07.26 MENTAL HEALTH
Report of the Virginia Inspector General
Your editor appeared on a panel last week with James W. Stewart III, Inspector General for Mental Health, Mental Retardation, and Substance Abuse Services for the State of Virginia. The topic (at a forum sponsored by Virginia Tech University) was "Dealing with the At-Risk Student." Mr. Stewart--an experienced clinician and outpatient center director--reviewed his office's recent report on the Virginia Tech shootings ("Investigation of April 16, 2007 Critical Incident at Virginia Tech: OIG Report 140-07") and provided additional insights likely to be of interest to SWR readers. Pertinent excerpts appear below. Additional commentary on this topic--especially on the role of college counseling centers--follows next week.
Excerpts from the Virginia Inspector General [OIG] report (and Inspector General James Stewart's related public remarks at Virginia Tech University on July 13, 2007):
[OIG Agency Authority]
The Office of the Inspector General (OIG) is established by Virginia Code § 37.2-423 to inspect, monitor and review the quality of services provided in the facilities operated by the Department of Mental Health, Mental Retardation and Substance Abuse Services (DMHMRSAS) and providers as defined in Virginia Code § 37.2-403. The OIG conducts inspections and makes policy and operational recommendations in order to prevent problems, abuses, and deficiencies in and improve the effectiveness of programs and services.
Prior to the fall of 2005, very little is known about the individual’s [Seung-Hui Cho's] life in the University community. Based on the information collected by the OIG, it appears that he did not stand out from other students in a significant enough way to come to the attention of university officials during the first two years on campus.
Between August and December 2005, the fall semester of his junior year, a significant number of incidents involving the individual occurred in which other students and faculty members perceived or experienced his actions or interactions with them as extremely odd, frightening and/or threatening. These incidents occurred in the residence hall, in the classroom and in various forms of communication between the individual and other students and faculty. Students and faculty members were concerned enough about the individual’s behavior to contact various offices within the university including the Virginia Tech Police Department (VTPD) to seek consultation, file complaints, and to request intervention . . . In summary, there was a great deal of communication involving many individuals and offices.
OIG interviews with students and Residence Life staff who knew the individual well and lived in close proximity to him during the 2005-06 school year made it clear that the individual was not the typical college student, that he exhibited behaviors that were far outside the norm for students, and that they had concerns that he might harm himself or others. Those who lived around him were increasingly cautious about their own safety as the semester proceeded. Following a series of incidents in which the individual was reported to have harassed other students, those who lived close to him took it upon themselves to warn other students about his behavior. At least one student communicated to a Resident Advisor (RA) a desire to move to another building to get away from the individual . . .
The OIG was informed that on December 12, 2005 one of the individual’s suitemates submitted a long statement to an RA detailing the increasing concerns about the individual’s escalating bizarre and threatening behavior. From the beginning of the fall 2005 semester to December 13, 2005, the incidents involving the individual occurred increasingly and were progressively more aggressive and threatening in nature but did not involve any physical contact with other parties . . .
Around the middle of the day on December 13, 2005, the individual sent an instant message to a roommate relating the events with the police [an interview and warning about harassing behavior] and revealing that he “might as well kill himself or something”. At approximately 2:30 p.m. the roommate called his father to report this information. At approximately 3:00 p.m. the individual told his roommate that he was only joking. At 3:42 p.m. the roommate’s father called the VTPD to report what his son had told him. The officer interviewed the roommate who told him about the individual’s comment and history of strange behavior. The roommate also informed the officer that he and other suitemates had documented all of the odd incidents they could recall involving the individual and had given them to an RA. The police officer contacted the On Call Coordinator for the dorm. The Coordinator told the officer that he was very familiar with the individual and would check on him later in the afternoon.
[Cho taken into emergency custody]
From the time the roommate’s father called the police to around 7:00 p.m. the individual was away from his dorm room. During this time he took an exam and had dinner. At 7:09 p.m., after receiving a call from the roommate that the individual had returned to his dorm room, the VTPD went to the dorm and interviewed the individual. After a brief interaction, in which the individual stated that he was only joking when he sent the instant message, he willingly agreed to speak to a counselor. The police officers took the individual into emergency custody and transported him to the Police Department for an assessment to determine the need for hospitalization or treatment as authorized by Va. Code §37.2- 808(F.). The officers described him as “shy and seeming down” about something. Efforts to engage him were not successful. At 8:15 p.m. on December 13, 2005, Kathy M. Godbey, LCSW, who worked in the New River Valley CSB Access Program at that time, traveled to the VTPD and conducted a prescreen evaluation (Va. Code § 37.2-809(B)) of the individual. Ms. Godbey is an experienced, licensed clinician and a Certified Prescreener (prescreener) . . .
[A lengthy process then ensued, eventually resulting in a commitment hearing before Special Justice Paul Barnett].
Between 11:00 a.m. and 12:00 p.m. on December 14, 2005, a commitment hearing was held for the individual at St. Albans Behavioral Health Center.
As a result of this commitment hearing, the SJ [Special Justice] recorded on the Proceedings for Certification form:
 That the individual presents an imminent danger to himself as a result of mental illness.
 That alternatives to involuntary hospitalization and treatment were investigated and were deemed suitable and that there is a less restrictive alternative to involuntary hospitalization and treatment in this case.
The SJ directed that the person receive treatment in accord with the following order: “Court-Ordered O-P (outpatient) – to follow all recommended treatments”. The hospital liaison reported to the OIG that he notified the New River Valley CSB regarding the outcome of the commitment hearing and faxed the discharge information to the Cook Counseling Center. Staff of the New River Valley CSB informed the OIG that the log on which this information is recorded is retained for one year and then discarded. Therefore, they were not able to confirm or deny receipt of the outcome of the commitment hearing . . .
