TOPICS > Health

Extended Interview: Mental Health Association President Discusses Cho Case

July 2, 2007 at 12:00 AM EDT

SUSAN DENTZER: The case of Seung-Hui Cho at Virginia Tech obviously was a horrible tragedy on multiple dimensions, but needless to say […] the mental health tragedy aspects of this are profound. In your view, what is this a case study of?

DAVID SHERN: Well, it’s really a case study, I think, in missed opportunities, some horribly missed opportunities, both to intervene effectively early in terms of promoting health behaviors and preventing the development of difficult behaviors. It’s a failure of an opportunity to do systematic screening and identify problems early on, and getting effective care for those problems. And, of course, finally, it’s a profound failure of our emergency care system to respond effectively with assertive outreach to a person who obviously, at least from what we’ve read and heard in the media, had profound significant problems.

SUSAN DENTZER: Do you think we can even say that we have a mental health care system in this country?

DAVID SHERN: Not if by system we mean really a tightly interwoven series of settings and services that respond to people with mental health needs. And not a system in the sense that we have a publicly funded system that delivers mental health services.

But we also know that we have huge populations of individuals with severe mental health problems and addiction disorders in our corrections system.

We know that 40 percent of people in our welfare system have significant mental health problems, and none of those settings are even part of what we ordinarily think about when we talk about the publicly funded mental health system. So no, we don’t have a system of mental health in this country.

SUSAN DENTZER: Let’s talk about what we’ve got now […] What would you say to characterize our system?

DAVID SHERN: Well, it’s difficult to access. It’s difficult to access because of system capacity issues and continuing issues of discrimination in terms of coverage.

It’s disjointed. It doesn’t involve a seamless continuum of care from in-patient settings, to residential settings, emergency settings. It doesn’t integrate at least contacts with people with mental illness to the degree to which it should, with other sorts of treatment settings.

It often times doesn’t promote recovery of people. Often times many of our mental health systems, particularly working with people who have severe mental illnesses, don’t provide services that really get people back into their lives to the degree to which we’d like to see them get back.

SUSAN DENTZER: And if we take the case of Seung-Hui Cho, he was obviously troubled as a child. His mother at one point apparently told relatives back in South Korea that he was autistic. We don’t know whether he was given that diagnosis, we don’t know where that came from, but [it is] a signal that people understood something was wrong, that he was either very socially isolated or something.

What, in a perfect world, would a functioning system have done for that child at that point?

DAVID SHERN: Someday maybe we’ll have a system in which kids get mental health checkups just like they have their eyes checked and their ears checked to make sure that they can fully participate in the educational environment. We know that someone’s socio-emotional health is a very important predictor of how well they’re going to do in school.

So he should have had–and every child should have had–a mental health checkup where there’s kind of a systematic review of how they’re doing.

In his case, there were indications of problems, from what you’re telling me, from his mom and others. So I think what’s important then is that there be a program to assertively link him with competent care, so there should have been some outreach to him and his family. There should have been an opportunity for them to see a mental health professional, preferably someone who has a specialization in children’s mental health issues. That’s another issue–we have a huge shortage of child psychiatrists in this country.

And subsequently, he should have been helped to […] understand these behaviors, to understand what was triggering them, and to start to give him sort of the skills and support that he needed to be successful in school.

Mental health checkups in school

SUSAN DENTZER: What would be your vision of a mental health checkup [...] be?

DAVID SHERN: Well, I think that number one, it's really important that parents be full partners in anything that we do that affects a child's health. And so what I would like to see, Susan, is I would like to see a universal program of mental health screening in our public school systems.

Now, by universal I don't mean mandatory. I mean a situation in which these services are available to everybody, but it's with parental consent that screenings are administered. We have scientifically validated screening instruments -- Teen Screen is one I'm most familiar with, having worked with colleagues at Columbia University to try to promulgate this throughout the country -- that are computer administered so kids can sit at a terminal and answer a series of questions that have been shown to be predictive of mental health problems.

