Thoughts Upon Cho and the Va. Tech Recommendations

There are dozens of recommendations scattered throughout the eleven chapters of the Report of the Virginia Tech Review Panel, the group tasked with trying to understand the Virginia Tech massacre that Seung Hui Cho committed on April 16 of this year. The panel should be commended for pulling together so much material, information and opinions relatively quickly, and basically completing what appears to be a thorough investigation of the events, the systems in place that day, and Cho’s life.

I don’t have much to say about all of the recommendations made, since there are so many of them, and since most of them are just functions of the tragedy and the panel’s mission. Some of them will be implemented, some of them won’t. And some folks, like the Treatment Advocacy Center, have already found one of the dozens of recommendations to latch onto and issue a self-serving press release to support its cause of greater involuntary commitment for all.

I supposed the most interesting document is the Mental Health History of Seung Hui Cho (PDF), 32 pages of background and history into Cho’s life. This is where people are going to be looking for the “Why?”

But there’s a big disconnect there too. People with selective mutism (a) aren’t usually considered “seriously mentally ill” like a person diagnosed with schizophrenia or bipolar disorder; and (b) aren’t usually involuntarily committed. Cho’s case would probably be the first ever to be considered for both. Selective mutism is one of those disorders which is rare, and when seen, is characterized by a person’s disconnection from the rest of the world around him or her. Someone who doesn’t feel much of a connection to those around them isn’t likely to also feel any type of extreme emotion toward them either.

The doctor diagnosed Cho with “selective mutism” and “major depression: single episode.” He prescribed the antidepressant Paroxetine 20 mg, which Cho took from June 1999 to July 2000. Cho did quite well on this regimen; he seemed to be in a good mood, looked brighter, and smiled more. The doctor stopped the medication because Cho improved and no longer needed the antidepressant.

In other words, as far as his doctor was concerned, Cho no longer suffered from depression in 2000. Cho’s selective mutism, a behavioral problem that is often more challenging to treat, seemed largely under control.

As Cho looked to the fall of 2003, he was preparing to leave home [to attend Va. Tech] for the first time and enter an environment where he knew no one. He was not on any medication for anxiety or depression, had stopped counseling, and no longer had special accommodations for his selective mutism.

In other words, he seemed to be doing largely okay when he entered college. Or at the very least, he was stable and functioning well within his environment.

The panel didn’t have much to report on about Cho’s early college years, except his change of majors to English, probably not the best choice because he didn’t excel at writing. His grades subsequently suffered. Things then changed.

The fall semester of Cho’s junior year (2005) was a pivotal time. From that point forward, Cho would become known to a growing number of students and faculty not only for his extremely withdrawn personality and complete lack of interest in responding to others in and out of the classroom, but for hostile, even violent writings along with threatening behavior.

This part of the report should be read in its entirety to get a complete picture of what the university saw of Cho’s increasingly erratic and antisocial behavior (it starts on page 11 of this PDF, labeled page “41”).

After you read that and get down to page 17 (marked “47” in the PDF), you’ll see this passage:

Shortly before the commitment hearing, the attending psychiatrist at St. Albans evaluated Cho. When he was interviewed by the panel, the psychiatrist did not recall anything remarkable about Cho, other than that he was extremely quiet. The psychiatrist did not discern dangerousness in Cho, and, as noted, his assessment did not differ from that of the independent evaluator — that Cho was not a danger to himself or others. He suggested that Cho be treated on an outpatient basis with counseling. No medications were prescribed, and no primary diagnosis was made.

Because here’s a young adult whom the professionals only see in one specific type of interaction — Cho in his selective mutism form. He’s quiet. He’s not going to say anything. And they apparently have little information about his aberrant behaviors from the school, which would’ve signaled more of a red flag to these clinicians.

But there is a disconnect between the school and the public health system, because of privacy laws (which the report addresses).

The hospitalization does nothing to quell Cho’s odd academic behaviors, but he doesn’t appear to have any other serious incidents with other students in the following year and a half before the murders take place. The report devotes only a few paragraphs to the year leading up the tragedy.

The following semester, spring 2007, Cho began to buy guns and ammunition. His class attendance began to fall off shortly before the assaults. There were no outward signs of his deteriorating mental state. In their last phone call with him the night of April 15, 2007, Mr. Cho and Mrs. Cho had no inkling that anything was the matter.

Cho’s senior year roommate explained to the panel that he tried speaking to Cho at the beginning of the semester, but Cho barely responded. “I hardly knew the guy; we just slept in the same room.” Cho went to bed early and got up early, so his roommate just left him alone and gave him his space. The only activities Cho engaged in were studying, sleeping, and downloading music. He never saw him play a video game, which he thought strange since he and most other students play them. One of the suitemates mentioned that he saw Cho working out at McCommis Hall and saw him return to the room from time to time in workout attire. Cho kept his side of the room very neat. Nothing appeared to be abnormal — no knives, guns, chains, etc.

There is nothing suggested in the report that the tragedy could’ve been readily forseen or prevented, even had Cho reached out more (which would’ve been impossible, given his diagnosis), or had all the people communicated their respective perspectives on Cho with one another.

