Sunday, April 29, 2007

Cho Copycat and Life is a Battlefield

On Saturdays, you know, I don't work. So I take it kind of slow, check out the weather, read the Wall Street Journal. If it's nice out I'll go outside and stare at the backyard, check for new buds, wild flowers, that sort of thing. We're pretty vegetation-starved by April in Chicago, and any sign of life makes us very happy.

If you haven't been in Chicago, by the way, in the springtime, when leaves and flowers are announcing themselves, literally bursting on the scene (with such drama), you're missing something. On a sunny day you can simply pass out it's so overwhelmingly stunning. It's like being in a musical. You half expect Julie Andrews to skip through the sidewalks, over the cracks, eyes dancing left and right at the rhododendrons singing, "The hills are alive, with the sound of music. . ."

Except we have no hills.

But yesterday, instead of reading my WSJ, I picked up my Chronicle of Higher Education. The Chronicle is THE journal to read if you're looking for a job in academe, or if you work in academe and want to read the trials and tribulations of other academics. Not only can you find out who is leaving which university and WHY, but you can get all kinds of ideas about teaching and what kids are learning these days.

So I read a couple of pieces in the Chronicle and thought, hmmm, which do I review for my blog, since a couple of them really grabbed me. One was a review of the intelligentsia on religion (why in the world would anyone believe in anything that can't be proven, dummy me and the rest of the Big 3 Abrahamic tradition-bound-cleaving public) and the other was about how important it is for people who work in academia to KEEP THEIR MOUTHS SHUT because everything they say in class can and will be posted on the Internet on some dissatisfied student's blog. Or worse yet, a video on YouTube.

Both would have been worthy things to blog about. However. . .

You know it was a beautiful day. And things happen. I locked up the house and headed off for shul (the synagogue), just feeling those allergies getting all excited and tingly. Across the street a neighbor walked her fabulous pedigreed dog. Let's call my neighbor Jill.

We waved.

Ordinarily I might have let it go at that and kept on my way, but it was a beautiful day, the kind of day you just don't hurry anywhere if you don't have to, so I crossed over to Jill to catch up with her news. We've never talked that much, but everyone on this block is really friendly and since nobody dares fight the cold to hang around and shmooze during the winter, spring is a kind of a social spring-time, too. So I was happy to stand on the street corner and talk with Jill.

Not that I got too close to the dog, I have to admit. Dogs like me, and I like dogs, I mean we have an understanding. But I don't like it when they simply have to show me how much they like me by jumping on me or licking me or sniffing at my skirt. I don't do the petting of the dog thing, and prefer a safe lunging distance. I hate it when they lunge.

"Oh, he won't jump on you," Jill says.

"I know, I trust him."

"He really won't."

"We're good, I'm okay," I say, reassuring her, yet stepping back another step.

She pulled the dog who was wagging his tail and drooling out of pure love and happiness, a little closer and asked me how long we've known each other. I thought about it. About 28 years. She was on the block when we moved here, I'm pretty sure. I've watched her kids grow and admired her dogs, too, for that long.

I asked about the boys, what were they doing, and she asked about mine. Somehow we got to talking about Cho. She asked had I read about what just happened in . . .she couldn't remember exactly where it was . . . Apparently some kid somewhere in the Chicago area wrote a story for class that really upset the teacher. . .full of spleen, murder, anger and hate. Just like one of Cho's plays.

"What happened?" I asked.

She couldn't remember the details, told me I could probably find the story online if I checked the Chicago papers. She reflected,

"Ya' know, my youngest was peer rejected, teased terribly as a little kid and he was pretty depressed. I'm really thankful that now, as an adult he's doing great. He survived his childhood."

I shared about my own kids' social angst, said that most of us do survive childhood, but it's not easy. It helps, of course, to have emotionally receptive families that encourage us to bounce off our feelings, express a little spleen.

We think most families are like that, emotion-sensitive, but many are not. In therapy I tell parents that they have to ask their children at the end of the school day:

Has anyone been mean to you, or picked on you today? How about your teacher? Was she nice to you? How was it out there in the big, world? Life is a battlefield, ya' know.

(Is life is a battlefield a Cheryl Crowe lyric, ? Talk about an interesting life/family!)

Jill, a teacher for many years, agreed. Life's a real challenge for every kid, much more so for some. The two of us could have talked for hours, but I really did want to get to shul, so I said goodbye to her and Poochie (name's changed, okay?!?) and headed off.

In shul, when my brain drifted to blogging, as it often does, I thought about this kid who copied Cho's writing style . I decided that that was more important to blog about that than whatever it was the Chronicle intelligentsia had me thinking about.

This morning I found the article Jill was talking about, and in the first draft of this post almost linked you over to the story. But after thinking long and hard about it I considered the idea that this kid's privacy has already been compromised, perhaps for good cause, who knows, but it wasn't right to add to his burden by announcing his name, yet again, on the Internet.

Let's call him John. One of the goals this month, apparently, for John's creative writing class was to learn to communicate ideas and emotions through writing. The students could write what they wanted but were warned that if they wrote something that posed a threat to self or others, the school could take action.

John was an excellent student. It sounds to me like he tried to meet the goals for the month but the caveat about posing a threat wasn't clear.

Either way, the teacher went, Gotcha'.

I don't think she did anything wrong. She reported the story to her supervisor and to the principal of the high school. They determined to report it to the police, and John was arrested for disorderly conduct. His father was interviewed and asked the first obvious question,

Is handing in a school assignment disorderly conduct?

What's a teacher to do? She couldn't risk another Virginia Tech!

I fantasize the following scene, bare with me if you're an educator, maybe it makes no sense.
The teacher reads the paper. She's upset, first tells a significant other who says, You have to turn this (him) in! The next day she tells her supervisor and the principal. They all agree that she should talk to the student alone, first. She arranges for that and addresses it like this, asks these questions in no particular order. . .

"Wow, John, that was quite a story. Do you mind if I ask you if it's based on your life or does it come from your imagination? Or where did it come from? Is it fiction? What do you hope to communicate by telling the story?"

The student answers. Then the teacher has the option of offering student resources at the school or outside mental health resources if appropriate. She might ask, "Are you upset about something? Do you have violent, real life thoughts? Would you like me to help you get a therapist, or maybe help get your family a therapist? It would all be kept confidential, maybe you'd feel better. We have to talk to your parents if we send you to see someone for help. "
The kid chose HER to tell his story. I feel she should have handled it first. Maybe she did. Maybe we don't have the whole story. The school, I'm pretty sure, can't offer a child any therapy or counseling without parental permission, at least I don't think so. But is there something wrong with that conversation before bringing in the parents and the police? I know that there are privacy rules, FERPA, the federal privacy act. I'm asking you educators out there for your opinions.

I know a teacher who once said,
"I'm not a rabbi. I'm not a priest. I'm not a minister or a psychologist.
Kids-- I don't wanna' hear about it."
Hey, I'm not judging.

In fact, I see many teachers who are in therapy who work in tough Chicago neighborhoods where it is common for students to walk away with anything teachers leaves on a desk when they step out of the room. On some days it feels to them like angry, sullen kids are in the majority and that haughty disrespectful, in-your-face behavior is the norm. Is a teacher supposed to help everyone of them? Any of them?

We have survivor research that indicates that people who survive family dysfunction and trauma in childhood can point to one person who saved them, who gave them the strength to get through adolescence, a person who said, You'll get out of here one day. You'll make it. Things will be better, you'll see.

Those people were often teachers.

And they didn't always have the kinds of chat I described above. More often than not, they simply showed that they cared, communicated that they understood the child's personal battlefield. To a degree, based upon the look on the child's face every day at school, based upon his writing, maybe they do understand. Empathy is medicine.

Empathy, however, is very difficult with belligerent and verbally violent children who may need to be admonished for their behavior in school, not patronized, whose families don't answer the phones because they're high or don't have a telephone that works, who need help but refuse to attend school to be there for the offer, who have already written off getting an education in favor of working the streets. Those kids are hard to reach.

The boy who wrote that story, the Cho copycat however, was not one of those difficult kids. The teacher might have tried talking to him, maybe she did. Reporting to the police did increase the odds he'd be evaluated by a psychiatrist, which he was, so maybe that was the administration's intent all along. Have him booked on something, then get him help. I've heard that before.

If a social worker like me were to work on a program to train educators to handle this problem, I'd need input from those of you with experience and ideas, who work in schools.

For sure leave a comment below and we can start talking (heck, anyone can do that anyway, I wrote about Lassie, didn't I?). Or you can email me at Therapydoc at I have to have made somebody angry with this post, right?

The lines are open.

Copyright 2007, TherapyDoc

Friday, April 27, 2007

On bananas and eating right

Do you see the problem here?

How am I supposed to pack the banana into that lunch bag? The lunch, you can see (really it's F.D.'s breakfast) packs nicely into the brown paper bag. I could have packed it much tighter, too, made it much more compact.

But the banana! It just doesn't fit.

S., my #4 son, tells me that they make banana cases and we can get them on-line. But this seems like one more thing to wash.

There should be a tougher brown bag with a special compartment. These are things to think about.

On this healthy moment, as long as we're talking about food, wanna' know what's for lunch, er, breakfast?

