What Went Wrong?

A troubled loner who rarely spoke, hiding behind dark glasses. An English major whose creative writing was filled with violence and obscenity so disturbing that professors repeatedly urged him to get counseling. A kid who was bullied in high school for being painfully shy. An awkward young man whose text messages to female students annoyed them to the point that they reported him as a stalker. A college student who kept his grades up, but who appeared so depressed that an acquaintance told authorities he seemed suicidal.

Those are the stark clues that came forth about Seung Hui Cho's mental condition in the past two years. Plenty of people noticed he was struggling. In fact, quite a few tried to get him help. Cho was even briefly hospitalized as a suicide risk in 2005, then released when he told a judge he wasn't going to kill himself. The final, awful revelation came last week, when Cho fatally shot 32 students and faculty at Virginia Tech before turning a gun on himself.

Now, university administrators and campus mental health counselors across the country are re-examining their decades-long struggle to identify and treat mentally ill students. Many are also pondering whether they would have intervened in time if Cho had been one of their students. This painful second-guessing, though more anguished than ever, isn't new. But in recent years, the task has become more challenging, as an increasing number of students arrive on campus with serious mental illnesses such as schizophrenia. At the same time, university officials are told that mental health and privacy laws prohibit them from contacting parents unless the child is clearly a threat to himself or others. Universities have been sued for kicking out students who said they were suicidal-and also sued for not preventing suicides.

"The legal system and the medical system conspire to leave these kids more alone than they should be," says Edward Shapiro, a psychiatrist in Stockbridge, Mass., who often advises college counselors and administrators on these dilemmas. "If the kid isn't failing courses, if they're not hassling people, and they're doing their work, there's not much the colleges can do."

Chris Flynn, who directs Tech's counseling center, has declined to discuss Cho's case. But counselors around the country say they often see students with symptoms as serious as Cho's and struggle to identify which ones are at risk of harming themselves or others, and with how to get them to seek help.

Lucinda Roy, former chairman of Tech's English department, says she told campus police and administrators of her worries about Cho's antisocial behavior and disturbingly violent writing. She says Cho repeatedly rebuffed her suggestions that he get counseling. In December 2005, Cho was detained by campus police after a second female student complained that he had been stalking her via text message and an acquaintance reported to campus officials that Cho seemed suicidal. He was judged "an imminent danger to self or others as a result of mental illness" and was taken to Carilion St. Albans Behavioral Health, a private mental hospital near Radford, Va. A court-ordered medical examination found that Cho "denies suicidal ideations. He does not acknowledge symptoms of a thought disorder. His insight and judgment are normal." A magistrate ruled that Cho was free to go but told him to get outpatient counseling.

Involuntary commitments are exceedingly rare and are ordered only if the person appears in imminent danger, a point of frustration for counselors and family members worried about the safety of someone who is seriously ill. People whose mental problems make them suspicious and paranoid, as Cho appeared to be, often don't recognize that others could help, Shapiro says. "If they're not in sufficient trouble where they're compelled to talk to someone, they get isolated."

It seems clear now that Cho had been isolated, and deeply troubled, or years. Classmates at Westfield High School in Chantilly, Va., say he was bullied for being shy and having an accent. An uncle back in South Korea says that Cho was so quiet as a young boy that some people thought he was mute. But the profile that has emerged of a socially awkward, morose young adult could easily fit a good chunk of the 17 million students on American college campuses. Almost 10 percent of college students say they've seriously considered committing suicide. Thirty-seven percent say they've been so depressed it was difficult to function. More than 30 percent of freshmen say they're feeling overwhelmed a great deal of the time.

"You're supposed to be happy," says Eric Heiligenstein, a psychiatrist who is clinical director for mental health services at the University of Wisconsin-Madison. "College is supposed to be a great time." But that's not the reality for many young adults. In any given year, 14.8 percent of college students say they have been diagnosed with depression. It's also the age when people have the most trouble with drug and alcohol abuse. And it's when serious mental illnesses like schizophrenia and bipolar disorder start manifesting themselves, as the long process of brain development that began in the womb nears completion. Add to that the fact that students feel far more pressured by the high cost of college and the need to excel than in generations past, and it's no wonder that for many, the stresses of college are just too much.

In the past 10 years, much scientific effort has gone into trying to figure out a way to "profile" school shooters and other students who pose a threat so that they can be stopped before they act. A 2000 study of school shooters by the Secret Service found that there is no one profile: The shooters came from many different racial and ethnic backgrounds; were rich and poor, excellent students and D-minus types, socially isolated and popular.

