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April 19, 2007


It's Giovanni. Nicki Giovanni, one of the top poets. Leave it to a poet to suss out someone who is really dangerous.

A member of my family has been mentally ill for over 20 years, and we have been through a number of "close calls."

The entire mental health system in this country is set up so that it only responds to "crisis." Services for prevention or follow-up are sketchy at best and in many places non-existent. When a mentally ill person "goes off" there are ALWAYS lots of warning signs, and people do notice them. A particularly egregious symptom of our broken health care system.

The senses of poets are acute: they see and hear and feel "things"--prophetically, in this case.

What Woodhall Hollow said. My wife works in public mental health, recently moving from a understaffed and underfunded 'crisis' position to one inside the corrections system. In short, if you're mentally ill, your best hope of treatment is to get sent to jail.

The main reason why mental healthcare is the poor cousin of the US system? It doesn't pay.

There isn't any question about Cho's diagnosis. He had Chronic Paranoid Schizophrenia. The question is why isn't that being said in the media? I know there's been some concern about the negative effects of "labelling" people, but this is getting absurd. Schizophrenia is a common illness. Cases of deteriorating Chronic Paranoid Schizophrenia are not so common as they once were since the advent of antipsychotic medications were introduced - but they obviously still exist. There's been a move for years to shut down all long term care facilities [which are expensive to maintain], but I find myself wondering if this movement hasn't contributed to this problem. If there's this much reticence to "name" Cho's illness in the media, it's little wonder that no one "named" it in his life and took on ther problem of dealing with Cho.

Today's mental health care system has no place to manage a Cho. If you look at Virginia's mental health web site, there's a power point presentation that proudly shows how their system is cutting the number of admissions to hospitals and shortening the length of stay. It sounds like since there's no place for Chronic Paranoid Schizophrenics, people have dealt with that fact by forgetting the name of the disorder.

Cho's going to change that...

They changed policy of campus police at Cal State Fullerton in 1976
following the death of 6 as campus police waited for SWAT to arrive. Now they have the ability to act.

Sara, excellent post. In fact, the revelations about Cho have sent shockwaves through academia — particularly the fact that one of VT's star professors threatened to quit unless something was done. For the most part, administrators are wired to avoid sticky and complicated legal confrontations, to "graduate the problem." But at what cost?

Then there's the fact that NBC decided to air those awful images. Cho all but threw down a challenge to other young men like him; so why did NBC think we needed to see that? What an irony that we weren't allowed to see the vast majority of Abu Ghraib images, but that the last dying wishes of a serial killer blanketed our airwaves even before his first victims were buried.

My wife is a retired psychiatrist, professor of psychiatry, psychiatry department chairman, associate medical school dean, and president of a professional society of academic psychiatrists. In matters political, she is well to the left of most physicians--lobbying, among other things, for a single-payer heathcare system.

And her response to this event? Straightforward and uniquivocal: "Our country has gone overboard on civil rights".

I think there's more to this yet to come out. I saw a report on the CNN website that his sister was a Princeton graduate now working as a contractor for the Fed.

Not trying to make conspiracy theory here, just pointing out the fact that we have a overachiever ivy league older sister, with a successful career well underway, and by comparison the little bro going to the lowly state school, majoring in english of all things, his family's secondary language. Nothing against state schools, went to one myself. But by comparison to Princeton: LOSER!

That is if the CNN story is correct.

The fact is that there is always a down side to calling someone crazy, or accusing someone of stalking. There's always the case of false accusation. And crazy bat shit stuff like this rarely happens in a vacuum. I'm sure his parents are the last ones who thought their son was a homicidal maniac. But every time they said "why can't you be more like your sister" like I'm sure they did, it drove a nail in his self constructed coffin.

My wife is a retired psychiatrist, professor of psychiatry, psychiatry department chairman, associate medical school dean, and president of a professional society of academic psychiatrists. In matters political, she is well to the left of most physicians--lobbying, among other things, for a single-payer heathcare system.

And her response to this event? Straightforward and uniquivocal: "Our country has gone overboard on civil rights".