He'll have a a modest omelet of one piece cheese, one egg (with yoke, sorry), and a small onion, fried together, egg last, sandwiched between two medium slices of some seedy, grainy-kind-of bread sliced off a baguette.

Pickle on the side and a couple of fresh vegetables (okay, one, a carrot, i got lazy, but it's a real carrot, not one of those pre-peeled things they call baby carrots). A piece of carrot cake, small, to die for when it was fresh-baked, now it's just "interesting, but edible." One chocolate chip cookie. He'll probably save the sweets, forget to eat them and bring them home.

And that's all F.D. will eat today until 8:30 when we finally sit down for dinner. Is that "healthy" not eating more than once in 13 hours?

Yeah. Probably.

Will he be good with that? Will he ride his bike home from work? Did I tell you how old he'll be next month? Am I pushing you all a little too hard today (see post below) on the stay healthy thing, bragging too much about how we try to eat right, exercise, etc., and you should, too, pushing this western agenda, this capitalist, privileged lifestyle on you?

Yes and Yes, No (K"H) and Yes . It can't kill you (K"H) to eat right and get some exercise. Unless you get hit by a truck, maybe. So please, please, please. If you do ride a bike or jog in the city, don't get hit by a truck or an SUV, seriously. Be careful out there.

Copyright 2007, therapydoc

And Another Thing: TV and Exercise

New feature

It's called, And Another Thing

Here goes:

And another thing.

People who buy a
new television with a screen that's larger than 19 inches should
also buy a piece of exercise equipment for the same room.

The exercise equipment should be used.

Perhaps the exercise equipment should be used proportionally to the amount of TV watching. Ask your
family doctor about what kind of exercise you should be doing.

Oh, that might mean get a mat and stretch, too. They cost 10 bucks at Marshalls, but have squirrely designs on them. People will make fun of you, but let them.

F.D. and I have 2 -19 inch screen televisions (neither in the bedroom) and 2 really archaic used pieces of exercise equipment- a stationary bike that's not very comfortable and a tread-mill that's too loud and almost killed my mother so she gave it to me (what's that say?)

So you you can stop romanticizing me by picturing me on a state of the art elliptical machine in front of a wide-screen digital tv, or whatever that is.


Copyright 2007, therapydoc

Thursday, April 26, 2007

On Self-Disclosure and Family Therapy

The question is on the table, eloquently served by readers

Why AREN'T you anonymous, TherapyDoc? I quote:
"Even your highest functioning clients could so easily become internally disorganized around learning so much about you, your views, your family, your experiences, etc."

"I am a budding therapist (psychology student) and wondered about your thoughts regarding the amount of self-disclosure you are making available to your patients via this blog. I know from my own therapy that 1) I am endlessly curious about my therapist's personal life and obsess about it sometimes while 2) it is much better for me therapeutically NOT to know too much. I think I would feel uncomfortable as a patient having access to so much of my therapist's personhood via a blog, and I imagine that as a therapist I would be worried about being so transparent to patients. Any thoughts? Do you ever worry about affecting your patients adversely because of your blogging?
Many thanks,
a loyal reader in PA"
Have I Any Thoughts? Well, now that you've asked.

But for a second opinion I showed these quotes to F.D. and asked him what he thought. He smiled, shook his head and said, "Anybody reading your blog knows nothing about you. Virtually nothing. Who knows your thoughts when you pray?"

Uh, well. . .

What he means is that we're all very complicated people and it takes a therapist many, many visits to really understand someone, so a couple of posts on a blog don't really tell you very much.

But as cute as he is, and even though I respect what he says, he's wrong. You know plenty. And I have a very different answer, anyway.

It's all about orientation. I'm a family therapist and a behaviorist.

It's about time you learned what that really means. And oh, I have so much to say, so get yourself a cup of tea and come back when you're ready.

In family therapy it really is all about the patient's family, no matter who presents as an "identified patient." From the very first encounter on the telephone it is the family and the way the family is coping with problems that is the focus of treatment. Although as therapists we recognize that we have a place in a patient/family system, the therapy is NOT about the patient-therapist relationship.

It's not about me. Family therapists like me very, very, very rarely talk about themselves in therapy unless a particular anecdote demonstrates a point and will clearly "work." But again, that's going to be rare and with a great deal of discretion and it's not necessary. There's so much better material to present, the reservoir of material the patient and the patient's family already have.

Oh, there's so much to say.

Family therapists not only treat, but we diagnose differently.

In couples therapy, for example, there really are 3 patients, the partners make 2, the relationship between them, 3. In family therapy you add a couple of kids or another member of the extended family or community, and you may have many, many dyads and triangles and individuals that might need tweaking! You need to know your algebra to do a decent assessment!

A doc who graduates with an MD, PhD, PsyD , MSW, etc., who hasn't really been through family therapy training certification is NOT a marital or family therapist. Individual therapists have the right to say they treat families and couples, but I'm sorry, they don't KNOW family therapy. In their heads it's still more likely to be about the patient/doctor relationship and how the doctor can get the patient (the most dysfunctional member of the family) to behave differently. Please, challenge me. Say it's not so.

But we really do use the family as the change agent.

Thus our take on the centrality of the patient/doctor relationship is very different. It is the patient's relationships with OTHER people that are important prognosticators for change.

Even when I'm seeing an individual, no matter what the content of the discussion, very early into it, unless it's a long initial patient soliloquy, a narrative of the story which I total hope for and encourage, I'll ask a variant of:
So what did So and So say about that? or
How does So and So feel about that?
What do you want out of your relationship with So and So? or
How do you want to fix that with So and So? or

If you could go back in time, how would you look at that relationship and what it meant to you, to So and So, to your future, to how you look at life, people, relationships, etc, now?
There are many variants of those questions.

The So and So's are multivariate, too. There are many people who both affect and are affected by every patient we see. Examining the psychological motives of these significant others and their relationships, we tease out patterns and feed-back loops.

This is where we discuss the therapist, too, how the therapist plays into the patient's ecology. The patient's transference does enter into the therapy and is discussed as such. But it's not the focus of therapy. The other relationships are paramount and more interesting. Most of the time, that is.

Family therapists see shifting the patient's relationships as ideally ameliorative. But many of us have a good deal of other training and know many other behavioral techniques, most with an individual's behavior as a target for change. We'll use family to reinforce a new behavioral sequence or interactional change that's been established as a treatment objective.
Still with me?

Even in individual work a behavioral family therapist will work to capitalize on the power of the family or others in the individual's eco-system. Strategies for change can and should be "designer" strategies, unique to a particular individual, couple or family. Determining what will work is a joint enterprise. I, for one, can't possibly know what will work for an individual or family without patient/family feedback.

I would guess, and it IS a guess, that behaviorists who put patients in charge of choosing designer therapeutic interventions are working to empower them. I do. There is little or no "resistance" in this process, usually, in my practice, probably because we're working together and the patient is in charge and feels in charge.

Another way of looking at it is that family therapists like myself who trained at the Family Institute of Chicago/Center for Family Studies (now a part of Northwestern University in Evanston) use a problem solving therapy which is very different, I think, from a psycho-dynamic or psychoanalytic therapy in which interpretation and transference play a much larger role.

Not to put down psycho-analysis, for I would hope that the training has changed by now, but in the 1980's I heard the following story from a colleague- again, I'm sure this would never happen now, in our hyper-therapy-Oprah-conscious-media-driven world:
A man, an alcoholic, tells his new therapist about his previous therapy. He saw an analyst (omniscient) for many years and talked about relationships with women. The new therapist asked why the analyst never got around to treating his alcoholism, or had he tried? The patient said, and I quote, "The doctor never asked about my drinking. We never discussed it."
What did they talk about? I don't know. But in family therapy that would never happen.

Being a family therapist does NOT mean that a patient's individual psychology is irrelevant, obviously, not in individual "family" treatment, not in couples therapy, not even in family treatment. Of course we talk about the past and how it has affected everyone in the family.
Transgenerational family dysfunction is one of the mysteries we want to unravel. One's family of origin can hold the key to understanding today's thinking and behavior. This is why we use genograms (family trees) to help us understand where individual responses, patterns and feedback loops come from.

Nor does family therapy obviate the need to discuss diagnosis or medication of family members who have an Axis I or II disorders. Family therapists probably don’t label people as often as other therapy docs, but many of us, depending upon our training still hold by a medical model of treatment. Medical diagnosis matters.

Okay. But for those patients who might obsess about me, like B? What about that?

I've handled it by telling all of my patients that I have a blog and that I share some of myself on the blog. I tell them that indeed, if they think that's too weird for them or if it makes them at all uncomfortable they have three options:

(1) they don't have to read the blog, it's not required, I explain all of the concepts that might relate to them in therapy anyway, first hand
(2)they can discuss anything that they do read on the blog with me and we can discuss how it relates to them
(3) We can always arrange for a referral to a therapist who is more of the omniscient variety.

I also tell patients that what they read on Everyone Needs Therapy (ENTx) is either about me or is fusion of case material or stuff I've seen on television or in the movies. Or I made it up entirely. I always change possible identifiers like age, race, gender, and context.

