By Ronald MahThe following e-mail arrived in my Inbox in late April 2007."I have a young Korean-American client who is a college graduate student in literature. He's a writer. I'll call him Jim. His initial presenting issues were dealing with a sense of isolation and his long-term resentment and anger from being misunderstood and bullied throughout his school career. This young man felt very alone and angry when he was younger. Jim wanted to work on this because he was concerned it might eventually affect his relationships and career. He is clearly exceptionally intelligent, and perhaps even brilliant in his work. He has been recognized for his writing and received awards since high school. He has been involved in an internship with one of his instructors, an editor for a literary magazine. He finds that very stimulating although he is doing somewhat menial work as a "gofer."He talked about working on a graphic novel where the protagonist is dealing with anger over rejection, "and being invisible" with the themes of justice, compassion, violence, suffering, victimization and bullying, and redemption. It is very clear, that the novel is semi-autobiographical and that he identifies with the main character. The plot of the novel culminates with an intense massive act of vengeance upon the main character's abusers. I don't want to be simplistic, and really don't want to be stereotypical or even worse, racist, so I need to be more clear if there is potential for violence with him. The conversation was disturbing to me after the recent violence at Virginia Tech. To be more blunt, my question is, how dangerous is my client?" (Details have been altered to protect the confidentiality of the client.)Less than two weeks earlier, at Virginia Tech on April 16, 2007, on the campus in Blacksburg, Virginia, a student, Seung-Hui Cho killed 32 people and wounded many more, before committing suicide. This was the deadliest school shooting in U.S. history. Only eight years before on April 20, 1999 at Columbine High School, two students, Eric Harris and Dylan Klebold, killed 12 students and a teacher, as well as wounding 24 others. They also committed suicide before they could be captured. Seung-Hui Cho was of Korean ancestry having moved here as a young child. Cho left behind angry and vengeful writings and videotapes chronicling a long history of mistreatment by others. His intense resentment seemed to motivate his homicidal actions. After the fact, laypeople and professionals have struggled to figure out the cause and origins of his violence, as was done after the killings at Columbine High. For some, this is to understand the tragedy. For others, it is also to understand, anticipate, and hopefully prevent similar explosions in the future. Unfortunately, examining prior episodes of violence by others such as the Columbine killers did not prevent Cho's outburst. "With his sadistic creative writing, contempt for snotty rich kids, militaristic posing, and heavily plotted revenge fantasy, Virginia Tech killer Cho Seung-Hui has eerily reminded many Americans of Columbine murderers Eric Harris and Dylan Klebold. Cho apparently saw Klebold and Harris as kindred martyrs, giving the boys two separate shout-outs in his suicide manifesto" (Cullen). None of us as therapists wish to be similarly reminded of Cho, Harris, or Klebold as we may fail to recognize a client's potential for violence.The e-mail I received shortly after the shootings, posted a question that was not hypothetical nor academic. Television and other media analysts (the Today Show, NBC Nightly News with Larry King among others) have argued as to whether Cho was an angry depressive, a psychopath, a schizophrenic, or a psychotic among other diagnoses. Several resources, including Time (Veale) quoted family members saying that he had been diagnosed with autism when very young. This brought a quick response from AutismLink and Autism Center of Pittsburgh Director Cindy Waeltermann that it was "unfair to blame Cho's actions on autism." As mental health clinicians, it is hard not to speculate on the evolution and causes of Cho's violence. Speculation however can be beneficial if it serves us to assess other individuals, such as our clients or our clients' intimate relationships for the potential of violence. The therapist who wrote the e-mail was concerned because there were elements in her client that were similar to Cho and his history. However, there were also distinct elements once identified that allowed her to have confidence that her client was unlikely to erupt into violence. These elements also help direct the therapeutic process.Here are fifteen criteria or elements to aid determination of the violence potential of children and teens. The concepts should also be applicable to adults. Eight of the fifteen criteria are highly compelling for an individual such as Seung-Hui Cho. These are • Self-Righteousness Attitude • Entitlement • Ego-syntonic Perception • Intense Emotional Arousal • Resentment • Characterlogical Nature • Isolation/Avoidance Behavior • Lack of RemorseTaking into consideration, that I have not, and in all probability, you have not undertaken an intensive formal evaluation of Cho's developmental, psychological, social, academic histories, these issues are highly suggestive from the media information that has been available. He had an intensive sense of self-righteousness that fed into deep resentment from his years of being ostracized and bullied throughout his school career. The self-righteousness and resentment translated into an intense entitlement to have vengeance, which created a complete lack of remorse for actions to be taken. It is clear that he deeply believed that his victims or targets deserved to be killed. He was also living up to the powerful and vengeful persona that he believed in. There was no conflict within himself regarding who he was and his eventual violent behavior; his violence was ego-syntonic. His issues and emotional state were not transitory, but rather seemed to be deeply embedded into his personality. His perception and relationship to others and the world appears characterlogical. His inability and difficulty in social relationships led to deep isolation and a lack of relationships or community to give him any kind of feedback or reality check or testing of his perceptions. While his lack of remorse would seem to suggest being a sociopath, his writings and his videos demonstrate intense emotional arousal unlike that of sociopath. In addition, it appeared that he intended to commit suicide or go down in a blaze of glory. Sociopaths are highly manipulative and can be extremely dangerous, but they also normally fully intend to survive their behavior. In other words, they do not want to go down in a blaze of glory, but to survive and to do it again in some other form to some other people. My best guess diagnosis from afar, is that Cho had paranoid personality disorder or some other issue that results in significant paranoia. Gregory Lester, Ph.D., trainer and therapist who specializes working with personality disorders identified the Columbine killers as having paranoid personality disorders.In my clinical experience with young children, pre-teens, and a few adults with high functioning autism or Asperger's Syndrome, I have seen a developmental progression that can lead in some cases to a paranoid personality disorder. This is by no means, the normal or only outcome. With early intervention and skillful education and care, children with Asperger's Syndrome or other high functioning autism can be highly successful in all aspects of life. Dr. Temple Grandin is one example of a very respected author with autism. She is an expert on cattle handling, and has written and spoken often from her experiences and insights as an autistic individual, including many television appearances. Unfortunately, with inadequate caregiving and/or highly negative social experiences, there can be extremely problematic outcomes for some individuals. Autism or Asperger's Syndrome does not cause violence. However, one of the major challenges for individuals within the autistic spectrum is the difficulty in reading social cues, especially nonverbal cues. Individuals within the autistic spectrum are also often more sensitive to environmental stimulation. These combine to make social interactions often extremely challenging for such a child. In communities such as classrooms or the playground, other children often identify such children as being different, and subsequently a target for teasing and victimization. The childhood history of Cho reports that he was brutally teased and bullied in school. Depending on the individual temperament or personality of the child, as well as the environmental and interventions support (or lack of) from caregivers such as teachers, children with these issues respond differently. It seems that Cho did not get the appropriate support or intervention, and with his intense personality suffered greatly and became ever more resentful. Another person with more positive support, with a similar intense personality may become a very attractive passionate individual. Because of the difficulty in understanding social cues, Cho may not have understood how he was perceived, or why others treated him so badly. This may have exacerbated his growing isolation, emotional trauma, and increasing resentment. Unable to identify why others were so abusive to him for seemingly no logical reason, a hypervigilance and hypersensitivity leading to paranoia may have resulted. Over the years, a paranoid personality disorder may have developed. Waeltermann is alluding to such destructive dynamics, when she says, "This is a wake-up call that stresses the importance of early intervention, research, and appropriate treatment strategies.... research has consistently shown that when children receive the help t