The nice thing about the Teen Screen program is that it allows both that initial screening, but then immediately follows up with a clinical interview to determine, if a positive signal is detected, whether or not it's a real signal or simply could be explained away by other kinds of individual circumstances.

To the degree to which, upon the secondary examination, it appears as though there is a problem, it's then important that there be assertive linkage to the care system. So case management kind of comes into play at that point in time to link people to the care system.

SUSAN DENTZER: So what one really wants then is a counselor, a mental health professional, somebody to say to parents, "We think that there's an issue here. Here are three or four places you could go, people you could talk to, to do some further evaluations."

DAVID SHERN: Right. And here's some information about how you might be able to finance these services, to help people understand what their insurance benefits might be, or other kinds of services that are available for people who don't have insurance coverage.

SUSAN DENTZER: Now, Teen Screen, as you said, is one model of this, and you have personal experience with having attempted to implement a Teen Screen program in Florida.


SUSAN DENTZER: Tell [...] me what happened.

DAVID SHERN: Well, I did have personal experience. Prior to coming to Mental Health America I was a professor and dean at the Delaport, Florida, Mental Health Institute, the University of South Florida in Tampa, and working with the Columbia Teen Screen group we attempted to implement the Teen Screen program in Hillsboro County and Pinellas County schools. And we dealt with the typical concerns, the legitimate concerns that schools have about, number one, the burdens that are already placed on schools in terms of everything that they're expected to accomplish, and then secondarily, their worries about identifying problems and not being able to appropriately and effectively respond to them and to be quite honest with you, some of their concerns about the adequacy of the mental health treatment system in Tampa.

We dealt with every one of those concerns in that we got the mental health center in Tampa, for example, to agree to see people on a no-wait basis without regard to whether or not they could pay for these services.

We were going to provide all of the labor necessary to do the screening and to do the clinical follow-up. We even worked through all the tricky litigation, informed consent issues between the University and the school district to large institutions -- bureaucratic institutions -- working together. And ultimately, the school district in Hillsboro County chose not to implement the program, from my perspective with really no good reasoning.

In Pinellas County, which is the Clearwater-St. Pete area, we came to the attention of the Church of Scientology. And as you may know, the Church of Scientology has a very strong anti-psychiatry, anti-medication orientation. It was their feeling that the Teen Screen program is really a ruse of the pharmaceutical industry. It's really all about selling more pharmaceuticals. And they were able to effectively launch a campaign against Teen Screen--such that although I [...] had spoken with many of the Pinellas County School Board members personally, and I felt as though we had addressed all of their concerns-- after the Church of Scientology got involved, they also declined to participate with us in the screening.

SUSAN DENTZER: So to state this in general terms, there has been push-back in communities that have attempted to implement Teen Screen [...] What's it really been all about?

DAVID SHERN: Well, a lot of it has to do with what people consider to be an inappropriate intrusion into family matters. There was a person on the Pinellas County School Board who opposed this from the very beginning, was always very straightforward about her positions and opinions. And she had sort of, I think, an approach that might be characterized as an educational fundamentalist, in that the school's business is reading, writing, and arithmetic, and it really should restrict its activities to those sorts of concerns, and therefore, I think it was felt that this was really getting outside of those bounds. And it's really a private family matter, and it's really not the school's business anyway.

Of course, our feeling is that some of the most important predictors of academic success are a child's socio-emotional health, and that's been shown in several different research studies, and that kids who have significant emotional problems are much more likely than other children not to successfully graduate from school. And we know that if you don't successfully graduate from high school, you are on a very difficult course in terms of your ultimate social well-being and community placement.

So we think it's very important that we continue to educate people about the prevalence of these disorders, about the fact that effective treatments are available, that we continue to push as hard as we can to develop more responsive systems of care so that we could address those concerns that Hillsboro County had about the lack of community resources for people who are identified. And ultimately when we do, we'll reap a huge social benefit. The families will benefit, the kids will benefit, and ultimately our communities will.

