Evil Deeds

Murder and Mayhem at Fort Hood: Post-traumatic Embitterment, Madness, or Political Terrorism?

Dr. Stephen A. Diamond, Ph.D. — Sat, 07 Nov 2009 03:43:48 +0000

Yesterday, a thirty-nine-year-old, never-married, Army psychiatrist with expertise in disaster and preventive psychiatry allegedly gunned down thirteen men and women, wounding thirty-eight. The murderous incident took place at Fort Hood, a military base in Texas where soldiers were being prepared for deployment to Iraq and Afghanistan. Though the suspected perpetrator, Major Nidal Malik Hasan had initially been reported killed by military police, we now know he was seriously wounded, is currently in a coma, but expected to survive. What could possibly possess an apparently polite, pleasant, quiet, reserved, compassionate, empathetic, forgiving and deeply religious psychiatrist to commit this incredibly evil deed?

Dr. Hasan is a life-long and devout Muslim with Palestinian roots. But he was born in America. He received his extensive medical education--approximately four years of medical school for his M.D. and another four of psychiatric training--compliments of Uncle Sam, who, in return, expected Hasan to serve his country in whatever manner the military saw fit. But there may have been a religious, moral and political conflict of interest for Dr. Hasan regarding present American policy in the Middle East, specifically the wars in Iraq and Afghanistan. He allegedly had been vociferous to some over the years in his denouncement of the "war on terror,"claiming it was tantamount to a war against Islam. It seems he had been hoping that with his election, President Obama would change course, and immediately withdraw our troops. Very recently, he apparently learned that he would soon be deployed for service as a "combat stress counselor" to Afghanistan, something he evidently objected to violently. His imminent deployment appears to be what finally triggered this furious ticking time bomb.

Hasan regularly attended daily prayers, sometimes in traditional Muslim attire. He appears, based on his suspected internet postings, to have been extremely sympathetic to Islamic suicide-bombers, evidently perceiving them as freedom-fighting martyrs heroically protecting their countrymen and fellow Muslims. These postings attracted the attention of federal law enforcement officials about six months ago. Ever since 9-11, Hasan apparently felt he had been unfairly targeted and harassed by his military colleagues regarding his religion and ethnicity. He was aggressively attempting to arrange a discharge from the Army, hiring an attorney and offering to repay the considerable cost of his eight-year medical education. He must have wanted out badly. But his bid to prematurely terminate his contractual obligation with the U.S. government had gone nowhere. This presumably frustrated Hasan immensely. As did his reportedly unsuccessful efforts to find a Muslim wife even more religiously devout than he is. (See my prior posting.)

As an Army psychiatrist, Dr. Hasan had been working intensively with soldiers suffering from post-traumatic stress disorder. PTSD--an anxiety disorder resulting from being exposed to actual or threatened death or serious injury to self or others--is a severely debilitating syndrome that can include symptoms of "flashbacks," nightmares, avoidant behavior, social withdrawal, depression, hypervigilance, irritability and outbursts of anger or rage. (See my prior post on trauma.) During his internship at Walter Reed Army Medical Center, there are reports that Hasan had serious problems dealing with his patients, problems significant enough to require personal psychotherapy and extra clinical supervision, culminating in a poor performance evaluation by his superiors. Being a mental health professional specializing in PTSD is stressful. Stress can be contagious, which is why psychotherapists need to take extra care regarding their own mental health.

Had Dr. Hasan himself been emotionally traumatized vicariously and ethically conflicted by hearing daily the grotesque horror stories of war from his fellow soldiers? By constantly being told about his fellow Muslims and Army brethren slaughtering and maiming each other--and sometimes innocent civilians--for their countries? This could result in a form of what we call countertransference: the psychotherapist's personal reactions to his or her patients and their particular presenting problems. Countertransference is a common phenomenon in mental health professionals, an occupational hazard, and must be carefully monitored. When it begins to become disturbing for the psychotherapist, impairing his or her objectivity and interfering with the treatment process, it becomes crucial to address it in supervision, consultation and/or one's own personal therapy. If the countertransference cannot be resolved in relatively short order, or at least kept in check, psychotherapists must ethically recuse themselves from such cases and refer the patient elsewhere. This begs the question: Should Dr. Hasan, given his apparently passionate religious and political beliefs, have been working with such patients in the first place?

From a forensic perspective, there is certainly far too little information available at this time to come to any meaningful conclusions regarding such a defendant's mental status. And it is improper to do so without having conducted a formal forensic evaluation. But determining his state of mind at the time of this crime and prior to it will prove crucial to his legal case. As a forensic criminal psychologist, here are some of the questions I would be asking myself if appointed by the court to evaluate such a defendant: Was the defendant clinically depressed, possibly to the point of paranoid psychosis? Could there have been any kind of substance abuse or intoxication involved? Was he in treatment and taking any psychiatric medications? Is there an underlying personality disorder? Were these shootings a tragic, impulsive manifestation of a manic or hypomanic episode, indicating the possible presence of bipolar disorder? Or, was this the hateful, calculating, vengeful act of a profoundly angry, frustrated, resentful and embittered--mad but not psychotic--person? (See my previous posts on post-traumatic embitterment disorder.)

Was Dr. Hasan a suicidal individual, who, like so many mass murderers, chose to die--very much like a suicide-bomber--taking as many victims with him as possible? Psychiatrists as a group have a notoriously high rate of suicides, though suicide rates in Muslim populations are exceedingly low. The notion that Hasan had become actively suicidal is supported by unconfirmed reports today that he advised his landlord two weeks ago that he would be leaving his apartment on the day of the shooting--despite the fact that he was not likely to actually be physically deployed for another few months. Hasan also is said to have given away his belongings, furniture, food, cleaned out his apartment, and said goodbye to friends just prior to the massacre, handing some of them copies of the Koran. Unless he was convinced he was leaving the country in the immediate future, such preparatory behavior could be interpreted as a prelude to suicide. Or, in this case, premeditated homicide-suicide. Hasan may have hoped to have time to take his own life after his murder spree, or be taken out by police. So-called suicide by cop.

But this raises the question as to whether such a defendant, if guilty, was suicidally despondent or more angry, resentful and bitter. (See my prior posts on anger disorder.) Angry, resentful and bitter enough to kill and to die for his fanatical cause. Was Hasan's presumed attack on U.S. troops primarily a political statement? What he intended to be a revolutionary call to arms to American Muslims? Quite possibly so. The FBI is presently investigating this bloodbath as a possible terrorist act. A suicide-bombing using guns instead of explosives. There are unconfirmed statements by witnesses that Hasan had at times angrily urged Muslims to violently "rise up" against Americans, and that at the chaotic scene of the shootings was heard to say "God is great" in Arabic. But until we have more information either medically, circumstantially or from the defendant himself--who evidently has no previous history of violent behavior--Hasan's hypothetical motivations for this atrocious evil deed remain ambiguous, suspicious, and somewhat mysterious.

Why Myths Still Matter (Part Two) : Cleaning the Augean Stables

Dr. Stephen A. Diamond, Ph.D. — Mon, 02 Nov 2009 05:53:05 +0000

Conquering Rage, Pride and Procrastination

For his fifth and probably filthiest labor, Hercules had to clean out decades of dung from stables owned by King Augeas. This task was deliberately designed to psychologically defeat and humiliate Hercules. His prior labors up to that point were heroic, glorious, ultimately victorious battles against the Nemean lion and Lernaen Hydra, and the time-consuming stalking, hunting and capture of another two elusive creatures: a fleet and golden deer known as the Hind, and a gigantic, violently aggressive wild boar. Having incredulously seen Hercules complete these first four death-defying labors successfully, Eurystheus, Hera's sadistic taskmaster, takes a different tack, ordering Hercules to cleanse the Augean stables in but a single day.

What made this labor so seemingly impossible was a combination of the immense size of the stables, the huge number of cattle it contained, the fact that it had never before been cleaned, coupled with the sheer prodigious amount of dung produced daily by these supernatural oxen. Hercules had already demonstrated his ability to overcome and redirect at least some of his own dangerous aggression into good deeds during the first two labors. Now he faced a different kind of challenge: one which demanded not just brawn--since no amount of physical strength could suffice to achieve this task in only one day--but brains, ingenuity, resourcefulness, and, most of all, humility. A recognition of his own human limitations. It is likely Hercules at first felt overwhelmed and defeated by the monumental task. But he finally finds a way to get it done by diverting the courses of two raging rivers to run right through the stables, flushing them out in short order.

There are some noteworthy parallels here to the psychotherapy process. Psychotherapy can often entail confronting a lifetime of accumulated shit. Psychotherapy patients sometimes experience the daunting task of delving into their past and dealing with their emotional demons in much the same way Hercules must have felt as he faced his disgusting, demeaning and ego-deflating fifth labor. For some, even taking the decision to seek psychotherapy is perceived as a failure or defeat. Such a seemingly impossible, tedious, menial task is tough on the ego and can be a severe blow to one's narcissism. But it can take just such a turn in life to teach us some healthy humility and diminish our neurotic narcissistic grandiosity. Carl Jung once commented that "the experience of the Self is always a defeat for the ego." What he meant is that in order for us to mature and become more whole (i.e., to individuate), the ego must relinquish its superiority and megalomanic delusions regarding its central and primary place in the psyche and personality. Our ego must learn to happily and humbly play second-fiddle to what Jung termed the Self: all that is beyond the conscious ego, far more powerful, and vital to the authentic personality. Namely, the unconscious.