I'm a retired Psychiatrist too. But I don't think it's just "civil rights." It's an unwillingness to deal with cases that don't respond to treatment. Cho had the kind of Paranoid Schizophrenia that used to be rampant at Alabama's Brice Hospital or Georgia's Central State. There's no place to put such people anymore, so Cho got crazier and crazier in his dorm room - and then let us know that Chronic Paranoid Schizophrenia still exists. A college campus is no place to let such disorders fester. So your wife and I both recall that the place for such people is a mental hospital - and the criteria for discharge are not the needs of the hospital and it's accounting department but genuine proof that the person can, in fact, live in the world...

This post analyzing all the dysfunctions in the system is incredibly good. Whatever a persons' opinion on gun control, obviously the compartmentalized and disjointed systems failed by allowing an identified crazy person to buy firearms, and for VT to have this identified threatening student still loose in the community.

Unhappily, in the absence of a funded mental health system, I have reason to believe that college professors and instructors may often get drafted into a warning system. My partner is a lowly adjunct at a private university teaching masses of freshmen in a required course. She has had 3 suicidal students among the eighty she is teaching this semester. The harm they threatened was to themselves, but was nonetheless serious. (So far the college counseling apparatus has been able to at least staunch their impulses.) For some young people, the transition from home to college is when the pressure becomes unmanagable. So then you get college teachers trying to cope as the pain breaks loose.

So how does Reagan closing the publicly funded mental institutions in the '80s square with those who wish to ensure those who were patients in those institutions are assured their civil rights?

I mean I'm sure there were abuses in the systems pre-Reagan closures, that abused civil rights of patients. But the reality is that it kept some of them from harming themselves and others. Where do you draw the line?

Regarding the background check, it's been reported yesterday and this morning (ABC news) that the judge's psych evaluation order didn't appear on the background check because Cho was never actually involuntarily committed (per the NYT, because the judge declined to order his committment after the evaluating psychiatrist determined that Cho was not an imminent danger).

Any confirmation of whether this is true? That is, that the instant check would pull up an involuntary commitment order, but not an evaluation order?

It would be helpful to know the instant check failed because of this type of deficiency in the process rather than because someone didn't file the order properly as suggested in the post.

(As always, great coverage and commentary by TNH posters and commenters. This site is always a great comfort to those of us who deal with trauma by seeking information.)

Interesting post thus far. I'm a counselor in Blacksburg, and have a fairly close up interest. One point, on which I don't know the answer is Sara's comment "Who didn't file the court order properly so it would show up on the instant check when someone wanted to buy a semi-automatic gun?" I just don't know the ins and outs of this. I'm also interested as to who disclosed the pdf of the dentention order -- is that a protected mental health record or a public legal document.

As to the instant paranoid schizophreia diagnosis, one could seemingly reasonably make that post hoc assumption -- or perhaps delusional disorder, etc., etc., etc. -- but its really useful to be leery of such labels, especially at a distance. One would have thought Bill Frist would have shown us that.

I've got to say that I totally agree there should be some better way of intervention, instead of just passing the problem off to the next "professional" or institution. The commitment laws and follow up procedures, at least in Virginia are an impediment to this. As are the institutional/university processes which are too often designed to present a good face and sweep real potential problems under the rug.

FYI, letters in the local paper running to a majority saying if more students were armed, that would have dealt with the situation. This is Virginia.

As to Nikki Givanni's comments, mostly she's a great force. But I was distubed by her comment that Cho being troubled was "crap"; that he was "mean". Talk about setting mental health back rather than forward.

SFO, that take on why the order did not trigger a gun prohibition flag sounds plausible. In Virgina, the MH professional/emergency intervention clinician evaluates and can obtain a temporary detention order on the signature of a magistrate, and then the indivdual is brought to a hearing before a special justice, I think within 48 hours, for a formal determination as to status, leading to either involuntary commitment for further treatment, or discharge, often with recommedation ("order") to follow through with outpatient counseling.

In this case the TDO was obtained on the 13th, and the hearing before the special justice, took place on the 14th.

The temporary detention order is here.

Regarding disclosure of the order, I would speculate that it was obtained from the mental health facility by police and then passed to the media. Assuming that the facility follows HIPAA rules (rather than alternative state rules) for records disclosure, HIPAA allows for police to receive medical records with a search warrant or a court order, or with authorization from a deceased person's personal representative (such as a family member).