Attempts to identify those who will commit suicide have been equally fruitless. One reason is that not many people kill themselves. Although about 6 percent of people think about committing suicide in a given year, less than 1 percent try, and of those, less than 1 in 70 succeeds. People who are intent on suicide often hide the fact. Suicide risk assessment protocols used by psychotherapists fail miserably at predicting who's most at risk; rather, they're intended to help pinpoint the patient's concerns. "You can't prevent these things," says Gregory Eells, director of student counseling at Cornell University in Ithaca, N.Y. "You can do some things to reduce risk."

Cornell, like many universities, has in recent years intensified its work to detect troubled students and lure them in for treatment. Four years ago, the school started training faculty and staff in how to recognize mental health problems and convince students that going for counseling is "smart" and "strong." Two psychologists are detailed full time to talk with professors and other community members who are worried about students. A phone triage service offers students instant telephone counseling, and informal "let's talk" hours station psychologists and social workers in campus buildings where people live and work.

Last fall, Cornell started screening all students who come to the health service for depression, even if they're just there to get a sprained ankle checked out. And like other schools, Cornell has created a multidisciplinary SWAT team comprising therapists, police, the dean of students, and dorm staffers who meet to discuss troubled students and create a coordinated response. All told, Eells says, students have many more opportunities for free, professional mental health care than young adults who aren't in school. That, he says, along with the lack of firearms on campus, helps account for the fact that suicide rates on American campuses are just half of those among young adults in general.

Campuses are alo rethinking how-and whether-to get problem kids off the campus. Expelling students who are mentally ill is a hugely controversial act. Just weeks before the Tech shootings, Virginia became the first state in the nation to pass a law prohibiting schools from ousting students just because they have mental problems or are considered a suicide risk. The law was prompted by several widely publicized lawsuits, including two last year. In one, the City University of New York paid $65,000 to a student who sued because she was barred from her dorm after being hospitalized for a suicide attempt. And in the other, George Washington University reached a private settlement with a student who sued after it suspended him when he sought hospitalization for depression. "Everybody's looking at this in a liability context," says Karen Bower, an attorney for the Bazelon Center for Mental Health Law, who represented Jordan Nott, the GWU student. "It's really not about liability. It's about stereotypes about mental illness." Nott sued under the Americans With Disabilities Act, saying the university had discriminated against him because he was depressed.

In the wake of the slayings, more university administrators will turn to mandatory medical withdrawal as the solution, predicts Gary Pavela, retired director of judicial programs for the University of Maryland. That would be a mistake, he says. Even though the law presumes that young people on campus are adults and should be treated that way, parents feel that many a 20-year-old is just starting on the path to independence.

Still, campus mental health experts say that offering a student an honorable way to take a mental health break is often the best solution, particularly for students who are struggling with isolation and loneliness. "Families can be very helpful and supportive, even though students often feel that they don't want to add pressure or stress to their families, who have often made big sacrifices to support them," says Richard Kadison, director of Harvard's mental health service and author of Col lege of the Overwhelmed. In some cases, Kadison says, parents might want to consider if a child would do better living at home and attending a school nearby.

One question is whether Cho's culture played a role in his apparent refusal to accept help. In general, experts say, members of minority groups in the United States are less likely to use mental health services. "In Korea, mental diseases carry significant stigma," says Young Shin Kim, an assistant professor of child and adolescent psychiatry at Yale University Medical School, who is Korean. "If you have a person in the family with a mental disorder, then your whole family is damned."

Cho's family emigrated from South Korea when he was 8 years old. His mother and father put in long hours in a dry cleaning shop near the family home in Centreville, Va. Cho's older sister, Sun-Kyung Cho, graduated from Princeton University and works for a contractor at the State Department. Cho, too, was poised for success, slated to graduate. "My brother was quiet and reserved, yet struggled to fit in," Sun-Kyung said in a statement. "We never could have envisioned that he was capable of so much violence."

Occasionally, Korean-American kids "have that sense of being of two worlds, not 100 percent Asian or American, and that as much as they are accepted they will never be fully accepted," says Daniel So, a youth pastor at the Korean United Presbyterian Church of San Diego. "It makes it that much harder when you're a teenager."

Of course, many native-born students share the same fears and frustrations. The most striking passages in a 2003 National Research Council report, "Deadly Lessons: Understanding Lethal School Violence," talk about how all the young people in the afflicted communities lived lives almost wholly separate from their parents and other adults. "Paents and teachers were mostly unaware" of the shooters' frustrations "and of their universal belief that there was nowhere to turn."

College campuses are eerily similar, with few opportunities for mentoring and coaching, leaving many students living in a "youth ghetto." Pavela praises Roy, the English professor, for making multiple efforts to connect with Cho. "There has to be more intervention," Pavela says. "There has to be more from teachers and administrators. They have to be more involved in the lives of the students."

By Nancy Shute, with Avery Comarow