I prefer to think of this infuriating and humiliating "defeat for the ego" as a traumatic yet potentially transformational process. We are insulted, humbled and, at first feel defeated by such untoward events, which can take the form of outer travails or hardships, involuntary psychiatric symptoms, and/or inner crises painfully demonstrating that we are not in complete command of ourselves but rather subject to the superior or relatively autonomous powers of the unconscious and of life itself. Naturally, the ego furiously resists such displacement and dethronement, seeking to maintain its illusion of control and mastery over reality. This resistance on the part of the ego to surrendering to the Self is so strong, persistent and pervasive--and we are so overidentified with it--that sometimes a seemingly insurmountable crisis or trauma is required to forcefully topple it from its narcissistic ivory tower. Life inevitably provides precisely that which is called for. A kind of psychological shock therapy. Often, the initial emergence or appearance of the Self is experienced as a life-shattering crisis or trauma, as, for example, in the biblical case of Job. When the ego is overwhelmed or defeated by the superior powers of life or the unconscious, we tend to fall into a state of depression, grief, narcissistic injury, and bitterness. The ego has failed to figure the problem out, to find a way to remain in control, to preserve its precious self-importance. But in that humiliating defeat and ensuing grief, depression and despair, the unconscious--and specifically what Jung called the psyche's inherent transcendent function--is activated, providing a different attitude, insight or perspective about the problem and how to constructively approach or resolve it. Paradoxically, this "defeat for the ego" liberates the helpful life-giving waters of the unconscious, making their revitalizing and creative energy more accessible to us.

The story of Hercules and the Augean stables can also be seen as a metaphor for what happens when we procrastinate too long--whether that procrastination is avoidance of psychotherapy or of getting daily tasks accomplished. Dung--like a neurosis, complex or anger--doesn't just disappear by ignoring or denying it. It builds up over time. Festers. Toxifies. And becomes more--not less--difficult, noxious and messy to deal with. People who tend to procrastinate (which includes all of us to some extent) often continue to do so because they feel overwhelmed by the task. Or, because they find the task too tedious. In order to overcome procrastination, it is vital that the person courageously confront rather than avoid the anxiety-provoking challenge, and accept the often tedious, ordinary and dirty work it demands. Simply placing "one-foot-in-front-of-the-other" rather than focusing on the enormity or tedium of the labor can be one helpful trick. Hercules creatively reroutes two rivers to help him get the job done. Metaphorically, this represents a masterful redirection of psychic energy or libido and a creative utilization of environmental resources, consciously focusing all of one's concentration or attention, and channeling one's anxiety--or, in some cases, anger or rage--into the current task at hand.

By now, Hercules has begun to learn to harness and control--rather than deny and be controlled by--his daimonic energies, creatively redirecting them into constructive activity. We must all learn to do the same. But there is still a tragic dark side to this fifth labor: Hercules had been promised by King Augeas the reward of one-tenth of his immortal cattle if he could accomplish this nasty task. When Hercules actually succeeded, the greedy king reneged on the agreement. Presumably enraged by this betrayal, Hercules impulsively kills the king, taking his well-earned reward by brute force. Anger, aggression and self-assertion in such a situation may be appropriate and often necessary. But not unbridled narcissistic rage. Nor homicide, which is how Hercules came to be condemned to his Twelve Labors in the first place. (See Part One.) So it appears that, though the dishonest king was clearly in the wrong, Hercules still has some serious anger management issues to address.

Why Myths Still Matter: Hercules and His Twelve Healing Labors

Dr. Stephen A. Diamond, Ph.D. — Mon, 26 Oct 2009 01:55:41 +0000

Part One: Rage, Evil and Redemption

Hercules (aka Herakles or Heracles) is perhaps the greatest of mythic Greek heroes. His courage, strength, skill and cunning are literally legendary, and were revered in ancient Greek culture. Hercules is honored and admired as someone who repeatedly fought against and conquered evil during his lifetime, a great demigod (fathered by Zeus himself) doing gloriously good deeds. But we tend to forget that, like Oedipus, in his youth, Hercules himself committed one of the most evil deeds imaginable: He slaughtered his own wife and children as they slept, in a violent fit of murderous rage and madness visited upon him by the vindictive goddess Hera, his hateful arch-nemesis. What can we still learn from the psychology of such enduring myths, and why does it matter?

This notion of madness--often associated with destructive anger or rage and resulting from the influence of gods, goddesses or daimones--raised for the Greeks the crucial question in such cases of personal responsibility: Was Hercules a victim of supernatural powers beyond his control when he brutally killed his helpless family? Was it a case of temporary insanity or diminished capacity caused by Hera's wicked spell? Or was he fully responsible for his heinous crime? Such tragic evil deeds were, of course, not unfamiliar to the Greeks, and poetically memorialized in their classic myths and plays.

Today, almost three-millennia later, we bear witness with escalating incidence to similar savage acts of so-called senseless violence in our own culture. (See my previous posts.) In courtrooms across the country, forensic psychologists and psychiatrists, judges and juries are confronted with exactly this same question, albeit employing somewhat different explanatory myths or metaphors: How responsible is the angry, mad, mentally disordered or psychotic violent offender for his or her destructive actions? Was it bad biochemistry, faulty neurology, defective genes, childhood trauma or the devil or demons that made them do it? Are they themselves, like Hercules, hapless victims of powerful forces--either biological, psychological, sociological or metaphysical--that eventually take control and compel them to do evil? Or are they--and should they be held morally and legally--accountable for such evil deeds? For the ancient Greeks, the answer was never unequivocally either/or, but rather, ambivalently both.

Hercules, despite presumably being driven homicidally mad by Hera, was nonetheless condemned by the gods to do penance for his horrific crimes. And it was Hera--who had maliciously induced his madness--who again had a hand in meting out his severe punishment. But unlike the consequences in such increasingly common criminal cases today--psychiatric hospitalization, incarceration or execution--Hercules, having evidently regained his senses, was sentenced to twelve years of penance, a prolonged penitent period of "hard labor," during which he would certainly suffer unimaginably, and most likely be killed. To atone for his evil deeds, Hercules was required to complete twelve seemingly impossible tasks, known to us as the Twelve Labors of Hercules.

In order to surmount these superhuman challenges, Hercules, for starters, had to learn to redirect his immense anger and rage into eradicating rather than wreaking evil. He could only expiate his existential guilt by counteracting his prior evil deeds with good deeds. There is a crucial difference between the practice of punishment and penance: Mere prolonged imprisonment is not true penance for most violent offenders. To be truly transformative or therapeutic, penance or punishment must be personally meaningful, fully accepted, actively willed, and humbly submitted to rather than viewed as societal authority imposed on one from without and met only with defiance, resentment and resistance. There can be no real atonement, absolution, rehabilitation or redemption without proper penance.

In this post, let's take a psychological look at just two of Hercules' penitent twelve labors, with an eye toward what they can teach us today about confronting and redirecting the daimonic. The daimonic (Rollo May,1969) is an archaic Greek concept that acknowledges the capacity of primal emotions such as anger or rage to take temporary possession of a person, driving him or her into destructive, irrational, evil behavior. At the same time, it recognizes that same extremely dangerous anger or rage as a potentially positive, even creative, vital, indispensible, libidinal, spiritual energy when properly related to and consciously channelled into constructive pursuits. (See also my book Anger, Madness, and the Daimonic.)

His first labor was to do battle with the Nemean lion, a creature so large and fierce that even the arrows from Hercules' powerful bow would not pierce its impermeable skin. Hercules must rely on brute force, his uncanny physical strength and courage alone to confront and kill with his bare hands the ferocious predatory feline terrorizing the town. In depth psychology, cats can connote basic daimonic instincts or drives such as sexuality, power and aggression. Here, Hercules constructively harnesses his own abundant aggression, anger and rage to help rid the community of evil. Having succeeded in so doing, Hercules dons the lion's armor-like protective hide to aid him in his upcoming encounters. Psychologically, we could say that when we successfully confront and overcome an especially difficult inner or outer challenge in life, we are empowered, and take on from that experience a confidence and courage helpful in all future ventures. Or as Nietzsche put it: "What does not destroy me makes me stronger." For Hercules, completing this daunting task was the first step toward redemption.

Next, Hercules must fight the hideous Hydra. The Lernaean Hydra was a highly venomous serpentine creature with nine hissing heads. No sooner had Hercules lopped off one, another two heads grew in its place. Recognizing he needed to take a different tack, Hercules cleverly cauterizes the decapitated wound, preventing any heads from regenerating, and finally defeats the dreadful Hydra. However, because the central head of the Hydra was immortal, Hercules could only bury it beneath an enormous stone in order to decommission the monster. Evil can never be completely or forever eradicated. Only controlled, contained, and constantly kept in check.

Again, Hercules is further empowered by this victory: He dips his arrow tips in the Hydra's poisonous blood to help him face whatever comes next. In some versions of the myth, it is the slain serpent's gall or bile with which the arrows are tipped. The English words gall and bile are--like madness--closely linked to anger, rage, resentment or bitterness. (See my previous post.) By vanquishing the horrible Hydra, Hercules transforms its daimonic toxicity into a power he can use for good in his one-man war against evil. We see this same mythological motif in the story of Perseus and the grotesque gorgon Medusa, whose blood gives birth to the beautiful winged white steed Pegasus, and whose petrifying visage is later employed by Perseus as a potent weapon against evil. Symbolically, the Hydra's blood, bile or gall can be likened to toxic anger: When consciously confronted, acknowledged, understood, mastered and controlled, pathological rage, resentment or embitterment can be alchemically transmuted and redirected into a positive force, in the form of healthy aggression, strength, power, resolve and perseverance, without which one cannot conquer life's sometimes hydra-like challenges.

