violence was almost always minor. From the data in these studies, we might infer that violence does not distinguish schizophrenics from normal individuals. The two sets – schizophrenics and violent adults – overlap to the same degree as the two sets – non-schizophrenics and violent adults — thereby suggesting a dissociation between the psychiatric condition and the violent behavior. To get inside
    the mind of the seriously violent adult and assume that he is violent because he is schizophrenic is, by this logic, simply wrong-headed.

    Another point made recently is that most psychiatrists would agree that schizophrenics aren’t able to process reality. Therefore, they need medication and treatment. It is interesting – ironic, really – that psychiatrists, who seem to understand the subtleties of reality testing, believe that evil is a relative concept. After all, lots of people refer to reality testing as if it is a simple notion, even though – many eye witnesses, for instance — will disagree about some simple chunk of reality. Many people, non-psychiatrists, usually, disagree about whether there is a reality at all. Why don’t psychiatrists and psychoanalysts consider these
    issues? Why don’t they question reality testing and reality as forcefully as they question the reality, cogency and relevance of the idea of evil?

    That these are thorny issues, we would all agree – especially in the area of language. Consider the suggestion that an empathic understanding of Cho’s
    “suffering” might have changed things for the better. Was Cho really suffering? He concocted a grandiose scheme to plant himself on the pages of cultural history by setting a murderous record. I would agree that his teacher, Nikki Giovanni suffered both before and after the murders. Many are inclined to see Cho as suffering because he is deemed to have had an illness that had afflicted him. This does not make much sense at all. Sure he was bizarre and violent and hidden. But so are clowns, soccer players and spies. Physicists call photons weird and astronomers refer to the violent universe. Are these last two examples different from the first three?

    I was struck by Tom Bartlett’s remark that he couldn’t help but feel sympathy for Cho when he heard the story. On the surface, he sounds much like Socrates, who insisted that it was wrong to harm one’s enemies. The late Gregory Vlastos, a philosopher who is acknowledged to have been one of the finest of Socratic scholars, makes the point that the figure of Socrates rings a bell with that of Jesus, who also held that love should supplant vengeance. But it’s the devilish details that make us wonder about Tom’s point. As I recall, Vlastos’s Socrates held that position, not on the basis of empathy, but on principle. In fact, I don’t think Socrates would have
    afforded empathy the distinctive position it has held since the 19th century. I go along with Vlastos’s Socrates and have trouble with the empathic view. I do share with Tom his impression of those responding to what I had written. He says my assertion that Cho was evil to the core “came off as bizarre and chilling”. Indeed, I imagine it did. Please keep in mind that I wrote this piece because no one in the public eye seemed to have offered a moral viewpoint of Cho.

    My concern was broadly cultural. What has happened to us that we don’t appear to recognize evil when it slaps us in the face? I don’t mind diagnosis, understanding, empathy and various other ways of figuring out what happened in Virginia. What troubles me is that we seem to have lost our moral sensibility. Morality appears to many as a quaint affectation from another age. As I mentioned in a previous note, we are heirs to the Enlightenment, at least to the spirit of that age, and we tend to jettison morality for a scientific understanding of ourselves. If that is the case, then how is it that Freud offers literary, esthetic and moral assessments of his patients and the problems that plague them? Sartre offers a radical interpretation of Freud and accepts absolutely no excuses for someone relinquishing his or her responsibility in a particular situation, not matter how troubling it was. Claiming that one had no choice is what Sartre refers to as bad faith.

    Increasingly, I find I am sympathetic to Sartre’s analysis. His account of human frailty is through and through a moral one, a perspective I would heartily recommend to anyone who has participated in this discussion.

    Indeed, this has been a rich discussion. I have enjoyed it immensely. It has a rich tone that welcomes people. That is very good.
    Irwin Savodnik

  37. Tamar Schwartz Says:

    05/06 4:35 AM
    Response from John Leonard:

    I have a somewhat different take on this subject of morality. From whence does it arise? Isn’t it from within the human organism? If so, then could it not be damaged as can any other system? From this thread it appears we may not have advanced our knowledge very far if at all. I still say we need to keep these hateful, evil, vengeful, etc., people alive so that they can be studied. John

  38. Tamar Schwartz Says:

    05/06 9:04 AM
    Response from Zvi Lothane:

    I am not as enthusiastic, as Irwin Savodnik is, about the connexion between schizophrenia and Mr. Cho. I consider this to be an emotional and not a scientific issue. Schizophrenia strikes awe and terror in the tender minds of Irwin and Henry as a fear-word, very much like the word cancer, with all its overtones of evil, the devil, the demons. Schizophrenia is a demonological EMOTION and IDEA. To my ears this diagnosis rings hollow.

    Moreover, you surprise me, as a disciple of Thomas Szasz, with your essentialist talk about schizophrenia. In his myth of mental illness Szasz did not deny the EXISTENCE of psychiatric disorder, he only criticized the claimed IDENTITY between psychiatric and medical disorders. The same year a similar claim was made by Michel Foucault in France, where Szasz remained virtually unknown, and in England, by Ronald Laing. In 1971 Laing came to Rochester when John Romano bequeathed the department of psychiatry not to George Engel (becoming the cause of George’s subsequent heart attack) but to Lyman Winne, an family and interpersonalist student of schizophrenia. In his opening remarks the still youthful Laing, whose eyes burned with a fire of Blake’s Tiger, said bluntly: there is no schizophrenia, there are only people called schizophrenic.

    (BTW, The same can even be said of the truly essentialist condition that diabetes is: there is no diabetes, there are only diabetics, although here at least there are findings about which there is no dispute, as there is about schizophrenia.)

    Violence, or violent acts, is the common denominator of human disorder variously labeled as sin (religion), vice (ethics), crime (law), psychosis (psychiatry). Society has a variety of ways of punishing violence. A psychiatric diagnosis is a linguistic invention and convention, dear Irwin, a convenient shorthand and label.

    And toying with diagnoses: I did not see anyone mention psychopathy or psychopaths, the latter defined as having no conscience and no compunction about doing evil. But then how much light is shed in calling Hitler a psychopath?

    For me there is only one method for approaching violent crimes: a depth and breadth SOCIOLOGICAL first and PSYCHOANALYTIC second analysis of the criminal act. Sociology makes us understand the entire human situation of the violence, Mr. Cho, his family, his fellow students, the women or men he was in love with, the slights and humiliations he suffered of that were dealt him, and the final revenge. Psychoanalysis would help us understand his intrapsychic and interpersonal conflicts and character with the help of dynamic observations and ideas about sex and violence.

    And as I said in a mail to Paula Hamm: yes, Christ and Socrates may come in as helpers, too: forgive them for they know not what they are doing. I do however, suspect, that they know what they are doing but have invented all kinds of causes, motives, and reasons, — religious, deomonological, political and social — to do what they are doing in cold blood.

    Once an ideational legitimation is found, e.g., the racist labeling and definition of the Jew as vermin, represented in films in conjunction with images of rats scrurrying through sewers, then esterminating Jews as vermin in gas chambers becomes an act that could not be performed by a person moved by common sympathy and becomes an act done in cold blood and with a psychopathic denial of guilt. But such denial is not fool proof. The executioners who made Jews dig their graves and then shot them at the edge of the ravine had to be anesthetized with lots of schnaps and vodka.

    Mr. Cho, like Jeffey Dahmer before him, and scores of other offenders, found all kinds of fantasies and delusions to satisfy their murderous and sexual lusts. Only psychoanalysis has shed light on the sex motive, and this being Freud’s anniversary let’s us pay tribute to his now nearly forgotten work: Three Essays on the Theory of Sexuality, now 102 years old.

    Zvi Lothane

  39. Tamar Schwartz Says:

    05/05 2:24 PM
    Response from Luba Kessler:

    Herb Gross’s memo to us about the non-verbal realm of experience and communication feels poignant to me: an attempt to touch the untouchable.

    I actually felt that Irwin Savodnik’s invocation of “evil” did the same albeit by verbal means. It provided a touchstone so that the act of sheer unredeemable annihilation could still be encapsuled in a word, for psychological survival value of meaning making.

    Do we really have to identify what “evil” is? The fact that the word can be co-opted into religious or criminal or political or psychoanalytic service cannot rob it of its essential function: to name something known which is unnamable by any other word.

    Luba Kessler

  40. Tamar Schwartz Says:

    05/04 10:53 AM
    Response from Arthur Meyerson:

    Like Joe Cronin, I have serious difficulty with some of the views expressed by Yale Kramer in his post. His experience at Bellevue may have seriously skewed his experience since it occured before the Civil Rights Revolution which while focused on race and sex, did effect the mentally ill with a variety of decisions in the courts and by legislators. Rather than see this as some therapeutic distortion of societies values, I see it as a valuable contribution to the body politic and to those with the least power within it. In addition, while Dr. Kramer talks of the ease of hospitalization, indeed the high percentage of those brought by police to the ER is cited, he
    can not say what percentage actually required involuntary hospitalization as he cites no data as to actual occurance of dangerousness as substantiated by the number of acts before and after the law changed. While there are some weakly designed scandinavian studies indicating a higher risk of dangerousness for mentally ill persons imprisoned for murder than others on release, that is the only really semi-hard evidence we have. The incidence of actual violence among the mentally ill, even paranoid and paranoid schizophrenia is sufficiently low that one would have to lock up hundreds, perhaps thousands who would not be dangerous to prevent one who would be. That is a decision that most of us do not support. In addition, paranoia and paranoid schizophrenia are the least responsive of the psychotic diagnoses
    to medication. All in all, Yale makes a poor case.

    This is especially true for his belief that the right of privacy should be set aside. Well, in this case it was and the perpetrator was sent for evaluation on the basis of his behavior. However, to reason, as Yale does, that letting him go many mmoths earlier was a mistake or failure because he later committed his horrid acts, is simply unreasonable though I do agree that the court should have ordered him to comply with treatment had he been deemed dangerous at that time. But, to reason post hoc is not valid as he truly may not have been dangerous at that earlier time. Even several months is too long to link with any certainty. Therefore, that the evaluation was
    poor, with which I would agree based on the facts cited, is only proof of poor practice and not that that poor practice was a proximate cause of the murders.

    The students and teachers who tried to help or ignored the behavior, who Yale accuses of some sort of culturally distorted, liberally imposed value system, are not to blame. Mr. Cho is to blame as is the ease with which he could obtain guns. Yale’s claim that he would have used other methods for serial killing is both tendentious and totally unsubstantiated. This slight man consciously patterned himself after the Columbine killers and the power of a gun to kill many in a short period of time is not arguable when compared to the other weapons Yale cites as alternatives.

    Arthur T. Meyerson, M.D.
    Cl. Professor of Psychiatry
    NYU School of Medicine

  41. Judith Logue Says:

    “COMMON SENSE IS ONE OF THE RAREST of commodities these days” is my favorite line in Yale Kramer’s report. I could not agree more!
    Thank you for a thought-provoking and excellent piece.

    Judith Logue, Ph.D.
    judith@judithlogue.com

  42. Tamar Schwartz Says:

    05/06 5:17 PM
    Response from Eliop Frattaroli

    Henry Friedman ascribed to me an argument completely different from the argument I actually put forward. I said nothing about treatment. I never said Cho could be effectively treated by an empathic therapist. That would have been a truly silly thing for me to say. Henry, and Art and and Irwin and anyone else who cares to respond, my question is, do you think of Cho and Hitler and Osama Bin Laden (insert your favorite psychotic or evil monster) as aliens, human beings of a fundamentally different kind than we are — motivated by forces that simply don’t exist in us but that we have names for, like “evil” or “malignant paranoid psychosis” — or do you see their motivations as understandable and explainable in terms of the human emotions and intrapsychic and intersubjective dynamics we all have in common. If the former, where do we draw the line between humans (like us) and subhumans or alternative humans (like them). It’s a very simple question and calls for a very brief and to-the-point answer.

    Elio

    Elio Frattaroli, M.D.
    http://www.healingthesoul.net

  43. Tamar Schwartz Says:

    05/06 6:56 PM

    Response from Alice Maher:

    Elio, I think the major difference between “them” and “us” has to do with the social forces that give certain people, at certain moments in time, more power than the ordinary psychotic or psychopath has. If symptoms in an individual precipitate out of a matrix that’s determined by multiple internal and external forces, so are symptoms in a society. I think the people you refer to are not just disturbed individuals, they’re symptoms of disturbed societies. Perhaps that’s the place where “mentally ill individual” transitions to “a representation of a force of evil.”

    Alice Maher
    http://www.wagingdialogue.org

  44. Tamar Schwartz Says:

    05/06 6:37 PM

    Response from Jane Hall:

    It continues to boggle my mind that as psychoanalysts we call people whose hurtful actions and motives evil. It behooves the analyst to be a benevolently curious person in the office, and intellectually curious in the world.

    This is not to say that if someone carelessly or deliberately harmed my dog, Django, I would not hesitate to retaliate on the spot – but this does not make me an evil person (I don’t think). And the person who hurt my dog would initially seem evil to me – but one of you analysts might be kind enough, after awhile, to explain to me that his sadistic behavior had roots, and his action had precipitating causes. Do we all not have both sadism, greed, destructive, loving, erotic, omnipotent, grandiose unconscious propensities?

    Our hearts break when we hear of atrocities – but our minds must keep trying to fathom the causes because if we do not, who will.
    Jane

  45. Tamar Schwartz Says:

    05/06 7:10 PM

    Response from Arthur Meyerson:

    If we do not try to understand Cho’s and other atrocities who will, asks Jane. Well for straters us, sociologists, behaviorists, geneticists, neurochemists, neuroscientists in general, moralists, anthropologists, etc. Of them all, we have the weakest tools given our own definition of how we learn things. from exposure to the individual. We don’t get that with Cho nor with others except exceptionally rarely.

