Natalie Keepers, shown in a photo provided by the Montgomery County Sheriff's Office in Virginia, is one of two Virginia Tech students charged in connection with the slaying of Nicole Lovell, 13. (Montgomery County Sheriff’s Office/Via Reuters)

A target of bullying, Natalie Keepers cut her arms and harbored suicidal thoughts in middle school. She learned to cope through therapy and medication in high school. But moving to Virginia Tech for college triggered new emotional distress. She sought counseling, help that ended just four months into her freshman year, she said.

It is common for students to have challenges in transitioning to college, and many among the millions of students at the nation’s schools seek counseling help as they move to adulthood and life on their own. But what happened next for Keepers is not: She allegedly helped a friend, also a freshman at Virginia Tech, plan the killing of a 13-year-old Blacksburg, Va., girl whom she had never met, according to prosecutors.

Keepers’s emotional travails — and her claim in court Thursday that a Virginia Tech counselor told her that she “no longer needed therapy” in December, less than two months before the slaying — have once again put the university’s mental health services at the center of a grisly criminal case. The case also highlights the harrowing transition to college that has served as a backdrop for other acts of violence by troubled students.

It is not clear whether Keepers showed signs that might have forewarned university counselors of any trouble, let alone the alleged plot to kill Nicole Lovell. But her only public statements thus far have forced Virginia Tech to again confront questions about its counseling center, which has expanded its services and revamped its procedures since 2007, when the campus was the site of the deadliest shooting by a single gunman in U.S. history.

In this 2015 photo provided by Tammy Weeks, her daughter, Nicole Lovell, flashes a peace sign in Blacksburg, Va. The 13-year-old girl was found dead just across the state line in Surry County, N.C., and two Virginia Tech students are charged in the case. (Tammy Weeks/AP)

Virginia Tech’s Cook Counseling Center, where Keepers said she was treated and deemed no longer in need of therapy, was faulted for missing the dire warning signs before student Seung-Hui Cho massacred 32 people and killed himself nine years ago. Cho had an extensive history of mental health problems, and his writings in class had turned dark and violent, providing glaring signals that counselors and university staff missed or failed to act upon.

Tracy Vosburgh, a Virginia Tech spokeswoman, declined to address specifics about Keepers’s treatment at the university’s counseling center, as did other officials at the school. But she said that it is common practice “to have an ongoing dialogue between a doctor and a patient to determine a course of action.”

“And it is a practice to provide service when asked,” she said.

Attorneys for Keepers declined to comment, and her family did not respond to requests for comment. Tim Keepers, Natalie’s father, spoke in court about his daughter’s emotional frailty, saying that she would have panic attacks when she had too much homework. But he said she had never been in trouble and was part of a “pretty close, very strong Christian family.”

Prosecutors said Keepers, 19, helped David Eisenhauer, 18, plan the slaying of Nicole, a middle school student who was bullied and survived cancer and a liver transplant. Nicole had met Eisenhauer online; authorities have said the two had an inappropriate relationship and that he lured her out of her home to kill her.

Keepers admitted to being part of the plot, helping to pick a spot in the North Carolina woods to dump the body and telling investigators she was “excited to be part of something secretive.” She is charged with accessory before the fact to first-degree murder, accessory after the fact and concealing a body.

At a hearing in Montgomery County, Va., on Thursday, neither prosecutors nor Keepers hinted at a possible motive for the killing, nor whether Keepers’s mental state played any role in it. Instead, Keepers gave a detailed account of her mental health history in a bid to be released on bail so that she could get appropriate treatment at home with her family in Laurel, Md. She said she had been bullied in middle school and suffered depression and panic attacks. A judge denied the request.

Keepers said she was taking an antidepressant and anti-anxiety medications and was working with a psychiatrist and a counselor at Virginia Tech as recently as December. Neither could be reached for comment Friday.