Perhaps it's the nature of family therapy, but people who see me really do want their problems solved and rarely ask about my life. They'll mention my bicycle. They'll ask where I go on vacation. Most questions about me are off limits and they respect that boundary. Most of the time I answer a question about me with a question about themselves. It's the Jewish way of learning.

I'm much more interested in you than I am in talking about me.
Me, I know.

The mission of this blog is international psycho-education. I feel, however, that the hypnotic quality of personal writing delivers powerfully, teaches by keeping the average attention span longer than might a list of things to do in a particular situation with a particular disorder or problem. We’ve all seen those lists. How-to’s, lists of symptoms-- those you can find anywhere. You can Google them or go to a bookstore. Research? You can access university libraries and journals on the Internet, too.

There's more. One of the reasons I blog is a religious conviction that if a person knows something, something important that should be common knowledge, then there is have an obligation to teach it. In therapy, during a psycho-educational discussion, patients have said to me, This should be taught to every school child.

I whole-heartedly agree. So I tell you on this blog. Teach your children.

As a social worker, my mission, the mission of my profession, is to educate and serve mankind, to reach out to individuals, families, organizations, and communities. It is only in the latter years of the 20th and now in the 21st century that we have begun to talk about reaching international communities. What I am doing here on this blog might be considered international social work.

Do I believe that the Internet is changing the way that we communicate professionally for the better?
Yes, I do.

Do I believe that the professions are changing and will continue to change for the better due to the ease, speed, utility, and price of disseminating knowledge on the Internet?
Yes, I do.

Do I believe that the face of psychotherapy and family therapy will change in ways we can’t even imagine due to the Internet?
Yes I do.

And we will have to adapt.

If we are going to prevent things like the Virginia Tech massacre in the future, professionals have their work cut out for themselves. No, we don’t have to tell the world what we prefer for dinner, or that we even go out for dinner. We don’t have to disclose some of the conversations we’ve had with our mothers, fathers, sisters or significant others; we don’t even have admit that we HAVE living relatives. But I don’t think it hurts anyone. I really don’t. It's more important that people read, that many people read.

The system does seem to work. We are talking. People are learning a lot with the price of a click. G-d knows I don't know everything (and I try to keep learning every single day.) But I feel good about doing this.

Now, all of that said, Couldn't I still have worked this blog anonymously? What was the point of putting my John Hancock on it?

As much as I want to give it all away for free, like I've said many times before, I don't want kids cutting and pasting and putting what I write in their papers. And I don't want other writers to take my way of saying things. I feel these are my words and if someone wants to steal them, not cite me properly, then I want them to feel guilty.

Guilt is the greatest motivator, you should know.

Aye, but you ask, why is it that my identity no longer is posted on the blog? What happened?

Family and friends, to be honest, have been on me about safety issues. The Internet is a dangerous place, they say. You're vulnerable. We worry.

And they're right, of course. I have a responsibility to protect myself from stalkers and sociopaths. I can't be naive about them.

If you've been reading my personal posts you know there's a lot about me that's very PollyAnn-ish, that gives the benefit of the doubt, expects the best from everyone, that closes her eyes to real life and negative aspersions, "evil" motives. It is the Jedi in me that says,

Fear leads to Anger. Anger leads to Hate. Hate leads to Suffering (Star Wars, Phantom Menace). So I've tried very hard NOT to be afraid as an identifiable blogger on the Internet.

But I have told you about my home invader dreams, right?

Who needs this?

Copyright, you bet, 2007, Therapydoc

Tuesday, April 24, 2007

Another diagnosis heard from: more Cho

Jeffrey Kluger, in this week's issue of TIME MAGAZINE interviewed several forensic psychiatrists and proceeded to propose a theory about Cho's psychology not much different than the one I did on Slow Burn, except that he adds a feature I left out. Narcissism.

It's worth a look as it adds another plausible diagnosis to the soup. Cho fit the features of the disorder, listed below.

Narcissistic Personality Disorder, 301.81.


A pervasive pattern of grandiosity (in fantasy and behavior), need for admiration, and lack of empathy, beginning by early childhood and present in a variety of contexts, as indicated by five (or more) of the following:

(1) has a grandiose sense of self-importance (e.g. exaggerates achievements and talents, expects to be recognized as superior without commensurate achievements)

(2) is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love

(3) believes that he or she is "special" and unique and can only be understood by, or should associate with, other special or high-status people (or institutions)

(4) requires excessive admiration

(5) has a sense of entitlement, i.e., unreasonable expectations of especially favorable treatment or automatic compliance with his or her expectations

(6) is interpersonally exploitative, i.e., takes advantage of others to achieve his or her own ends

(7) lacks empathy: is unwilling to recognize or identify with the feelings and needs of others

(8) shows arrogant, haughty behaviors or attitudes
Although it may look like a match, based on the video, keep in mind that people with Narcissistic Personality Disorder (NPD) usually aren't mute. They interact socially with people who respect and flatter them, and can be as physically attractive as anyone else, so they have something of a social network, although it's usually small and the turn-over is high. They're not real likable, despite thinking they should be.

Cho never interacted with anyone, which is why I skipped right over NPD to Schizoid Personality Disorder, premorbid to Schizophrenia, Paranoid Type, which presented later in his early 20's, probably the year before the massacre.

Mr. Kluger says that mass murderers like Cho and Harris and Kliebold (the Columbine murderers) suffered from "clinical narcissism"
a condition characterized by "disablingly low self-esteem, requiring the sufferer to seek almost constant recognition and reward."
He goes on to say that if a narcissist is denied recognition, especially if he has had a history of abuse and marginalization, he can become enraged, gradually moreso. A sense of powerlessness is replaced by a (my addition in parenthetic italics)
"heady experience that may produce an implacable serenity on the one hand (Cho), or the eerily jocular banter that surveillance tapes picked up between Harris and Klebold in Columbine on the other."
Kluger says that the gunman is calm because he knows he's right
". . .the world has brought the carnage upon itself."
I would say that yes, it looks like that, like Cho was confident in his decision to kill and felt justified, like he'd been harmed and was delivering vengeance. But in this case the gunman was calm, very probably, because he knew he was following the orders of the voices in his head that said, They've harmed you, cheated you, ignored you. Kill them. Soon.

The narcissist would be thinking for himself, the person with schizophrenia has help. The thoughts are the same, but the person with schizophrenia is hearing voices and is fearful, not righteously indignant like the narcissist.

This is why I'm not quick to join Time Magazine's journalist who concludes by saying that we can predict these things because murderers who suffer from clinical narcissism do tell people, even brag to others that they intend to perpetrate their crimes. Harris and Kebold said so on the Internet. I don't remember reading that that was the case with Cho at all. Who did he talk to? Did he tell someone? Am I missing something? It would have been difficult for anyone to read his mind. Again, it's very possible that we're missing information. We're only one week from the event. More will tumble out over the coming weeks, months and years.

So I'll stick to my original diagnosis of schizophrenia for now.

Nevertheless, this is a perfect example of why diagnosis per se is often a dead end and tells us little.

On the surface, Cho had most of the symptoms, if not all, of Narcissistic Personality Disorder. But it certainly wasn't a pervasive disorder as it didn't manifest until the episode, the massacre.
We don't even know if he slept. Perhaps he had a manic episode.

And if we add narcissism to Cho's Axis II disorders, does that mean we have to be very careful with every narcissistic adolescent we see? Normal adolescents can go through a very narcissistic phase but the grow out of it and everyone is grateful. Also, in NPD there is typically a LACK of self-destructiveness, impulsiveness, or concern with abandonment. You did this to me might be saying something about abandonment. Suicide IS self-destructive.

I think the key word to look at, forget the clinical diagnosis for a minute, is arousal. Screaming anxiety/anger, uncontrollable, painful arousal, likely caused by dysfunction of the limbic system and perhaps voices in his head or perhaps, as Kluger says, righteous indignation.

Thus when we send psycho-educational teams of mental health professionals and peer counselors to our schools to teach children about mental illness, as I've suggested on other posts, they will focus on communication and anger management. I am working on the program right now.

I base that trajectory, by the way, the Schizoid Personality Disorder premorbid to Schizophrenia upon what the American Psychiatric Association finds statistically significant in the data analysis of studies in the general and clinical populations. The DSM is a product of 13 Work Groups and a Task Force, consensus scholars without previously held views, who analyzed cross-cultural data.

By the way. This is not to say that people who do have personality disorders don't have some kind of genetic predisposition that presents as lacking empathy. We'll save empathy, however, for the next discussion.

Copyright 2007 TherapyDoc

Saturday, April 21, 2007

Show the Video

Friday afternoon I talked to my son who had written 3 pieces about the Virginia Tech massacre for a t.v. show that generally spins celebrity gossip. He said he was surprised that the producers were so into real world news, as opposed to gossip about Brittany or Halle, Brad and Luke.

Y. said that what they're really talking about in Hollywood is how badly NBC goofed by releasing the video Cho sent to them in his "manifesto." The video was subsequently picked up by all of the other major networks and everyone who owns a television saw it before the network executives thought about it and realized that this was a bad idea. The video glorified Cho and would encourage copycats, people who might perpetrate violence to further political agendas.