SUSAN DENTZER: So if I sat here as a parent giving you that feedback and said, "It's none of the school's business if my kid has problems. If my kid has problems, I'll deal with my kid and I'll take my kid where I want to go, and maybe that's going to be my church. Butt out." What would you say?

DAVID SHERN: I would try to discuss the issues with you and make sure that you fully understand what's available to you and the choice that you're making, but ultimately, as a parent, that's your choice. And so I would respect that, and that's what we were going to do in these two situations. They involved active consent, so parents would literally have to actively indicate that it was okay for their kids to participate in that.

In short, I think the only instance in which the "butt out" response would not be honored by me would be if there was a sense that there was imminent danger involved, and that in fact, by making that decision you were placing your child in imminent danger. And then a whole different set of legal concerns kick in. But short of that, it's the parents' responsibility -- and that's the way we want it to be. I mean, we want families to function in that way.

A dispute over responsibility

SUSAN DENTZER: Now, another point along the way at which Cho could have been helped, and wasn't, was when he did go off to college, and it did become evidence that he was really ridden with troubles. There were reports of roommates who just noticed that he wanted to have no contact with them, or a situation that evolved in a creative writing course, where what he was writing was very, very disturbing to the professor, such that she took it upon herself to meet with him privately.

And then in the final analysis, when he finally was in effect apprehended, it was because he was sending emails to women on campus that were deemed to be of a harassing nature.


SUSAN DENTZER: What, in a perfect world, would have happened with all of that evidence amassing, when he was at university, that there really were problems?

DAVID SHERN: Well, number one, a lot of things went right in this situation. Obviously the ultimate result was horrible. But one of the things that we noticed following the Columbine shootings--and a study was done by the Secret Service and a group of psychologists, sort of a post-mortem of Columbine and 30 or 20 other school shootings-- and one of the things that they noted was that in all of those instances, someone knew that a plan was afoot and didn't do anything about it.

The things that we were initially encouraged about as we started to learn about what happened at Virginia Tech was that several people in the environment, in fact, had tried to get help for Cho, or certainly to point out the fact he was having significant problems, and that actually is a very good sign. It's a sign of really a caring community, if you will, and one in which people are trying to take care of one another, and I thought that was a great sign.

The tragedy is that when that occurred, even to the point of Cho being formally evaluated and adjudicated through an administrative process to be a danger to himself and ordered by a court into care, that there was no care to be ordered into. There was no response from the system's perspective in terms of reaching out to him.

[...]It's an irony that the first major study on providing assertive community treatment to people, a randomized clinical trial, was published in 1975, 32 years ago. It's been replicated, I think, over 20 times.

So we know what to do. We know what to do in cases like this. It involves assertive outreach and engagement to people. Number one, reaching out to them, not letting them simply fall through the cracks as he did here, and working with them as cooperatively as one possibly can to try to design a program that responds to their needs as they understand them.

And again, our science base is relatively strong. The problem is we just don't have these sorts of services routinely available, or if available, they're not really appropriately linked with, in this case, another component of the mental health system. Often times it's police who come in contact, and so it's important also to have linkages with the criminal justice system because the police are often the first people to contact someone who's in acute distress.

So he hit the system, but he wasn't captured by the system and brought into an environment that would have been helpful for him, and would have promoted his well-being, and that's a huge missed opportunity. And it happens every day, all the time. Occasionally -- very, very rarely -- it results in a tragedy of this magnitude. But I can assure you -- you know, 30,000 people a year in this country kill themselves. That's 80 people a day. That's a person about every 17 minutes, and these tragedies occur every hour. And so all this was a particularly horrible incident, so I think that the moral of the story for us is we have to start to garner the political will necessary to say enough is enough. We know what to do. We have the resources necessary to mount and to link these systems much more effectively than they are linked right now. We can't stand this level of carnage anymore.