Human existence and the individuation process itself demand such heroic strength, stamina and courage from each of us in various ways. We all face at times seemingly impossible tasks, intimidating obstacles, serious stumbling blocks-- our own Herculean labors to reckon with in life. And, as we shall see in the following series of posts, that greatest and best loved of Greek heroes, Hercules, still has much to teach us about bravely meeting life's challenges, dealing with fate, and finding and fulfilling our destiny.

Evil and Creativity: Does Talent Redeem Bad Behavior?

Dr. Stephen A. Diamond, Ph.D. — Sat, 03 Oct 2009 04:36:12 +0000

The recent surprise arrest in Switzerland of Oscar-winning film director and international fugitive Roman Polanski raises some fundamental questions regarding the relationship between creativity and evil. Does talent ever redeem bad behavior? Can creativity excuse evil deeds?

Polanski, now seventy-six, was convicted three decades ago of raping a thirteen-year-old female model he was photographing at Jack Nicholson's Hollywood Hills home. On the night before his sentencing hearing, he fled on a plane to France, his home country, and has resided there ever since. Had he ever set foot in the United States again, Polanski would have been subject to immediate arrest. Hollywood lost one of its most promising, visionary and talented filmmakers when Polanski left town to avoid doing jail time for his lewd and lascivious sex crime. When he was suddenly arrested by Swiss police last week in Zurich on behalf of the United States and held in jail for extradition, many in Hollywood expressed outrage that an artist of his stature would be held accountable for a mistake he committed more than thirty years ago. We all make mistakes. And our mistakes have consequences. In this case, Polanski made two: choosing to have unlawful sex with a minor (statutory rape), and then skipping town to avoid being punished for what he did. He subsequently had to live the rest of his life looking over his shoulder, wondering when and where the authorities would finally catch up to him. Now they have.

I do not know whether what happened around 1977 here in Los Angeles was an isolated incident or such sexual behavior is part of a long-standing pattern for Polanski. In the latter case, when a person repeatedly experiences, over a period of at least six months, sexually arousing fantasies, intense sexual urges or has engaged in behaviors involving sexual activity with minor children thirteen years or younger, he would typically warrant a diagnosis of Pedophila. However, it seems Polanski was committed for psychiatric evaluation following his first arrest, and apparently found not to be a pedophile. But, in his own mind, did he view himself as a child molester vindicated by his vocation, status and talent? There is some reason to believe that Polanski didn't feel, then or now, that he did anything wrong as a forty-something-year-old man having sex with a thirteen-year-old girl. He may feel himself to be the victim of a puritanical, erotically repressed, uptight, almost Victorian American morality with which he, as a European, avant-garde artist, disagrees, a rebellious, Promethean breaker of cultural sexual taboo. He and some of his colleagues may not consider what he did a serious crime or evil deed at all. Or, even if it was, feel that his creative contributions to society far outweigh and overshadow this perhaps isolated and relatively "minor" transgression. Can the presence of creativity preclude or transcend evil? Are artists above or beyond doing evil? Does their creativity vindicate or give license to their evil deeds? Or merit special considerations and treatment?

In 1981, acclaimed author Norman Mailer championed the publication of an extraordinary book: In the Belly of the Beast: Letters From Prison by Jack Henry Abbott, written while an inmate at Utah State Penitentiary. The letters sent to Mailer from prison that eventually became the book were poetic, powerful, and seething with rage. Mailer described Abbott's untrained, neophyte writing as having "an eye for the continuation of his thought that was like the line a racing car driver takes around a turn. He wrote like a devil, which is to say (since none of us might recognize the truth if an angel told us) that he had a way of making you exclaim to yourself as you read, ‘Yes, he's right. My God, yes, it's true.' " So infatuated was Mailer (who was himself once arrested for stabbing his second wife) with his new literary discovery that, in addition to arranging for the publication of Abbott's letters and contributing an introduction to the book, he somehow arranged for Abbott's early parole from prison--apparently forgiving, forgetting or glossing over the glaring facts of his extensive and violent criminal past: a childhood spent in foster homes and juvenile institutions, later serving time in federal penitentiaries for bouncing checks, bank robbery, and killing one fellow inmate and wounding another while in prison. Much like Charles Manson, by the time he turned thirty-seven, Jack Henry Abbott had become a classic "career criminal," a typical institutionalized sociopath or antisocial personality, having spent his entire adult life, with the exception of about nine months, incarcerated, mostly in solitary confinement. Within six weeks of being released to an adoring initiation into New York's elite literary society, Abbott was once again on the run from the law after fatally stabbing a young waiter outside a trendy Manhattan restaurant. He was eventually apprehended, convicted of manslaughter, and re-incarcerated. Stunned, novelist Jerzy Kosinski expressed his horror and sense of complicity this way: "I feel guilty, terribly guilty. . . . We had chosen to ignore that we had a violent man in our midst. Instead I think we preferred to see him as a man who is going to become an intellectual of violence. . . . Maybe I share with my intellectual friend Norman Mailer the feeling that talent redeems." Jack Henry Abbott spent the rest of his life behind bars, committing suicide in 2002 while in prison.

What was it about Abbott's newly born literary talent that blinded members of the literati like Norman Mailer, Jerzy Kosinski and others to his chronic criminal proclivities? What is it about Roman Polanski's creative genius and persona that causes other prominent artists like David Lynch, Martin Scorsese, Michael Mann and Woody Allen (all men) to protest his arrest and punishment under the law? Do artists see themselves and their peers as being above the law? Does creativity trump evil? Part of the difficulty is reconciling the co-existence of both evil and creativity in the artist. From Beethoven to Picasso, Pollock or Bergman, there is always some amalgamation of both evil and creativity present in the personality. But because we simplistically tend to want to view life in black and white, we think of people as being either creative or evil, good or bad, rather than recognizing that even the most virtuous, gifted or creative individuals harbor the capacity for evil, while the most evil have the hidden capacity for creativity or good. One of the great ironies of this situation is that Polanski himself has always been fascinated by both evil and creativity, as evidenced in his impressive body of work.

It is a very difficult lesson. A true reality check. For some, a bitter pill to swallow. Creativity, talent or genius cannot be unequivocally equated only with good--though the one is commonly perceived to include the other. On the contrary, no quantity of creativity, no matter how colossal or prodigious, can ever preclude evil. Even the creative genius is responsible for his or her bad behavior. But what creativity can do is counterbalance evil, both in one's self and in the world. This is no small matter. While such culturally and intellectually enriching contributions can't be used to minimize the evil an artist like Polanski, Pollock or Picasso--or anyone--might do, some of it inevitably comes with the extraordinary and often torturous emotional territory explored by true artistic genius.

On the one hand, such supportive public reactions, including from female artists like Debra Winger and Whoopi Goldberg, seem to demonstrate the high esteem, veneration, reverence and respect in which parts of our society-especially the creative community--hold the artist. Artists contribute something truly precious and essential to society. And it is vitally important that we recognize and honor the inherent value of this culturally enriching activity. But what if Polanski was not Polanski, but rather some unknown, starving filmmaker? Would Hollywood still react the same way? I don't think so. Part of what makes Polanski--whose pregnant wife, actress Sharon Tate, was brutally and senselessly slaughtered in the infamous Manson family murders seven years prior to his sex crime (a conceivably psychologically significant traumatic fact in this case)--worthy of special consideration for some has as much to do with his celebrity as his talent. We worship celebrity today--with or without talent. And, as has been repeatedly demonstrated during the high-profile criminal trials of celebrities like O. J. Simpson, Michael Jackson or Robert Blake here in Los Angeles, celebrity, in the minds of many, does indeed trump almost any evil deed.

This posting contains excerpts and material from Dr. Diamond's book Anger, Madness, and the Daimonic: The Psychological Genesis of Violence, Evil, and Creativity (1996, SUNY Press).

Anger and Catharsis: Myth, Metaphor or Reality?

Dr. Stephen A. Diamond, Ph.D. — Mon, 28 Sep 2009 06:58:42 +0000

Cognitive scientist Dr. Art Markman's recent posting on the nature of anger and catharsis raises significant questions about how to best deal with anger--both in and out of psychotherapy. This is a subject another PT blogger, Dr. Steven Stosny, and I briefly debated here previously. (See postings here and here.)

First, let me say that there is a very good reason for the numerous metaphors we apply to the misunderstood phenomenon of anger: They describe quite accurately and phenomenologically the subjective and objective experience of anger as a highly volatile emotion that can, depending on how we manage it, build over time, reach a crescendo, and eventually explode. Anger can be "bottled up." Fester, turn toxic, and seep out slowly and destructively in daily life, like radioactive contamination. Simmer and boil over. Anger is a primal force of nature, a hurricane, tornado, volcanic eruption, a thunderstorm, lightning bolt, a natural form of energy, not unlike electricity. When easily enraged, one "blows a fuse"or exhibits a "short fuse."