SFO; yes. And that business by which the order found its way into the public/media from the police will probably never be known. Probably impossible to get information, even protected information, that hot to remain protected.

For financial reasons, my own University has been expanding its resident student population from 12,000 to 19,000 over a period of seven years. Though it has built (and continues to build) the housing to handle this increase, it has yet to expand much of anything else--such as classroom space, dining facilities, health services, or faculty. It is setting itself up for an episode of this kind.

In the 1850's, incidents of gunfire so overwhelmed the campus that its Trustees converted it into a military academy. Impeccable logic, this, for the regulating of firearms! It took them a good fifty years to re-civilianize the place.

I cannot imagine the number of guns currently secreted on campus, but I expect it to increase exponentially in the near term. Needless to say, the Administration has neither the resources nor the will to enforce a ban on such firearms.

Lots of good comments here. mental health is a subset of health care generally, and the fundamental problem with our system is that the goal is not to create conditiosn for health where possible and treat illness when it happens, but to make money for various people. So in mental health there is very little assistance for parents, teachers etc, and then meds for people who get ill. If they have something not amenable to chemical treatment or won't take their meds, then that is a big problem.

This need to save money came just at the time the patient rights movement got some real strength. That is what happened when Reagan was Gov of California. There were court decisions giving more rights to people with mental illness (remember these were the days when families could commit a child for being gay or girls for being incorrigible), and then when the Legislature proposed a system of local mental health facilities instead of the big state hospitals, Reagan leapt at it--out came the patients, but the local facilities never really materialized. We ended up with the worst of both worlds.

There does need to be a rethinking of what is the best treatment for whom, and some form of custodial care for people who just can't make it for whatever reason, at taxpayer expense because society has an interest in not having too many disturbed people running loose. But we don't want to go to the opposite extreme of locking up merely eccentric or difficult people.

In short, we need less attention to profit, more clear goals, more individualized treatment and more oversight of facilities.

As to the instant paranoid schizophreia diagnosis, one could seemingly reasonably make that post hoc assumption -- or perhaps delusional disorder, etc., etc., etc. -- but its really useful to be leery of such labels, especially at a distance. One would have thought Bill Frist would have shown us that.
I'm aware of the dangers of "labelling," but I think that there's another side to your point. Not "labelling" allowed the man with obviously flagrant symptoms to deteriorate unchecked. Just because there's a danger in "labelling" does not mean that "labelling" is bad. Any clinician sitting in a room listening to Mr. Cho talk like he did on that tape should "label" him as 1. Probable Paranoid Schizophrenia and 2. Dangerous. There's no issue of distance here. Cho put it right in front of our faces.

"Lots of good comments here. mental health is a subset of health care generally, and the fundamental problem with our system is that the goal is not to create conditiosn for health where possible and treat illness when it happens, but to make money for various people."

Bullseye Mimikatz. What few resources exist, are sucked up by the psychiatrists writing scripts and Big Pharma. Just like some attorneys set up bankruptcy mills, some psychiatrists set up Medicaid billing mills. Medicaid will pay out $18,000 per year per client for psychiatric support and case management without any clue if any of it ever happened. On top of that, Medicaid will pay out $6,000 per year for medications and no one knows if they ever get consumed. In addition, the patient may be homeless or live like an animal. Milwaukee just had a case like this recently, where the caseworker said she was visiting the guy six days a week. Guy died and nobody found him for four days.

Great post Sara, as per usual.

Wow, thanks for keeping up with this story, the initial reporting was so stale and inhuman, and I guess that was based upon the CYA behavior. Then I also heard of wingnuts blaming those in the line of fire, for being passive.

But now it appears that the passivity was in the Administration: those who are charged with providing a safe and fertile environment for study and learning. This is very different than the world outside of a college or university. Teachers and students need to be able to _give up_ certain worldly concerns, but the concerns do not go away, they are supposed to be handled by the non-academic managers. This was their job, and the responsibility was far greater than that of similar managers in the outside world. Maybe an analogy is parent/child. The child really needs to have a protective shield provided by the parent, for the purpose of development.