    I read these emails and empathize with the passionate desire to understand, to be helpful, to care, to empathize but none of that stands in the way of decrying the act and more important, humility in the face of our own and the race’s inability to truly understand such behavior and to modify it in most instances.

    Mental illness does not create mass murderers, nor does conflict of the sort we deal with and have come to understand. We don’t even have analytic case studies, beyond a handful, of persons who go on to or have already committed murder. What is Jane talking about, if we don’t who will? For such a wonderfully articulate and conserned person that is analytic chutzpah of the highest order.

    We all want to help and wish we had the tools to understand murderous actions in ethnic, tribal contexts and in individual contexts like Cho’s but we don’t yet and answers if they come from anything but genetics and neuroscience will not be likely to come from our speculations. We only make ourselves look like grandiose graspers for control of our sense of helplessness which, in this case, is quite appropriate, the helplessness that is.

    Arthur
    Arthur T. Meyerson, M.D.
    Cl. Professor of Psychiatry
    NYU School of Medicine

  46. Tamar Schwartz Says:

    05/06 8:56 PM

    Response from Deborah Hamm:

    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 deomstrate, 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.

    Deborah Hamm, MD
    182 East 79th St
    Suite D
    New York, NY 10021
    tel. 212-439-9535
    email: dsh1@columbia.edu

  47. Tamar Schwartz Says:

    05/07 2:06 AM

    Response from Irwin Savodnik:

    Elio states that he is asking a simple question, namely, “do you think of Cho and Hitler and Osama Bin Laden (insert your favorite psychotic or evil monster) as aliens, human beings of a fundamentally different kind than we are — motivated by forces that simply don’t exist in us but that we have names for, like “evil” or “malignant paranoid psychosis” –or do you see their motivations as understandable and explainable in terms of the human emotions and intrapsychic and intersubjective dynamics we all have in common.”

    Well, actually, I don’t think the question is simple at all. It’s a great question, but it is not simple. People differ from one another with respect to visible features, physiology and values. I suspect that Elio is thinking about something like the latter, though perhaps not entirely. With respect to their actions, I’d like to think I’m very different from any of these people. Of course. But great novels often revolve around a character that is ambiguous or vague in his or her commitments or even identity. What is appealing is his claim that we offer such people (and others) diagnoses in an effort to maintain a separation from them. “He is not I,” we are saying as we commit pen to paper. Of course, non-psychiatric physicians do the same thing. They enter medicine so they won’t be sick; they choose psychiatry — well, fill in the spaces. More importantly, I dislike the idea of diagnosis, in part because it does appear to serve the process of separation or alienation of the Other from us. I suspect that highly trained analysts don’t bother with diagnosis very much, certainly not the sort of thing we find in the DSM-IV. That is not to say we can’t think conceptually in the work we do; it’s just that a rigid system of diagnostic terms probably hampers our imagination more than anything else.

    Another interesting question had to do with whether the idea of evil is tautological — apparently because we come to this idea by observing instances of it. Hence, we simply summarize what we saw with the term ‘evil’ and don’t need it because it adds nothing to what we know. ‘Evil’ is a name for the set of individuals who committed evil acts or cursed God or whatever criteria may be employed in establishing a norm. Such a nominalist position is not one I find all that appealing, though I won’t argue against it here. Many philosophers of science prefer nominalism to its opposing viewpoint, namely realism, which holds that categories — ‘man’, for instance — are real. The point I want to make in this context is that my position does not rise to the level of metaphysics. I simply think that evil is explanatory
    and ignoring the reality of evil characters (not evil, per se) hampers our understanding. So I afford my position some epistemic weight, but extract any metaphysical heft from what I am saying.

    Jane Hall offers an interesting comment: “It continues to boggle my mind that as psychoanalysts we call people whose hurtful actions and motives evil. It behooves the analyst to be a benevolently curious person in the office, and intellectually curious in the world.” I agree that when we do analysis, it’s critical to adopt a neutral, forbearing stance with respect to the patient. But no one here is doing analysis on Cho. And as I tried to make clear in an earlier note, moral ideas logical precede psychoanalytic ones. We couldn’t do psychoanalysis without understanding this point. When I think of Cho and of what he did, should I spare myself a moral judgment of him? I don’t think so. Somewhere Bertrand Russell argued that killing one person is bad, and killing two is worse (I have probably misstated him badly), by which he meant, in part, that it is not merely the intention to kill, but the actual number of awful deeds one commits that go into a moral assessment of someone like Cho. he murdered 32 other people. He was decidedly not a victim. He was a murderer. And, other things being equal, he was 32 times worse than someone who murdered one person. Thirty-two! We should also keep in mind that murder is not a morally neutral term. It means wrongful killing. Cho stood there and shot each person one by one. He did so rapidly but he took aim and fired each time. That’s evil. Hitler and Stalin were many times worse. That’s why I used them as examples of evil people. Once we identify them as evil, we may gain some insight into what we think evil is. I don’t think it’s all that easy to come to an answer. After all, as Jonathan Lear points out in his book on Aristotle, ethics is not a field in which we can construct or come upon precise rules that prescribe how we should act. he goes on to offer a well-known passage in Aristotle on this point: “Our discussion will be adequate if it has as much clearness as the subject matter admits of, for precision is not to be sought for alike in all discussions, any more than in all the products of crafts… We must be content then in speaking of such subjects … to indicate the truth roughly and in outline …”

    Enough for now.

    Irwin Savodnik

  48. Tamar Schwartz Says:

    05/07 7:34 AM

    Response from Zvi Lothane:

    Elio asked a wrong, and naive, question: are Cho and Hitler and Osama Bin Laden (insert your favorite psychotic or evil monster) as aliens, human beings of a fundamentally different kind than we are — motivated by forces that simply don’t exist in us but that we have names for, like “evil” or “malignant paranoid psychosis”

    1. It is wrong to lump together multiple murderer Cho and mass murderer Hitler and terror murderer Osama bin Laden. There is a world of difference between an individual criminal and a mass criminal who has an army, a society, a nation of that has the support of willing executioners within a police state run by terror.

    2. I agree with Art Myerson, the only one in this discussion who has actually worked with criminal individuals, that psychoanalysis is overreaching itself here. We extrapolate observations from the analytic couch and convert them into facile formulas in APPLIED, not CLINICAL psychoanalysis. We can write essays in applied analysis but we HAVE NOT ANALYZED Mr. Cho. We don’t know why HE did what he did. It is thus futile — Art rightly says it is chutzpah — to brandish those facile formulas.The same goes for psychiatric formulas.

    3. The argument that violence is in nature is of no avail here: animals kill other animals as part of the food chain, or when they defend their turf, NOT OUT MALICE AND REVENGE AND FOR PROFIT, as humans do. Animals are beyond good and evil, humans are not. Human societal, political, economic, intellectual, and moral lives have been created by humans. As Kant says: they have created RADICAL EVIL.

    4. Human violence has been isntitutionalized as WAR. As conduct, our soldiers in Iraq and Afghanistan are killing people, some of whom are soldiers, some of whom are civilians. Their killings are called war, embelished by war-mongering Bushies by all kinds of slogans, i.e., legitimations. Evil can only be understood in a societal context, not as a psychology of individuals, unless we are dealing with that individual alone.

    5. Evil is not a linguistic or a philosophical pastime: it is an issue in ETHICS, the source of laws and rules that regulate the relations between an individual and society. The criterion is PRAGMATIC, not theoretical. and I am against any form of relativism in ethics. Here my guide is not Aristotle but Socrates who unambiguously defined good and evil.

    6. But well before Socrates the ancient Hebrews have enunciated this “do” principle in Leviticus 19:18: You shall not take vengeance or bear any grudge against the sons of your own people, but you shall love your neighbor as youself, I am the Lord.

    This was later paraphrased as a “don’t”: don’t do to ohters as you would not like done to yourself.

    7. Conclusion: Cho, Hitler (the savior of the German nation, supported by Jewish capitalists as well), Stalin (the benevolent Uncle Joe during Roosevelt’s days), Pol Pot, and many others of their ilk were good to some and evil to others. As with global warming based in greed and the boundless exploitation of nature, so with war-mongering and mass-murdering, it is US, you and me and the multitudes, who have contributed to evil existing as a constant reality in human societies.

    Zvi Lothane

  49. arolde Says:

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

    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 2 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 (noone 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 3 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 noone 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 noone has mentioned so far that comes to mind now is “the bad seed”.  In my opinon 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.

    Sasha Rolde

    Alexandra K. Rolde, M.D.
    27 Fields Pond Rd.
    Weston, MA 02493
    tel.(781)894-2177, fax (781)891-9419

  50. Tamar Schwartz Says:

    05/07 9:26 AM

    Response from Ron Abramson

    In 1571 the Ottoman Turks completed their conquest of the island of Cypress from the Venetians, the former overlords of the island. The last city to fall was Famagusta in Aug. 1571. The Venetian commander, Marcantonio Bragadin, negotiated a safe conduct out with the Turkish commander, Lala Mustafa Pasha.
    Bragadin and numerous other Italians marched to a formal surrender ceremony dressed their best, under the protection, they thought, of a signed treaty. After exchanging a couple of insults, Mustafa had Bragadin’s ears cut off, and most of the accompanying Italians decapitated. Italians waiting in boats to get out were enslaved; those waiting on the docks were slaughtered. Eight days later, Bragadin was flayed alive. Following the decapitations, Turkish soldiers ran wild in the city raping women and looting. (Niccolo Capponi, “Victory of the West – The Great Christian-Moslem Clash at the Battle of Lepanto.”)

    I don’t know whether we would call the behavior of Mustafa “evil,” or just the way that war was conducted in those days. When word went out about the Turkish behavior at the surrender of Famagusta, it became a rallying cry among Venetians, and other Christians, as they gathered their resources toward their subsequent naval victory at Lepanto.

    So do we think of the decapitation of prisoners as “evil?’ I tend to think so, because I would not wish to have been one of those Italian prisoners who could not defend themselves.

    We also might consider the fire bombing of Dresden during WWII. There ensued a lot of unnecessary killing of German civilians. As I remember it, our “heros,” Curtis Lemay and General “Hap” Arnold, were involved with this. Evil?

    What about the rape of German women by Russian soldiers as Berlin fell in 1945? I had a patient once whose mother was raped in that atrocity in her presence when she was a child. I am not sure she ever got over it. This, I think, was also evil.

    Ron Abramson

  51. Jane S. Hall Says:

    Ella Sharpe attributes the phrase ‘benevolent curiosity’ to Ernest Jones. She said:

    A deep seated interest in people’s lives and thoughts must in a psycho-analyst have been transformed into an insatiable curiosity which, while having its recognizable unconcsious roots, is free to range over every field of human experience and activity, free to recognize every unconscious impulse, with only one urgency, namely, a desire to know more and still more about the psychical mechanism involved…When we come to a habit of thought, a type of experience, to which we reply: “I cannot understand how a person can think like that or behave like this,” then we cease to be clinicians. Curiosity has ceased to be benovelent.

    Also: The urgency to reform, to correct, to make different, motivates the task of a reformer or educator. The urgency to cure motivates the physician.

    I would add: the job of judging good and evil belongs to the clergy and his/her congregation; to the parent raising children; to the court system and the decisions it makes and the punishments it sees fit. But when left to the public in general, such judging often goes awry. Lynchings are carried out in some kind of mass hysteria for instance.

    As an analyst, my philosophy is to question and not to decide. As a parent and educator, to teach right from wrong. But my studies and work have a great effect on my propensity to try to understand whenever possible. You might well say that Cho, Son of Sam, Ted Bundy, etal were not my patients – but they were human beings and ‘the bad seed’ notwithstanding, they put their rage into devastating action. They each had a history and even perhaps genetic abnormalities, chemical imbalances, brain damage. But, where the line between action and words is becomes a question that the concept of evil does not answer.

    Jane S. Hall

  52. Tamar Schwartz Says:

    05/07 11:05 AM

    Response from Elio Frattaroli

    So far, Jane is the only person who has even tried to answer my question. (Thank you Jane!) But there have been the usual lengthy diversionary speechifying non-answers. As a student of human motivation I find this interesting. But perhaps it’s simply ADHD and isn’t really a motivated behavior at all. Perhaps Art implicitly answered my question though, by arguing that “sociologists, behaviorists, geneticists, neurochemists, neuroscientists in general, moralists, anthropologists, etc.” are ALL better equiped to understand Cho, “given our own definition of how we learn things. from exposure to the individual.” From this I infer that Art thinks Cho was indeed motivated by something that is alien to most of us. Because if we believe that all people’s motivations are “understandable and explainable in terms of the human emotions and intrapsychic and intersubjective dynamics we all have in common” (to quote myself), then it is possible to extrapolate from one person’s self-awareness to an understanding of all human beings. That was certainly what Freud believed and was his only justification for writing “The Interpretation of Dreams”
    and proposing psychoanalysis as a general psychology. But what did he know? (I can’t wait to hear the responses that focus on that last comment and continue to ignore the original question)
    Why is my question important? Because it has to do with the philosophy that informs our daily work as psychoanalysts. If we don’t know what our philosophy is or if we don’t want to know, then we will act it out unconsciously on our patients.

    Elio

    Elio Frattaroli, M.D.
    http://www.healingthesoul.net

  53. Tamar Schwartz Says:

    05/07 12:51 PM

    Response from Sasha Rolde

    Dear Elio,

    I have not answered your question directly, and please forgive me for “speechifying” (though I do not understand what that means), but I did try to say that in my opinion, your question cannot be answered on philosophical or theoretical or psychological grounds, because 1)people behave differently on an individual basis – thus possibly Cho could be “understood” by us, if anyone were to get to know him well, but people who organize mass murder may not be. 2)There are other variables at play that are coming up now in the neurological/genetic research, which are probably not easily recognizable in a clinical interview and even harder to put into a philosophical framework. As more knowledge is acquired, psychoanalysis may need to change its approach and theory.
    At least from my point of view, an answer to your question is very complicated and you would probably call it even less direct than you already do.