SUSAN DENTZER: Now, a point you just made I'd like to expand upon is [that] many people who are mentally ill do come into the system through the criminal justice system. [...] How common is that?

DAVID SHERN: Well, the police are often first responders. Police almost always see people when they're at their worst, and when people are having a lot of problems, and particularly if they're starting to get out of control, or become violent, police are very frequently called.

In most states physicians or police officers can put involuntary holds on people to get them psychiatrically evaluated. And so in a [...] system that was really working well, we [would be] intervening with people even before they got into a state of acute crisis.

But if a person finds themselves in that circumstance, ideally a police officer would take them to a psychiatric emergency facility, they would be evaluated and appropriately treated either by admission to that facility if it's a hospital, or by, again, a strong linkage to ongoing care in a community setting.

We've developed some programs like crisis intervention training [...] Crisis Intervention Training is a program developed in Memphis, and it's really about training police officers in situ, on site, to better recognize and to more appropriately work with people who have severe mental health problems when they contact them, and that's another area where our system could definitely strengthened.

SUSAN DENTZER: In this case, it looks like that piece of it went okay. They referred him to treatment, or referred him for an evaluation. He was evaluated, he was held. It was when the judge, the administrative judge reviewed it and referred him to outpatient treatment, and you said that's where things fell apart. There was no -

DAVID SHERN: Right. And an irony in this case is that there is an involuntary outpatient commitment statute in Virginia, and from my perspective it shows the potential significant limitations of having a sort of a statutory fix, if you will, a law that says you can compel people into care in an outpatient environment without that care, in fact, being available and provided to them.

It's a well intentioned piece of legislation to try to link people to care who are having a difficult time accessing that care. But it's clear that it's not enough, and just passing those laws without an adequate service system to respond is really a cruel fiction, I think.

SUSAN DENTZER: So there is a dispute in this case over whose responsibility it was or was not to follow up on this, and the community board has said "It's not our responsibility."

DAVID SHERN: That's very diagnostic, I think, isn't it? I mean, that's exactly the problem. Who is responsible? If there was a system in place it would be clear how responsibility was delegated.

[...]And the fact that there is some argument now about who really is responsible, to me, is clearly diagnostic of the problem. And again, it's not just Virginia. This is a very common problem across the United States.

Assertive community treatment

SUSAN DENTZER: We began to talk about assertive community treatment, and you said the evidence has been around for a long, long time. Let's just talk briefly about where this model came from and why it works so well.

DAVID SHERN: It was actually a psychiatrist named Len Stein and a psychologist named Mary Ann Test, of the University of Wisconsin, years ago did a bold experiment and they said, you know, I think if we designed an outpatient treatment program effectively, we could take people who are presenting to the Mendota State Hospital and treat them in the community. We'd have better outcomes, and we think it will cost less than the hospital. And they even paired up with an economist, which was unheard of -- an economist named Burt Weisbrod -- at the time.

So they had an economist studying this along with them, and they took people who met criteria for admission to Mendota State Hospital, and they randomly assigned half of them to go into the hospital and half of them to be followed and worked with by this program with assertive community treatment that they had developed, and it was a very simple concept in many ways.

It's a multi-disciplinary team of individuals -- of psychiatrists, psychiatric nurses, people in rehabilitation, counselors who were available seven days a week, 24 hours a day to individuals in need, and who are mobile, who go to where those people are. They don't rely on people coming into the office. In fact, many programs have no offices. So all of their work is done in the field with people.

The experiment was done; the results were that people could be adequately served in the community, that the outcomes that were achieved were as good or better than the outcomes that were achieved with hospitalization, and that with Weisbrod's work looking at the total social cost that it was in fact a more efficient, more effective, less expensive alternative.

And that study was published in 1975, so it probably was done in 1973 or 1974. And as I mentioned earlier, has now been replicated many, many, many times. I think there are over 20 replications in all kinds of different settings. It's a very high standard of evidence in terms of the quality of the science that's behind it.