My feeling? I know I'm going to hear about it, but
Show it in schools. Show it at community centers. Show it in churches, synagogues and mosques. Have assemblies with panels of experts talking about it in front of as many listeners as you can find. In schools, have students and mental health professionals discuss it in front of everyone, microphones on! Talk about it, don't shove it under the rug!

It is wrong that millions of people even see what Cho did as a political statement. He was very, very ill. That's all. He was mentally ill, a person suffering, yes SUFFERING, from a disorder, Paranoid Schizophrenia. To prevent copycats, the public needs psycho-education. In a big way.

Children especially need to know about this disorder. They need to know, if you ask me, about all kinds of mental, behavioral and emotional disorders that we discuss on this blog. Who's going to teach them?

How hard could it be to find professionals willing to speak to kids, participate on panels?

I think it's the Chinese who say, Crisis Equals Opportunity.

If we let this one pass, we really should be ashamed of ourselves.


Friday, April 20, 2007

Q & A: Expressed Emotion and Schizophrenia

A reader writes:

I have a friend, let's call him X, who refuses to communicate with me now because I keep telling him he should be on medication to help him with his paranoia. I'm pretty sure X hears voices and he also is quite sure that Jesus speaks to him personally. He won't go to therapy. Any advice or
insight would be welcome. Thanks!

First of all, you can't put yourself in the place of a trained mental health professional.

Be that as it may, I think from your letter that you recognize that X may suffer from schizophrenia, a disorder that drastically affects cognitive functioning. You budding therapists out there may know by now that that means we don't do any rational cognitive therapy in this case.* What it means in plain English for everyone else is that you don't try to reason with a person who has difficulty reasoning, as is often characteristic of persons with schizophrenia.

You can and should contact X's family, tell them of your suspicions, ask them to help X get help. You said he is high functioning, so they may be in denial and may have little control over X and his compliance to treatment. But you never know until you ask.

As a friend you can remain supportive and caring. That may seem like no big deal, but it is a tremendous deal, and it translates into avoiding "expressed emotion," and telling others to do that as well.

"Expressed emotion" in this context is anger. People with schizophrenia are extremely sensitive to stress, and conflict/anger is stressful. We protect loved ones who suffer from this disorder by avoiding any criticism, sarcasm, argument, loud noises, yelling, even angry facial expressions, decisions, demands, bad news when in their presence.

You can also ask X what he's thinking. If he says voices speak to him and to no one else, then ask him what the voices are saying. If the words he's hearing in his head scare or stress him, he might confide in you. It might be a relief to tell you about them. He might get to a point where he really wants help. He's scared. Then you're there to take him in to see a psychiatrist. Skip right to a medical doctor with a person who has schizophrenia if at all possible.

Being supportive and non-conflictual is the best way to help someone who says they don't want help. Persons who suffer from mental illness who are mistrustful of the health care system have a right to be afraid. It is terrifying to them. They have to trust you or someone else, like a physician or a therapist, to the degree that they will confide their fear before there is a possibility of lowering resistance. If a sick person is in enough psychic pain, he might reach out for relief.

You may be that person who gets to hear
how bad it really is for X. Then it is in your court to somehow reel him in. Until he's there, meaning until X really is in tremendous psychic pain and is willing to talk about it, all you'll get is denial and social withdrawal.

You want him to get help before he hurts himself or someone else. Not every person with schizophrenia is dangerous, but that's not your call to make. So if you really are friends with X or someone with this disorder, without seeming too invasive, hearing the thoughts is pretty important, and attending to them without being conflictual or demanding is the objective.

You want to ask him directly (gently) if he ever feels like hurting himself or anyone else.
In that case, you really have some convincing to do, and might have to bring in either the police or a mental health professional who will help you bring him to a hospital. Sometimes the police are actually well-trained for this kind of thing.

And good luck.

*Studies have shown, according to F.D., that cognitive therapies are used successfully as an adjunct when drug therapies have successfully stabilized patients with schizophrenia.

Friends, if you have any other suggestions, by all means comment below. But...
I'm not encyclopedic, certainly, and don't pretend to know everything. I just want to be helpful generally, not to advise in particular cases. These are merely guidelines. Please consult appropriate mental health and legal professionals with problems when you think they might help.


I can hear you breathe

Alternatively titled, Food is Love.

I get a little light-headed, you know, when I'm feeling pressured.

It's been a crazy week, the first full work week after a long holiday, so many patients to see, give or take a couple of cancellations, double the usual number of calls, loads of laundry, house work, family medical nonsense, and


Lots of it, no thanks to a certain massacre in Virginia.

Since I wrote a lot, working it all out as I went along, there was pressure to read and post your thoughtful comments and respond to them, too, which takes time. It's not something I'd really considered when I started writing this thing, but it is undoubtedly a labor of love now.

Still. You should see my desk, a casualty of neglect, and don't ask me where your anything is until Friday when it all gets filed away or shoved into a drawer until I can decide what to do with it. Who's got a match?

So last night was a welcome relief. Went out with a colleague, which took me away from this world, sort of, except for that occasional reference over salad and fish to my Internet Addiction and pressured speech. It was suggested that I could actually post only a couple of times a week if I really wanted. I told my friend that if and when this gets dysfunctional to my family, myself, or my practice, that'll happen.

But so far, everyone's let me slide.

Still, let me tell you something about some of the consequences of doing anything new that disrupts the rhythm of your life. When that happens everyone in your world, including you, has to adapt to it, and sometimes their adaptation is actually for the better. It's called growth.

Growth is a key concept in therapy.

Just this week a patient was saying to me that she didn't know how to develop confidence (she's one of the highest functioning individuals I know, of course). I gave her the No Calculated Risk, No Growth adage, similar to No Pain, No Gain.

No Pain, No Gain is what the skiers all say, but ever since the time I wiped out and lost a ski at the top of a mountain in Utah, looked up at the sky (for there was no place else to look but up), and said, never again, No Pain, No Gain has not been my philosophy.

If it might hurt (physically), it's not my kind of risk and I'm not going to be on board. Unless it's your physical therapist telling you to do it. Then maybe.

But a behavioral stretch without dire consequences? Sure. Consider it. Emotional growth is more likely to happen when you try something different, something new, stretch. Especially if it works out. So we try to make sure, going into it, that it'll work out when we do these kinds of things as therapeutic interventions.

Let's say you're generally a people pleaser. But one day you wake up and you're in the mood for a change. Say your hair has always been long and you're thinking of trying something different. But the significant other might not like it, based upon what's been said in the past.

Still, you calculate that it's low risk even though it's so weird for you to think of yourself differently. But it'll grow back if you don't like it. If he (she) doesn't like it, it's okay, it'll eventually grow back.

Imagine this. You do it and S.O. really IS put off, maybe even makes a not-so-supportive comment at first. But everyone else likes it. Still, you're shaky. After a couple of hours, however, S.O. sees you're sad, looks at you critically, smiles and says, "It's nice. It's really nice."

You say, "You really like it?"

He loves you so no matter what he thinks he says, "I really like it."

He had to grow here, too, had to rise to the occasion. If he didn't, you would have to trot on over to my office or call your mother in tears. Of course, if this had been my case you would have dragged your significant other into therapy with you and we would have strategized together from the get-go so that you would have been supported in your risk.

When the results of change are positive, you're pumped, powerful. When they're negative you find that you still survived, anyway. The confidence light somewhere in the confidence center of your brain (one of those spots on the PET scan, as yet unidentifiable) burns brighter because the risk hasn't turned to disaster, and it won't, face it, when it's a calculated risk.

I'm NOT advocating gambling in this post, okay? I don't consider gambling a calculated risk. It's calculated, perhaps, for you to lose.

Others notice changes like the one in the haircut example and go crazy with delight. They praise you. (Wow, love the haircut!) You're different in their eyes, gutsier. That praise reinforces your emotional growth, your sense of mastery. You are so cool. One small clip of the scissors, one giant step for mankind.

Here's another example, small scale. Maybe not the best example, but it's not a bad story. It's actually a love story. So don't spleen me.

I said to F.D. early in the week, I'm going out with so and so for dinner on Wednesday night. You're on your own. Okay?

He didn't seem happy but didn't say anything.

You have to understand, it wasn't about the food or jealousy. He could live on air. But he usually has band practice on Wednesdays, and this particular Wednesday he didn't, so he could see the two of us going out for dinner or to a movie maybe. He's not used to being the one home alone in the evening. He's the one who goes out, does community activities. So this threw him off, I think.

But he knows I need this female-female diversion thing.

There was a point when I could see his wheels starting to turn.

So I went out and when I got home last night I walked into the house and the smell of his cooking was, I am not exaggerating, was better than anything I have ever inhaled in my life. He's a marvelous cook, although it has been very limited to an occasional omelet and his special barbeque sauce, a concoction he makes to baste a bird on Friday nights. The sauce is always a little different and I get to give it the taste test as he experiments, shake my head and stare at him, mesmerized with gustatory admiration. It's a great sauce.

But he's never seriously ventured into anything besides chicken, probably because I'm always puttering around the kitchen when I'm home and it's a SMALL kitchen.

So I came home on Wednesday night to an unbelievable stir fry. He had used two fry pans, separating the meat from the vegetables, and had saved some of the latter for me, lest I didn't eat enough at the restaurant, which I had. He said, "You'll have this for lunch tomorrow. Try the rice."