    Best

    Sasha

    Alexandra K. Rolde, M.D.
    27 Fields Pond Rd.
    Weston, MA 02493
    tel.(781)894-2177, fax (781)891-9419

  54. Tamar Schwartz Says:

    05/07 12:32 PM

    Ella Sharpe attributes the phrase ‘benevolent curiosity’ to Ernest Jones. She said: A deep seated interest in people’s lives and thoughts must in a psycho-analyst have been transformed into an insatiable curiosity which, while having its recognizable unconcsious roots, is free to range over every field of human experience and activity, free to recognize every unconscious impulse, with only one urgency, namely, a desire to know more and still more about the psychical mechanism involved…When we come to a habit of thought, a type of experience, to which we reply: “I cannot understand how a person can think like that or behave like this,” then we cease to be clinicians. Curiosity has ceased to be benovelent.

    Also: The urgency to reform, to correct, to make different, motivates the task of a reformer or educator. The urgency to cure motivates the physician.

    I would add: the job of judging good and evil belongs to the clergy and his/her congregation; to the parent raising children; to the court system and the decisions it makes and the punishments it sees fit. But when left to the public in general, such judging often goes awry. Lynchings are carried out in some kind of mass hysteria for instance.

    As an analyst, my philosophy is to question and not to decide. As a parent and educator, to teach right from wrong. But my studies and work have a great effect on my propensity to try to understand whenever possible. You might well say that Cho, Son of Sam, Ted Bundy, etal were not my patients – but they were human beings and ‘the bad seed’ notwithstanding, they put their rage into devastating action. They each had a history and even perhaps genetic abnormalities, chemical imbalances, brain damage. But, where the line between action and words is becomes a question that the concept of evil does not answer.

    Jane

  55. Tamar Schwartz Says:

    05/07 3:22 PM
    Response from Steven Rolfe

    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 ontributing 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.

    Steven S. Rolfe M.D.

  56. Tamar Schwartz Says:

    05/08 7:14 AM

    Response from Elio Frattaroli:

    To be consistent with myself, let me clarify that I consider the diagnostic differences between the three to be real but superficial. At a deeper level they are motivated by the same emotional forces we are. To appreciate that consider their (our?) common delusion: that there is a group or class or race or nationality of people out there who are all evil and deserve to be killed.

    Elio

    Elio Frattaroli, M.D
    http://www.healingthesoul.net

  57. Tamar Schwartz Says:

    05/08 7:14 AM

    Response from Eliio Frattaroli:

    Jane, I’m an admirer of Ella Freeman Sharpe also. One clarification. I don’t object to the attempt to define what evil is and I don’t think we as analysts can avoid feeling that some things we hear about in our offices are evil. What I object to is as you put it the lack of therapeutic curiosity involved in going directly from that feeling to a pseudo-explanation that the evil we hear about was caused by evil people. It’s the labelling of people as evil that I object to. Same principle as never saying to your child, “you’re a bad girl,” but rather saying “you did a bad thing.” A very important distinction because one statement implies that you are beyond the
    possibility of redemption (you are inherently bad, or as Irwin put it, “evil to the core”) while the other assumes that you are inherently good and so of course you will be upset about doing a bad thing and want to do better. The reason analysts can afford to be non-judgmental (at least in principle) is that we assume our patients are inherently good and so will naturally (eventually) be able to apply their own healthy moral standards to any impulses they have toward bad behavior, once they understand — by feeling it — the full meaning of those impulses.
    Sasha, I didn’t think that you were speechifying and I shouldn’t have made such a blanket statement. But my question can in fact be answered because it is not a question about Cho. It is a question about the philosophy with which you and I treat all our patients. What I am concerned about is that some analysts may say to themselves, in effect, “If the patient’s words, behavior and symptoms are in my comfort zone then I will assume he is motivated by the same emotional forces that I am. If his words, behavior and symptoms are so bizarre and terrifying that they feel alien to me, then I will assume he is motivated by an impersonal force by which he is possessed that I can’t possibly understand because that force is not in me (evil, bad seed, chemical imbalance, brain damage, genetic mutation).” That
    kind of thinking is a slippery slope indeed. As a patient, I would certainly not feel comfortable being completely open with a therapist who thought like that, and I’m absolutely certain I would be able to tell if my therapist thought like that.
    Steve, our current mental health system is pretty much in denial about mental illness generally. Are you saying that in Cho’s hospitalization they didn’t recognize he was paranoid and potentially dangerous? I’m sure they did. But they weren’t equipped to do anything about it. It’s easy to say that if Cho’s mental illness had been properly treated the tragedy wouldn’t have happened but in our current system NOBODY’s mental illness is properly treated except if they are lucky enough to be able to afford to see a therapist like (most of) us, who is interested in their inner life. If we as psychoanalysts are going to do something to reform our mental health system the one thing we will most definitely NOT be effective at is educating the public about the diagnosis of psychosis. That is distinctly not our area of expertise. Who would listen to that from us? What we ARE expert at is understanding the inner emotional life of human beings and if we are going to do anything to improve mental health care in this country then we will have to be a bastion against the tide of dumbing-down superficial neurologizing of experience (that denies the inner life of human beings and goes hand in hand with managed care and the denial of the real nature and impact of mental illness that you are talking about). If we are to have any chance of doing that, in fact to have any chance of surviving, we need to be aware of our philosophy. Otherwise, before we know it, we will have been
    co-opted by the dumbed-down superficial neurologizing philosophy that denies the inner life we are supposedly dedicated to understanding. At least for all the patients who aren’t in our comfort zone.
    About the obvious fact that Cho and Hitler and Osama are very different people whose evil actions cannot be explained in the same way. That is obvious and I never meant to imply otherwise. (Of course I do think they were/are all delusional but there are different kinds of delusion). My point was that when we abandon our psychoanalytic understanding of motivation in the face of all three by calling them all evil (as quite a few of us on this
    listserve have in fact done), as if that explains anything, or as if we understand what that is, then WE are treating them as if they are all the same.

    Elio

    Elio Frattaroli, M.D.
    http://www.healingthesoul.net

  58. Webmaster Says:

    Posted on behalf of Melvin Mandel:

    Bravo, Jane. How do analysts analyze ‘evil’? If, that is, they are operating in an analyzing world that they are supposed to occupy, differentiating us from the others? We are not the judges, the religious leaders or the prosecutors of the world, we are some of the only people truly concerned with questions like ‘how did this person come to be the person before me?’

    I operated with a sense of this sort before ever entering analytic training. As a resident in the E.J. Meyer Memorial Hospital in Buffalo, NY, from 1948 to 1950, my non-analyst but very humanely oriented chief ( the son of an Australian Minister of faith) taught us that understanding the tension, the terror of the inner world of those engaged in violence ( I know very well that it many times becomes so incorporated that it can only become projected as an instance of projective identification)was necessary to develop an empathic understanding. He showed us that when we interviewed patients in a barred cell it was more important to let the patient have access to the exit door, by placing ourselves against the barred windows so that patients would not see themselves as trapped in that interview room. In those days there was a NY State law called the Mental Hygiene law, and disturbed people were brought in for violating this rediculously set up law, but which worked beautifully to create the illusion of a legal process. The cops would bring
    disturbed, troubled people in all hours of the night, handcuffed. I would quickly tell police to free them, all the while talking to the patient, reassuring them that I wanted to understand what had happened, etc. The cops used to tell me I was insane, but it worked every time. Eventually the Buffalo newspaper caught wind of what was going on, they featured me full page, in a white coat, smoking a pipe, labelled me an ‘angel’ doctor, and made the point that there never was a serious problem in all the time I was on duty. I’m not sure I could do it all today, given the intensification of violence and ease of getting guns, but the police stripped guns before they brought the people in, so maybe I would still operate that way. I learned that communicating a desire for understanding was the sine qua non. I could tell you more, but won’t right now.

  59. Webmaster Says:

    Posted on behalf of Deborah Hamm, MD

    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 belligerant…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 possibilites regarding intentionality (“can’t” related to impossibility or degree of difficulty, “won’t” because of conflict, etc).
    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…

    Deborah Hamm, MD
    email: dsh1@columbia

  60. arolde Says:

    This is a response to an earlier comment on this matter.

    To Elio: I have not answered your question directly, and please forgive me for “speechifying” (though I do not understand what that means), but I did try to say that in my opinion, your question cannot be answered on philosophical or theoretical or psychological grounds, because 1)people behave differently on an individual basis – thus possibly Cho could be “understood” by us, if anyone were to get to know him well, but people who organize mass murder may not be. 2)There are other variables at play that are coming up now in the neurological/genetic research, which are probably not easily recognizable in a clinical interview and even harder to put into a philosophical framework. As more knowledge is acquired, psychoanalysis may need to change its approach and theory.
    At least from my point of view, an answer to your question is very complicated and you would probably call it even less direct than you already do.

    On this topic, Alice Maher wrote that Freud pointed out the importance of the body and that the brain is part of the body. Freud in fact also said that it will be up to future research on the brain to establish more accurate answers to human psychology and behavior.

    Sasha

    Alexandra K. Rolde, M.D.
    email: arolde@hms.harvard.edu

  61. Tamar Schwartz Says:

    05/08 5:47 PM

    Response from Alice Maher:

    I have some affinity with Deborah’s perspective on mind/brain. Freud showed us the importance of the body, and representations of the body. The brain is also a body part, is it not? How can we understand and integrate our experience of our mind/brain, including neurotransmitter shifts, if we can’t attach words to those xperiences. Even if those words are later shown to be wrong, at least it’s a way to begin, no?

  62. Tamar Schwartz Says:

    05/09 6:50 AM

    Response from Henry Friedman:

    The recent exchange of notes following the Virginia Tech massacre lead to a fairly clear division between those of our members who felt
    that mental illness, as in the case of Cho, was integral to understanding his violent actions, and those who felt that implicating paranoid schizophrenia was absurd because so few paranoid schizophrenics are violent, no less murderous in their actions. The later contributors focused attention on the concept of evil, the idea
    being that the desire to destroy, murder, others stems from developmental experiences that produce something we all can agree is evil in its intent. The question would appear to be not whether the actions were evil but whether a mental disturbance that could be classified was central to the actions that we would call destructive or evil, semantics playing a large part in the choice of terms.

    The question was raised as to whether or not we all have within us and have experienced the kinds of feelings that Cho and other mass murderers have experienced. This was presented as a kind of litmus test of whether the respondent understood dynamic thinking about severe mental illness. The implication seemed to me to be that if you didn’t view things in this framework that you couldn’t be available to treat such individuals. This at a superficial level appeared quite powerful as an rgument and many who were asked to comment on this question did so in the affirmative, as in, yes we are all human so we all have these feeling states. In this, those who agreed were following in the analytic footsteps of Harry Stack Sullivan and Freda Fromm- Reichman, both pioneers in the adaptation of psychoanalysis to the treatment of psychosis in general and schizophrenia in particular in the pre- psychopharmacology days. Sullivan, more or less, invented the idea of schizophrenics as
    individuals dealing with conflicts similar to those common to all of us. Sullivan as an interpersonal psychoanalyst failed to attempt any explanation of the ego defects that are found in patients suffering from schizophrenia. In the days of ego psychology’s dominance in the theory battles it was easy for analysts to exclude schizophrenics from the category of treatable by psychotherapy, no less psychoanalysis.

    The advent of effective psychopharmacology has introduced new ways of thinking about the human qualities involved in schizophrenia and other Axis I diagnoses. Perhaps Sullivan and Fromm-Reichman need to be seen in an historical context; schizophrenia’s causality may well having nothing to do with emotional conflicts or fantasies. We may have missed the boat in assuming that these were emotional disturbances of an ordinary human type only accentuated as an explanation for such a severe illness. Increasingly we have evidence of genetically based brain pathology as a factor in the etiology of schizophrenia. Properly administered anti-psychotics are necessary in the treatment of the schizophrenias; they appear necessary to allow human qualities and conflicts to emerge from under the obscuring influence of a most certainly organically based illness.

    While it may appear politically incorrect, or even dangerous, to express a belief, drawn from progress in psychiatry, that schizophrenia obliterates human conflicts rather than is the result of such emotions it nevertheless deserves to find expression within our group. There should be no litmus test of loyalty to the
    emotional basis of all psychiatric illnesses or a demand for disavowal of psychiatric diagnoses and treatments as a test of psychoanalytic purity.

    Henry J. Friedman

  63. Tamar Schwartz Says:

    05/09 7:22 AM

    Response from Elio Frattaroli

    Henry, let’s say we were to agree that schizophrenia is an inherently meaningless neurological disease that ablates inner conflict rather than resulting from it. Then could we also have to agree that bipolar disorder is similarly meaningless and ablating of meaning? All the varieties of bipolar disorder? OK, now that we have removed bipolar disorder from the sphere of meaning let’s look at depression. That’s a neurological disease right? Based on a genetic defect, right? So it must be inherently meaningless too, ablating inner conflict rather tthan resulting from it? And would that include Hamlet’s depression? Full of sound and fury, signifying nothing.

    Given that the research program for modern neuroscience includes finding a genetic and neurological “cause” for all mental illness — something I am sure they will eventually succeed at — where should we draw the line between mental illnesses that are meaningless because they have neurological causes and mental illnesses that have meaning despite having neurological causes? It seems to me that you either have to give up and admit that all mental illness is meaningless and that there is no role for psychoanalysis in the world OR admit that our decision about what is meaningless and what is meanginful has nothing to do with neurology – that’s just a rationalization – but rather has to do with what we are able to identify as “human like me.”

    Maybe you disagree, but if so, where do you personally draw the line between meaningless neurological events and meaningful neuropsychological experiences, and why do you draw it precisely where you do?