Anger is red hot. A smoldering or raging fire. Sometimes a "slow burn." We call someone quick to anger a "hot-head." A ticking time-bomb easily "set off" or "triggered." A powder keg. A steaming tea kettle. A boiling cauldron in which one "stews" in their own juices. Angry people "blow a gasket" under excessive internal pressure, like a heated cooking vessel that "flips its lid" or a missile warhead that "goes ballistic." Someone overcome by rage is often compared to a nuclear reactor that catastrophically and violently "melts down." Paradoxically, in other cases, the characterologically angry, resentful, bitter or hostile individual appears "cold-blooded" and calculating, as seen, for instance, in antisocial personality disorder, sometimes described as being "icy," "cool as a cucumber" or "stone-cold."

Perhaps metaphorically closest to the truth, anger or rage is a powerful explosive like dynamite, which can be used destructively or constructively, for evil or good. Like nuclear radiation or nitroglycerine, anger can be used both to harm and to heal. Anger can, under certain circumstances, take total possession of a person, driving us blindly into self-destructive behavior and evil deeds. Like love, anger can be "blind." Anger is often experienced as a threatening, malicious alien force taking over mind, body and soul. A ferocious beast, a berserk bear, a poisonous serpent, fire-breathing dragon, wrathful god, vindictive devil or demon. Such common metaphors clearly bear an archetypal quality, and have, in one form or another and across cultures, been part of how humans linguistically conceptualize and describe the subjective experience of anger for millennia. Like myths, metaphors of anger tend to contain a basic kernel of vital truth about the elemental, enigmatic nature of anger or rage.

But the mistake with using such metaphors is taking them too literally rather than metaphorically. For example, extreme rage may feel or appear like it takes possession of a person like a demon or the devil. This is a common myth or metaphor, one often seized upon by psychotic patients to explain their dissociated impulses. But that doesn't make anger the Devil. Literalism or reification is the problem in this scenario, not the metaphor. Likening anger to heated fluid in a closed container does not literally make it so. Nor can one extrapolate from that metaphor that anger will behave exactly like that heated fluid. It will not, because it is not literally heated fluid, and will not necessarily act as such. Anger is not this or that. It is what it is. But it does have similar qualities to other primary human experiences such as sadness, anxiety, and sex drive. Like other instinctual drives, existential experiences and primitive affects, anger can be denied or repressed. And when anger is chronically repressed, it becomes problematical, pathological, toxic and potentially dangerous to self and/or others. Once this occurs, the solution, however, is not to hit a punching bag: This will not make the anger, resentment or bitterness disappear. But it will likely provide some momentary release of tension, which, like masturbation, feels pleasurable. Striking a pillow, bag or bed when one is not already angry can be an effective technique employed by some Reichian or Bioenergetic therapists for inducing, evoking and becoming more aware of one's repressed rage. But one cannot "drain" or empty the anger permanently in this way, just as one doesn't drain sex drive permanently by masturbating. Indeed, this can serve instead to "prime the pump."

Dr. Markman and others argue against "catharsis," concluding that it only causes a person to become more angry than before. In support of his position, he cites a certain experimental study conducted in 1999. (See his posting.) A century before that study, Viennese physicians Josef Breuer and Sigmund Freud (1895) discovered and documented the therapeutic value of catharsis or what they came to call abreaction: "The fading of a memory or the losing of its affect depends on various factors. The most important of these is whether there has been an energetic reaction to the event that provokes an affect. By ‘reaction" we here understand the whole class of voluntary and involuntary reflexes--from tears to acts of revenge--in which, as experience shows us, the affects are discharged. If this reaction takes place to a sufficient amount a large part of the affect disappears as a result. Linguistic usage bears witness to this fact of daily observation by such phrases as ‘to cry oneself out' [‘sich ausweinen'], and to ‘blow off steam' [‘sich austoben', literally ‘to rage oneself out']. If the affect is suppressed, the affect remains attached to the memory. . . . The injured person's reaction to the trauma only exercises a completely ‘cathartic' effect if it is an adequate reaction--as, for instance, revenge. But language serves as a substitute for action; by its help, an affect can be ‘abreacted' almost as effectively." This was the birth of psychoanalysis.

By "language," Freud and Breuer mean verbalizing feelings like anger, as opposed to physically acting them out. Punching a bag or pounding a bed are obviously physical expressions of anger. But in order to be truly cathartic, the patient must experience--or re-experience--these emotions as profoundly as possible rather than just physically expressing or rationally discussing them. The more apropos metaphor for repressed anger would be an underground oil or natural gas field. The oil is under tremendous pressure. When tapped into, some of that pressure is suddenly released in the form of a "gusher." But this doesn't do anything to significantly reduce the subterranean pressure built up over eons. Similarly, tapping into deep and chronically pressurized reserves of anger, resentment or rage can, indeed, bring more anger to the surface. This is why merely abreacting or ventilating anger is not necessarily therapeutic: Ventilation, as Dr. Markman suggests, can fan the flames of anger rather than extinguishing its fire. Certainly giving destructive expression to anger in the form of physical violence is no solution. Can mass murderers or abusive spouses said to be "cured" or made less angry by physically discharging their rage on their victims?

When we are dealing with anger, we are not dealing with a metaphor. We are dealing with an existential reality. A psychobiological phenomenon. Punching a bag, let's face it, is not the same as punching out the person who hurt your feelings or betrayed you. It is not, as Freud and Breuer put it, an "adequate" response to the insult, no real revenge or talionic lashing out against a real person. It gives someone a tiny taste of what real revenge might feel like, but lacks the complete psychological satisfaction. Such ventilationist behavior knocks on buried anger's door, opens it briefly letting just a little anger out, and then promptly slams it shut again--which is exactly what happened in the experiment mentioned by Dr. Markman.

Of course, the problem here is that we cannot, in a civilized society, go around punching out, pummeling or verbally abusing every person who insults or infuriates us. (Though some seem to have started resorting to such primitive behaviors.) There is much to be angry about in modern life. And we must learn to accept, control, tolerate and redirect that anger as constructively as possible. But when left unexpressed, where does the anger go? Yes, sometimes, if we are aware of the anger in the moment, it will pass. But generally, it does not simply evaporate, like some stored, uncovered liquid might. Anger, when denied or repressed, tends to collect or accumulate over time, in the same way that knowledge and experience collect and accumulate over time. It turns bitter or rancid. And it grows ever more powerful and potentially dangerous, in the same way that a toxin can accumulate gradually and insidiously in some part of the body, eventually reaching life-threatening levels.

The arbitrary use of expressive, ventilationist or cathartic techniques like pillow-pounding, primal-screaming, bed-beating or bataka-bashing and so forth, designed to "drain off" or disperse anger and rage is, in the long run, ineffective and clinically counterproductive. Today, psychotherapists tend to fall into two basic camps when it comes to dealing with anger: suppressive therapy versus expressive ventilation of anger. But many psychotherapists utilizing such expressive or experiential techniques depend too heavily upon them in treatment to induce and dispel anger, prematurely forcing it out into the open in a misguided and ultimately futile attempt to "get the rage out" and be rid of it in once and for all. If the mere mechanical catharsis, abreaction or ventilation of anger or rage was invariably a constructive or curative practice, the psychotherapist's task would be far less complex, comparatively clear-cut and, in most instances, somewhat superfluous. But such is not the case. As psychologist Rollo May (1969) observed, this ventilationist mentality is "an egregious mistake of much contemporary psychotherapy--mainly the illusion that merely experiencing or acting out is all that is necessary for cure. Experiencing is absolutely essential; but if it occurs without the changing of the patient's concepts, symbols, and myths, the ‘experiencing' is truncated and has a masturbatory rather than fully procreative character."

However, concluding, as Dr. Markman and others seem to, that catharsis is never helpful is incorrect. The term catharsis derives from the Greek katharsis, which in turn stems from the root kathairein, meaning to clean or purify. Aristotle used this term in describing the therapeutic effects of theatrical tragedy in purging the emotions, resulting in spiritual renewal or gratifying tension release. Freud, of course, used catharsis to connote the process of re-experiencing repressed and therefore unconscious emotions in therapy. But the diverse practice of catharsis can be traced back to primitive healing rituals, exorcism and confession, the latter having been employed at one time by the Incas and Aztecs as well as the Catholic Church, where both exorcism and the traditional healing ritual called confession still survive today. When it comes to dealing effectively with anger, catharsis is not merely a matter of "letting off steam," though this can be beneficial in treatment when done verbally as opposed to physically. But the verbalization must be directly connected to and rooted in the true source of the anger. When such anger is acknowledged and verbally expressed, it can clear the way to discovering that which caused it in the first place.

Psychotherapy is partly about helping patients to acknowledge, accept and make more constructive use of their anger to change themselves, their relationships and their lives. It requires a re-owning of personal passion, power, resolve, strength and determination. Dr. Markman is asking the right question: Is it always best to express one's anger verbally and/or physically? So much depends on context, timing and circumstance. "Doest thou well to be angry?" asked God of a frustrated Jonah in the Old Testament, prompting Jonah to pause, sit in the shade, and ponder before impulsively or reflexively acting on his anger. Anger, and even violence, have their rightful place in human affairs. There is a time for fight as well as for flight. A time for aggressive action and a time for passive contemplation. A time and place for speaking our mind and for holding our tongue. And yes, sometimes the best thing to do in the heat of the moment is nothing at all--at least until the metaphorical smoke stops streaming from your ears.