And indeed I did.

That red tupperware on the corner of my desk? Yup, that was it.

Now that he's got some confidence, I'm thinking that one night a week for sure, F.D. should be cooking dinner. It'll help me catch my breath, slow me down so that I can stop, exhale and inhale, maybe get close enough to him to hear him breathe, as the song goes.

That, or I'll have to leave him alone more often so that I can get a decent meal.

P.S. You should know that when I suggested this to him he said I was out of my tree. (sigh). And really? He said he made that stir fry for himself. I was going out. Whatever works, I say.

Copyright 2007, TherapyDoc

Thursday, April 19, 2007


An anonymous reader pointed out that I should not have equated "psychotic" and "murderous".

Absolutely correct; that was insensitive and gave you permission to make the same association, which of course you should not.

In my mind I never thought of them as equivalent, but wanted to use the word murderous journalistically. It sounded good in the sentence. Interestingly, there was a ping in my head that said, take that back, and I didn't listen, thought, well, they know I don't really mean it that way. Denial.

But I take it back!


We use the word psychotic to define a certain class of disorders in which an individual suffers from one or more of the following features:

1) delusions
2) hallucinations
3) disorganized speech (e.g. frequent derailment or incoherence)
4) grossly disorganized or catatonic behavior

I define them in the post below.

We do not include a symptom if it is a culturally sanctioned response pattern.

The type of psychotic disorder, an actual diagnosis, depends upon its duration, how it presents, if it is in the context of a close relationship with another person who has an already-established delusion (a Folie a Deux), if there is a medical condition that causes the symptoms, or if it is induced by substance abuse or marked stress.

Humbly yours,


Since You Asked: Schizophrenia

Schizophrenia involves dysfunction in one or more major areas:

interpersonal relationships
education, or

Typically functioning is below what it was prior to the onset of the illness. In children and adolescents, educational progress is disrupted, adults can't usually continue to work.

Schizophrenia is one of the psychotic disorders and is a disturbance that lasts for at least 6 months* and includes at least 1 month of 2 or more of the following:

often persecutory, I'm being tormented, tricked, spied on;
referential, certain gestures, articles in the newspaper are aimed at me; someone has replaced my kidneys while I was asleep;
thought insertion, an alien is telling me what to think, or
thought depletion- an alien has taken my thoughts

these beliefs, cognitions, experiences aren't funny, they're terrifying


generally auditory, hearing voices,
sometimes one or two voices that are discussing a sufferer's thoughts,
sometimes they tell the sufferer what to do, i.e., shoot someone;

other hallucinations affect the other senses:
olfactory (smells),
gustatory (taste),
and tactile (bugs are crawling on me).

Some studies indicate that the brain really does light up in these areas when a person is experiencing a hallucination.

Hallucinations can occur in the absence of schizophrenia, I (therapydoc) sometimes feel there's an ant on me when there isn't, but actually, sometimes there is. Avoid dry skin, perhaps is the solution

disorganized thinking
derailment or loose associations,

answers that are not related to the question,

sometimes speaks aphasic, as in "word salad" or incoherence that is severe enough to impair effective communication

grossly disorganized behavior-
ranges from childlike silliness to unpredictable agitation

inability to stay on tasks, such as making meals

doesn't, can't attend to hygiene

appears disheveled or wears unusual attire (many coats)

catatonic motor behavior -
a marked decrease in reactivity to the environment
rigid posture
resists efforts to be moved
is in a stupor

negative symptoms
affective flattening- a person's face appears immobile, unresponsive, poor eye contact, reduced body language;

alogia is poverty of speech, manifested by brief, laconic, and empty replies (or none at all), due to lack of thoughts or decreased fluency;

avolition, characterized by an inability to initiate and persist in goal directed activities

The features can't be explained by another disorder (such as Bi-polar Disorder), a general medical condition, or the effects of a drug.

That's it in a very large nutshell, but there is much more for you to know.

*all of this material, except for my examples and commentary is in the Diagnostic Statistical Manual, or DSM IV-TR, American Psychiatric Association


Wednesday, April 18, 2007

Cho update

So it's looking as if my assessment in the last post wasn't all that far off.

Cho was a very silent guy during childhood, but went to school and managed to perform well in school. His detachment justifies a Schizoid Personality Disorder diagnosis, premorbid to Schizophrenia, Paranoid Type that presented at Virginia Tech in 2005, perhaps even earlier, in his early 20's. A very common onset for schizophrenia.

His final words, "But you decided to spill my blood. You forced me into a corner and gave me only one option. The decision was yours. Now you have blood on your hands that will never wash off."

To me that sounds as if he thinks he's the one who had been crucified 2 millenium ago (I'm admittedly no expert on this), a sign of schizophrenia, thinking you're the father of Christianity.

We still don't know if he was an abused child. It has been repeated in the news that his parents worked very hard and stressed achievement, which explains why he and his sister tried and did very well in school, despite whatever stressors they suffered. CNN quotes someone as saying that Cho's father said that he had to leave Korea to come to America "where no one knew him."

That sounds suspiciously like foul play somewhere, somehow. In any case, Cho's mental illness surely could have been flagged much younger.

My guess is that therapy docs will be seeing many very quiet children in the next few months, perhaps years, and that's for the best if you ask me.

I like quiet kids. They have a lot to say once you get them talking.


Tuesday, April 17, 2007

Slow Burn- Cho Seung-Hui-Differential Diagnosis

Yesterday I saw the morning news and posted all those questions, knowing full well that much would come to surface in the coming days. It didn't stop me, all day long, from forming an opinion.

I saw kids doing that on television, forming opinions, and I've read blogs with opinions. I mostly heard words like "evil" and "sociopath."

After 2 hours of ABC News (who can resist Diane Sawyer?)and spontaneous tears through the footage of kids hugging and crying, and those pictures of the dead, the young, the beautiful, the talented, I still hadn't heard from the therapy docs.

There was one forensic psychiatrist on t.v., a great looking guy with a really convincing manner, very animated and right-on in some respects, for sure. He said that Cho had contempt, vicious contempt and conceit, and was filled with hatred towards the people who had hurt him.

So knowing that, I feel you need more about Cho's condition. "Contempt" hardly cuts it for me as a diagnosis.

If he was paranoid, he either had a personality disorder, perhaps Paranoid Personality Disorder, or a biological axis I disorder such as Schizophrenia, Paranoid Type.

But that's all too easy, because there are premorbid disorders, conditions people have prior to the onset of say, a psychotic disorder like Schizophrenia Paranoid Type, 295.30. And generally, people with that disorder do not function throughout childhood to the degree that we think he functioned (although at this writing, we really don't have the details about his childhood).

You notice that nowhere am I using words like evil or sociopath. That's because they aren't diagnoses. Sociopathy is a symptom of Antisocial Personality Disorder, but I haven't read anything to indicate that Cho had that. He was considered quiet and detached, not openly defiant through out his life.

Until April 16, 2007, when he defied very openly.

That can happen if a person is hearing voices (delusions) that tell him to do that, to kill people (Schizophrenia, Paranoid Type).

It surely happens when people are psychotically depressed, meaning they are suffering from a mood disorder and they want to die and are at the point of suicide, but their anger (I told you it's bad to be angry) gets the better of them. Add to that the energy (a sequela to anger) to take everyone down with them.

The ticking time bomb thing. They noticed that on campus.

According to his friends, Cho had an imaginary girlfriend. He stalked 2-3 female students, and he told his roommates about a rejection, "I might as well kill myself."
The police say he didn't threaten the women he stalked, meaning he was obsessed with them, a feature of Borderline Personality Disorder and several anxiety disorders. He didn't go home for winter or spring break (detached socially). He slept with the lights on (anxious). He may have had voices speaking to him in the dark.

Here's what I think was going on, and maybe we'll find I'm wrong in a couple of hours (it's still good to go over the different possibilities for your edification).

I think Cho had a Social Phobia and a Schizoid Personality Disorder (DSM IV-TR 301.20) that was premorbid for either Schizophrenia Paranoid Type, or Mood Disorder with Psychotic Features (psychotic = murderous), the primary DX that he had before and during his very violent outburst. Schizoid Personality Disorder looks like this, credit to the DSM:

A. A pervasive pattern of detachment from social relationships and a restricted range of expression of emotions in interpersonal settings, beginning by early adulthood and present in a variety of contexts, as indicated by four or more of the following:
(1) neither desires, nor enjoys close relationships, including family
(2) almost always chooses solitary activities
(3) has little, if any, interest in having sexual experiences with another person
(4) takes pleasure in few, if any, activities
(5) lacks close friends or confidants other than first-degree relatives
(6) appears indifferent to the praise or criticism of others.
(7) shows emotional coldness, detachment, or flattened affectivity

B. Does not occur exclusively during the course of Schizophrenia, a Mood Disorder With Psychotic Features, another Psychotic Disorder, or a Pervasive Developmental Disorder, or another medical condition.

Schizoid Personality Disorder is found premorbid to schizophrenia.

Anyway. If I think he either he always suffered from schizophrenia but he was highly functional, or

H was an abused person, abused from early childhood, either physically, verbally, emotionally or sexually. Or he lived with someone who beat or abused someone else, perhaps a sibling or a parent.