    Elio

    Elio Frattaroli, M.D.
    http://www.healingthesoul.net

  64. Tamar Schwartz Says:

    Response from Don Coleman:

    Zvi Lothane brought up Elio’s question. I had forgotten his question (as I do so many things today coping hydrocephalus) and so I’m grateful to Zvi for quoting: “are Cho and Hitler and Osama Bin Laden as alive, human beings of a fundamentally different kind than we are—motivated by forces that simply don’t exist in us but that we have names for, like ‘evil’…” I agree with Zvi that there are errors in Elio’s question.

    Mine may be one of the “diversionary speechifying non-answers.” I had worked briefly with a young man sent to me by the probation officer. He had been caught making obscene phone calls. I had gathered some history. He had been sexually abused by his mother and grandmother. I had suggested that perhaps he
    had felt some angry feelings toward the women in his life. He poo-pooed such a suggestion and had already heard such nonsense from social workers and clinicians at the agencies. And, oh, did you hear that they found a raped and dead young lady out in Schenley Park? Her body was covered with Cheerios, the work
    of a serial killer.” I pointed out how quickly he had switched from poo-pooing my hypothesis and his telling his so-called joke. He responded, in hushed tones, that he’d never gotten “it”before until right now.

    Zvi goes on to say that evil can only be understood in a societal context…it is not a linguistic or a philosophical pastime…it is an issue in Ethics. Many years ago I studied philosophy in Latin & Greek and vaguely remember the “problem of evil” but find Zvi’s writing more digestible. In our neighborhood, the best kept secret is not thanatos but love between analyst and analysand.

    Don Coleman

  65. Tamar Schwartz Says:

    05/09 9:42 AM

    Response from an anonymous psychoanalyst:

    At 06:13 AM 5/9/2007, Elio Frattaroli wrote:

    “… where should we draw the line between mental illnesses that are meaningless because they have neurological causes and mental illnesses that have meaning despite having neurological causes? It seems to me that you either have to give up and admit that all mental illness is meaningless and that there is no role for psychoanalysis in the world OR admit that our decision about what is meaningless and what is meanginful has nothing to do with neurology – that’s just a rationalization – but rather has to do with what we are able to identify as “human like me.”

    Elio,

    I’m not sure this contributes to the current discussion, but I’d like to repeat here a passage I first posted on the members list in 1998. This my paraphrase of a passage from “The Dynamics of Transference” published in 1912, about 95 years ago! I think it clearly shows the spirit that has permeated most sensible views of psychoanalysis — that it’s not an “either/or” situation except in the most unusual circumstances:

    “I would like to take this opportunity to defend myself against the mistaken charge that, because I have stressed the role of early hildhood experience, I have denied the importance of genetic/constitutional factors [in personality formation]. This sort of charge arises from the simplistic way people think about causation: in contrast to what actually goes on in reality, people prefer to grab onto a single cause when trying to explain something. Psychoanalysis has talked a lot about the role of childhood experience as a cause of personality development, and little about genetic makeup and other physical factors; but that is only because we had something new to say about the role of childhood experience, while, to start out with, we knew no more about the physical factors involved in mental development than anyone else. But that doesn’t mean that we accept any idea that these factors of early experience and genetics should be considered separately; on the contrary, we assume that early experience and genetic endowment act together in bringing about development. [Genetic Endowment and Experience] determine a man’s fate — rarely or never one of these alone. The extent to which each factor is causative appears to vary from one person to another. We assume that people are arrayed along a apectrum according to the extent of the role played by genetics and experience, and no doubt there are some individuals near each end of that spectrum. As our knowledge increases we may change our estimate of the relative importance of genetics and experience in specific cases…”(1)

  66. Tamar Schwartz Says:

    05/09 11:26 PM

    Response from Alice Maher:

    Elio (or anyone), where would you draw the line with a patient who suffered from asthma, or migraines, or colitis? You can get such attacks from dust, heat, food, or your mother, right? I think of psychiatric “disorders” from the same vantage point. It’s often hard to know which side to focus your attention on at any one moment and it’s easy to make mistakes of emphasis, but… nobody said our job was easy. Would you agree with this perspective?

    Best regards,
    Alice

  67. Tamar Schwartz Says:

    Continuation of post from the anonymous analyst

    (1)The Dynamics of Transference footnote 2, paraphrased Standard Edition, volume XII, p. 99

    Sorry if my paraphrase upsets anyone. Here’s the original Strachey translation, which I think is somewhat archaic:

    “2 I take this opportunity of defending myself against the mistaken charge of having denied the importance of innate constitutional) factors because I have stressed that of infantile impressions. A charge such as this arises from the restricted nature of what men look for in the field of causation: in contrast to what ordinarily holds good in the real world, people prefer to be satisfied with a single causative factor. Psychoanalysis has talked a lot about the accidental factors in aetiology and little about the constitutional ones; but that is only because it was able to contribute something fresh to the former, while, to begin with, it knew no more than was commonly known about the latter. We refuse to posit any contrast in principle between the two sets of aetiological factors; on the contrary, we assume that the two sets regularly act jointly in bringing about the observed result. [Endowment and Chance] determine a man’s fate—rarely or never one of these powers alone. The amount of aetiological effectiveness to be attributed to each of them can only be arrived at in every individual case separately. These cases may be arranged in a series
    according to the varying proportion in which the two factors are present, and this series will no doubt have its extreme cases. We shall estimate the share taken by constitution or experience differently in individual cases according to the stage reached by our knowledge; and we shall retain the right to modify our judgement along
    with changes in our understanding. Incidentally, one might venture to regard constitution itself as a precipitate from the accidental effects produced on the endlessly long chain of our ancestors.”
    SE, XII:98, Footnote 2

  68. Tamar Schwartz Says:

    05/09 3:34 PM

    Response from Henry Friedman:

    While I remain uncertain as to the etiology of schizophrenia and true manic-depressive illness I have little doubt that patients in the throws of these disorders are “beyond interpretation” in any of the usual analytic meanings of interpretation. In the early 1960’s, Elizabeth Zetzel, one of my favorite teachers discussed schizophrenia and its treatment with a well known British organic psychiatrist. Zetzel, never one to mince words, confronted Dr. Sargent by informing him that having schizophrenia didn’t excuse a patient from having an emotional life particularly after a psychotic episode had run its course. This was early in the effective use of anti-psychotics but Zetzel’s point was that having a therapist to help was important even if you did have a schizophrenic illness based upon a genetic disposition. Most serious clinicians have had experience in treating patients who, outside their psychotic episodes, are able to work well in psychotherapy and psychoanalysis. What I have learned in conducting full analytic treatments with patients who have bonafide Axis I diagnoses is that the determination of need for medication and its effective utilization are crucial in maintaining the patient’s important life relationships and work efforts. There analytic treatments, however, don’t aim at uncovering unconscious conflicts as either the cause of the psychosis or its amelioration. When such a patient has responded to the proper ychopharmacological intervention the relational part of the analysis can continue; it is also possible to utilize the relationship to enlist the patient in being motivated to take medication and protect their work and love relationships. The tendency in the past to relegate such patients to supportive treatment was a mistake, the result of believing that analysis on a 4-5x a week basis was a technique aimed at elucidating the unconscious elements of the transference with its resultant impact on the patient’s understanding of their issues.

    I mean here to answer Elio’s note drawing upon clinical experience rather than literature. Hamlet’s depression certainly isn’t one that can easily or even possibly be relegated to psychopharmacology. However, in the office it is usually possible to know where to draw the line with any particular patient with a serious clinical depression (psychosis of the schizophrenic type offers less ambiguity). Many patients who enter treatment looking so depressed that they would apparently qualify for the psychotic depression label actually respond very rapidly to the presence of an understanding therapist. As such, it is relatively easy not to bother them with anti-depressants but instead to conduct therapy at a frequency that is compatible with their situation, degree of distress and ability to reflect upon themselves and their depression. Likewise, with those patients who on’t “believe in medication”, are severely, psychotically depressed but insist that they only want talk therapy it may be possible to talk with them quite intensively until they are able to accept a component of their illness that is beyond talk and really needs medication. In such situations the response to a properly select anti-depressant is often rapid and gratifying to the patient who has suffered too long in the depression but at least understands their own role in delaying effective symptom relief.

    No less a clinician-teacher than Elvin Semrad spent years insisting that schizophrenic patients in the midst of agitated, delusion episodes didn’t need anti-psychotic medication. His interviews with patients who were in a psychotic episode were famous for his ability to get the patient in touch with a loss and its accompanying sorrow for both the patient and the audience. Unfortunately, his assignment to the resident psychiatrist was always that he or she should help the patient mourn the loss that had in his mind precipitated or even caused the psychotic schizophrenic episode. Left to this task we had to learn to use medication on our own. Many didn’t figure it out and apparently may still not have understood their esteemed teacher’s blindspot. The residency was huge in those years numbering 75 residents distributed over the three years. It is very distressing to think of how many psychiatrists trained at Mass Mental Health Center, THE Harvard psychiatric teaching hospital went out into the world to practice under the illusion that Dr. Semrad was fundamentally correct and that medication was the enemy of real treatment of schizophrenia. How many brave but wrongheaded psychiatrists visited such a limited perspective on those patients and families who entrusted their care to them? Who knows but we certainly should care as we should care that no amount of grandiosity (personal) or blind faith in psychoanalysis leads us to believe in psychoanalysis for patients where it isn’t effective without the use of appropriate psychoactive medication.

    Henry J. Friedman

  69. Tamar Schwartz Says:

    05/09 7:53 PM

    Response from Luba Kessler:

    Elio writes in response to Henry: “Given that the research program for modern neuroscience includes finding a genetic and neurological “cause” for all mental illness — something I am sure they will eventually succeed at — where should we draw the line between mental illnesses that are meaningless because they have neurological
    causes and mental illnesses that have meaning despite having neurological causes? It seems to me that you either have to give up and admit that all mental illness is meaningless and that there is no role for psychoanalysis in the world OR admit that our decision about what is meaningless and what is meaningful has nothing to do with neurology – that’s just a rationalization – but rather has to do with what we are able to identify as “human like me.”

    Elio, your dichotomy seems forced to me. Each of us has a brain such as has been shaped individually by dynamic forces of nature and nurture, and it is that brain with which we then make our meanings ( with their own potential for changing the brain). Since all our psychological functions are underwritten by functional biomarkers in our brain, it becomes inescapable that such meaning making will be affected by however those biomarkers might malfunction in schizophrenia or bipolar disorder or autism etc. It seems to me that if Cho’s biomarker brain circuitries were misshapen by a psychotic neurophysiopathology, and his life served up insufficient protection from the contagion of potentially ever=present “evil”, then the combination of both spelled an annihilation of his own psycho-social viability. The classmates died because they were in his world and his world went dead. Nor do we know that antipsychotics would have made a difference, with their
    crude therapeutic action so far outweighed by biological complexities needed to sustain psychological life.

    Luba Kessler

  70. Tamar Schwartz Says:

    5/10 6:02 AM

    Response from Herb Gross:

    Around the turn of the century 1898-1904, Hollos and Ferenczi visited patients hospitalized with General Paresis who were disoriented to time. When they asked what year it was the patients replied with the wrong year. When they investigated possible reasons for the particular choice of the (wrong) year, they found out that the year the patients chose had dynamic meaning, e.g., it was the year they lost money or developed a chancre.

    The non-analyst dismisses the meaning as she emphasizes the mistake. The analyst searches for the meaning conveyed whether or not there was a mistake. By no means is the analyst free to use the information gleaned from faulty responses oblivious to patho-physiology or the clinical pragmatics.

    When some researchers conducting “research interviews” on a hospital ward told me that they would not let me see the results of their “research interviews” I denied them access to the patients. I was worried that they might tell the research Doctors in white coats information that we the treating staff who also wore white coats needed to know.

    Elio is right that we extrapolate meaning using our shared humanity but I disagree with him that the products of faulty hardware are meaningless. I would be very interested in an example of meaningless behavior.

    Herb Gross

    Herbert S. Gross, M.D.
    Clinical Professor of Psychiatry
    Department of Psychiatry
    University of Maryland School of Medicine

  71. Tamar Schwartz Says:

    05/10 6:07 AM

    Response from Irwin Savodnik

    It seems to me that a problem with this discussion is that it lacks a few distinctions that would take it a long way. Most of the issue revolves around the crucial distinction between meaning and truth, or perhaps, between semantic meaning and truth functional statements. In a broad cultural sense, we might see it as a division between humane studies and hard science. The first has to do with meaning and the latter with formal, i.e., logically or deductively organized statements. This latter idea, namely, that scientific theories can be organized as deductive arguments has a long history and was nicely presented by Carl Hempel in a wonderful
    article, “The Function of General Laws in History”, about 60 years ago. Hempel used deductive explanation as an example of a scientific account of a
    phenomenom, e.g., a revolution. The irony in using a social science, i.e., history, as an example is obvious.

    Another distinction is that between the cause of a behavior and a reason for it. I might raise my arm suddenly because I touched a hot surface. I had no
    reason for doing so, just a cause, i.e., my finger touching the hot surface. We sometimes say that a reason “rationalizes” and action, i.e., it provides
    an account of why the action occurred. A famous article about this subject is one by Donald Davidson, “Action, Reason and Causes.” It appeared sometime
    about 1964. I might raise my hand to wave hello, certainly not a reflex act. Davidson treats the act of flipping on a light switch and looks at it from both sides.

    Now, here is the problem for this discussion. Some people believe that behavior, or actions, can be explained entirely to our satisfaction by causes alone. These people, obviously, are the behaviorists. Others believe such explanation requires reasons to illuminate an action entirely. This sort of issue is almost the entire sum and substance of the philosophy of history. The question is: Can human behavior be satisfactorily explained strictly on the basis of a causal model, or does it require “intentional” or meaning-laden notions? I think Eleo holds that having reasons, acting upon them, and speaking about “rationalized” actions (not in the psychoanalytic
    sense of “rationalization) is what understanding human existence, conflict and psychology are all about. I tend to agree with him rather strongly.

