Toward more responsive campus mental health care

SoodEight years ago this month, Seung-Hui Cho, a senior at Virginia Tech, shot and killed 32 people and wounded 17 others on campus before committing suicide.
In the aftermath, Aradhana Bela Sood, senior professor for child mental health policy and professor of psychiatry and pediatrics at Virginia Commonwealth University School of Medicine, was named to an independent panel to recommend policy changes that might prevent future tragedies.
Sood’s new book, The Virginia Tech Massacre: Strategies and Challenges for Improving Mental Health Policy on Campus and Beyond (Oxford University Press, 2015), highlights what can be done to better treat people who are struggling emotionally.
“Overall, the telltale signs of a mind unraveling were observed by students and faculty,” Sood says, “but there was no coherent action from the institution to provide to Seung-Hui much-needed psychiatric attention.”

Your book includes a remarkable chart of Seung-Hui Cho’s behavioral red flags and various people at Virginia Tech who were aware of individual incidents. Yet the connections were never made.
Here we have a situation where there were so many things that were said and done by the young man, as well as picked up by his professors. Some people did sit up and pay attention, but the ones who could have done something with this information did not respond to it.
So these are opportunities for us to look at a system failure. We have to be more aware when these red flags occur and develop a better strategy of addressing them.

Cho had written dark poetry and stories about death and murder. Young people often have a fascination with dark subjects. How do you distinguish art from illness?
That’s a major issue. We certainly don’t want to stifle creativity.
I see these kids even in my practice, where a teenager might come in and be very preoccupied by Goth stuff or they might be really dark in what they are writing about, which concerns parents. Sometimes it’s just an outside veneer and there’s nothing going on that is of concern.
But I think that also needs evaluation and assessment. What does this mean in context of the person’s life?

What is the role of faculty here?
Two of Cho’s English professors were concerned enough that they weren’t really just viewing it as creative expression. They were also concerned about his ancillary behavior.
He accused classmates of being “low-life barbarians” and “despicable human beings.” He took covert photos of other students with his cell phone, among other things, which the professors were picking up correctly. One of the professors had him removed from her class.
But the role of the faculty has always been confused by the fact that educators think their job is limited to education, and that even if they identify problems, they don’t know what the university does in response to it. The information goes into a black hole and they are left wondering, “What do I do? How much should I push this with the student or the behavior?”

How do we rectify that situation?
One of the strongest outcomes of the Virginia Tech massacre has been alerting universities about threat assessment and how they can handle these issues. Virginia Commonwealth University, where I am a professor, did the same thing. I was one of the consultants to the university. We came up with multiple strategies.
One approach was to set up a code of conduct for everyone—students, faculty and staff—of what is expected behavior on a university campus. If there are aberrant behaviors occurring, there should be a mechanism wherein that is picked up and the dean of student affairs is alerted.
That student should be evaluated. It can vary from a threat assessment situation, to counseling, to seeing a psychiatrist, to seeing a substance abuse counselor—something gets done when that behavior is noticed. This way, when faculty bring up an issue, they can be assured it doesn’t go into a black hole where they have no idea what is happening.
They don’t need to know the granular details of what is happening with the student, but they should know and feel comfortable that the dean of students is responding.
We are not making the faculty counselors or therapists or interventionists. We are merely making them aware of the expected behavior. We are setting up the structure so that when these things are identified there is an appropriate intervention plan for them. That takes faculty out of the equation of making a judgment call for which they don’t feel qualified.
Of course, anyone can recognize aberrant and weird behavior. But they may think it is a private matter in which they can’t intervene.

There’s a lot of confusion over FERPA and HIPAA privacy laws.
Clearly, one of the things that is misunderstood when it comes to FERPA and HIPAA rules is that anything that is observed—that is, not written down on paper—can be communicated with peers, or with others in faculty and the administration.
You are not prohibited from doing that. Anytime there is an issue where you are worried about safety, you can immediately communicate that to anyone without danger of reprisal.

Cho’s parents were not notified that he had been hospitalized earlier for making suicidal threats.
I interviewed his folks. They took him for therapy weekly because they were concerned about him. That was one of the reasons, given his problems, he had been doing relatively well to that point.
So, there is no reason to think that, had they been told he was hospitalized or was expressing these behaviors, they wouldn’t have removed him from school. They clearly understood the need for mental health treatment.

A record number of college students are struggling with depression and anxiety. Do we know why?
I can list multiple reasons. Number one is the stigma around mental health. I see this all the time—when you are losing your seat of reason, which is the brain, it is very scary. That’s a tough place to be for young adults. Sadly, people don’t realize that these are eminently treatable conditions.
Second is that young men and women who transition to college are suddenly taken from highly sheltered environments and put into campus life. It’s very different from the highly supervised arena they had in high school.
They have to think for themselves and be responsible for their own well-being. Stress and insomnia are major problems. There is substance abuse, which is rife within college campuses. You have the first precipitation of psychotic illness, which occurs in late adolescence.
The third thing is access. Even when these problems are identified, there are often very few providers to help a person in crisis. These kids are on waiting lists and they can’t get in to see anyone.
If they do get in to see someone, it is often a student counselor who may not be as well trained and may not be very helpful.

After a tragedy like Virginia Tech, the response is often reactive—more guards, more guns—rather than proactive.
Yes, and that doesn’t make any sense. Wouldn’t you want to know what is making these people unhappy? Unhappiness is not something that can be totally obliterated, but you can begin to look at the foundations of where it’s coming from.
You can help those people by asking, “Why is this happening? What could we do to reduce the stress so people don’t end up with these kinds of events?”

Where does that job begin at the university?
It is very important to involve key leadership. They have to empower the people below them. They have to initiate open, progressive policies around mental health. If the president or the provost doesn’t see a value in it, it’s not going to go very far.
Another problem is that many counseling centers are good at things like adjustment problems, but they often will have little experience with severe mental illness, such as schizophrenia and major depression. Counseling centers need to be able to access care for these students.
Statistically, one in five people have some sort of mental health issue that requires intervention. It’s not an uncommon thing. We need to embrace that.
Schools have generally done a very good job at the threat assessment piece, because that is low-hanging fruit. It’s the least aggressive approach when someone is exhibiting weird behavior. But the mental health piece of it still has a lot of room for improvement.
Change starts small, but you have to keep pounding away at it, just like cancer. Mental health is where cancer was 50 years ago. The more we talk openly about it the more we will remove that stigma, but we have to start that conversation.

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