In the aftermath of the Virginia Tech shootings, it is the "if onlys" that bombard us for days afterward. For me, as a psychiatrist who has worked in college health for more than 25 years, the crucial hypothetical is: "If only the killer had gotten appropriate help." In attempting to make sure that someone like Seung-Hui Cho gets the critical assistance he needs in the future, we may wish to dissect the lines of responsibility for providing that intervention.
In our culture of self-reliance, the essential responsibility for getting help when distressed lies with ourselves. A saying in Alcoholics Anonymous may state it best: "I am not responsible for my illness, but I am responsible for getting help for my illness." Yet the nature of the illness and some cultural imperatives may get in the way of seeking out the necessary treatment.
For example, a psychotic student - one who has lost touch with reality and who may be hearing voices commanding him not to talk, say, with any mental health professional - cannot be expected to come in on his own. Likewise, a student with a drinking or drug problem almost invariably does not come in without someone on campus using leverage to get him into treatment.
Cultural beliefs can also lead to significant resistance to receiving help. Many first- and second-generation Asian-American students cite the message, taught from an early age, that one does not share one's "dirty laundry" with anyone, especially strangers.
Almost invariably, a troubled and suicidal student will give some clues about his distress. Even if he is unable to share his inner life with his friends and family, his writings - as in Mr. Cho's case - will alert faculty, often in the English department, to the student's distress.
The crucial element in any intervention is the tremendous coordination required among faculty, student affairs staff and the counseling service. The counseling service cannot afford to see itself as following a private-practice model in which all troubled students are expected to come in on their own.
In some circumstances, a mandated evaluation is essential. The dean of student affairs or the dean of residence life, after vetting the situation with the concerned faculty member and a consulting mental health professional, can insist that the apparently troubled student meet with a well-trained psychiatrist or psychologist on campus.
It is a privilege, not a right, to attend a college and to live in a residence hall on campus. Any university has the right to terminate that privilege if a student who is perceived as "scary" and "troubled" refuses to go through a simple in-person evaluation. If the evaluation shows that the situation is dangerous, campus mental health professionals can get family and friends fully involved in order to intervene with treatment, including medications and hospitalization if necessary. The need to ensure safety and protect life trumps concerns about confidentiality, and the courts recognize this fact.
It is essential to make a distinction between required evaluation and required treatment. Required treatment, except for a clear-cut substance abuse addiction or a profound anorexia, is almost never helpful. The troubled student can engage in a faux treatment if required - providing the therapist with what he wants to hear. Plus, these required treatments have a pernicious effect on the campus' perception of the counseling center: Counseling is seen as punishment for bad behavior.
The crucial psychiatric model is that of a community mental health center, not a large private practice. The counseling service must see itself as the caretaker for the entire university, not just for the students who are fortunate enough to have come in without stigma and on their own. Faculty and staff generally have great instincts. It would be bizarre not to respond to the cues provided to a faculty that often refers to Hamlet's suicidal pondering on whether "to be or not to be." Accordingly, as director of the Counseling and Psychiatric Service at Georgetown University, I met with the entire English department faculty on a yearly basis to remind them how valuable their access to the inner life of students was to the safety of the university community.
Tragically, when students show us their terribly troubled inner lives and we do not actively intervene, we are left potentially with the slings and arrows - and bullets - of absolutely outrageous misfortune.
Paul Steinberg, a psychiatrist and writer in Washington, was director of the Counseling and Psychiatric Service at Georgetown University and a student health psychiatrist at the University of Maryland. His e-mail is firstname.lastname@example.org.