    However, this is a rather thorny subject and there are some pretty smart people on both sides of the issue. Daniel Dennett would side with the behaviorist camp; John Searle would likely go with the opposing side. But the sides are not always all that clear at times.

    Finally, I do think that when Eleo seems to say that neurology has nothing to do with our decision about what is meaningless and what is meaningful, he is making use of these distinctions without mentioning what they are. He does not, though, seem to distinguish between the idea of meaning as significance and meaning as a semantic category. It’s helpful to do so since the two uses of the term have different applications and patterns of use.

    Irwin Savodnik

  72. Tamar Schwartz Says:

    05/10 8:16 AM

    I agree with Herb.

    A more contemporary example is the McCarley-Hobson activation-synthesis hypothesis of dreams. This used discoveries about the reticular-activating system and REM sleep to purport to show that dreams are random neurological events.

    The challenge is to have a dialogue wherein discoveries in brain research and psychoanalysis and other relevant fields inform each other and advance knowledge and treatment.

    Charles Pinderhughes described a “drive to dichotomize” (Psa. Inq. Vol 6(2): 1986, 155-173). We see it all around us.

    Mark

  73. Tamar Schwartz Says:

    05/10 10:59 AM

    Response from Zvi Lothane:

    We live in the brain millennium, with the chiliastic promise to be saved by the brain as we still anxiously cling to our souls. Do we need the brain to be our savior?

    Psychiatry as almost entirely been reconverted into neurology and neuroscience, as evidenced by the bulk of the publications in American Journal of Psychiatry and Archives of General Psychiatry. Now Henry wants to do same for psychoanalysis. Good luck.

    George Engel was my first teacher about brain and mind. He taught about somato-psychic sequences and about psycho-somatic sequences: brain functions belongin both. But Engel did not need to invoke the brain when he described the behavior of hysteria as playing a game of charades. Nor when he wondered is grief a disease. When Engel was unique in American Psychoanalysis: he did not have any formal educationi in psychiatry and went from medicine into analytic training. For some reason the biopsychosocial idea did not fly, but it was a good one and the brain was given its due in the “bio.” Unfortunately, his sound ideas about the education of medical students, as good as Flexner’s report and better, did not change much in medical education which still clings to a materialistic, neurological model of the mind and where errors of diagnosis and treatment are committed daily. My residents at Mount Sinai have reported not a few cases showing that the medical interns and residents were ignorant of the basics of abnormal mental functioning and it was the psych consult resident that picked up the gross brain pathology complete with neurological signs.

    Such was the case of the Texas killer described by Deborah Hamm: he was misdiagnosed and mistreated and, like Cho, slipped through the net because of severe systems failures.

    But it was clear for George as it was for us his students that as long as the brain is anatomically normal, we don’t have to bother with it.

    And, Herb, there is no justification for extrapolating e from diseased brains to normal brains. We all know we have a brain, but, as Elio and Irwin have eloquently pleaded, we also have minds, intentions, emotions, dreams, daydreams, wishes, and, above all, as Don Coleman reminded us, perhaps thinking of Nat King Cole, the need to love and to be loved in return.

    Zvi Lothane.

  74. Tamar Schwartz Says:

    5/10 2:14 PM

    Response from Arthur Meyerson:

    Yes Zvi, we know we have a brain but we don’t have “a mind” in the same sense. The mind is a heuristic construct which we use to understand certain observable behaviors of we human beings. These include thoughts, feelings, defensive functions, intelligence, imagination, empathy, transference, etc.

    These behaviors are functions of something we, for heuristic value call and lump together as the “mind”.following Freud. However, none of those functions exist without some interaction of experience and constitution (brain mediated vulnerability and strenght of adaptation). Freud chose to abandon his search to understand behavior via the brain as the tools were not available.

    Now, on the threshold of understanding brain, if we reify the mind as if it were totally explanatory of behavior, we abandon the hope of understanding how experience (our area) modifies the brain as we develop, thus leading to the mental functions (mind) we observe as adaptive or maladaptive. If the latter, we try to modify the influence of those experiences with our methods.

    Where brain alone is the cause of the behavior such as seizures secondary to a temporal focus, no analyzable contribution from experience has taken place although the seizures certainly can effect “mental” functions in a transcient fashion. We are at an important threshold for neuroscience and analysis. I would hate to see us reify concepts that were meant to be heuristically valuable as if they were facts. That will kill us a lot more surely than political discontent.

    Arthur
    Arthur T. Meyerson, M.D.
    Cl. Professor of Psychiatry
    NYU School of Medicine

  75. Tamar Schwartz Says:

    05/11 1:18 AM

    Response from Sasha Rolde

    Luba has pointed out that “since all our psychological functions are underwritten by functional biomarkers in our brain, it becomes inescapable that such meaning making will be affected by however those biomarkers might malfunction in schizophrenia or bipolar disorder or autism etc.’. I want to bring to your attention the current efforts to treat autistic and Asperger’s children. The theory behing the methodology is that the brain of all humans is able to develop new pathways if the post natal experiences occur early enough. I have not had the time to look up the names, but some years ago at an APsaA meeting a child analyst from California presented a tape of a therapeutic nursery school in which he works. They have done a decades long longitudinal study of children 2 yrs – 6yrs., diagnosed with mild autism and Asperger’s Syndrome. The children are not only “taught” by special education teachers but they have daily, one hour long 1:1 session within the classroom with the child analyst. During this time, their actions are translated into feelings by the analyst. The child throws something or tries to hit someone – the analyst says, “you were feeling angry at Johny”…, etc. The idea is to teach children very early both about their feelings as well as those of others, thus attempting to develop “empathic” pathways, which a lot of these children when they are older, if untreated, do not seem to be able to do. Similarly they are taught about social cues. Periodic psychological testing evidently shows marked improvement in functioning, as well as real jumps in IQ. Many of these children go on to have successful carreers, mary and have children. Some have written back to thank the staff at the school. Many have children who carry diagnoses of autism or Asperger’s. A genetic component is therefore postulated, but with early intervention, it is felt hat the “neural defect” can be at least partially corrected. Note, that this is what parents do with their “normal” very young children, but usually not at such an intensive pace.

    There are many parts of the country now, where similar programs are being given, partly due to a much earlier recognition of the problems these children have. This type of work with children is I think further demonstration of the interphase between genetics, neurological/biochemical brain fuction and psychodynamics. I am therefore reluctant to say that depression is any less biological than autism or schizophrenia, and equally as reluctant to say that one can be treated psychodynamically and not the other. It is probably a matter of degree, and of different medications for different conditions as an adjunct to psychodynamic treatment.

    Sasha Rolde

    Alexandra K. Rolde, M.D.
    27 Fields Pond Rd.
    Weston, MA 02493
    tel.(781)894-2177, fax (781)891-9419

  76. Tamar Schwartz Says:

    05/11 6:29 AM

    Response from Zvi Lothane:

    Yes, Art, we have a mind, but we are not using it as much as we were in the habit of doing.

    Yes, we have a brain, too. It has a dual function: it is a neuronal and neurohumoral regulator of various biological systems, it is a center. But we also have A BODY. As the brain became the new fetish and faith, of which you have become a devoté, the rest of THE BODY has been forgotten. But also have muscles, intestines, adrenals, thyroid, and more. Can you say that the center is the only one that counts?

    The brain is also the organ in which mind and speech reside. Memory is done by the brain. But what about the memory done by muscles? The concert pianist, the tour the France cyclist, the olympic swimmer, perform with the help of muscle memory. It is not the brain as commander in chief that issues orders to the muscles, it is the combined brain and muscle memory that does it. The same with the tissues of pleasure: it is those receptors in the penis and vagina and their connections to brain sites that make the delights of heavenly friction.

    Now it is patently wrong for you to say that

    “The mind is a heuristic construct which we use to understand certain observable behaviors of we human beings. These include thoughts, feelings, defensive functions, intelligence, imagination, empathy, transference, etc.

    These behaviors are functions of something we, for heuristic value call and lump together as the “mind”.following Freud.

    The mind is a heuristic construct which we use to understand certain observable behaviors of we human beings.”

    The mind is not a construct and it has not been created by Freud. The mind is AN ACTIVITY, A BEHAVIOR. To be sure, it requires an intact and well-functioning brain to manifest itself, we know that, we need not reinvent the wheel.

    Does the brain secrete or excrete mind activity the way the kidney excretes urea? Or the liver bile? This epiphenomenal view of mind is a deplorable reduction, and a reduction ad absurdum, to boot.

    A respect for mind requires a knowledge of mind’s achievements down the ages in the philosophy of cognition, of science, of ethics, the arts, literature, architecture — all manifestations of a CREATIVE MIND, a tradition that has been stored in countless brains while they were alive and immortalized, i.e., preserved continuously, in a rich written and oral tradition and transmission that is the cultural heritage that we still own. To say that mind is just a construct is a construction you should abandon without much regret.

    Of course, you can continue to cultivate your interest in neuroscience, the latest of heuristic constructs about mind. But remember: these constructs are fruit of animal observation and experimentation and some fancy diagrams concocted from those animal experiments. Remember also: if the brain is like a computer, than by itself it cannot GENERATE any thought. It can only store and manipulate thoughts that have been put into it.

    From the standpoint of evolution, it is not the random appearance of the brain that produced thinking. It is the humanoids experimenting with their polluxed hands and teeth that resulted in the first tool (chimps use them, too), and it is the mind IN USE that stimulated the growth of the brain, until it attained the size of yours and mine.

    BTW, are our brains different from Einstein’s or Freud’s? Either way, how were they able to come up with their zany ideas that disturbed the peace of the world?

    Zvi Lothane.

  77. Tamar Schwartz Says:

    05/11 7:16

    Dear Herb,

    you write:

    So I disagree that there is a sharp distinction between intact and diseased brains. Intact brains are vulnerable to malfunction in ways similar to diseased brains because of their complexity and because complex systems are fragile. I don’t believe that loving and scientific curiosity are mutually exclusive. I may be presuming but I don’t think that you and Elio and Irwin do either.

    Where did you see me say or imply that scientific curiosity and love are mutually exclusive? I LOVE my own scientific curiosity just as you love yours, nay, I am addicted to it.

    Anxiety and panic states are related to the neurobiology of emotions, as shown by Walter Cannon decades ago when he described the fight and flight reactions. George Engel talked a great deal about the patterns of fight and flight in anxiety and energy conservation in depressive states.

    Where did you read me say that I exclude the brain?

    And no Herb, with all due respect, there is a huge difference between brain modules being attacked by anxiety and such modules (I don’t quite know what module means here) being attacked by a glioblastoma or compressed by a meningioma.
    No, there is a qualitative and quantitative difference between the two conditions.

    It is not mind people who deny the brain, it is the brain people who love to deny the mind. I have heard a number of neuroscientists giving talks where the first remarks were disparaging of mind in one way or another. I was unable, however, to diagnose what was going on in their brains.

    Now a question to you: is the difference between procedural learning and the symbolic domain something demonstrated by experimentation or is an idea that was IMPLANTED in the experiment design?

    Zvi Lothane

  78. Tamar Schwartz Says:

    05/11 8:43 AM

    Response from Zvi Lothane:

    A propos our brain battles:

    Todat’s New York Times conains fascinating reportage about the trial of Peter Braunstein

    A former Women’s Wear Daily writer accused of holding a former colleague captive and sexually tormenting her for 13 hours wrote a personal manifesto and mused in a diary about why New Yorkers were so captivated by the crime, according to testimony at his trial yesterday.

    the diary is from previous instalments.

    Today’s centers on Mount Sinai’s PET expert Monte Buchsbaum testimony about Mr. Braunstein’s brain and schizophrenia, an insanity defense.

    Zvi Lothane

  79. Tamar Schwartz Says:

    05/11 10:26 AM

    Response from Henry Kaminer:

    Let me answer Zvi’s question about the difference between declarative and non-declarative memory (or procedural and explicit memory)- I think the proof of
    their separate existence is originally on the basis of studying the effect of naturally occurring brain lesions- BTW I think the famous case of the man whose hippocampi were removed bilaterally showed that he could not lay down any declarative memories but could learn non declarative tasks (physical).
    I also like the idea of the brain secreting- nay, Excreting, mind- perhaps it is a noxious substance that must periodically burst forth (creative imagination) or else the person will have a terrible headache? just in jest. hk

  80. Tamar Schwartz Says:

    05/11 2:51 PM

    Response from Yale Kramer

    I am delighted that my comments have stirred such a wide ranging discussion. I have learned much from it. Thanks to all and a warm hello to my old classmates Zvi Lothane and Art Meyerson.

    Yale Kramer

  81. Tamar Schwartz Says:

    05/11 4:45 PM

    Response from anonymous:

    Today’s Wall Street Journal contains this “Science Journal” article which I think may contribute to the recent discussion, even if it’s not exactly on point.

    SCIENTISTS DRAW LINK BETWEEN MORALITY AND BRAIN’S WIRING

    May 11, 2007; Page B1

    “Most of us feel a rush of righteous certainty in the face of a moral challenge, an intuitive sense of right or wrong hard to ignore yet difficult to articulate.

    “A provocative medical experiment conducted recently by neuroscientists at Harvard, Caltech and the University of Southern California strongly suggests these impulsive convictions come not from conscious principles but from the brain trying to make its emotional judgment felt.

    “Using neurology patients to probe moral reasoning, the researchers for the first time drew a direct link between the neuroanatomy of emotion and moral judgment.