Masks of Sanity (Part Five): The Mysterious Murder of Annie Le

Dr. Stephen A. Diamond, Ph.D. — Mon, 21 Sep 2009 04:35:26 +0000

Annie Le stood all of 4 feet, 11 inches and weighed 90 pounds. She was a petite, Asian, twenty-four-year-old Yale University pharmacology doctoral student scheduled to be married last Sunday. On that same day, her lifeless body was found concealed behind a wall in the experimental laboratory in which she worked and was last seen. Who committed this atrocious crime? And why?

While it seemed likely at first that Ms. Le may have been the random victim of a possible sexual assault, there are now indications that she and alleged killer knew each other as co-workers, and that there may have been some bad blood between them--ostensibly regarding her improper treatment of lab animals. Statistically speaking, most murder victims have had some sort of previous contact with their killers. Some studies suggest that almost half of homicide victims were in an intimate relationship with their murderer, and another quarter were killed by friends or acquaintances. Less than ten percent of homicides involved total strangers.

Police have arrested Raymond Clark, also twenty-four, who worked as a "technician" cleaning cages in the lab where Le's body was eventually discovered five days after her mysterious disappearance. The suspect reportedly was sporting what could be defensive wounds on his face, arms, chest and back, and reportedly did not pass a polygraph. He is presently refusing to talk to police. Additional gruesome speculations that Le's diminutive body had to be dismembered in order to be secreted into such a tiny space behind a wall have been floated but definitely not confirmed. This could certainly explain all the blood at the scene, some of which was found on Clark's boots and reportedly identified as belonging to Le. But so could injuries resulting from a violent physical struggle between the two. Le may have been beaten up prior to being strangled and appears to have valiantly fought for her life. A bloody shirt found concealed on top of ceiling tiles reportedly belongs to the defendant, who apparently returned home in the evening to his live-in fiancee clothed differently than when he left in the morning.

If the police do have the real killer in custody (Clark is, of course, assumed innocent until proven guilty in a court of law), his motivation still remains a major mystery and subject of wild speculation. What many observers and commentators forget is that motive cannot always be understood objectively, but often depends at least partly if not entirely on the defendant's subjective state of mind prior to and during the commission of the alleged offense. This is why properly diagnosing the defendant is so crucially important in forensic criminal cases. Diagnosis can disclose motive. And in order to correctly diagnose defendants, knowing about their prior behavior patterns or psychological problems is essential. As a court-appointed forensic psychologist evaluating such a defendant, there would be a significant number of questions to consider. For example, did Clark have any psychiatric or mental health history of any kind? Was this a rage killing? Is Clark a profoundly frustrated, angry, bitter, resentful young man? One neighbor describes him as "negative," stating that he would sometimes yell angrily at her sixteen-year-old son, and verbally abuse his own fiancee. If so, what could have made him angry enough to commit such a heinous crime as charged? Untidy animal cages? Graduate students neglecting to wear protective booties in the lab? Probably not in and of themselves, though these could have been objective triggers. Was the defendant deeply frustrated and embittered about his life in general? Or, perhaps more specifically, about his work? Or might he have harbored some hostility toward Le for other reasons, either regarding her gender, race or possibly both?

Then there is the question of sexual motivation: Was he secretly infatuated or in love or lust with Le? Was this an attempted or completed rape? Had he been romantically or sexually rejected by her at some point? Did any sexual relationship ever actually exist between he and the victim? Or could such a defendant, behind his daily mask of sanity, be delusional? Erotomanic Delusional Disorder, a specific form of psychosis, typically consists of the unfounded and irrational belief that a person of higher status is secretly in love with the lower status, deluded individual. Otherwise, the person often appears to function normally. Could this break with reality be what drove the defendant to commit the alleged crime? His desperate hope and psychotic conviction that she would call off her impending marriage in order to be together with him? Despite the inconvenient fact that he himself was already engaged to another woman? Was there any correlation between Le's imminent wedding and this horrific crime? Or was the timing mere coincidence?

We may never know the answers to such questions unless Mr. Clark, whether guilty or innocent of this crime, agrees to talk to authorities and/or to a forensic psychologist or psychiatrist. In the event of an insanity defense--which, given the purported strength of the evidence against him may eventually be resorted to--this will be inevitable. And, if not, at least some of his motivation may become clear as the evidence is presented during trial. While I have no direct involvement in this particular case, and can ethically offer no formal diagnosis from afar, a defendant charged with such a violent offense under similar circumstances might conceivably be found, for instance, to meet diagnostic criteria for an anger or impulse disorder such as Intermittent Explosive Disorder. Or sometimes a Major Depressive or Bipolar Disorder. Substance use would also have to be carefully explored and ruled out as a potential contributing factor. And the presence of Antisocial Personality Disorder must always be carefully considered in alleged violent offenders like Clark.

Readers of my previous post may recall that one of the key diagnostic criteria for Antisocial Personality Disorder includes, from before the age of fifteen, evidence of marked aggression against people or animals, such as destroying or vandalizing property, forcing someone into sexual activity or sadistically torturing domestic pets or insects. Could Clark himself have engaged in cruel or inhumane treatment of the laboratory animals, and been confronted or criticized by Le? Or was it, as now appears to be the case, the other way around: Clark, who is reportedly described by acquaintances as highly controlling and compulsively neat, being angry with Le for how she cared for the rodents? Clark is said to have been capable of becoming irate at those who did not comport precisely and rigidly with the protocols for working in the laboratory.

Clark also is said to have been observed going to great lengths at extreme risk to try to retrieve his favorite green pen from the crime scene. Why? Was it merely to remove incriminating evidence? Or was it a manifestation of obsessive-compulsive behavior? Obsessive-Compulsive Personality Disorder or perhaps some mixed personality disorder including traits of Narcissistic, Obsessive- Compulsive and Antisocial Personality might be other diagnostic possibilities in such cases. (See my previous post.)

Additional criteria for APD include impulsivity and irritability, and a history of physical fights or assaults. And, of course, the psychopath's characteristic and extremely telling classic lack of guilt or remorse about such hideous evil deeds. According to Yale, there was nothing in Clark's work history that would indicate such violent behavior, and no known criminal record. That could make the diagnosis of full-blown APD dubious in some defendants. But Mr. Clark apparently had some history of sexual harassment while he was still in highschool. The New Haven Independent reported that when a girl tried to break up with Clark, he aggressively attempted to confront her and defaced her locker. His ex-girlfriend allegedly also claims he forced her to have sex at some point. The young woman did not pursue the case, and no charges were filed. However, Clark supposedly was warned in 2003 that police could pursue criminal charges against him if he attempted to contact the girl again.

Is Raymond Clark a violent misogynist who harbored a venomous hatred of women? Did the defendant, who is believed to have texted or e-mailed possibly threatening messages to Le on the day of her disappearance, lose his temper while arguing with the victim, fly into a murderous rage, and throttle Le until she was dead? Was this a platonic crime of passion? A premeditated or impulsive sexual assault? The angry reaction of a jilted lover or psychotic admirer? Or was it a sadistic, misogynistic, coldly calculated killing by a compulsively controlling sociopathic co-worker? An outrageous and grotesque instance of what police are euphemistically describing as "workplace violence."

Anger, hostility and violence in the workplace have been on the alarming rise for decades. In just a one year period (1992-93), 2.2 million workers were victims of physical attack; 6.3 million were threatened; and 16.1 million were harassed. By some estimates, billions of dollars are being lost because of the negative impact violence has--both directly and indirectly-on the morale, productivity and mental or physical health of victimized American workers. Workplace violence--like school shootings, shopping mall massacres and domestic abuse--is a prime manifestation of our raging anger epidemic.

"This incident," said university president Richard Levin in a somber and sobering message to the stunned Yale community, "could have happened in any city, in any university, or in any workplace. It says more about the dark side of the human soul than it does about the extent of security measures." Sadly, Levin is right. The dark side of the human soul indeed. No amount of security measures can neutralize human evil. Negate the human shadow. Depotentiate the undeniably destructive power of the daimonic. But the right type of psychotherapeutic intervention at the right time can, in many cases, prevent it from escalating into violence. (See my previous posts and the new book by Dr. Ingrid Rose titled School Violence: Studies in Alienation, Revenge and Redemption.) Workplace violence is symptomatic of our pervasive and volcanic anger epidemic. This festering rage is part of our collective shadow, resulting in part from the chronic repression and mismanagement of anger. Until we as a culture are ready to admit this, and acknowledge the dire need to make the psychotherapeutic treatment of pathological anger, resentment or rage--anger disorder-- a true priority in mental health services, the shocking, evil carnage will continue.

Beauty, God, Death: What is Real Psychotherapy?

Dr. Stephen A. Diamond, Ph.D. — Sun, 06 Sep 2009 18:11:10 +0000

Most psychotherapists today are trained to take a rather technical approach to treatment. CBT is a prime example of this standardized, manualized, mechanistic, technical type of therapy designed specifically to reduce or suppress a patient's symptoms and suffering as quickly and economically as possible. Psychopharmacology--the mainstay of contemporary psychiatric treatment--is another example of a bio-mechanical, medicalized, symptom-centered orientation. But is this what psychotherapy is really about? Is this all psychotherapy has to offer? Rapid, rote symptom-reduction? Drugging away or suppressing emotional pain or discomfort? Rationally rooting out and restructuring the patient's distorted cognitions? Modifying and "normalizing" or making more socially acceptable his or her aberrant, eccentric or maladaptive behavior? To be sure, timely pharmacological relief of intolerable and crippling psychiatric symptoms is practical, valuable and sometimes life-saving. But ought that be the end or merely the starting point of therapy? With the advent and wild popularity of psychopharmacological and brief cognitive-behavioral treatments today, is there any room or reason left in the therapeutic process to speak of esoteric subjects such as beauty, God, evil or death?