"Not "labelling" allowed the man with
obviously flagrant symptoms to deteriorate
unchecked. "

Mickey, points taken. However, sad to say, in Virginia, right now, regardless of label, and assuming one does not call additional undue attention to oneself, someone labelled paranoid schizophrenic or whatever can walk the streets undisturbed. This is sad and, as we know, dangerous at times, both from the angle that the indvidual does not receive appropriate treatment, and that a small percentage of such individuals can be very dangerous to others. At the time of his hearing, regardless of the diagnosis, Cho was deemed not a threat and released to outpatient. The weak[est] link here is the lack of followup/follow through. The fact is, he did not meet criteria for committment at the time of the hearing -- according to the very strict standards of Virginia law. Maybe thats a weak link too, i.e., the criteria that are deemed suffcient to invoke a stricter dispostion. [In Virginia, a patient must be treated in "the least restrictive setting"].

I am not a psychiatrist, but I have had a tremendous amount of exposure to people with chronic paranoid schizophrenia; and it seemed clear to me, early on, that this illness (& if this was indeed the case, he was not "disturbed" he was very ill) was a very real possibility (ie, his lack of response/affect when speaking with other people, running out of rooms before he could be approached, etc etc).

It is clear to me that the system fell apart, as it almost always does, due to lack of follow up.

As for the civil rights argument, I have a great deal of sympathy for that perspective, having been in situations during which I and other family members have tried to get a seriously ill family member (step-brother with paranoid schizophrenia) committed while he was in a non-compliance phase vis a vis his medications and rapidly melting down. It is almost always impossible and we have had to watch him carefully until he does do something threatening to himself or another, at which point we could call the cops and have him committed forcefully. Hugely stressful to family and friends, and traumatic to the patient who is repeatedly hauled into a mental hospital in handcuffs, often after spending the night in a jail cell, untreated and completely in the grip of the paranoid thoughts and voices over which he has no control.

It is a barbaric system.

The weak[est] link here is the lack of followup/follow through. The fact is, he did not meet criteria for committment at the time of the hearing -- according to the very strict standards of Virginia law. Maybe thats a weak link too, i.e., the criteria that are deemed suffcient to invoke a stricter dispostion. [In Virginia, a patient must be treated in "the least restrictive setting"].

I couldn't agree more. The concept of "the least restrictive setting" is nationwide. But I would caution that Cho was not "treated in the least restrictive setting." He wasn't treated at all. He was simply released to live with the ravages of his illness alone. There's a big responsibility to treatment in "the least restrictive setting" - that responsibility is to follow such people closely.

We don't know how good Cho was at masking symptoms -- exactly how blatant those symptoms were, versus a differential diagnosis that might come to mind. Or how good the pre-screener was. Plus the general predilection of the system to resist committment [for too many of the wrong reasons]

I return, therefore to the venue in which cho's disturbing and dysfunctional behavior was observed longest and in a setting where it would be apparent -- the university. Back to the civil right's argument; and the in loco parentis argument [fast fading in this era of emanicaption]; and the CYA/don't make waves factor. I am leaning strongly to the notion that a university ought to be able to compel disturbed individuals to counseling; to get them in front of a mental health professional who can make the jusgment and take the action a teacher or an administrator cannot.

DonS, I suspect under contract law any college or university could make it a condition of admission that for either Medical or Mental Health reasons any student could be obligated to accept a consultation or diagnostic proceedure. It just needs to be made explicit, and written into an agreement accepting admission.

We had an interesting case here in Minnesota a few years ago that eventually got around to confirming this understanding of implied consent in accepting admission. U of MN in Duluth has a two year Medical School focused on Family Practice Medicine (students take the 2nd two years at the U in Minneapolis). They also have an undergraduate program that feeds into this Medical Ed program. They admitted an African Student, who was working ten hours per week in a local teaching hospital. They soon found they had a serious epidemic of TB, drug resistant. The Epidemologist tracked it to the student, but he refused TB testing. (Flutter all the civil rights folk here.) Eventually they did get a court order that stood on appeal -- yes the School did have the right to compel not only testing, but treatment. I suspect similar law could be applied to a serious mental health issue.