    “Knock out certain brain cells with an aneurysm or a tumor, they discovered, and while everything else may appear normal, the ability to think straight about some issues of right and wrong has been permanently skewed. “It tells us there is some neurobiological basis for morality,” said Harvard philosophy student Liane Young, who helped to conceive the experiment…”

    “At the University of Iowa Hospital, the researchers singled out six middle-age men and women who had injured the same neural network in the prefrontal cortex. On neuropsychological tests, they seemed normal. They were healthy, intelligent, talkative, yet also unkempt, not so easily embarrassed or so likely to feel guilty, explained lead study scientist Michael Koenigs at the National Institutes of Health. They had lived with the brain damage for years but seemed unaware
    that anything about them had changed.

    “To analyze their moral abilities, Dr. Koenigs and his colleagues used a diagnostic probe as old as Socrates — leading questions: To save yourself and others, would you throw someone out of a lifeboat? Would you push someone off a bridge, smother a crying baby, or kill a hostage?

    “All told, they considered 50 hypothetical moral dilemmas. Their responses were essentially identical to those of neurology patients who had different brain injuries and to healthy volunteers, except when a situation demanded they take one life to save others. For most, the thought of killing an innocent prompts a visceral revulsion, no matter how many other lives weigh in the balance. But if your prefrontal cortex has been impaired in the same small way by stroke or surgery, you would feel no such compunction in sacrificing one life for the good of all. The six patients certainly felt none. Any moral inhibition, whether learned or hereditary, had lost its influence…”

    Full article is at:
    http://online.wsj.com/article/SB117884235401499300.html?mod=Science+Journal
    (requires subscription)

  82. Tamar Schwartz Says:

    05/11 4:58 PM

    Response from Herbert Gross:

    Zvi writes:

    “And, Herb, there is no justification for extrapolating from diseased brains to normal brains. We all know we have a brain, but, as Elio and Irwin have eloquently pleaded, we also have minds, intentions, emotions, dreams, daydreams, wishes, and, above all, as Don Coleman reminded us, perhaps thinking of Nat King Cole, the need to love and to be loved in return.”

    Zvi,

    The intact brain might not always be as intact as you think. For instance, Paul Schilder believed that anxiety could attack any brain module and Sullivan believed the same. Also do you believe that the modification that we effect in psychoanalytic treatment is totally independent of change at the synapse?

    George Engel followed his patient Monica, from the time she was a child born with a closed esophagus who had to be fed through a gastric tube into her adult life. He showed that she fed her dolls holding them the way she was held, and later fed her children in the same unique upside down way. Neuroscience informs us that so called procedural learning is very different from the symbolic verbal domain with which we are familiar. Knowing this might give us pause when we want to comment on Monica’s upside down way of feeding her children. This doesn’t mean we shouldn’t but it is good to appreciate that there might be a non-symbolic way to construe her behavior.

    You are right to note that your residents are careful observers and do indeed pick up pathology missed by their colleagues in other specialties. In my experience psychiatric residents spend more time with their patients and are more curious about what makes them tick than their colleagues.

    That they pick up neuropathology seems to validate our paying attention to brain along with attending to them in our heartfelt soul searching way.

    So I disagree that there is a sharp distinction between intact and diseased brains. Intact brains are vulnerable to malfunction in ways similar to diseased brains because of their complexity and because complex systems are fragile. I don’t believe that loving and scientific curiosity are mutually exclusive. I may be presuming but I don’t think that you and Elio and Irwin do either.

    Herb Gross
    Herbert S. Gross, M.D.
    Clinical Professor of Psychiatry
    Department of Psychiatry
    University of Maryland School of Medicine

  83. Tamar Schwartz Says:

    05/12 &:51 AM

    Response from Zvi Lothane:

    Thanks, Paul, for calling attention to neuroscientists’ observations on moral judgment in BRAIN DAMAGED patients. I wish you had also expressed your own opinion on the matter. Brain lesions help in LOCALIZING the relevant brain areas, and changes in moral function in the brain impaired. But what does it teach us about moral judgment and action in the brain intact? Precious little.

    Should we conclude that Hitler, Himmler and Heydrich suffered from brain lesions in the areas indicated? Or the millions of their executors and exectutioners?

    Yes, there is a neurology and biology of moral judgments and behavior, it is hard wired in ANIMALS, too: they do not practice cannibalism (some lions kiil the cubs sired by other lions to make sure their own genes are used in the progeny), some chimps kill intruders into their domain, but INTRASPECIFIC AGGRESSION AND VIOLENCE are not practiced even on the scale of sectarian violence in Iraq.

    Yes, some things are hard wired in humans as well: not eating your girlfriend, no matter how sweet she is, and not sleeping with your mother, even though in Israel they say: Oedipus schmedipus, as long as you love your mother.

    But in the course of becoming civilized, i.e., human rather than animal, we have dispensed with the moral injuction of the Decalogue, thou shalt not murder (lo tirtsah, murder, nor just kill). By dint of linguistic tricks we have created a civilization in which some killings are crimes, and the same linguistic tricks and rhetoric can make a killer like O. J. Simpson go free.

    And we have also institutionalized killings on a mass scale in war, howsoever letitimized by other linguistic tricks.

    No Paul, my thanks to Damasio and Co. for having confirmed Freud’s discovery of the unconscious, that unconscious emotions, transferences, beliefs shape our conscious judgments. If you insist on the equation unconcsious=brain, I still will argue that the two are not exactly the same, not even in the Project (we do not know, and never will, what brain arguments Fliess brought to bear on Freud for Freud to write the Project in the first place).

    And once more to Art Meyerson: the autonomy of mind from brain was not Freud’s “heuristic” games. He was heir to a two millennia old mind brain debate first started by the Greek philosophers, men like Herakleitos, Zenon, Democritus, Pythagoras, Plato, and Aristotle, and, above all, Socrates. As a medical student Freud’s ideas were shaped by the neo-Aristotelian Franz Brentano and by Herbart.

    We are still engaged in this ancient debate, some for fun, others for big profits.

    So please don’t try to convert me to the neuroscientists’ belief, no brain, never mind; but rather: no brain? Never mind!

    Zvi Lothane

  84. Tamar Schwartz Says:

    05/12 11:15

    Response from Alice Maher

    Paul writes: “Making moral judgments about people is all too easy, and it is no problem for any of us to be glib and righteous in judging each other…. I think we need to be open to the possibility that changes in the brain can make any of us vulnerable to the unleashing of impulses we might have spent an honorable lifetime keeping in check and, when that happens, it makes the moral equation a lot harder to solve.”

    Maybe it’s not as hard as it seems, if we can think about the problem from a different perspective…

    A headline on page 9 of today’s New York Post reads “Lovelorn Nut Job on Airport Cam,” and begins with “The pathetic NASA moonbat…” How dare we tolerate the fact that the outside world conceives of people that way? (Come to think of it, APsaA analysts think about one another using a similar derogatory, morally-judging framework, whether we speak about it aloud or not, don’t we?) They fire people who use words like “nigger” and “fag” and “nappy-headed ho’s” and plaster their mug shots all over the news, but “nut job” and “pathetic moonbat” are still just fine.

    I think we should “Just Stop It,” and then go directly to people with money who can fund campaigns to advertise the need to “Just Stop It” – stop using that kind of language to describe people with psychological problems or psychodynamic differences. If we can get people (starting with ourselves!) to reframe the language they use to think and communicate with one another, the “brain wiring” of society may begin to change, and that could potentially lead to a greater trust and an improved ability to empathize and communicate on a wider social scale.

    Best, Alice

  85. Tamar Schwartz Says:

    5/13 7:12 AM

    Response from Zvi Lothane:

    To Herb,

    of course I work with unconscious mind, I said so many times. But this is NOT the same as unconscious mind. You wrote to me offline:

    “Our minds seem enabled by the unconscious influences of the way they are wired to do some things more easily than others and some of us intact brained individuals are geniuses like Heifetz and others should be forbidden to play the violin in public. Are these influences not those of genes and neuronal alignments?”

    No, Herb, they are not. These alignments are only a POTENTIALITY, not an ACTUALITY. They become the latter through PRACTICE. Innate abilities we now call “hard-wired” become acquired ways of adaptation, or maladaptation, as the case may be, by a person with a specific biography. It is the latter that is the business of analysis, not the former.

    We learn to use our brains in the process of development and maturation of the whole personality.

    To Paul,

    You wrote:

    “Making moral judgments about people is all too easy, and it is no problem for any of us to be glib and righteous in judging each other. However, even in the startling and well know cases of boundary violations committed by some of our esteemed senior colleagues I think we need to be open to the possibility that changes in the brain can make any of us vulnerable to the unleashing of impulses we might have spent an honorable lifetime keeping in check and, when that happens, it makes the moral equation a lot harder to solve.”

    A lot harder to solve does not mean impossible to solve. You are copping a plea, a brain insanity defense, for the esteemed senior colleague by resorting to an ORGANIC condition of the brain that “made him do it,” a variety of the “twinky defense.” I think it is you who are making the glib moral judgment here.

    No, Paul, man is not just an animal, that is a very old and glib cliché: as I have argued previously, animals don’t start wars over oil or to make the world safe for democracy, i.e., to make sure that oil is sold at a higher profit. Civilization has many discontents, as we all know, but it is at least one cut above the animal.

    Was the man devoid of the ability to distinguish between right and wrong? Was he that far gone? Did he consult a friend? Another analyst? Did he speak of a deterioration of his mental functions to his physician? What was his social network like? His family life and marriage? His sexual history? His political views? His psychoanalytic politics? His relations with his peers and standing in the community?

    Yours and Herb’s arguments float in a vacuum, they do not relate to clinical judgments made about a PARTICULAR, INDIVIDUAL situation, they are based on generalizations and abstractions.

    The organic model of reasoning is a return to a pre-dynamic era in medicine and psychiatry: it is based on a SOMATIC CAUSAL SEQUENCE. In the 19th century, the brain was the cause of mind, based on the model of tertiary syphilis. After Freud we think of the mind as causing the brain to react in patterns of anxiety and stress.

    Engel defined stress as a PSYCHOSOMATIC SEQUENCE as follows:

    “Psychological stress refers to all processes, whether originating in the external world or within the person, which impose a demand or requirement upon the organism, the resolution or handling of which requires work or activity of the mental apparatus before any other system is involved or activated. … Highly individual factors determine whether a particular situation or process constitute a psychological stress for a particular individual.”

    It is not the CONDITION of the brain that causes stress, it is stress in a GIVEN SITUATION that mobilizes the fight and flight reaction of the organism as a whole, be it in an animal or in a human being, i.e., person.

    I haven ‘t seen too many neuroscientists using their tools to breathe new life into the nearly defunct psychosomatic medicine.

    In the above Gestalt stress is an INDIVIDUAL experience and evaluation. Soul, or mind, and body, work as one person, that’s what individual means, not divisible except as in the dissection of the body or the dissection of the mental apparatus into the topographic picket fence model, as in the Traumdeutung, or into id, ego, superego in the structural model, or the schemas proposed by neuro-psycho-analysis. There all the difference in the world between analysis on paper and analysis as actually lived in working with individuals from session to session.

    Zvi Lothane

  86. Tamar Schwartz Says:

    05/13 2:28 PM

    Response from Ron Abramson:

    < >

    FYI,
    The various epidemiological studies seeking to ferret out a genetic “cause” for schizophrenia, or for bipolar disorder always seem to average about a 50% contribution of bio-genetic factors. This is also true for such entities as panic disorder.

    I think that the best way to understand the situation is what gets inherited are “predispositions” to major mental illnesses, or “constitutional factors” in the older terminology.

    I also disagree with Henry in his assertion that it is not possible to do psychoanalytic work with people who have major mental illnesses. I think it is. Techniques for doing this go as far back as Federn.

    I would also like to add that certain authors have reported a 40% or so recovery rate among pretty ill people with schizophrenia. I am thinking here of Courteney Harding’s study of patients in Vermont who had been on the “back wards” of the State Hospital who were living productively in the community 20 years later. This recovery suggests to me that there is a lot more to work with psychotherapeutically than we have thought.

    Ron Abramson

  87. Tamar Schwartz Says:

    05/13 4:37 PM

    Response from Ron Abramson

    friedmanhj@aol.com writes:
    < <...the idea that interpretation has an essential role in the treatment of the schizophrenic illness is what I would challenge as being a myth rather than anything backed by more than anecdotal reports...>>

    In my view, psychoanalytic psychotherapy with people who have schizophrenia involves helping them make sense of the chaotic plight they find themselves
    in. The techniques of doing this certainly differ from the techniques utilized with much less disturbed people. It seems to me that reaching an understanding of oneself is the essence of psychoanalytic treatment, and I am not willing to give up on it for psychotic people. Also, there is a literature on this subject which does mostly feature anecdotal reports. I don’t know of a literature with the “evidence based” statistical and scientific proofs that are currently in demand, but, of course, this is hard to get to with any kind of research in psychoanalytic psychotherapy. However, I am aware of work in Norway in which people who are identified as “at risk” for schizophrenia receive a program of psychotherapeutic help and who improve. Also, I have had the personal experience of working with such patients who improve through the work we do, and I don’t view this as a myth.

    FYI, It appears that there is more of this work going on in Europe than there is in the USA, and I am going to a meeting in Paris in June where some of
    this will be reported.

    Ron Abramson

  88. Tamar Schwartz Says:

    04/13/ 10:09 PM

    Response from Elio Frattaroli

    This is not going to be a very friendly em because after the discussion that followed my last em (and was seemingly triggered by it, although it bore almost no correlation to anything I was trying to say in that or any recent em) I am not feeling very friendly.

    The easiest thing to do with any mental/emotional disturbance we don’t understand is dismiss it as a neurological disease that can’t be understood. Before Freud, that’s what was done with ALL mental illness. And within a few years that’s what most psychiatrists will be doing again. (Actually a lot of them are doing it now.) Looks to me from what I’ve been reading on this listserve that psychoanalysts are moving in the same direction.