One of my former mentors, existential psychoanalyst Dr. Rollo May (1909 -1994), passionately argued that psychotherapy should be less about technique or what he pejoratively called "gimmicks" designed to subdue symptoms than about enhancing the patient's capacity to feel, experience, create, find meaning, and in general to become more receptive and accepting to life and love in both their positive and negative aspects. In some ways, this is a radically divergent view on the nature, meaning and purpose of psychotherapy compared to the conventional, symptom-centered approach of today. Dr. May's neo-Freudian, and especially existential attitude toward psychotherapy and his humanistic emphasis on the healing power of the relationship between patient and therapist over the primacy of technique is closely related to that of C.G. Jung, who quipped that psychotherapy "demands all the resources of the doctor's personality and not technical tricks." Clearly, real psychotherapy of any sort depends partly on specific techniques. But the utilization of such techniques is secondary to and never a substitute for the working relationship between patient and therapist.

Another former mentor of mine, Jungian analyst Dr. June Singer, taught that typically, the symptoms presented initially by patients seeking psychotherapy are not the primary problem, but rather represent, symbolize or mask a more fundamental underlying intrapsychic, interpersonal, sexual, existential or spiritual imbalance or conflict. Sigmund Freud, of course, was the first to formally recognize this fact and developed his own still controversial theory (psychoanalysis) to explain and resolve the intrapsychic source of these neurotic or psychotic symptoms. Freud famously focused on enhancing the patient's capacity to work and to love. One of his most innovative and ingenious techniques designed to unearth and reveal such conflicts was what came to be called free association: The patient, while lying on a couch, was encouraged to speak freely about whatever entered his or her mind at the moment. For Freud, the point of free association was to help make what was unconscious more conscious. During their free associations, Freud focused primarily (and seems to have been dogmatically fixated) on evidence of repressed infantile and childhood sexuality in his patients musings and memories.

But what happens when the psychotherapy patient spontaneously free associating starts speaking in treatment not of implicit or explicit sexual conflict, nor of his or her various symptoms or interpersonal problems, but rather of esoteric topics like beauty, God, death and evil? Is this still considered real psychotherapy? Certainly Jung and May both thought so. Some might say such subjects are inappropriate and superfluous--perhaps even taboo--in today's dollar-driven psychotherapeutic marketplace. But I wonder whether any mental health treatment which consciously or unconsciously excludes such basic spiritual or existential concerns can or should be considered real psychotherapy.

In his semi-autobiographical book My Quest for Beauty (1985), Rollo May relates his own rediscovery of beauty and its far-reaching therapeutic power. Finding himself as a very young man alone in a completely foreign culture for the first time and in the throes of a debilitating depression or "nervous breakdown," May accidently stumbles in this disoriented state of mind upon a gorgeous sea of wild poppies while wandering aimlessly in the hills of Greece, and experiences a life-altering epiphany: "I realized that I had not listened to my inner voice, which had tried to talk to me about beauty. I had been too hard-working, too ‘principled' to spend time merely looking at flowers! It seems it had taken a collapse of my whole former way of life for this voice to make itself heard." This sudden reawakening to beauty helped lift him out of his funk and propelled him toward a new, less regimented and rigidly moralistic, more creative, vital life.

This is sometimes a problem in seekers of psychotherapy today: They have lost touch with their transcendent sense of beauty, being so totally preoccupied with their worldly interpersonal problems and distressing symptoms. May, who later briefly became a minister and then a psychologist, shares the following excerpt from a therapy session with a woman he once treated who, up to this point, had been exclusively focused solely on her marital problems: "I stopped my car on the way here to look at the twilight. It was just beautiful, the purple hues with green hills, behind them. . . it is the most beautiful time of day. . . . I don't believe in a God, at least in a personal God, there is so much evil in the world, it makes it so pointless. But when I see such beauty, I can't believe it is by accident. . . . This time of day would be a good time to die, a good time to be alone. . . . I would like to die at this time. . . It is so peaceful here in your office. . . I keep noticing the beauty outside the window. . . ." Beauty, writes May, "is serene and at the same time exhilarating; it increases one's sense of being alive." The beauty of nature, for example, can inspire a profound sense of inner peace, joy and awe, helping to place our petty daily problems or even major life crises into cosmic perspective.

Now, some readers, including psychotherapists, might find this patient's talk of beauty, God, death and evil irrelevant to treatment, possibly a form of what Freud called "resistance," and her comment about wanting to die surrounded by such serene beauty perhaps alarmingly suicidal. Indeed, the patient herself, recounts May, "expressed her fear that she had said nothing today, maybe it was all superficial talk. I assured her that no topics could be more important than beauty, God, death." What did May mean by that? He meant that psychotherapy is not merely a process to "fix" or eliminate people's problems, symptoms and anxieties. Symptoms abate as their root causes are resolved. But we will always have problems. Psychotherapy is about helping people to become more present, more whole, more free, more responsible for themselves, more authentic, more creative, more resilient, more courageous, more capable of love, and more aware. It is about accompanying patients through and, when pragmatically possible, beyond his or her personal demon-filled hell toward discovering and fulfilling their destiny. Or, at least, getting them back on that path. This is a far cry from what frequently passes for psychotherapy today. The goal of real psychotherapy is to help the patient learn to stand on his or her own two feet, to face and accept the stark existential facts of life--difficulties, struggles, suffering, disease, loss, frustration, disappointment, evil, death--with dignity and courage, while at the same time appreciating and being fully present to life's sublime pleasures, wonders and beauty. It is about becoming more authentically ourselves and embracing both the hideous and beauteous, divine and diabolic, destructive and creative polarities of life May poetically called the daimonic.

The kind of psychotherapy I am describing here has less to do with the duration or cost of treatment than with how the psychotherapist views the nature and purpose of treatment itself. People have an innate need to ponder life's awesome mysteries. Real psychotherapy provides patients the opportunity, when needed, to grapple with these thorny questions--which are often closely, though unconsciously, related to their presenting problems. The goal of such therapy is to assist patients in finding their own philosophical or spiritual perspective in life, so as to be able to deal with future problems from a position of inner strength and stability. If psychotherapy continues to be viewed as a prescribed, predetermined, mechanistic cookbook recipe of techniques designed just to rapidly reduce or eliminate certain troublesome symptoms or behaviors, such topics will increasingly seem moot. Patients receiving such severely limited treatment today are tragically being deprived of a much-needed chance to consciously wrestle with what theologian Paul Tillich called "ultimate concerns" like the problem of evil, suffering, spirituality, meaning and mortality. We live today in a therapeutic culture that devalues talking or even thinking about such things. Today, psychotherapy patients are implicitly or explicitly discouraged to discuss or dwell on such soulful matters. But if psychotherapists and patients can recognize and respect the pragmatic therapeutic value, power and importance of addressing meaningful subjects such as beauty, God and death in treatment, then maybe psychotherapy--real psychotherapy--has some chance of surviving.

Masks of Sanity (Part Four): What is a Psychopath?

Dr. Stephen A. Diamond, Ph.D. — Mon, 31 Aug 2009 16:48:07 +0000

If you ever watch television shows like Nancy Grace and Issues with Jane Velez-Mitchell, you have probably seen criminal profiler Pat Brown and numerous other experts commenting on sensational cases like the recent shocking murder here in Los Angeles by former reality star Ryan Jenkins of his ex-wife, model Jasmine Fiore, after which he hanged himself in a Canadian hotel room. And you may have noticed that, especially for profiler Pat Brown, almost all violent offenders seem to be "psychopaths." Ms. Brown, who, so far as I know is not a mental health professional, is certainly not the only one guilty of such diagnostic overgeneralization: Guest panels commonly include clinical psychologists and psychiatrists making similar proclamations. But seasoned forensic psychologists know that it is dangerous to leap to such diagnostic conclusions prior to evaluating the criminal defendant and reviewing all the facts in such cases. For example, do Ryan Jenkins' gruesome efforts to conceal his murdered victim's identity by removing both her teeth and fingers and then stuffing her into a suitcase, or Chris Coleman's apparently premeditated slaughter of his wife and two children while they slept (see my previous post), or Casey Anthony's alleged killing of her own daughter (see my prior posts) necessarily make them psychopaths? Possibly. But it seems that for some of these commentators, the facile label of "psychopath" can be pejoratively pinned onto just about any bad behavior--especially when it involves extreme violence, such as the recent shootings of random women at a fitness club in Pittsburgh (see my previous post.) Meanwhile, did you know that the American Psychiatric Association's official diagnostic manual (DSM-IV-TR) does not even consider "psychopathy" a legitimate formal psychiatric diagnosis?

