Cho Didn't Get Court-Ordered Treatment

By Brigid Schulte and Chris L. Jenkins
Washington Post Staff Writers
Monday, May 7, 2007

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.

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.

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