    If at this juncture, somebody is tempted to say, “Wait a minute, I have a lot of patients with neurotic conflicts that can be understood psychoanalytically without needing to invoke any neurological disorder and psychoanalytic interpretations have been intensely meaningful to those patients and pivotal in their healing process,” better watch out, because Henry Friedman might respond, “(T)he idea that interpretation has an essential role in the treatment of [insert mental illness du jour] is what I would challenge as being a myth rather than anything backed by more than anecdotal reports.” In his last post Henry said that about schizophrenia but what’s to stop him from saying it about any other mental phenomenon that strikes him as being primarily or exclusively neurological simply because he doesn’t understand it?

    I have done long-term dynamic psychotherapy with two schizophrenic patients (who have also been on meds throughout the course of treatment but who have never been completely responsive, even to Clozaril) and their symptoms are clearly explainable in terms of intrapsychic and intersubjective conflicts and they have gotten considerably better through my interpretive approach. (The choice of schizophrenic rather than ocd or depressive or borderline symptoms I ascribe to biological factors but the meaning of their symptoms has been fairly easily accessible to psychoanalytic investigation, once I got over the prejudice that their symptoms were neurological and therefore had no meaning.)

    Henry, your facile dismissal of a psychoanalytic approach to schizophrenia is nonsense. Statistical research may be able to answer the question of what percentage of patients get better (by whatever quantifiable criteria of “getting better” the study defines) with an interpretive approach versus a non-interpretive approach, but even if 100% got better, that wouldn’t say anything about the meaningfulness or validity of the interpretations used. Whether an interpretation is an accurate reflection of a meaning that is actually inherent in a patient’s illness is something for which anecdotal reports are THE ONLY EVIDENCE POSSIBLE, so unless you are prepared to dismiss ALL analytic interpretations as mythical on the basis that we have only anecdotal evidence of their validity and centrality in the curative process, you simply can’t rationally dismiss interpretations of schizophrenia on that basis. You are still free to do it of course, but it would be irrational to do it, and that would be risky because someone might be unable to fathom your motivation and think you must have a neurological disorder.

    And by the way, to those who somehow got the impression that my earlier question to Henry suggested that I was dichotomizing (proposing a false dualism) between disorders that are neurological and meaningless and disorders that are psychological and meaningful, you really weren’t reading very carefully. A lot of people on this listserve, and in the American generally, do that kind of dichotomizing but I have never been one of them.

    I know Freud is aften quoted to the effect that he believed one day everything would be reducible to a neurological explanation, and he did say things like that a few times in his life. But those remarks did not represent the original, brilliant, creative or even remotely useful side of his thinking. If that were all he ever gave us – a reductionistic neurological explanation of mental illness — there would be no psychoanalysis. So here are a couple of more intelligent and useful things he said on the mind/brain question, one from his autobiographical study (1925), referring to the early years of psychoanalysis, the other from the posthumous Outline of Psychoanalysis, expressing his last word on the topic.

    “But the direction taken by this enquiry was not to the liking of the contemporary generation of physicians. They had been brought up to respect only anatomical, physical and chemical factors…. They obviously had doubts whether psychical events allowed of any exact scientific treatment whatever… (T)hey regarded such abstractions as those with which psychology is obliged to work as nebulous, fantastic and mystical; while they simply refused to believe in remarkable phenomena which might have been the starting-point of research….Even the psychiatrists, upon whose attention the most unusual and astonishing mental phenomena were constantly being forced, showed no inclination to examine their details or enquire into their connections. They were content to classify the variegated array of symptoms and trace them back, so far as they could manage, to somatic, anatomical or chemical aetiological disturbances. During this materialistic or, rather, mechanistic period, medicine made tremendous advances, but it also showed a short-sighted misunderstanding of the most important and most difficult among the problems of life.”

    “Psycho-analysis makes a basic assumption, the discussion of which is reserved to philosophical thought but the justification for which lies in its results. We know two kinds of things about what we call our psyche (or mental life): firstly, its bodily organ and scene of action, the brain…and, on the other hand, our acts of consciousness, which are immediate data and cannot be further explained by any sort of description. Everything that lies between is unknown to us, and the data do not include
    any direct relation between these two terminal points of our knowledge. If it existed, it would at the most afford an exact localization of the processes of consciousness and would give us no help towards understanding them.”

    Elio

    Elio Frattaroli, M.D.
    http://www.healingthesoul.net

  89. Tamar Schwartz Says:

    05/13 3:20 PM

    Response from Henry J. Friedman

    I welcome Ron Abramson’s note with his question for me that allows the clarification of the point I was making. Schizophrenic illness is complex and hardly monochromatic; it ranges from severe and unrelenting to episodic to mild and chronic. My central point wasn’t
    that psychotherapy was irrelevant. Rather, it is important to be aware when without medication the patient suffering from a schizophrenic psychotic episode is left “hanging in the breeze”. In my experience many schizophrenics experience long periods of remission between bouts of psychosis. The recovery rate of 40% seems
    totally compatible with the idea of a spontaneously remitting illness. Psychotherapy in such cases may well help with reintegration into the community but the idea that interpretation has an essential role in the treatment of the schizophrenic illness is what I would challenge as being a myth rather than anything backed by
    more than anecdotal reports. Interpreting to an organic disturbance (or one that surely looks like it is based upon something involving brain chemistry) isn’t really what psychoanalysis should be expected to do. The days of John Rosen are gone thanks to effective psychopharmacology, in every way safer and better for the patient.

    Henry J. Friedman

  90. Tamar Schwartz Says:

    05/14 10:22 AM

    Response from Elio Frattaroli:

    Given the hostile tone of my last post (coming from someone who thinks tone is important) I was asked off list “What’s your problem?” A very reasonable question. Without excuse or apology let me say that I think the future of psychoanalysis is in MUCH more jeopardy from our accelerating slide into biological reductionism and a keeping-up-with-the-neuroscientists mentality — the danger being that we will more and more think neurological explanation first, psychodynamic meaning second if at all — than it is from either BOPS or the anti-BOPS coalition. It’s not at all inconceivable to me that BOPS will succeed in upholding standards but it won’t matter because psychoanalysts will have stopped believing in the most basic truth of psychoanalysis, that inner experience has meaning. I say this being quite cognizant of the excitement about neuroscience confirmation of the existence of the unconscious. I personally didn’t need the confirmation but am happy to have it. The problem is, if the unconscious and even the conscious experience of people are considered meaningful only for people who don’t have a neurologically based mental illness, then psychoanalysis stops being a valid method of treatment for those people. And since the trend is toward defining ALL mental illness as neurologically based (not neuropsychologically based or psychoneurologically based or biopsychosocially or psychobiosocially based but neurologically-and-not-psychologically based), that means psychoanalysis will no longer be considered valid for ANY patient. Of course that’s already what most psychiatrists and neuroscientists think but it worries me that we seem so eager to agree with them!

    Elio

    Elio Frattaroli, M.D.
    http://www.healingthesoul.net

  91. Tamar Schwartz Says:

    05/14 12:44 PM

    Response from Leo Rangell

    What concerns me is the tendency to polarization, mind vs. brain. My view is that the mind/brain issue is a very important and practical matter in our daily practice. Essentially, we are here to serve in the best interests of those seeking help. It is of no concern to the those people what approach we take as long as they benefit. And to that end we need to continue and expand this discussion in order to hone our skills/judgement in making an appropriate therapeutic plan. Those intent on developing biological and psychological understandings will, over time, add further details to help refine our decision making, but if the healers/providers take on those polarities in daily practice, the patients/clients will be the losers.

  92. Tamar Schwartz Says:

    05/15 10:02 PM

    Response from Herb Gross

    Zvi Wrote:

    “Yours (Paul’s) and Herb’s arguments float in a vacuum, they do not relate to clinical judgments made about a PARTICULAR, INDIVIDUAL
    situation, they are based on generalizations and abstractions. The organic model of reasoning is a return to a pre-dynamic era in
    medicine and psychiatry: it is based on a SOMATIC CAUSAL SEQUENCE. In the 19th century, the brain was the cause of mind, based on the model of
    tertiary syphilis. After Freud we think of the mind as causing the brain to react in patterns of anxiety and stress.”

    And Elio Wrote:

    Without excuse or apology let me say that I think the future of psychoanalysis is in MUCH more jeopardy from our accelerating slide into biological reductionism and a keeping-up-with-the-neuroscientist’s mentality ….. I say this being quite cognizant of the excitement about neuroscience confirmation of the existence of the unconscious. ”

    I am not so worried about the threat to psychoanalysis posed by neuroscience. I do agree with Zvi that the particularities of an individual situation, trumps every other point of view and with Elio that reductionism threatens attending to those particularities.”

    I know that neuroscientists are as interested in the influence of the mind on the brain as I am about the influence of the brain on the mind. We are possessed of tools that less developed species don’t have and these tools such as consciousness, culture, imagination and many more have a “top-down” influence on the brain’s ever changing “wiring.” And also the bottom-up structure of the brain constrains us, facilitating here and inhibiting there.

    An awareness of the confluence of these streams of influence, the bottom-up of brain on mind and the top-down of mind on brain, enlarges the scope of psychoanalysis. Awareness does not mean enslavement and awareness of neuroscience, like an awareness of “metapsychology” in and
    of itself does no harm but either one can be misused to reduce the particularities of an individual situation to fit a formula.

    Herb Gross
    Herbert S. Gross, M.D.
    Clinical Professor of Psychiatry
    Department of Psychiatry
    University of Maryland School of Medicine

  93. arolde Says:

    This will be a “simplistic” message from me regarding the very sophisticated matter of mind vs. brain controversy,

    Since my college years at McGill University, which had a very advanced Psychology department, I have watched this argument between the social scientists and the neuropsychologists and wondered why one as to be right and not the other.    As a psychology honors student, I listened to endless discussions between the behaviorists and the psychodynamic psychologists, each putting the other down.  My sense was always that they were talking about the same thing, only from different perspectives and that they both had a point.  As a lowly student, I did not dare to ask why they did not put their heads together and try to understand how a behavioral approach to certain symptoms can be explained in psychodynamic terms and vice versa.

    My feeling about current discussion is somewhat the same.  I tell my patients that there is a constant interplay beween the psychological and the biological, in that everything that we think, feel, hear, understand, remember, learn (and accomplish in therapy/analysis) and do is processed on the cellular/chemical level in the brain.  Without the biological brain we could not think and feel and translate that into action.  When they tell me that they have a biological depression, I ask them to explain that to me.  They all think that they were born with some abnormality.  I then tell them that at best they may have a predisposition to becoming depressed more easily under certain circumstances and that most studies show that antidepressants do not work well after a while without concomittant therapy.  They usually know that part by the time they come to me, because most have had a course  of antidepressant medication from their PCP or a psychopharmacologist who saw them once a month at most, more likely once every three months and “it stopped working”.  They experience relief when I tell them that chemical changes not dissimilar from those with the drugs occur when we talk in my office, but the further benefit of therapy is that they can also gain some insight into their problems by talking through or thinking about what we talk about.  The medications cannot give them insights .
    I will not go into similar analogies with BI-Polar Disorder, Schizophrenia and the various degrees of autism and psychosis, but they can all be made, even while it is true that some concommitant medication may be necessary in order to be able to connect with the person in a therapeutic way.

    I don’t pretend for a moment that this is particularly profound, but it amazes me that people in the mental health profession feel that they have to take sides.  However, I  profoundly appreciate the fear that the psychoanalytic approach will disappear and that mental health will be relegated to old Kraeplinian psychiatry, because that is the direction in which the insurance companies, research, and pharmaceutical industry is pushing the public.    My only hope is that it is part of the human psyche to want to communicate, hug, hold, touch and experience one another, and that when in pain, noone wants to be alone with a brain and a drug without a thought to connect to another human being.

    Sasha Rolde

    Alexandra K. Rolde, M.D.
    27 Fields Pond Rd.
    Weston, MA 02493

  94. alido Says:

    Persons with mental illness are prone to a range of coping behaviors that are used to interpret the world around them. Proper assessment & input from those close to the individual is vital for appropriate treatment and support. Not talking to the family and providing a simple follow up phone call from the community mental health board to the campus mental health dept short changed options for the patient. This compromise cut out options for Mr. Cho, and later left him underserved, and affected innocent bystanders on campus.

    We must weigh the rights of the mentally ill along with the rights of his community, surely the victims at Va Tech also had rights to consider. There has to be an improved common ground where both sides are weighed.

    Personality, which is someone’s character, particularly of the way he/she behaves towards other people should not be taken for granted. There were ample indications pointing to Cho’s extreme moods, violent writings and unpredictable behaviour.

    For Virginia Tech University management not to have appropriate medical, guidance and counselling mechanism put in place for sociological correctional application on its students to identify personality infractions, even when dangerous signs were emerging, was a serious indictment of the system. The mass murder would have been avoided if the University authorities had been more responsible and responsive by isolating or rusticating Cho for his abrasive and violent tendencies.Also the Virginia Mental Health Board could of been a backup, had they followed written procedure and followed up, making one one call to Tech’s mental health dept, think of the difference in outcome. What is wrong in wanting a different outcome?

  95. Alice Maher Says:

    Here’s yet another spin on the problem of psychopathology, humanity, and evil.

    What’s the first word that comes to mind when you think of George W. Bush?

    Are your first associations that much different from the tabloid associations to Britney Spear’s “psycho” behavior or Lisa Nowak’s description (in the NY Post) as a “pathetic moonbat nutjob?” I think analysts can do wonderful things for suffering individuals, but if we have any hope of impacting society at large, we’re going to have to deal with the problem of ridicule and labeling across the board, not just with regard to the specific groups of people we want to protect and defend. And that includes looking at ourselves. Speaking about our president with his humanity in mind doesn’t mean that you have to like him or his policies. Like any other human being, he comes by his defenses and personality problems honestly. I think we’d have a much greater impact if we could empathize with one hand and confront with the other, without constantly making him look like a person too stupid to be evil, as if there’s not much in between.