The term psychopath has been kicking around since the nineteenth-century, but was popularized by psychiatrist Hervey Cleckley in his 1941 classic The Mask of Sanity: An Attempt to Clarify Some Issues About the So-Called Psychopathic Personality. For Dr. Cleckley, the psychopathic personality was initially defined by a relatively high-functioning, aggressively narcissistic, extraverted persona concealing an antisocial and latent psychotic core. Whether most psychopaths are truly psychotic beneath their affable, charming, manipulative mask is dubious, as Cleckley later recognized, though some may in fact, like severe borderline, paranoid or schizotypal personalities, be compensated psychotics. Someone like Charles Manson (see my prior posts) may exemplify this semi-psychotic type. Based on Cleckely's conceptualization, psychologist Robert Hare developed the Psychopathy Check List (PCL-R), designed to be administered by a trained mental health professional to detect and measure the presence of psychopathy. The term "psychopath" was replaced at some point in psychiatry by "sociopath," in part to try to lessen its social stigma. The World Health Organization refers diagnostically to such individuals as suffering from Dissocial Personality Disorder. But the DSM-IV-TR, the most widely accepted and utilized psychiatric diagnostic system today, employs neither of these three terms, preferring deliberately instead to dub this troublesome syndrome Antisocial Personality Disorder. So any time you hear the terms psychopath, sociopath, asocial, amoral or dissocial personality, the appropriate corresponding DSM diagnosis may (or may not) be Antisocial Personality Disorder.

The diagnosis of Antisocial Personality Disorder focuses primarily on observable or documented long-standing patterns of behavior such as disregard for social norms, lying, impulsivity, irresponsibility, recklessness, cruelty, violence, law-breaking, lack of guilt or remorse, etc. Psychopathy or Dissocial Personality Disorder emphasize somewhat more subjective, qualitative and inferred traits like lack of caring or empathy, easily formed but superficial interpersonal attachments, low tolerance for frustration, chronically irritable mood, absence of conscience, failure to learn from negative consequences, and defensive projection of blame onto others. Hare's PCL-R test looks for specific characteristics such as glibness or charismatic charm, narcissistic grandiosity, need for constant stimulation, shallow affect, parasitic lifestyle, sexual promiscuity, multiple brief marriages, and extreme manipulativeness or deceitfulness. Antisocial Personality Disorder incorporates most of these symptoms and traits into its diagnostic criteria. One major difference, however, is that the DSM-IV-TR requires the presence of antisocial behavior in the form of what it calls Conduct Disorder ( a pattern of destructive, aggressive, deceitful, cruel and socially defiant behavior seen as a prelude to APD in childhood and/or adolescence) with onset before the age of fifteen, and that the person receiving this diagnosis be at least eighteen years of age. ICD-10, the international diagnostic system of the World Health Organization, acknowledges a prior history of Conduct Disorder as being common, but not invariably so, and therefore not requisite to make the diagnosis of Dissocial Personality Disorder.

As we have seen in certain recent cases like that of the "Craig's List Killer" (see my prior posting), it may be that some individuals are particularly skilled at masking their sociopathy and at cleverly evading detection--at least up to a point--and present no clear history of Conduct Disorder during childhood or adolescence. But I would argue that even in such unusual cases, antisocial behavior does not spring fully formed from the head of Athena. And, if it does, it may be due to something other than psychopathy. The specific diagnostic criteria set forth by DSM-IV-TR make it clear that psychopathy, sociopathy, dissocial or antisocial personality disorder cannot and should not ever be diagnosed in a vacuum on the basis of a violent crime without having concrete evidence of there being a "pervasive pattern of disregard for and violation of the rights of others occurring since age 15 years." When conducting forensic evaluations of violent offenders, gathering such behavioral history is prerequisite to making a diagnosis of Antisocial Personality Disorder, as is making sure the defendant meets all the minimal diagnostic criteria for this severely stigmatizing mental disorder. And yes, contrary to what certain expert commentators proclaim, Antisocial Personality Disorder--by whatever name one uses--is a real mental disorder, and a very severe, dangerous and debilitating one at that, as Cleckley himself insisted.

The knee-jerk reaction of calling all violent offenders "psychopaths" is inaccurate, irresponsible, misleading and unethical. According to the Handbook of (Forensic) Psychology (2003), "there are many ways that someone can be at high risk for violence that are unrelated to psychopathy.. . . This is especially true," it continues, in cases of "spousal assault, stalking and sexual violence, where violence may be related more to disturbances of normal attachment processes rather than the pathological lack of attachment associated with psychopathy." Indeed, there are a multitude of mental disorders associated with violent behavior, including substance abuse or dependence, bipolar disorder, dissociative disorders, narcissistic and paranoid personality disorder, and psychotic disorders. Violent behavior is multi-determined, and cannot be simplistically reduced to or conveniently explained away by glibly dismissing all such offenders as "psychopaths." In reality, the bulk of violent behavior is not engaged in by individuals meeting the current diagnostic criteria for Antisocial Personality Disorder. Psychopathy is, in my view, just one of many anger disorders, though the majority of these disorders remain officially unrecognized. (See, for example, my discussion in previous postings of the newly proposed diagnosis of Posttraumatic Embitterment Disorder, and on anger disorder in general.)

Equally irresponsible is the matter-of-fact assertion by some commentators that violent offenders, whom they view as psychopaths, can never be helped by therapeutic intervention. The truth is that most reports of therapeutic failures with psychopaths tend to be anecdotal. Personality disorders of any kind are notoriously difficult to treat briefly, requiring intensive, long-term psychotherapy by expert clinicians. According to forensic psychologists James Hemphill and Stephen Hart (2003), there have to date been no well-controlled and sophisticated studies of structured therapeutic treatment programs for psychopaths. Part of the failure in rehabilitating such dangerous individuals has to do, in my view, with our inability as mental health professionals to recognize and treat psychopathy or APD as fundamentally an anger disorder. (See my previous posts.) These are, without exception, profoundly embittered, resentful, angry and narcissistically wounded individuals. Violent antisocial offenders are mainly made, not born. Future research on treating this population needs to focus on acknowledging their resentment and confronting the roots of their pathological rage against authority and society in general, teaching them to redirect some of this anger into more constructive activity.

Psychiatric diagnosis is a difficult and highly skilled process, requiring years of clinical training and experience, and should never be engaged in by anyone not formally educated and licensed to do so. Still, when it comes right down to it, whether we view a violent offender as suffering from antisocial or dissocial personality disorder, sociopathy or psychopathy, what we are really doing is trying to make sense of evil by identifying and naming it. But we cannot dismiss human evil simply by calling those who commit it some epithet such as "psychopath." Indeed, when used glibly and indiscriminately, the term" psychopath" is merely a means of avoiding or projecting the problem of evil and the inherent potentiality for evil in us all. It would be a dangerous error to naively comfort ourselves with thinking that so-called psychopaths are the only ones among us capable of evil deeds. Were the vast majority of German citizens perpetrating the Nazi holocaust all depraved psychopaths? How about the otherwise law-abiding, stable, responsible person who suddenly commits a violent crime of passion? Evil is an ever-present potentiality in each of us, given the right temptation, threats and circumstances. "Psychopaths" are not the sole purveyors of evil. But by better understanding the angry, resentful, bitter roots of psychopathy, we will be better prepared to deal with and reduce the pervasive and insidious problem of human destructiveness and violence.

Parts of this posting were derived from (and are expanded upon in) Dr. Diamond's article "Violence as Secular Evil: Forensic Evaluation and Treatment of Violent Offenders from the Viewpoint of Existential Depth Psychology" (2003), which was subsequently published in slightly revised form in the textbook Forensic Psychiatry: Influences of Evil (2005).

The Trauma of Change: Healthcare Reform and the Angry American

Dr. Stephen A. Diamond, Ph.D. — Sun, 16 Aug 2009 02:38:26 +0000

"There is more anger in America today than at any time I can remember."-- Democratic Senator Arlen Specter commenting on public reaction to President Obama's proposed health care reform legislation.

Change can be scary, stressful, and sometimes, traumatic. Americans are currently confronted with changes every bit as fundamental as those that shook this country to its very foundations during the turbulent 1960's. First, there was 9-11. Then the protracted and unpopular war in Iraq. Followed by the worst economic crisis since the Great Depression. The stock market and real estate crash. Next, the election of our first black President as part of a backlash against Republican policies. And now, radical healthcare reform. Should we really be surprised by the outrage, anger and embitterment of many concerned and nervous citizens regarding the controversial issue of universal healthcare coverage?

Americans are very angry. Just look at some of the rowdy recent town hall meetings regarding healthcare reform. This anger has been festering for decades now, but appears to be reaching a boiling point, as seen in the explosive epidemic of violent mass killings (see my prior posts), rampant incivility, and a pervasive embitterment rooted in a barely suppressed, smoldering rage. The anger, resentment and hostility I refer to here is also raising its ugly head in the form of racial hatred. Congressman David Scott, a supporter of the President's healthcare legislation and who happens to also be an African-American, found a swastika spray-painted outside his Atlanta office last week. He expressed concerns about the "racial hatred bubbling up" right now, and the "hatred out there for President Obama."

Hatred is a feeling closely correlated with chronic embitterment, and frequently, evil deeds of various sorts. This widespread bitterness has become so prevalent and problematic that the American Psychiatric Association is now debating whether to include a new diagnosis to describe it: Posttraumatic Embitterment Disorder (see my prior post). In my view, there is very good reason to do so. Change can be traumatic. And how we deal with the trauma of change can be maladaptive, leading to mental disorders of varying kinds, including depression, anxiety, substance abuse, and sometimes even psychosis.