She testified that the counselor decided “the counseling was no longer needed.” Keepers originally sought treatment at the center in August because she was having problems with the transition to college, she said.

Aradhana Bela Sood, a professor of child mental health policy at Virginia Commonwealth University and an author of a report on Virginia Tech’s response to the 2007 massacre, said a critical question is whether the therapy was discontinued because of a lack of symptoms or a lack of resources at the center.

There is no guarantee that a counselor would have seen the warning signs if therapy had continued, she said.

“Any honest individual who works in this field can safely say that we try to predict things, but we often can’t,” she said. “But it’s unforgivable if you have red flags coming up and you don’t do anything about it.”

A review commissioned by ­then-Virginia Gov. Timothy M. Kaine (D) after the 2007 killings found that Cook had “failed to provide the needed support and services to Cho” in the two years before the attack. “The system failed for lack of resources, incorrect interpretation of privacy laws, and passivity,” it found.

Since then, Cook has doubled in size and is now the largest university counseling center in Virginia, said Chris Flynn, the center’s director. The center has 20 counselors, two psychiatrists, two nurse practitioners and four pre-
doctoral interns.

The school also has seen an increase in students’ requests for help. In the 2015 fall semester, student appointments spiked 10 percent compared with the previous year; student appointments have grown by 24 percent during the past five years, Flynn said.

“This does not mean students are more distressed or disturbed, but rather that they have had services previously and are more likely to have been in counseling or on medication in high school,” he said. The societal stigma about seeking counseling has dissipated, he said, creating more awareness among parents, more willingness to seek help and more services.

Students who go to Cook generally meet with a counselor for an individual assessment, Flynn said. Each student is screened for “distress,” including depression, anxiety and hostility; during intake interviews, staff members assess students for the risk of suicide and potential for violence against others. Students can choose to continue in individual or group counseling or may request a medication evaluation, he said.

Schools nationwide are straining to provide mental health services to students who need them. Many have expanded counseling centers and outreach in recent years, but questions remain about whether staffing is robust enough to meet demand.

A 2014 survey of nearly 500 counseling center directors found that 150 used waiting lists for clients to receive ongoing treatment. At some large schools, those lists grew to have dozens of students, according to the Association for University and College Counseling Center Directors. The survey found that small colleges typically had fewer than 1,000 students for each counseling professional on staff. At large colleges, the ratio ballooned to 2,300 to 1.

“All of this comes to funding and the cost of higher education,” said Gregory Eells, director of counseling and psychological services at Cornell University and a former president of the association. “Those are questions. Nothing is for free. There are costs to adding therapists to do this work. The demand is still clearly beyond the capacity of centers.”

Even when schools have ­adequate staff, it is a challenge to connect services to students. Often, those who need them don’t seek help.

To overcome that obstacle, Marney White, an associate professor of psychiatry at Yale University, said schools should consider mandatory mental health screening for all students, to ensure early intervention.

“The problems with the mental health systems on college campuses parallel those of the mental health system in general: insufficient resources to provide affordable, effective, and immediate services,” White wrote in December on The Washington Post’s Grade Point blog. “Instead of providing care only in the case of crises, we should flip the emphasis — we need to provide mental health services early, before the onset of serious disorder, and we need to devote attention to mental health wellness campaigns.”

Daniel Eisenberg, an associate professor of health management and policy at the University of Michigan, said many colleges are training faculty advisers, residential assistants and others known as “gatekeepers” on how to spot students who might need help and provide them with referrals.

Early and effective treatment can prevent tragedies such as suicide or simply make the difference between whether a student stays in school or drops out.

“It’s a key point in their lives,” Eells said. “Their life trajectory is being set. You reach people now, and you can make a huge impact. It’s like a moon launch. If they’re off target now and they don’t get a course correction, they’re headed to Mars instead of the moon. That’s part of why college mental health is so important.”

Balingit reported from Blacksburg. Justin Jouvenal contributed to this report.