    But that’s just one example. Think of the adjectives used to describe other candidates, or the political cartoons, or the abortion/anti-abortion groups, etc. APsaA members know about the way we tend to ridicule, dismiss and/or ignore one another on the Openline. I could go on…

    My fantasy remains a billboard/bumper sticker/TV campaign. Something like “Just Stop It,” superimposed on a wide range of dramatically different examples of ridiculing, dismissive language that cuts across all intellectual, religious, cultural, psychological, and political groups.

    Oh well… a girl can dream, can’t she?

    Alice Lombardo Maher, M.D.
    http://www.wagingdialogue.org

  96. Tamar Schwartz Says:

    Response from Ralph Fishkin

    “I know Alice well enough to know that she is not motivated by mere political correctness, but by a deep desire to play a role in the resolution of conflict and injury via the promotion of empathic understanding between people.

    Alice has proposed that a consortium of psychoanalytic organizations fund an advertising campaign to promote this kind of understanding between people and in our national discourse. Despite the recognition that ridicule has a long tradition in human communication, I think her idea is a good one.

    Should we encourage/empower her to pursue it?”

    Ralph Fishkin

  97. Tamar Schwartz Says:

    Response from Zvi Lothane:

    Sure, Alice, you can, and should, dream, but you also need to reckon with reality.

    I like your dream: of a more humane humanity; but also ask you to distentangle wishful thinking from the world we live in.

    Your dream conflates politics and psychopathology. Both are based on LABELING, except that the latter carries with it the pretense of being scientific, while the former uses labeling as a weapon to kill opponents and win votes. All the campaing ads and speeches are based on heavy use of labeling, of suggestive adjectives and adverbs, of innuendo and insinuation.

    Labels are the heart and soul of propaganda, suggestion, persuasion, swaying people emotionally to get what you want. I am not against persuasion, and your use of the Nancy Reagan-like slogan has its merits.

    Moreover, you forget that it is not Bush as Bush: the era of great presidents as leaders of the nation is gone. The last ones I remember were FDR, Truman, Eisenhower, and, to some extent, Reagan. Bush is not a leader: he is a servant of the vested interests of the military-industrial-oil complex and globalization. It is the economy, stupid, it’s the dollar that is the bottom line. Our pope Freud said very little about money, even though money was a big reason for inventing psychoanalysis iin the first place.

    However, i must disagree with you on one issue: psychoanalysis has nothing to fear from ridicule, the Pope does. Vottaire, one of the most passionate propaganists for the Enlightenement, ridiculed the pope and catholicism (and absolutism). Ecrasez l’infame, stamp out the infamy, he roared. SPQR meant not the senate and the Roman people, but Sancte Papa Quid Rides, Holy Father, why are you lauging? Becase he was laughing at our expese, duping us to believe in a nonexistent God, which, however, needed to be invented. Voltaire’s self-mockery?

    Ridicule is a twin brother of the skeptical, questioning, mind. It derives from humor, the most healthy of defenses (my article on humor will be published soon). Psychoanalysis, like God, has nothing to fear from ridicule. If the target of ridicule is weak or shaky, it will be destroyed by ridicule. If it is strong, it will be made stronger.

    Let us laugh at psychoanalysis, at Freud, at ouselves, to relieve the tensions, hurts, disappointments inherent in practicing psychoanalysis. At the same time, let us welcome an engage in debates with its critics (my rebuttal of Adolf Grünbaum is in press), but without losing sight of its essential ethical soundness and the rewards of practicing.

    Zvi Lothane. .

  98. Tamar Schwartz Says:

    Response from Alice Maher:

    Thanks, Ralph and Joan (and the others off the record), for your support of my idea.

    Zvi, I want to take your argument further. Who was it (forgive me; I’m awful with references!) that did the study of MRIs of political partisans? He discovered that 35% on either side couldn’t have their minds changed no matter what evidence you gave them, while the middle 30% could, but only if you engaged them using affect as well as idea. He said that the republicans won because they used affect in that way – calling the estate tax a “death tax,” and the abortion campaign ads.

    That’s where the affect often is these days – in ridiculing opponents. I think we need to figure out a better way to engage the outside world, using affect as well as intellectual education. And I think that pointing out ridicule as it exists in every arena is a place to start. Such a campaign would put pressure on writers and speakers to find different words to explain what they mean, and that might open up new pathways for understanding and communication.

    Zvi, you write: “Ridicule is a twin brother of the skeptical, questioning, mind. It derives from humor, the most healthy of defenses (my article on humor will be published soon). Psychoanalysis, like God, has nothing to fear from ridicule. If the target of ridicule is weak or shaky, it will be destroyed by ridicule. If it is strong, it will be made stronger. Let us laugh at psychoanalysis, at Freud, at ouselves, to relieve the tensions, hurts, disappointments inherent in practicing psychoanalysis. At the same time, let us welcome an engage in debates with its critics (my rebuttal of Adolf Grünbaum is in press), but without losing sight of its essential ethical soundness and the rewards of practicing.”

    Zvi, I couldn’t disagree more. Ridicule is never a good thing, and allowing it to exist – even giving it theoretical validation! – works against our “essential ethical soundness.”

    Let me modify that a little bit, using an example… My younger son has a mild problem with expressive language, and he’s 4 years younger than his brother. When they were young, the older one would talk rings around him, and try to convince him of things that made no sense at all. His brother would sense that he was trying to control him, and he’d respond with “You’re a jerk!” or “F U.” My friends would worry that I was allowing hin to use that kind of language, but I thought it was OK at the time, because he couldn’t fight on a level playing field and I didn’t want him to come crying to me to mediate if he could communicate effectively himself, which he
    usually did.

    But as he got older and the playing field leveled, the peer pressure and parental pressure was such that he felt the need to stop, and he did.

    When the “rebels” started rising up against the APsaA establishment, I reacted the same way. At first I was horrified at the language y’all used against your analytic “parents.” But later I came to understand why you needed to do it, and I actually began to ally myself with you, despite my discomfort with the ad hominem attacks and the ridicule.

    But the playing field is leveling pretty quickly, and now it’s time to say, “Just stop it.”

    As Arnie pointed out yesterday, the discussions here have become much more civil and thoughtful, and we’re able to deepen discussions more than we ever
    have.

    Perhaps at certain moments in time, ridicule serves a purpose. But on a larger scale, in American society, we do it to one another, to our children, our parents, our teachers, and our leaders, way too much. Freedom of speech is one thing, but approving regressive speech, except for brief periods, interferes with communication and insight.

    Wishful thinking? “Some men see things as they are and ask why. Others dream things that never were and ask why not.”

    Why not a billboard/bumper sticker campaign?

    Alice

  99. Tamar Schwartz Says:

    Response from Sasha Rolde:

    In the interest of clarification and more understanding, I have tried to review Alice Maher’s proposal and Zvi Lothane’s reply.
    Although I agree with Zvi’s suggestion that the basis of ridicule is humor, I do also feel that it is not “nice” and is often hurtful. In this connection, I would ask Alice if she would say that it is “bad” for clowns to ridicule themselves and put themselves in a position to be ridiculed by others for the sake of entertainment. We could have a long discussion about it. Personally I have always felt uncomfortable watching clowns perform, but realize that the rest of the world does not feel that way.

    It is my understanding that Alice wants to use psychoanalysis (i.e. us)to help the rest of the population be less ridiculing of others and more proactive in the solving world/societal problems. From Zvi’s post, it is not clear whether he understood this, or whether he thought that she wanted to reinstate psychoanalysis’ good name in the world – i.e. save psychoanalysis. If I am correct on her aim, then I think she wants to be “political”, using analysis as politicians do – to speak to the emotions of the masses for the good. I would be very loathe to do that for a number of reasons, of which I will only mention one below, for the sake of brevity on this post, but can provide others.

    In Alice’s own example, she is inconsistent in her conclusions. Her son did not stop his nasty verbiage because there was peer pressure and parental pressure. He had pressure on him before. What happened is that he got older and the playing field became more equal.
    She mentions this when she speaks about more civility on the APsaA listserves – but concedes that now the party’s are closer together and the playing field is more equal.

    Civility comes with equality, so in my opinion, what needs to happen are more efforts at helping the disadvantaged, the poor, the nations that are suffering etc. so that they can all feel empowered and more “equal”. I doubt this is going to happen very fast, but we are all trying to do what we can, and maybe we can do more. My doubts are based on examples such as the notion of equality in nuclear weapons – I dont mean that every country should have them, nor do I think it likely that every country will get rid of them, or on facts such as that some politicians have triple the amount of campaign funds than others, which also is not changing in a hurry, or to go closer to home that some children get the best healthcare and some are dying of disease, malnutrition, abandonment, etc. all over the world.

    Best

    Sasha Rolde

  100. Tamar Schwartz Says:

    Response from Zvi Lothane:

    Sasha, you write:

    “ridicule is humor, I do also feel that it is not “nice” and is often hurtful.” Truth can be hurtful, too. The hurt is in the intention of the jester or in the eyes of the beholder. In the public arena, humor performs as social function as satire. It is a truth confrontation.

    When the Danish cartoonist portrayed the Islamists invoking Muhammad as destructive and vengeful he used humor and satire to drive home the truth that fundamentalist religion destroys rather than builds, and thus, as you say, is indeed a method that is “proactive in the solving world/societal problems.”

    And yes, Sasha, I do understand this and I am surprised you doubted I did.

    Doctors have often been ridiculed as greedy and ignorant, misdiagnosing and mistreating patients, and proverbially burying their mistakes.

    Psychiatrists have been ridiculed as cruel jailers and sadistic tortures of their wards.

    Psychoanalysts have been ridiculed as show-offs, hurling hostile “interpreations” or subjecting the unwary to “silent treatments,” or, like the arrogant doctors and psychiatrists, behaving like omniscient god-like professors.

    It is not nice to use ridicule? What has “nice” to do with it? Such ridicule was often justified for it targeted real abuses and performed the social function of confronting the professionals with their ethical failing, not in keeping with their Hippocratic oath, making it a hypocritical oath.

    The remedy: increase knowledge, fight ignorance and arrogance, raise the ethical standards of serving the patient. Yes, foster civility and love everywhere, in patient relations and in collegial relations.

    Zvi Lothane

  101. Tamar Schwartz Says:

    Response from Sasha Rolde:

    Dear Zvi,

    I did not doubt that you would agree with me at all. That was never the issue. I just tried to elaborate and maybe was not specific enough. Obviously truth can be hurtful but often needs to be said. It is the art of diplomacy to figure out in which way it will be heard to tis greatest advantage.

    And yes, “nice” has nothing to do with it – I was referring to Alice’s post in which she was advocating placards that would basically say “be nice”.

    My comment was more a polemical one – how does one decide that ridicule is used for a reasonably ethical purpose and when is it used to express sadistic tendencies in the ridiculer – as in how the nazi’s talked to the jews in the concentration camps. Just trying to get the discussion to a deeper level, which you are of course doing. We are completely on the same page in what you say.

    BTW, some of the statements you quoted were mine and some were not – maybe they came from Jane’s post?

    This is my 2nd post on Member’s line this week, so I may not be able to reply immediately again.

    Best

    Sasha

  102. Tamar Schwartz Says:

    Response from Zvi Lothane:

    Dear Sasha:

    you ask: “how does one decide that ridicule is used for a reasonably ethical purpose and when is it used to express sadistic tendencies in the ridiculer?”

    It is not as aracane as it sounds. You provide the answer yourself, when you cite as an example

    “how the nazi’s talked to the jews in the concentration camps.”

    Of all the synonyms, ridicule may be malicious and may be devoid of malice. The Nazis mocked, derided, and taunted the Jews, as they also beat them and demeaned them in various physical acts of violence.

    The aim and tone of ridicule is determined by the whole situation in which it occurs, from bemused laughter to vicious sarcasm: it is not just in the content, but in the intent. The more experienced you are, the less under the sway of wishful thinking, the better you can read other peoples’ intentions. But even Freud made a few slips, e.g., with Jung.

    So back to where we started: how can we tell friendly ridicule of psychoanalysis from hostile ridicule? And here is a case in point: the brain guys often ridicule the mind or soul and take pot shots at psychoanalysis and psychoanalyst; the mind and soul guys, among them a diminishing number of analysts, are uusually respectful of the brain.

    Zvi Lothane

  103. alan miller Says:

    Over one hundred and two comments?

    Wow!

    I have two associations I would like to share.

    Once upon a time (Talmud Bavli, Massechet Yoma, Folio 69B – my version) – in illo tempore, you might say – mythical time – the rabbis decided that they had had it up to here with the Evil Inclination and decided that they had to do something about it. So they formed a posse and hunted the Evil Inclination uphill and downdale until they finally captured it, handcuffed it, and threw it into jail. They were so exhausted after their exertions that they decided they would sleep on it and discuss what to do the next day. But in the morning they discovered – that there were no eggs for breakfast.

    Finally they decided not to kill the Evil Inclination but simply to blind it.

    Elsewhere in the Talmud (adumbrating Jane Hall?) it is written that without the Evil Inclination nobody would ever get married, have children, build a house, write a book, become a psychoanalyst – or plough a field.

    Does anybody remember Arthur Koestler? I read this story in one of his many books and I recount this also from memory. It was after the Second World War and there
    was a conference of journalists in Paris discussing the Brave New World which Communism was going to bring about. After listening to endless predictions of how wonderful everything was going to be Andre Malraux stood up and asked: “But what about the child run over by a bus?” On the podium there was consternation but after several minutes of discussion one of the speakers rose and announced: “In the perfect Socialist Society which we intend to build – there will be no traffic accidents.

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