Toolkits have been developed and are available from the federal government that show you exactly how to do it. There are things called fidelity measures which means there are measures of the program to make sure that you're doing it right [...] The issue, of course, is getting it in routine practice around the country.

SUSAN DENTZER: So as you said, that evidence about the success of assertive community treatment is 30 years old. How widespread across the country is this today?

DAVID SHERN: Well, it's becoming more available. Many states have implemented programs of assertive community treatment, and that's the good news. The bad news is it's taken 30 years for this to happen. It's certainly not universally available, and it's not available in instances like this in terms of a tight linkage with an emergency care system. And that's, I think, sort of the critical failure that happened here.

SUSAN DENTZER: Is it not in existence in Virginia at all, to your knowledge?

DAVID SHERN: Susan, I don't know. I know we had it in Florida, we definitely have had it in New York, and the Midwest has been relatively earlier adapters. Michigan was a state that was very progressive in terms of putting it in place.

Part of our problem is that in contrast to the pharmaceutical industry, nobody has a real financial incentive typically to develop and promulgate these programs. The irony, you know, is they're available for free. [...] But nobody really has kind of a commercial interest in getting the psycho-social programs in place typically.

That's changing a little bit, and in our country, I mean, the way we get our technology used is by having someone have a business model essentially in which they can use it. I just think that's the way things work here, and it's ironic because with all these good psycho-social interventions, we don't have anybody who's out moving the technology into action like we do in pharmaceuticals, and even in the pharmaceutical case, where they devote a lot of money to marketing their products, the adoption rate is still pretty slow.

SUSAN DENTZER: But a community has a business case to do this, it could save a bunch of money on imprisoning people with mental illness, as has been shown to be the case in Rochester. It certainly is a lot cheaper to prevent somebody from shooting up your campus than it is to deal with the aftermath.

DAVID SHERN: Oh, and immeasurably so. I mean, we can't even think about the consequences of that. You know, I mean, absolutely. No. I think that for me it's -- obviously, I'm a tech convert -- for me it's compelling, that it's an essential cost-effective way, and these are extraordinary cases where horrible things have happened. And when someone takes their own life, obviously that's horrible, and families and loved ones are marked forever when those kinds of things occur. And we go right down the line in terms of incarceration charges, charges for people who go into the hospital because they don't have anyone helping them stay out of these crisis situations, all the way down to the less productivity and lost human capital to our communities in our overall well-being. So I think the economic case is very strong.

SUSAN DENTZER: I think you were saying earlier, in effect -- correct me if I am paraphrasing this incorrectly -- but you can go on the SAMHSA [Substance Abuse and Mental Health Services Administration] Web site and download a manual on how to do this.

DAVID SHERN: Right. Right. Yeah, it's available. It's highly codified in terms of how to do it, and there are several other practices. But [...] SAMHSA has developed something called the National Registry of Effective Programs and Practices, so they actually have a process that they go through vetting and making sure that the science is strong, and making sure that there are tool kits available.

So they're working assertively, aggressively to try to get this technology into play, and so it is available to anyone who wants to download it from the SAMHSA website.

SUSAN DENTZER: So what's the barrier?

DAVID SHERN: Well, there are a couple of barriers. Number one, we have a very diffuse system of settings in which people with behavioral health problems, problems with mental illness and addiction present in crisis or present for care, and no one really is in charge of that system.

So they're all -- there's the child welfare system, there's the education system involved, the police, the courts, the primary care system, the primary health care system, the specialty behavioral health care system, and nobody provides the strategic leadership and integration for all of these different settings in which people may present.

And so there's a diffusion of responsibility, a diffuse of accountability. Of course, we're all responsible, and that's where we need to go in terms of architecting a system, is realizing that all of us need to work together to make these things happen, because we're not going to change the architecture, I don't think, of where people present themselves who are ill.

SUSAN DENTZER: So we're not going to stop a situation where it might be Cho one day showing up because the campus police haul him in. [...] People are going to come in this way. What we need is what?