I think two things need to be front and center in looking at the matter of Mental Health in Academic Institutions. Today, CNN is running a story that about 9% of American U Students have some sort of mental problem during college years, but only about 1% are serious. I suspect that study may be pretty superficial -- but some attention should be given to properly replicating it, and then tying accreditation to whether an instutution has adequate resources to provide proper services. For the most part, these would be counseling on a short term basis -- but for more serious cases, institutions need to be required to provide back-up either from their own resources, or contractually from the community.

The second matter in my mind has to do with dealing with the interface between students and all staff -- academic as well as administrative, in nurturing a strong mental health environment. The persons most likely to observe troublesome behaviour are the "adults" who interface with students -- Resident advisors, academic advisors, perhaps other students, and certainly teaching faculty. How one passes such concerns to someone with responsibility for such things -- with a sense that serious attention will be paid, at the same time respecting confidentiality -- that's the nut of the problem.

When I was teaching, I twice encountered students I considered at a high risk for suicide. I asked my Department Chair what was the proceedure -- and was told there was none. So I had to invent one. My solution was to make a copy of the student writings that concerned me, and ask more experienced department members to read them, and in essence second guess me -- did the writing ring a bell with them as it did with me. In two cases they agreed. So -- I made additional copies, wrote a cover letter, and sent them off to the academic advisor for the student, the Dean of the College, and then I called the mental health people in Student Health Service, got a case manager by name, sent the material to them, and asked for a consultation of Me, the Dean, the Academic Advisor, and the mental health professional. Not a round robin of memo's -- a meeting. And in both cases, the Student Health Service eventually told me I had ID'd a real problem -- I asked for no further information beyond this, because once I had forced a referral, it was out of my hands.

Now I worked in a resourse rich environment. U of Minnesota has a medical school, with Speciality programs in Psychiatry with numerous sub-specialities, one of the leading Counseling Psychology Departments in the country, The Health Service has a locked facility for diagnostic purposes, And the University Hospital has additional custodial facilities. The U of Minnesota owns the copyright on the MMPI -- which is now in over 45 languages, and they have a huge program norming this now 70 year old diagnostic tool to many languages, cultures and sub-cultures. So once you got a referral in motion, it turned out that all these resources could be focused on a troubled student. Our problem was that the level of the Academic instructor-student interface there really was not a process for making a referral. I had to invent it.

But at the same time I was involved with the second of these, I didn't pick up signals from my office mate -- she committed herself voluntarily, but then hung herself while in the hospital. That haunts me to this day. But what does strike me is the necessity for institutions to designate one source who can facilitate appropriate action and break through the fragmentation, but at the same time recognize that the signs of serious problems are most likely to be apparent to those in direct student-adult interface.

". . .I didn't pick up signals from my office mate . . . ."

Not that it may help but, many years ago one of my counselor colleagues , in an office of 15 or so professionals, suffered from chronic pain, and planned a leave of absence because of the pain. I thought I related to her pretty well, because we were about the same age, i.e., older than the rest. She arranged everything to have the best possible care for her clients while she was to be on leave for 3 months. Shortly after her last day she walked into the river and drowned herself.

As to the possibility of contractual arrangements to allow for better attention to mental health issues of students, some places it might work easier than others. But with the stakes as high as they are, its seems unconscionable that we don't seem to try harder to make it work.

I would say that my experiences with campus health and mental services has been pretty bad. Usually you are given a certain amount of "free" sessions and from there on out they charge hourly rates. Of course, four or five free sessions is enough for someone to go in and come out with a prescription for some wonder-pills, but that's not nearly enough time to get a complex diagnosis or actually start helping a person. Mental health is a journey. Pills should not be taken without other therapy, though they often are. I'd say the uptick in campus suicides (this one a particularly violent one) should point towards a real need in expanded campus services.

Think about it. More and more kids are going to college, often spending large amounts of time away from their families and support systems for the first time. Is it any wonder that a lot of them need mental healthcare?