Posttraumatic Embitterment Disorder (PTED) was first proposed by German psychiatrist Dr. Michael Linden in 2003, based on his clinical work with troubled immigrants from East Germany following the fall of the Berlin Wall. That profound cultural change proved to be quite traumatic for some of those whose lives were directly affected by it, and the disturbing repercussions of this life-changing event--seen almost universally by the rest of the world as a positive development--were felt for years. We in this country are going through some significant social changes of our own. As Linden (2003) observes, some of the debilitating emotional symptoms of those patients meeting his proposed diagnostic criteria for PTED include chronic feelings of injustice, victimhood, helplessness, hopelessness, powerlessness, self-recrimination, aggression, anger, rage, resentment and, of course, embitterment. Such individuals feel they have lost control of their lives and their destiny. The values and structure that once provided a stable sense of self, meaning, purpose and personal or professional identity have been lost or eroded. The old life has been altered irrevocably. The new life has not yet been established, leaving the person in a state of existential limbo.

Viennese psychiatrist Viktor Frankl referred to such limbo states as living in an "existential vacuum." This is a classic existential crisis, not unlike what typically occurs to some extent or another to us all during mid-life. But the crucial difference is that these patients--like those in the throes of a protracted major mid-life crisis-- have been unsuccessful in navigating this treacherous transition from the old existence to the new. They have been unable to let go of their anger and grief about losing the status quo or feeling unfairly treated by life. They remain stuck and become bitter rather than accepting change and bravely moving forward in life. In a sense, they bitterly choose to live in the past: At least dwelling in the past and dreaming of retribution provides some sense of meaning and purpose that the present and future appear to lack. But, existentially speaking, this refusal to relinquish one's past and embrace the present and future can be understood as a fundamental failure of courage. Life requires courage precisely because of its inherent insecurity and transitory nature.

So America is in crisis again. Change is the cause of that crisis. Psychotherapists know all too well how difficult it is for people to change themselves and to accept change in their lives, even when they know that change is inevitable. (See my previous post on change vs. acceptance.) There is great anxiety and resistance accompanying change. The anxiety and fear of moving from the familiar to the unfamiliar. The known to the unknown. We humans have a primal fear of the unknown, which is one reason we tend to fear the unconscious. And most people will do almost anything to avoid the anxiety of change, including choosing to persist in a lifestyle which no longer really works for them, and, in some cases, clearly causes them harm. This is the decision, the existential choice with which Americans are currently confronted: To courageously move forward. Whatever its legitimate pros and cons, no one likes to be forced into confronting such a choice before being psychologically ready to do so. No one wants to confront the anxiety of change unless they absolutely must. And this is part of why so many Americans are reacting to these proposed sweeping changes so negatively and with such vocal hostility. It is a primal defensive response, a form of "fight or flight." It is also an example of the classic "frustration-aggression hypothesis": Frustration in certain segments of the citizenry is leading to anger, rage, aggression, and conceivably at some point, violence. (See my prior post.)

What is the therapeutic treatment for this pandemic embitterment? As with treating any anger disorder, the anger must be acknowledged, heard, accepted and understood, even validated at times. And the therapist must help the patient to channel that anger constructively, to help them move through their fears, insecurities and anxiety about change. Life is change. Americans need to be encouraged to confront the unknown, and to recognize that existential anxiety can be a kind of excitement about the future and its new possibilities. We all must embrace change, and the normal anxiety that inescapably comes with it. The angry refusal to do so is an oppositional, negativistic, cowardly choice to become embittered rather than empowered, to stagnate rather than grow and develop, to remain vengeful, passive victims of fate rather than willing participants in our own collective destiny.

Anger Disorder (Part Four): Frustration, Madness and Misogyny

Dr. Stephen A. Diamond, Ph.D. — Fri, 07 Aug 2009 03:55:21 +0000

Forty-eight-year-old George Sodini was a deeply frustrated, bitter man. Yesterday, his anger, resentment and rage finally exploded into the premeditated madness of violence. Sodini strolled into an all female aerobics class at LA Fitness in Pittsburgh, PA, shot three young women to death, wounded nine, and then committed suicide. What was Sodini so angry about? It appears, based on his own self-published blog entries beginning more than nine months ago, that Mr. Sodini was frustrated primarily about his difficulties with women. He complains of an inability to find a girlfriend since he was twenty-three, not having sex for almost two decades and, most recently, failure to find a date during the past twelve months.

Could chronic sexual frustration have caused this catastrophe? To conclude so would be a gross oversimplification of this and other violent offenders' profound existential embitterment, fury and frustration.

This horrific case is reminiscent of so many others we have witnessed in recent decades. (See my prior posts.) Colin Ferguson's massacre on the Long Island Railroad in 1993, killing six passengers and wounding nineteen comes to mind. Ferguson, a black man, had lost both parents in an accident as a teen, and immigrating from Jamaica to the United States, found only frustration in his attempts to find success. He was unable to surmount the apparently immovable obstacles that destiny so indifferently placed in his path. Feeling utterly frustrated, defeated and depressed, Ferguson aimed his accumulated resentment, rage and anger at a random representation of those whom he perceived to be prejudiced against him: middle-class, caucasian commuters. Seung-Hui Cho, the alienated young perpetrator of the Virginia Tech shootings was another frustrated, angry and bitter individual who lashed out against those he felt rejected and hurt by.

Such frustrated loners have also been dramatically depicted in movies like Martin Scorsese's classic Taxi Driver (1976), and Joel Schumacher's quintessential American film, Falling Down (1992). In Falling Down, when Bill Foster (Michael Douglas), an unemployed, divorced engineer finally flips, setting out (like Ferguson, Cho and Sodini) on a violent rampage against society and the perceived sources of his problems, we are reminded that there are limits to the repression of frustration, anger or resentment required by social civility. Feeling helplessly victimized by circumstance, society and fate, perpetrators of "senseless violence" turn the tables, venting their venomous frustration, aggression and hatred on innocent bystanders. In so doing, mass killers, unable to assert their power positively in the world, become--albeit only fleetingly--powerful vicitmizers as opposed to powerless victims.

Social isolation, rejection, alienation and loneliness-even when self-imposed and perpetuated-is a powerful existential root of violence. Existentially speaking, we are each thrown into the world alone, often must walk through life alone, and die alone. Most of us frantically do everything in our power to avoid facing this difficult fact of life. As human beings, we inherit a level of loneliness that can never be completely overcome, though our ability to connect intimately with others certainly serves to assuage, albeit temporarily, this existential aloneness. When we are unable to find suitable companionship, solace, support or love, and are frustrated in fulfilling our fundamental need for human warmth, caring and acceptance, a sullen rage accrues over time, culminating for some in violence. Psychologist Rollo May (1969) observed that "Violence is the ultimate destructive substitute which surges in to fill the vacuum where there is no related-ness. . . . When inward life dries up, when feeling decreases and apathy increases, when one cannot affect or even genuinely touch another person, violence flares up as a daimonic necessity for contact, a mad drive forcing touch in the most direct way possible." This aptly describes Sodini's situation, and that of so many alienated and marginalized members of society today.

Frustration, that exasperating experience of being foiled, thwarted, blocked or baffled in our best efforts to find satisfaction in life begins at birth and follows us for the rest of our days. Frustration is an existential fact of the human condition. Even under the best of circumstances, infants cannot always be fed at the exact moment they experience hunger pangs, freshly diapered when wet, cuddled, held and comforted when distressed, no matter how loudly or persistently they cry. Much of what infants and children want, they cannot have. With luck, kids get what they need to survive and, hopefully, thrive. The same may be said of adults: We are not always able to succeed in our endeavors to attain goals or satisfy our desires, no matter how hard we try. Like infants, children and adolescents, adults are destined to frequently be disappointed and frustrated. And to feel angry about being frustrated.

The direct relationship between frustration and aggression was first postulated by psychologists Neal Miller et al. (1939) in their classic, psychoanalytically influenced "frustration-aggression hypothesis" : Frustration of basic needs tends generally to result in aggression; aggression can typically be traced to some form of frustration. There may be good psychobiological reason for this archetypal human response to frustration: We need to get angry at life's inevitable frustrations if we are to overcome them. Constructive anger or even rage provides the power, strength, resolve and impetus to move beyond the many frustrating impediments life so predictably presents. But what happens when someone is unable to overcome his or her frustration? Cannot use this anger and aggression creatively? Fails to find fulfillment, satisfaction and meaning in life? Discouragement, despair and depression. Nihilism. Not infrequently, he or she angrily chooses destruction and death over life.

George Sodini, a man without any known criminal history, was evidently such a case. No matter what he tried, he felt powerless to change his lonely, sterile life, projecting his own problems outwardly onto the world in general--and women in particular. Feelings of helplessness and hopelessness were his only companions. Whether he ever sought professional assistance is not clear right now. "The biggest problem of all is not having relationships or friends, but not being able to achieve and acquire what I desire in those or many other areas," he ranted in a recent journal entry. "Everything stays the same regardless of the effort I put in. If I had control over my life then I would be happier. But for about the past 30 years, I have not." And so finally, Sodini decided to violently end his frustrating, meaningless life, choosing death, evil and infamy instead. But not before taking out his rabid hatred toward an entire gender--and life itself--on his twelve female victims.

Parts of this posting are excerpted from Dr. Diamond's book Anger, Madness, and the Daimonic: The Psychological Genesis of Violence, Evil, and Creativity (1996, State University of New York Press).