DAVID SHERN: Well, we need a strategic leadership plan. We need a community vision for what an effective system of care would look like. We need clear lines of responsibility. [...] It's very common where people are saying well, that's not my responsibility. This person isn't within my particular purview.

We need a system architecture that makes sense and is understood by the key actors in that system. We need to prepare people who ordinarily come in contact with individuals who are going to be in distress--and police officers are the very first group that come to mind--so that they're better able to realize and to keep themselves safe, and to keep the people they're working with safe. But all of that's achievable. We've got the information, we know how to do it; we need the leadership and the political will to get it done.

The stigma of mental illness

SUSAN DENTZER: Now, I want to go back -- another factor that people think was at play in the Cho case was possibly a sense of stigma that his parents may have felt about mental illness. And when his mother did reach out to some entity to get care for him, she did not go to a mental health provider. She went to the family church and said please help my son. And there was some suggestion, at least coming back from the pastor of the church, that whether it was believed he was haunted by an evil spirit or something, that his problems were spiritual, they were not mental, they were not organic, if you will.

So again, we don't know whether what lay behind this was a stigma about mental illness so much as it was ignorance, but how common are either of those characteristics?

DAVID SHERN: Well, a couple of really important points. One is that this was a Korean-American family that had come from a culture that's very different than ours, and that presents a series of specific challenges, I think, for designing a system that responds to people who come from very, very different sort of belief systems. That's an area again where we're trying to do a lot of work to develop cultural and linguistic competencies, and to try to make sure that those are available in our system.

So that's part of the issue here, I think, is the different backgrounds from which people come. Secondly, this gets back to this point about identifying and properly equipping, if you will, natural helpers because many, many people go to their pastors, and go to their spiritual counselors when they're having these kinds of problems.

There are associations of pastoral counselors. And as you know, many people who are in pastoral counseling have some specialization in terms of understanding mental health and mental health issues, and [...] they're a particularly important component of the system because of the fact that they are routinely in contact with people and are very trusted by them.

And that also is a potential avenue into some of the cultural diversity issues because people's churches are very much an important part of their culture and their belief system.

I don't know exactly what to say about the fact that as we understand it, the thought was that there was an exorcism that was needed here or something. To tell you the truth, I don't really know where to go with that because there's a notion then about the boundaries of effective practices, and to tell you the truth, I don't think we - at least I don't know enough about it to make an intelligent comment.

So I guess my point would be pastoral counseling is really important. People seek those individuals, trust them, trust them a lot, and that's why it's important that they also be supportive and be part of this system we were talking about linking together.

SUSAN DENTZER: What about stigma? It may well be the case that the family also eschewed going the mental health provider route because it was, if anything, better, safer for them to believe that it was a spiritual issue than it was a clinical issue.

DAVID SHERN: It's interesting because, I mean, the continuing ignorance about the legitimacy of mental disorders that results in people feeling shameful about having those disorders and not wanting to disclose to others how they're feeling continues to be a problem. We've made huge in-roads over the last several years in terms of educating people and making it much less shameful, and making it much more appropriate and acceptable for people to reach out for care.

But we haven't gotten that needled down to zero, and there still are those issues which frustrate people from receiving care, and that's something we work on a lot at Mental Health America, trying to continue the public education effort about the fact that these are real conditions, they're diagnosable, they have got biological correlates associated with them. We have a range of effective treatments, and our goal is to close that gap between what people need and what's routinely available to them in ordinary care.

SUSAN DENTZER: One point that I think is probably worth making is that in the case where Cho was referred to mandatory treatment and then did not get it, one thing that's operative is that many people who are mentally ill don't perceive that they are ill--if they perceive that anybody is ill, they perceive that the rest of the world is crazy and they're fine. To what degree does that play a role in making it even more important that we have assertive community treatment or a person gets followed, not just left on his or her own.

DAVID SHERN: I think that's critical, in those instances where people don't have what's characterized as insight into their own illness, which means that they're not understanding their circumstances in the same way that we are.