On December 14, 2005, a VA Tech police officer notified the Assistant Director of Residence Services in the Summit Community where the individual lived about their involvement with the individual related to the harassment incident and the TDO. This information was then forwarded by email to a number of university personnel in Student Programs.
[Cook Counseling Center does not accept ordered referrals]
In interviews with the administrative and clinical staff of the Cook Counseling Center (CCC) at VA Tech, the OIG learned that the center does not accept involuntary or ordered referrals for treatment from any source including other departments of the university, outside agencies and the courts. CCC will not report to outside agencies (including the courts) regarding treatment because it disrupts the voluntary nature of the service and it takes too much time away from direct services to other students. Anyone who needs treatment and will not come in voluntarily is referred to an outside agency. A student who is dangerous to self or others would only be treated at CCC center willingly or voluntarily. If these students are not willing to be treated voluntarily, they are referred to the New River Valley CSB. The CCC will not accept referrals as a part of disciplinary action by the university. Students who are disruptive to the university community are only treated if willing to be served. The majority of the students who are served by CCC are experiencing anxiety, depression and relational issues with other students. CCC provides treatment related to substance abuse issues only if the substance abuse is a secondary issue. CCC staff reported that they are serving increasingly “complex students”. They do provide services for students with thought disorders and follow a number of these cases throughout their college career; however, the student must be willing to be served. Approximately 20 to 25% of the students who are served at CCC see a psychiatrist or a psychiatric nurse practitioner and may be receiving medication as needed. Students with eating disorders or severe substance abuse problems are referred to outside resources. Cases that require long-term therapy are also likely to be referred out. CCC staff reported that all referrals receive a “triage appointment” within 24 hours, either face-to face or by telephone. The director of CCC serves on the Care Team, along with representatives of other offices of the university. The director brings back information about students who are discussed at these meetings, but does not share information with the Team about any student who receives services at CCC. The director of Judicial Affairs reported to the OIG that they do not use mandated counseling with students because CCC will not accept these referrals. They do not make mandated referrals to outside agencies or professionals because the cost is too high.
Related comments/recommendations (selections)
Editor's note: One of the troubling facts in the Virginia Tech case is the breakdown in monitoring and enforcement of the Special Justice's treatment order. The OIG report paid special attention to this issue--which also relates to the Virginia Tech counseling center policy
of not accepting mandated referrals.
 It is recommended that the court’s expectations for outpatient providers who provide treatment to individuals who have been ordered to outpatient treatment be clarified, by Code, regulation or policy . . .
 It is recommended that the expectations of . . . designated provider[s] to monitor the person’s compliance with the treatment ordered by the court . . . be clarified by Code, regulation or policy. Specifically address what action is to be taken by the . . . designated provider in relationship to the court when the person fails to comply . . .
 It is recommended that the criteria that must be met for the judge or special justice to hold a second commitment hearing when the person fails to comply with the earlier order to outpatient treatment be clarified in Va. Code § 37.2-817(C) . . .
 It is recommended that a brief study be conducted to determine what level of community outpatient service capacity will be required and the related costs in order to adequately and appropriately respond to both involuntary court ordered and voluntary referrals for these services. Once this information is available, it is recommended that outpatient treatment services be expanded statewide . . .
 It is recommended that university counseling centers develop a written policy regarding:
Whether or not the center will accept referrals for court ordered involuntary treatment, and if so, the types of referrals they can accept.
Whether or not the center will report treatment related information to the courts . . . when the client is under order to receive court ordered treatment.
 It is recommended that university counseling centers notify the courts, CSBs and BHAs in their surrounding cities and counties of this policy.
 It is recommended that the university counseling centers develop criteria and procedures for providing required treatment to students who have been deemed in need of mental health services and for whom the treatment is a part of a university support plan for these students.
Pertinent observations from Inspector General James Stewart's July 13, 2007 public remarks:
Within the university we found the following concerns:
 No single office or team was fully aware of the extent of concern about [Cho].
 Despite all the dialogue about this student and the involvement of various offices in responding to single incidents, there was no comprehensive, university-wide plan for supporting [the student]. In response to one of the identified concerns or incidents a voluntary referral was made to the Cook Counseling Center. The most direct interventions were made by the police toward the end.
 The role of the Cook Counseling Center in responding to at risk students appears to be very limited by a reported policy or standard practice of not treating students unless they are fully willing to receive treatment voluntarily. Judicial Affiairs [at Virginia Tech] reported to the OIG that they did not use mandated counseling with students because the counseling center would not accept these referrals . . .
 At the time of the TDO [temporary detention order] there was no single identified VA Tech contact to which the . . . prescreener could go. . 24 hours a day 7 days a week, to determine if information that may be relevant to a particular student's mental health crisis was available within the university community.
 Finally, our team was not able to identify a university policy or procedure that clarifies any role that university personnel may have in assisting with or participating in discharge planning for students who have been hospitalized or in supporting them as they follow through on their discharge plans.
 [Characteristics of] effective community mental health systems:
>Therapists serve as more than therapists. They manage cases to assure coordination of service among all providers . . .
>Cases are tracked to assure follow-through . . .
>Not all services are delivered in the office . . .
>When hospitalization is required, the clients are followed into the hospital by their therapists or case managers to assure continuity. They work actively to see that the treating physician has a complete picture of the individual , , ,
>Therapists and case managers work actively to have communication with other agencies . . .
>Therapists and case managers develop active consultative relationships with law enforcement and other agencies that deal with people when they are in trouble. . .