He developed severe, severe anxiety and a Social Phobia, and more damage, damage to the psyche and to the personality.

The personality is paralyzed in schizoid individuals and Cho didn't talk to people. He did speak through his plays, and he undoubtedly (in my guess-tim-ation) talked to himself about his anger at people who teased him for his inability to spit out words, and his anger at people for being rich, beautiful, whatever. He was his only friend.

One student at VTech said that they used to play games with Cho. "I'll give you ten dollars if you'll say, 'gimme five'."

That makes a shy person angry. It builds up. It's likely it went on throughout his childhood, derision for being socially unskilled, "weird." Socially detached people aren't understood by others, they're teased. But they have feelings and get angry. It can simmer through the years. The anxiety turns to anger. They're both symptoms of arousal.

That kind of psychotic anger is typical in Schizophrenia, Paranoid Type, too. We feel that stress triggers the genetic predisposition to schizophrenia. The stress of needing female companionship, the stress of grades, the stress of comparative poverty--these are triggers. People with schizophrenia are very sensitive. You don't want to upset them, criticize them (expressed emotion, discussed elsewhere in this blog). This is why I keep stressing Be Nice. We do have a societal obligation, among other things, to be nice. His room mates, by the way, are amazingly wonderful people. They were so patient with this boy who was so ill.

The therapy doc he saw didn't recognize the arousal, the potential for harm, because Cho was probably mute. He looked anxious, probably depressed. They'd call it "agitated depression" perhaps.

People did see him seething, however, and one teacher threatened to quit if he wasn't removed from his class, so he was clearly out of control of his emotions. He needed what we would call, Major Meds.

He was psychotic, of that there's not doubt, regardless the cause, and his teachers DID call the police, and students DID treat him with kid gloves. (Go to the CNN website and see that video with his roommates on 360.)

Sure, 20/20 hindsight, he needed to be forcibly hospitalized and treated. I won't hold by evil, or by sociopath, cold-blooded killer ala Sopranos.

The guy was mentally ill.

I have to go watch t.v.

P.S. I'm adding this to the post later. I chose schizoid personality disorder over childhood schizophrenia based upon his high functioning in academics, but indeed, his poor functioning socially, and perhaps inability to relate to anyone, including a therapist, might have indicated childhood schizophrenia. For all we know he was delusional all of his life, and it's possible that he had many incoherent, mind-jumbled days during his childhood.


Cho Seung-Hui's Plays

Cho Seung-Hui, the student who killed 32 people at Virginia Tech, was a writer of "twisted plays." Ian McFarlane, his former classmate and a current employee at AOL has them.

Ian writes about Cho Seung-Hui at AOL

After hearing about the mass shootings, I sent one of my friends a Facebook message asking him if he knew anything about Seung Cho and if he could have been involved. He replied: "dude that's EXACTLY what I was thinking! No, I haven't heard anything, but seriously, that was the first thing I thought when I heard he was Asian."

While I "knew" Cho, I always wished there was something I could do for him, but I couldn't think of anything. As far as notifying authorities, there isn't (to my knowledge) any system set up that lets people say "Hey! This guy has some issues! Maybe you should look into this guy!" If there were, I definitely would have tried to get the kid some help. I think that could have had a good chance of averting yesterday's tragedy more than anything.

While I was hesitant at first to release these plays (because I didn't know if there are laws against it), I had to put myself in the shoes of the average person researching this situation. I'd want to know everything I could about the killer to figure out what could drive a person to do something like this and hopefully prevent it in the future. Also, I hope this might help people start caring about others more no matter how weird they might seem, because if this was some kind of cry for attention, then he should have gotten it a long time ago.

The plays are now posted on AOL and you can read them (unless you suffer from depression and I've been telling you to avoid disturbing news stories) by clicking on this link to that site

Now that's the power of the Internet. Amazing that we could read this if we wanted.

No, I haven't read the plays. I still have 2 more patients to see and even later, I don't know how much "twisted" I can take. But we were looking for the Why's in the last post, so here they are.

On subscribing to ENTx

If you haven't received emails announcing recent posts, you probably have to re-subscribe. I messed up, technologically speaking. It's fixed now, but re-enter your email address and start over. Really sorry.

Virginia Tech Massacre

2 weapons recovered at the scene
22 mm. handgun, 9mm semi-automatic

I don't understand these things, guns

an isolated domestic violence incident

Hospital official: This man was brutal. There wasn't a shooting victim with less than 3 bullet wounds, abdomen, chest, head. We're a small rural hospital, 126 beds, we had to send three out to Roanoake.

Roanoacke trauma center 3
Louisgale Hospital 3
Montgomery Regional Hospital 9
families are bedside
these are the survivors


deadliest shooting spree in US history
one year post-Columbine, almost to the day

Zach Petkowicz--hero--barricaded another classroom shut using a rectangular table, held off the gunman who tried to push into the room full of students

psychotic energy (my words)

Face Book

black ribbons

The Virginia Tech Web Site:
Campus closed today; convocation at Cassell

Updated at 7 a.m., Tuesday, 04.17.2007

Counseling assistance for students is available at West Ambler Johnston and McComas Hall until 9 p.m. Students are encouraged to utilize these services. Students may also gather at the Old Dominion Ballroom in Squires Student Center.

Counseling assistance for faculty and staff today has been moved to Brush Mountain Room A in Squires, from 8 a.m. to 5 p.m.

Two shooting incidents on campus Monday left 33 dead. Thirty-one, including the gunman, died at Norris Hall; two died at West Ambler Johnston Hall. Fifteen other victims from Norris are being treated at area hospitals.

Officials are in the process of identifying victims and notifying next-of-kin. Names will not be released until that process is complete.

Essential personnel are to report for work today. Classes are canceled.

A public gathering will be held at Cassell Coliseum at 2 p.m.

How does this happen? Why?

Can we assume he had counseling and that it didn't help?
Can we assume he was either an emotional, physically, or verbally abused person?
Can we assume that he was failing? Engineering is hard.
Can we assume that he lost in love?
Can we assume he was mentally ill, that he heard voices, that it was premeditated?

Therapy doc pundits like me assume it all in varying combinations. The median age for onset of schizophrenia is early to mid-twenties, and delusional paranoid schizophrenia is associated with violent behavior. That's certainly possible. Bi-polars are usually spontaneous and this seemed premeditated.

He wore something that looked like a boyscout uniform.

We'll find out, I hope, in the coming days. Meanwhile, the counseling centers in Blacksburg have their work cut out for them. Graduation is in three weeks and there is no way, simply no way that the students at this school will put the past behind them so soon.

Oh. And of course, I forgot. If you happen to need to buy a gun? Go to Virginia, the second easiest state in the country, apparently to whiz through the purchasing process. No background checks, no licenses. Anyone can get one.

Ironically, it's an election day in Chicago. Now here's a cause, for those of you who feel you need to get involved in something. I'm always pushing my patients to get involved in SOMETHING. This might be interesting, gun control.

I wonder what people will be talking about in my office today?

Sadly yours,


Monday, April 16, 2007

A Moment of Silence

I woke up a little early this morning and thought,

Something’s going on.

Don’t know why, just had that feeling. So I threw on some sweats and trudged downstairs to make the coffee, flipped on the radio. No. Nothing’s going on. Snow in the east, poor Dovid and Cham.

Slipped into the family room to check out the television news.
Ah, ha. I KNEW IT. Even though I read several Jewish-Israeli blogs last night (there are thousands of them, Jews have a lot of words), I missed it!

Today is Holocaust Remembrance Day.

What’s that mean?

Well, I was there, so I know. No, I wasn’t alive during World War II unless you believe that the souls of the victims of the Holocaust were recycled and those of us who were born after the war and are alive today are vessels. Which is plausible.

But I refer to being in Israel on a Holocaust Remembrance Day.

I remember that feeling when the sirens sounded throughout the country and life came to a standstill, literally, as millions of Israelis stopped whatever it was they were doing at 10 a.m. Buses stopped in the streets, cars on major highways, shoppers put down their bags, merchants stopped selling, balcony rug-shakers stopped shaking. Everyone stopped to pay respect to 6 million killed by the Nazis. That moment of silence is for remembering.

It’s a powerful, chilling.

Holidays in Israel start the night before, as does the Day of Remembrance. Last night, according to the Jerusalem Post ( the Knesset, the legislative arm of the government, began its Holocaust Remembrance Day ceremony, "To Each a Name." Ministers and members of Knesset read names of victims.

Quotes from President Dalia Itzik’s speech:

“The Holocaust proved evil can be organized," said Itzik. "The world needs to beware, and remember that the Nazis were human beings. The atrocities were created by people. The Holocaust is an "Ot Kain", a stain on humanity."

"There are no words that can explain the horror of the Shoah. Only the testimonies, silent and spoken can attain to this atrocity," said Itzik.

Prime Minister Ehud Olmert reminds us:

"Sixty-two years have passed since the end of the most gruesome battles history has bared witness to. On the day of victory, the entire world danced in the streets of the capital cities. Only the Jews did not join in these celebrations, there was no reason to celebrate - a third of their people were wiped out."