Chapter 5 goes into the breakdown of this lack of communication, largely because of concerns about an individual’s privacy at the expense of public health. I’ll just copy in the key findings from this chapter (which is still worth a read, it’s only 8 pages long):

Organizations and individuals must be able to intervene in order to assist a troubled student or protect the safety of other students. Information privacy laws that block information sharing may make intervention ineffective.

At the same time, care must be taken not to invade a student’s privacy unless necessary. This means there are two goals for information privacy laws: they must allow enough information sharing to support effective intervention, and they must also maintain privacy whenever possible.

Effective intervention often requires participation of parents or other relatives, school officials, medical and mental health professionals, court systems, and law enforcement. The problems presented by a seriously troubled student often require a group effort. The current state of information privacy law and practice is inadequate to accomplish this task. The first major problem is the lack of understanding about the law. The next problem is inconsistent use of discretion under the laws. Information privacy laws cannot help students if the law allows sharing but agency policy or practice forbids necessary sharing. The privacy laws need amendment and clarification. The panel proposes the following recommendations to address immediate problems and chart a course for an effective information privacy system.

One of the key findings of the panel is that some additional communication and information-sharing could’ve occurred with Cho, but that it didn’t because people weren’t aware that they could. Chalk this up to difficulty in understanding the myriad patchwork of state and federal laws (not to mention Va. Tech’s own rules), how they intersect and what is and isn’t allowed. People just naturally err on the side of the patient’s privacy, which is a good side to err on. But as the panel notes, to err on the side of patient’s privacy is also to perhaps keep some critical information out of the realm of public health.

But to make a public health argument, you need data to show that given all of this information the panel compiled on Cho, could anyone draw any legitimate conclusions about his dangerousness? Could one argue that a person with a prior mental health history be considered more dangerous?

Well, we’ve commented on the violence and mental illness issue previously here and here and don’t believe there is a significant body of strong evidence to support any link between the two unless illicit substances or alcohol are involved (which was not the case with Cho, who didn’t do drugs or alcohol).

So given the lack of a scientific link between the two, even if given all of this information, there would still be little evidence to support thinking Cho was in imminent danger of killing others. In other words, even had all of the panel’s recommendations been in place prior to Cho’s outburst, I doubt anyone could’ve predicted it with any degree of certainty (or prevented it).

At the end of the day, all of that is not as insightful to me as this paragraph, which lays out the truth of the mental health system in virtually every state in the U.S. today:

In the wake of the Virginia Tech tragedy, much of the discussion regarding mental health services has focused on the commitment process. However, the mental health system has major gaps in its entirety starting from the lack of short-term crisis stabilization units to the outpatient services and the highly important case management function, which strings together the entire care for an individual to ensure success. These gaps prevent individuals from getting the psychiatric help when they are getting ill, during the need for acute stabilization, and when they need therapy and medication management during recovery.

As I said, this observation about the state of mental health in Virginia could be said about almost every state in the union. Our disregard for the care and treatment of people with mental health concerns is second to none.

But the panel also asks a question I asked or suggested earlier,

It is common practice to require students entering a new school, college, or university to present records of immunization. Why not records of serious emotional or mental problem too? For that matter, why not records of all communicable diseases?

The answer is obvious: personal privacy. And while the panel respects this answer, it is important to examine the extent to which such information is altogether banned or could be released at the institution’s discretion. No one wants to stigmatize a person or deny her or him opportunities because of mental or physical disability. Still, there are issues of public safety. That is why immunization records must be submitted to each new institution. But there are other significant threats facing students beyond measles, mumps, or polio.

The Full Va. Tech Review Panel’s Findings

This is somewhat offtopic, but I do have to note a consistent disturbing lack of documentation and failure to document at the Cook Counseling Center. Throughout the report, anything pertaining to Cho at the Cook Counseling Center seems to have “disappeared.” Three instances are noted in the report:

On Wednesday, November 30, at 9:45 am, Cho called Cook Counseling Center and spoke with Maisha Smith, a licensed professional counselor. This is the first record of Cho’s acting upon professors’ advice to seek counseling, and it followed the interaction he had had with campus police three days before. She conducted a telephone triage to collect the necessary data to evaluate the level of intervention required. Ms. Smith has no independent recollection of Cho and her notes from the triage are missing from Cho’s file. (pp. 45-46)

and

According to the Cook scheduling program documents, Cho was again triaged by telephone at 4:45 on December 12. This triage was conducted by Dr. Betzel who has no recollection of the specific content of the “brief triage appointment.” Written documentation that would have typically been completed at that time is missing. (p. 46)

and

Cho was discharged from St. Albans at 2:00 p.m. on December 14. No one the panel interviewed could say how Cho got back to campus. However, the electronic scheduling program at the Cook Counseling Center indicates that Cho kept his appointment that day at 3:00 p.m. He was triaged again, this time face-to face, but no diagnosis was given. The triage report is missing (as well as those from his two prior phone triages), and the counselor who performed the triage has no independent recollection of Cho. It is her standard practice to complete appropriate forms and write a note to document critical information, recommendations, and plans for followup. (p. 49)

That is either some sloppy paperwork and record-keeping, or a poor attempt to cover one’s tracks in the degree of their involvement with this case.