Seung Hui Cho never received the treatment ordered by a judge who declared him dangerously mentally ill less than two years before his rampage at Virginia Tech, law enforcement officials said, exposing flaws in Virginia's labyrinthine mental health system, including confusion about the law, spotty enforcement and inadequate funding.
Neither the court, the university nor community services officials followed up on the judge's order, according to dozens of interviews. Cho never got the treatment, according to authorities who have seen his medical files. And although state law says the community services board should have made sure Cho got help, a board official said that was "news to us."
It is impossible to know if the treatment, ordered in December 2005, would have prevented the massacre last month, which left 32 students and faculty dead before Cho killed himself. But interviews with state and university officials, lawmakers, special justices, attorneys, advocates and mental health agencies across the state made clear that what happened with Cho is not unusual in cases of "involuntary outpatient commitment" — Virginia's name for the kind of order issued by Cho's judge.
Cho, they said, slipped through a porous mental health system that suffers from muddled, seldom-enforced laws and inconsistent practices. Special justices who oversee hearings such as the one for Cho said they know that some people they have ordered into treatment have not gotten it. They find out when the person "does something crazy again," in the words of one justice — when they are brought back into court because they are considered in imminent danger of harming themselves or others.
"The system doesn't work well," said Tom Diggs, executive director of the Commission on Mental Health Law Reform, which has been studying the state mental health system and will report to the General Assembly next year.
Involuntary outpatient commitments are relatively uncommon in Virginia, officials said, because those in the system know they are not enforced. They are almost an act of faith.
"When I let the person go outpatient, I always put on the record, 'I hope I don't read about you tomorrow in the paper. . . . Don't make me look like the foolish judge that could have stopped you,' " said Lori Rallison, a special justice in Prince William County. "And knock wood, that hasn't happened. But it can."
Cho's case is a classic example of some of the flaws in the outpatient treatment system.
'In need of hospitalization'
By 2005, Cho, an English major at Virginia Tech, had frightened teachers and classmates with his macabre and violent writings. He referred to himself as Question Mark, never made eye contact and rarely spoke. But it wasn't until two undergraduate women complained that Cho sent instant messages and left cryptic lines from "Romeo and Juliet" on their dry-erase boards that Cho came to the attention of police. Although the girls decided not to press charges, police met with Cho on Dec. 13 and warned him to leave the women alone.
That night, Cho e-mailed a roommate saying he might as well kill himself. The roommate contacted police, who brought Cho to the New River Valley Community Services Board, the government mental health agency that serves Blacksburg.
There, Kathy Godbey examined Cho and found he was "mentally ill and in need of hospitalization," according to court papers. That was enough to have Cho temporarily detained at Carilion St. Albans Behavioral Health Clinic in Christiansburg, a few miles from campus, until a special justice could review his case in a commitment hearing.
New River Valley's Mike Wade maintained that the community services board's responsibility ended there.
"Unless, out of the commitment hearing, the judge issued outpatient treatment specific to our agency, that's where it ends with us," said Wade, the board's community liaison. "Since we weren't named the provider of that outpatient treatment, we weren't involved in the case."
A day later, on Dec. 14, 2005, Paul M. Barnett, the special judge, decided that Cho was an imminent danger to himself as a result of mental illness and ordered him into involuntary outpatient treatment. It is a practice that Terry W. Teel, Cho's court-appointed lawyer and a special judge himself, said they use "all the time" in Blacksburg. Special justices such as Barnett are lawyers with some expertise and training who are appointed by the jurisdiction's chief judge.
Teel said he does not remember Cho or the details of his case. But he said Cho most likely would have been ordered to seek treatment at Virginia Tech's Cook Counseling Center. "I don't remember 100 percent if that's where he was directed," Teel said. "But nine times out of 10, that's where he would be."
And there, he said, ended the court's responsibility. The court doesn't follow up, he said. "We have no authority."
Falling through the cracks
Virginia Tech mental health officials declined to discuss Cho's case because of privacy laws. But they said they are never informed when a person is referred to their facilities by the court.
"When a court gives a mandatory order that someone get outpatient treatment, that order is to the individual, not an agency," said Christopher Flynn, director of the Cook Counseling Center. The one responsible for ensuring that the mentally ill person receives help in these sorts of cases, he said, is the mentally ill person. "I've never seen someone delivered to me with an order that says, 'This person has been discharged; he's now your responsibility.' That doesn't happen."
Virginia law says community services boards — the local agencies responsible for a range of mental health services — "shall recommend a specific course of treatment and programs" for people such as Cho who are ordered to receive outpatient treatment. The law also says these boards "shall monitor the person's compliance."
When read those portions of the statute, Wade said, "That's news to us."
In fact, the law even says that when a dangerously mentally ill person ordered into treatment doesn't show up, as was the case with Cho, he or she can be brought back before the special judge, and if found still in crisis, can be committed to a psychiatric institution for up to 180 days.
None of that happened in Cho's case.
Community service boards saw 115,000 mentally ill people in Virginia in 2005, at a cost of $127 million.
Rigid mental health requirements
Virginia is one of only eight states in the country to require that people be an "imminent" danger to themselves or others before they can even be brought before a judge. Advocates argue that that is such a high standard that only the most dangerous cases are considered and involuntary hospitalization is usually required.
When involuntary outpatient treatment is ordered, officials say they often have no idea what happens to the mentally ill person once they leave the courtroom.
Tom Geib, director of Prince William's Community Services Board, who also serves on the Mental Health Law Reform Commission Task Force studying outpatient commitment, blames the lack of follow-up on a lack of resources. Caseworkers at his agency may make calls or write letters if someone ordered into involuntary outpatient treatment doesn't show up for appointments. "But in terms of going out and trying to find them, we don't have the resources to do that," he said.
Mary Ann Bergeron, head of the Virginia Association of Community Services Boards, which represents the 40 agencies within the state, said the boards are responsible for a person committed to outpatient care only "if he seeks treatment. But we can't give him treatment if he refuses it."
But advocates and some special justices disagree.
"The services board job is not to say, 'We tried, and they don't want treatment.' Their job is to report back to the court," said Mark Bodner, a special justice in Fairfax County. He said that in his six-year tenure, that has happened only once.
Staff writers Jerry Markon and Sari Horwitz and researcher Meg Smith contributed to this report.