"Only on the day of Israel's independence did the Jews allow themselves to celebrate. In eight days we will be celebrating Israel's Independence Day. The correlation between this Remembrance Day, and the following celebrations is direct," Olmert continued.

So that’s what Israel Independence Day will be about next week.

Does that mean that Jews are out of the woods?

Bad news.

According to Tel Aviv University’s Stephen Roth Institute for the Study of Contemporary Anti-Semitism and Racism, anti-Semitic incidents world-wide increased 31% in 2006 from 2005. In France and Norway chief rabbis are calling on Jews not to step outside as Jews. They’re not to wear Jewish symbols.

This comes as no surprise to those of us who are outraged by threats of Holocaust denier Iranian President Mahmoud Ahmadinejad to eliminate Israel.

So I read all of that this morning and took notes for you as I sipped my coffee and waited for my battery to go dead.

And I thought of a story that the daughter of a Holocaust survivor sent me. We had been corresponding and at one point I had been ruminating about the loss of my brother who drowned while away at college, whose body, born in 1950, passed on in 1970. He probably had a victim's soul in it, a soul that only needed to accomplish something that would take 20 years to accomplish.

I shared with her that sometimes I let my imagination go and when there are regrets-- it can really get out of control.

My new friend learned that I wish my parents had sent my brother to Israel to study in a seminary after high school, like modern Orthodox Jews try to do these days. Then he wouldn’t have been where he was and it wouldn’t have happened, he wouldn't have drowned at college.

She wrote me the following:

My mom tells a terrible story of her cousin who was locked up in a barracks in the final days of WWII in Auschwitz. This cousin heard that her barracks were set to be killed off. She smuggled her way out and snuck into a barrack nearby. The next day, prisoners in the new barracks were taken out and killed, my mom's cousin included. Most of the people in the original barracks survived.

Point of story? You can try to save yourself or be someplace else, but what will be will be. This story haunts my mom even now, more than 60 years later. She wishes her cousin had been someplace else, too.

Packs a punch.

What will be will be? Maybe for most things, maybe.

But we have to do what we can to be sure that atrocities like the Holocaust never happen again. What that means to each and every one of you, I don’t know. What it means to me is that I have to tell people that the Holocaust really did happen, despite what the idiot despots out there will have you believe. I know, I'm preaching to the choir.

Good morning friends. Have a good day. Stop and remember.

Copyright 2007, TherapyDoc

Saturday, April 14, 2007

Obesity Wars

"Mr. Coca, do you think I'm fat?" a 5th grade girl asked her physical education instructor at Wagonwheel Elementary School.

According to journalist Anne Marie Chaker, in the Weekend Edition of the Wall Street Journal Jim Coca was just following instructions when he chose 20 children for the Healthy Schools Initiative,the district's new fitness and nutrition program. Parents of students who performed poorly in physical education and had high body mass indices received exclusive letters inviting their children to participate.

The body mass index (BMI) is a feature now posted on report cards in their town, Gillette, Wyoming. Several parents, infuriated at the districts' audacity, grading body mass, were appalled that their children had been singled out for the program. Mr. Coca says that he won't make the same mistake again next year. He won't be hurting feelings. Someone else can do the choosing from now on.

The Healthy Schools Initiative more than complies with new federal regulations. Schools receiving federal meal subsidies must create a "wellness policy" that outlines goals for nutrition and fitness. Policy-meisters at Yale University recommend interventions that create a healthier educational culture. So Wagonwheel Elementary is in with the in-crowd.

My opinion on the program? Great. But the implementation leaves a lot to be desired. And sending home the body mass index (BMI) on a report card is shaming, humiliating, and wrong. Arkansas, one of the first states to take this measure, responded to parental backlash. The physical fitness evaluation and BMI is no longer mandatory in Arkansas. Parents effectively told administrators to leave their children's health and mental health alone. They said they didn't need to hear about it and nobody else did, either.

They know their kids.

It's true, I feel, that schools do create social norms, as the researchers at Yale point out. But one of the norms shouldn't be to humiliate students who are already suffering the taunts of other children regarding the shapes of their bodies.

But the program idea is a good one. After all, childhood obesity is on the rise, 17% higher today than it was 25 years ago and obesity is a serious health hazard. It may be true that between the ages of 6 and 13, if children are not already obese and haven't developed fat cells yet, that their chances of winning the war against obesity will be greater. So we don't need to throw out the idea of waging this war with youthful soldiers.

Programs in schools that promote healthy thinking, healthy communication, healthy bodies and healthy minds-- they're all good.

Implementation, however, should be conceived with sensitivity. These are sensitive matters.

The letter, for example. What a terrible idea! Why would the schools send home letters to tell parents that their children are obese? Parents are painfully aware. Many actually shield their children from the label knowing how hurtful it can be, hoping that their children will grow out of it, and many do. Surely there is a better way to publicize a program than to invite a select few to participate. Perhaps invite EVERY child to participate. Then a letter, depending upon how it is worded, might be a good idea. Better yet, make the program mandatory for every child.

There isn't enough money for that? Fine, then at parent-teacher conferences have teacher discuss with the lucky "chosen" parents the option of the Healthy Schools Initiative. But that discussion should be scripted, perhaps with the help of a mental health professional who could coach the staff.

I'd script it like this:
Mrs. Jones, how do you feel Suzie's doing socially? Does she seem happy in my class? I really try to create an environment where all the children are nice to one another but this isn't easy. Some kids, we all know, pick on other kids. I try to keep that to a minimum in my class, but I can't watch them all of the time. I worry about every student. Does Suzie ever say anything to you about being unhappy at school?
If the parent says no, her kid is just fine, thank you, then that's the end of the discussion. If it's a yes, then we have something to talk about.

Parents do bring children to see therapy docs like me because their children are depressed about their weight. It's not an easy thing to live with, obesity, and it's sometimes one of the most difficult problems to treat. A family therapy works best, one in which everyone is supportive, everyone works on eating healthy, and everyone is conscious of the psychological side effects of obesity.

Food's a very emotional subject. We love our food and we love to eat.

In alcoholic families, the nurturing can come from alcohol. Parents in alcoholic families give alcohol to kids with sore throats, ear infections, and conversely give doses of alcohol to children on happy occasions, like birthdays. It's the same in food families. Food for a bad day, food for a good day, food for a good grade, food for a bad grade. We're always consuming something to celebrate or to feel better.

Many of us come from families in which parents grew up in cultures of poverty and couldn't afford food. Our parents starved as immigrants or survivors. To them, stocking up on food was survival, being fat a good thing, a safe thing. Es, kind, eat my child, was kindness.

And our brains are wired with a pleasure center that lights up when the palette is happy, the tummy full (not so much the latter).

Plus, we're bombarded by advertisements for new tastes, foods we HAVE to try.

And you know you can't just eat just one potato chip. Even if I said, actually, you can, you can eat just one potato chip, you wouldn't believe me.

We eat when we're happy, we eat when we're sad. We eat when we're bored or we're anxious. We eat when we're talking, we eat when we're driving. Some of us would eat all day long if we could. We just haven't learned to put that space between meals and we haven't learned what it takes for our bodies and minds to be truly be satisfied with healthy eating. These habits and genetics, too, are surely passed onto our children.

That makes it first a family problem and then perhaps a village problem.

The real cultural war is the one we have to wage at home, I think.

Copyright 2007, TherapyDoc

Thursday, April 12, 2007


Not to distract you from the blog, but I've been messing around with feeds and need to test something out, so if you're reading this post, go ahead and ignore it. Read stuff below instead for ENTx or just go ahead, say hi.

Anyway, if you subscribed, you might want to unsubscribe. I'll let you know when it's safe to start over and am sorry for the inconvenience.

Wednesday, April 11, 2007

When the Little Things Go Wrong

today's story is about relativism.

This morning I made two runs to Ohare. The airport is 30 minutes from my house and in good weather, if traffic is light, I can make it in 25. The foot of snow in Cleveland had by-passed Chicago, but we were in for a good 1-3 inches in Chi-Town for the morning's rush hour.

Which was good but not so good. My grandsons love snow. Thus it was good. Not so good because they had a 7 a.m. flight back to Los Angeles and if we were to get to the airport on time, then building a snowman would be out of the question. Unless the flight was canceled. And who knew?

Because we like to know, F.D. sets it up so that the good people at American Airlines call us when a flight is delayed or canceled. So he set it up last night so that my son-in-law Y. would get the call. Y. didn't get a call from American and the on-line screen at the website said It's A Go. So off we went.

We had to borrow a second car because they have a lot of stuff: two little boys, a stroller, a couple of suitcases, books, food, and none of that fits on a bicycle. You might already know that F.D. and I ride our old ten-speeds to work when the weather's not weather. Sometimes our one and only car, an old Altima, just sits in front of the house, happy, I think, to be safe-guarding the lawn from something mysterious. So we borrowed another small car this morning, a Kia, from F.D.'s mom.

Mom, can we borrow your car?

Take my car, take my jacket, take my furniture, please, whatever you need.

Thanks Mom.
So I had the boys and Empath Daught in the Altima. F.D. had Y. and lots of luggage in the Kia.

Was it ever coming down! Snow, here. Snow there. Snow was simply everywhere!