It's obviously even more important that we have assertive outreach to those individuals, and that we establish a relationship with the person where they are, not where we think they need to be, and start working with them from their perspective, to start to develop a relationship and alliance around trying to accomplish what they want to accomplish.

You and I were talking earlier about this program in New York City that we started, an experimental program, a random assignment study of individuals who are homeless with severe mental illnesses.

It was a program really designed to engage people in care, and to assertively follow them. But the thing that distinguished it was really working with them from their perspective, so they were in charge. They directed what happened in terms of their rehab program, and we showed very powerfully that we could engage people in care, and we could dramatically improve their clinical status, their housing status, and their general health status.

But the idea, again, is working with people where they're at, not where you think they need to be, establishing a relationship, and then from the foundation of that relationship starting to craft a rehab plan for people to get better.

SUSAN DENTZER: So to sum up, let's redo the history of Seung-Hui Cho. Let's take it a different place. Let's say he has a happier outcome in elementary school than he clearly had in terms of his illness being recognized. Walk me through what would have happened if things had gone better.

DAVID SHERN: First of all, [...] hopefully he would have access to a universal prevention or health promotion program. We have good science that shows these universal interventions, some as short as six sessions, delivered to children in grade school have long-lasting effects through high school, into young adulthood, in terms of decreasing the level of problem behavior.

So in an ideal situation, he would have received a health promotion or prevention -- a science-based health promotion or prevention intervention.

SUSAN DENTZER: And what would that have looked like?

DAVID SHERN: They're essentially giving kids skill sets that allow them to better manage their behavior, so it allows them to better manage anger behavior, to understand how to more effectively work with their fellow students and co-workers, to discipline themselves to focus and concentrate on their work.

In fact, the one that's been developed and tested at Johns Hopkins is called the Good Behavior Game. And so it's about teaching kids and giving them skill sets and then also some of the positive behavior support interventions that are becoming quite popular now, and around which we're developing a good science base. Also they have to do with structuring school environments so they're orderly, they're predictable, they work for the kids, and they work for the school.

SUSAN DENTZER: So to simplify it a bit, he would have sat down with a concerned, compassionate mental health provider who would have counseled him on some of these behaviors.

DAVID SHERN: Well, actually, in the first case, these are classroom education sessions that are delivered to everybody, and so they're universal. So everybody gets them and they have long-term laudatory effects.

The second step then is that he would have received a mental health checkup of some sort, and in that case, ideally he would have been given a standardized, validated instrument to measure how he was doing, and if there were problems indicated in that instrument, he would have met with a clinician, who would have seen whether or not the problems really met criteria for intervention. If they did, there would have been an active process to link him into a competent care system that could respond to his needs. So that would have been a second point in which the trajectory of this young person's life could have been perhaps set in a different direction.

And the next step, there were people in his environment who were suggesting to him that he had problems. Like we said earlier, [...] ideally in those kinds of circumstances, there would have perhaps been some sort of a peer support program. We haven't talked about peer support, but many college programs are developing -- peer support and counseling programs -- and there could have even been an informal response in the college to his situation, in which his peers with some level of training, or professional backup and support, might have reached out to him and had some effective tools to get him engaged. That would have been yet another opportunity.

We get to the next level, in which his behavior becomes troubling enough that the police become involved. At that point in time, he would have received a timely and competent psychiatric evaluation. A decision would have been made about his level of dangerousness either to himself or others, and as it turned out here, he was found to be dangerous. But even if he wasn't, there would have been an affirmative attempt to link him up with care, because clearly anyone who finds himself in those circumstances is probably having some sort of a crisis.

In his case, he was found to meet a dangerousness criteria, ordered into care, and there would have then been an assertive response to reach out to him, and to try to engage him in care, to monitor him, to make sure that he was doing okay, much like we would do for someone who had an infectious disorder, to make sure that they were getting appropriate care and getting better.

Any one of those four points might have substantially changed the trajectory in this.