I'm in the business, which is to say I teach at a well-known institution of higher learning where from time to time in 30 years I have run into disturbed students. The problem is the following. You talk to them, you try to get them to Student Counselling, but you can't really finger them, and if you do, you won't be backed up by the administration, who are afraid of lawsuits. As we say in my game, it's type-I versus type -II error. If you take a really hard line, you label a lot of people who are not at risk as being at risk. If you take the soft line, you end up with a Cho. Most University administrations don't want to take chances, and the obvious chance is the chance of being sued. Mass murder is a low-probability event. Cho was an outlier, and I think in this case he was an obvious enough risk to have something done. But the kind of persons who end up being Associate Dean of Students aren't the brightest bulb in the box,which is why they ended up as Associate Deans. It's not insoluble, but it's not easily soluble.

Knut, one of my hopes right now is that someone among the families who have lost either a faculty member or a young adult at VT will find the kind of Plantiff's attorney willing to invest in a case -- (John Edwards and like types, are you listening?) and bring a nice big civil negligence suit -- and force discovery and trial, and not just accept an out of court payment. It is precisely the matter of not trying to figure out a solution to the type I and type II situation that needs to be put on the table. My guess is that if one group of administrators has to deal with a strong negligence suit, done out there all in public, you'll see good people trying to figure out the solution.

I generally agree with J-Ro, campus services organized around counselling principles, but with a resident or consulting Psychiatrist depending on the size of the school probably can do a very good job if the have the latitude to treat properlyand adequately, and if necessary, make referrals. And if that CNN story is near right (and after citing KO and Sun Times as a source, I beg one check validity) and 9% of American College Students have some degree of need for Mental Health Services, then I think one can argue for doing what is necessary to just normalize getting them. What I've seen through in the last day or so of reading and TV watching is the need to sock the Public Relations Happy Face in the Kisser as people not experienced with spinning it have made a bad job of it, put the Academic Enterprise up front as to the "why" of the institution, listen to the point of that poet, Nikki Giovanni, regarding her requirement that she control her own classroom (gads, how basic), and then organize support and administrative services around that idea. Right now I am hopeing that she is connected into something like AAUP (American Association of University Professers) or MLA, Modern Language Association, and can push them to conceptualize this fairly simple issue. Sadly, I note that Governor Kean is putting together an investigative panel that includes no activist yet respected and experienced academics. He needs calling on that loud and hard.

Knut, I think we're probably in agreement here, but I just wanted to throw this in. You as a faculty member are imvho, the last step in the quality control process for the academic institution. Ultimately it's your job to ensure a "safe" classroom environment. You can when circumstances warrant, request/document very aggressively that someone certify that a given student is not a "threat" or a drag on the communal learning process. It's not your job to be right or wrong about the assessment. It's a teacher's responsibility to document that there is evidence that requires an assessment. The good news is that you have a lot lower threshold in the classroom than out on the street. The kid should not be a drag on classroom communication. The bad news is, if the M.D.'s assessment comes back that the kid is safe, what can you do? If the kid will not submit to an assessment, I think it's fair of you to request that the kid not be allowed into your classroom until some M.D. says he's safe. My guess is that it's at this point where Admission issues, tuition reimbursement issues, and the understandable fear of litigation come into play.

I'm not connected with Virginia Tech as faculty. I know a lot of senior faculty and staff, however. As is the case at many universities it is certainly the case at Tech that there are very serious tensions between faculty and administrators, almost to the point of disconnect on a lot of issues. At Tech, the engineering and hard sciences, and now the "bioinformatics" faculties rule the roost, and have the most sway because, surprise, they bring in the research bucks. The humanities, social sicence and arts faculties are the stepchildren. That said, and recognizing that the whole communitiy seems to be closing ranks, regardlesss of the difficulties of addressing the knotty and real issues involved in bringing some utility to the mental health component on campus, the fear of litigation, etc., can the university(s) really afford to do a whitewash yet again?

The teachers want to say, we do what we can, but we're powerless (and not trained at intervention). The administrators say our hands are tied because of legal constraints, and not want to interfer in the academic process (though they do it all the time). The politicians say its the problem of the universities. I can tell you, as a community mental health professional, we do not get many referrals (except DUI mandates from out of area); the university keeps that within their own counseling component, except when the case gets too complex. All real factors to some extent. So, where does the buck stop?

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