In April!

About ten minutes into the drive I got a call from F.D.
Uh, I'd take Touhy. The expressways are jammed up.

Okay. Well, you know he's right about everything. We flew down Touhy and we were at the airport in record time despite the weather, snow and sleet and whatever that was. Kisses, hugs, tears.

Empath Daught says to me curbside: So in the end it was good, right, our trip? No drama once we got here and we did get here, eventually. We had a wonderful time. I had a wonderful time.

Me: Yup. It was good. More than good.

E.(larger grandson, all of 4 years old, K"H): Bubbie, come to see us VERY soon, okay?


A. (smaller, all of 2 years old, an essential exaggeration of life as it should be, K"H): VERY SOON!

Right-o. Sniff. Bye. F.D. has zipped off to work already in the Kia. I take one last look curbside, start the car again, drive away, no looking back again.

Indeed we had been shorted on time. The kids missed their original 6 a.m. flight to Chicago last week and did not make it home for the holiday, not for the first 2 days of the 8 day fete, the ones that are the most fun, when Passover is most new. It was a heart-breaker and a continuing saga, since they waited stand-by for three more flights that day, missing out on each by a hair.

This had threatened to make the holiday a serious downer, had we not all been able to stay relativistic. The grandchildren not performing at the seder meals would have been the worst thing possible at the time, had we not stayed relativistic. Because it's all for children in the end, the story telling at the seder.

What could possibly do that, make us relativistic?

Well, what truly IS the worst thing in the world?

Loss of life, of course. And we were to have a death in the family in only a few short hours. So Empath Daugh missing her flight seemed small. And Dovid and Cham, my near-to-the-youngest and his wife were there, with us. They were sad, but they were there, in our home. And we will miss Aunt R. forever, all of us, a kind, generous, caring, wonderful human being.

So her passing put flight-missing in perspective. We couldn't handle putting our feelings on the table at all, really. None of them. We talked it out for an hour before dinner then left the sadness in the family room. The odds were good that we would see some family members soon enough, and another not for a long time. When Dovid married Cham and I realized this aunt would be in my family I was so happy. That's how life is.

But there's more to the story, less sad. You SAID you liked long stories.

I had a second run to the airport today, remember? The Stooge, his beautiful wife and my precious granddaughter K"H still had to get to the airport! And the snow refused to stop. They, too, had been delayed coming to Chicago. The baby's ear infection held them up and they didn't get in on Shabbas, shaving 2 full days off of their visit, and here we were again, dealing with a coming/going only 2 days and 17 hours later.

Now if you remember, on my first trip to the airport when I took Empath Daught and her family to Ohare, I hadn't bothered looking anywhere but three feet directly ahead as the driving snow (love that pun), had literally blinded me to the construction in the east bound lane to my left, the lane I would be taking home.

An hour and 13 minutes later after dropping off Empath Daught and her family, I had crawled through that traffic and made it to B.B.'s Bagels. A Jewish mother has to bring home food. The Stooge, his beautiful wife and my grandDaught K"H had to have food for their trip, and I'll admit, I was hungry, but really, really tired. Minutes later I was flopped out on the sofa in the living room shoes on (so not me), bag of bagels dangling at my side.

House phone rang. I accepted that, (meaning ignored it). Cell phone rang. Fumbled in my coat pocket, whipped it out, recognized a patient's number, took the call. But boy, did I make it a fast one.

Closed the eyes again. Five minutes later. Group 2 is UP, trudging up the stairs, granddaught in arms. Doesn't Bubbie want to handle breakfast so the Stooge and Southern Daught can finish packing?

Ummm. Sure. Aargh.

Coffee. Things are brighter.

Rush, rush, sandwiches to go, tighten the car seat. Traffic's fine, Southern Daught is as amazed as her nephews that snow sticks to trees! More tears, one more with one more look at you. Scoot on down to the office, this time taking the highway. Traffic's a charm.

Crazy technological difficulties right off the bat. Palm stops accepting new information. Just stops, teases at first, then laughingly quits. Printer refuses to print ANYTHING. Woman, the lousy H.P. scanner/printer/ All in One-er is telling me, We're finished.

Fine. Be that way, I know a fine garbage can in the alley.

So what if I don't know who's coming in tomorrow (it's true, I had backed up, so let's not get carried away). So what if I can't bill insurance and can't print a letter to an employer about why an employee really won't be making it in at 7:30 anymore for work, not anytime soon, that is.

Because I'll tell you something my friends. I generally get upset with technology when I can't figure it out, when things don't sync and nothing is copacetic. I want to fix it quick and I like to do things on time. I like to be on time. And when I lose minutes, hours, days that have been promised to me by my family? I'm tested, seriously. Even my patience is tested. But today? I'm good with all of it, all of the electronic aggravation, any of that sadness about the kids leaving home. It's all okay, all reversible.

Life can be, is, so easy sometimes. Relatively speaking.

P.S. If you read this post previously, then you'll notice the stuff on empathy is missing. I took it out, even though F.D. really liked it (see comments) because I want to make it longer, add to it. I'm also responding to reader feedback that it didn't sync with the rest of the post. Thanks, Christine.

Copyright 2007, TherapyDoc

Tuesday, April 10, 2007

As they pack up to leave

An Expedia itinerary

A St. Francis Hospital discharge summary protocol

An In Style Magazine with Sandra Bullock on the cover

Leggos, big ones, surprisingly not all over the place

Bibs, dirty

Many ping pong balls and similarly-sized wiffle balls in corners of the living room, dining room, kitchen, and family room

At least 7 empty matzah or cake meal cans* used to play the Grand Prize Game (that's why there are so many wiffle balls). If you're too young for Bozo the Clown, you can't possibly get this.

a high chair piled high with things that don't go on a high chair, like Passover Hagaddahs and sweaters

many paper plates, some clean

cognac, barely touched

many, many aluminum foil containers of varying sizes, strewn earlier around a one-year old toddler who is now asleep in her bed

an inside-out long-sleeved forest green striped shirt, size 4

a lime-green pair of cargo pants, size 4. Empath Daught: I couldn't resist these.

A tie-dyed burnt sienna and gold body suit, sized 12 mos., from India, a present from Uncle Bean to H-squared, but it's too small. Which is totally a shame.

Jonathan Safron Foer's second novel, how could you be surprised, he is my favorite author. It boggles my mind that one person can be so young and yet so psychologically brilliant.

sherry, kosher of course, not all that good, no where near as as good as the wine my father made in our basement, also hardly dented for obvious reasons

A car seat and 2 "child" seats. They had neither in my day. How did I make it?

A Reader that begins, "Who baked the cake?"

One of those toy vacuum cleaners that seconds as a popcorn popper.

More leggos.

More books, mostly about Spider Man, no one knows why.

A very small apple on a stuffed chair, Jonathan

sippy cups, 4 of them, some with apple juice, some grape juice, all dangerous if left unattended for too many days

2 magna doodles, one with a Pixar Toy Story book attached

Hungry Hippos. I know, the noise did do me in.

2 vases of wilted flowers with that crud that builds up on the inside

water bottles with varying amounts of left-over water

machzors and a sefira counter (you don't want to know)

Several neck ties.
Oh, that's enough. My voicemail messages sound urgent. Mainly did I get the LAST messages about the cancellations? So the 11 people I had on my schedule for today (it is 1 a.m. as I write this) have shrunk to 8, and I've learned there are 2 very nervous people who do not trust that I receive voicemail if I don't return their messages, even though my voicemail clearly says, I probably won't get to returning your messages. But who can blame them for being nervous?

*cake meal is a "fake" flour that some of us use on Passover' I know no more than this.

Sure. I'm looking forward to eating chometz (bread, or anything with flour given half a chance to rise), as soon as I get an appetite (I'm so stuffed). It's been a long 8 days.

Thank G-d.

Copyright 2007, TherapyDoc

Friday, April 06, 2007

Annoucements, Corrections, and Mirror Terrorists

I know I said I wouldn't blog during this 8 day holiday, but I have to make a quick announcement and a correction.

The announcement:
Something has to be done about mirror terrorists.

Mirror terrorists are people who knock off your side-view mirror and run.

Some have been known to leave notes before running. They'll even pay for the damage. That happened to me last fall. I left Jewel, the local grocery store, with a cart full of groceries to find a note stuck to my pathetic-looking dangling side-view mirror.

Sorry, I'll pay for it.

He scribbled his name and number on a grocery receipt and was indeed, true to his word. Marshall made a few bucks.

I don't call note-leavers mirror terrorists, but Marshall does. He fixes cars in West Rogers Park and he gets work from at least one mirror terrorist a week.

Anyway that was last fall, and here it is springtime and it's happened again, only this time, no note. So. . .to whomever knocked off my side-view mirror a week ago Friday at a drive-way on Touhy:

I mochel (forgive) you. You can sleep at night.

And thanks, F.D., for putting it back on.

F.D., by the way, always willing to give people the benefit of the doubt, is SURE the wind blew off my mirror.

Here's the correction: In the Awards post I thanked my producers, Mom & Dad but forgot to include the Old Mighty (how my grandfather referred to G-d) as a full partner in (re)production.


Three more days of matzah to go.


What's Going to Be with Our Kids?