A Review of: The Virginia Tech Massacre: Strategies and Challenges for Improving Mental Health Policy on Campus and Beyond,edited by Aradhana Bela Sood and Robert Cohen

“Our current healthcare system is not in the business of planting trees but it should be.” This was a statement made late in the book, The Virginia Tech Massacre: Strategies and Challenges for Improving Mental Health Policy on Campus and Beyond in response to the limited focus of the policy response in Virginia after the tragedy. Thirty-three people died as a result of Seung-Hui Ho's actions on April 16, 2007. In the year that followed, the Virginia General Assembly aggressively responded by enacting more sweeping reforms in mental health than had occurred in the previous 30 years combined. More than100 bills were introduced during the 2008 session and ∼$42,000,000 was appropriated for mental health care services. Unfortunately, the desired changes in mental health services did not come to fruition. The bills were limited to crisis stabilization rather than prevention, and the money allocated in 2008 was cut in 2009 as the recession deepened. There was a lack of policy makers who understood the complexities of the mental health system and the need to fund primary prevention and early intervention services in order to develop systems with the potential to avert future mass tragedies. Unfortunately, as the authors point out, policy makers' careers do not last long enough to see the “planted trees” bear fruit.

This book was undertaken to examine the mental health systems in university settings and, more broadly, in the United States. The intended audience was broad, but the book will be of most interest to policy makers, those working in college mental health, and all mental health practitioners who are faced with threat assessment in their daily clinical work. The initial chapters focus on the numerous failures of the system, specifically relating to lost opportunities to prevent Seung-Hui Cho's actions. The later sections discuss contemporary college mental health care services and identify successful approaches as well as barriers to providing care. A global review of how mental healthcare is delivered in the United States and in other developed countries reveals that there are few, if any, model systems. The final and most sobering section discusses the challenges facing policy makers to ensure that well thought out, evidenced- based mental health programs that also emphasize prevention are in place and –most importantly – that they are adequately funded.

The lead authors/editors are well suited for their identified goals. Dr. Sood is a senior child and adolescent psychiatrist who was appointed to an expert panel by the governor of Virginia at the time, Thomas Kaine. The panel included eight members from different professional backgrounds who were tasked with reviewing both how and why Seung-Hiu Cho committed the murders, and the response of the Virginia commonwealth to the shootings. The panel was also to make recommendations to improve laws, policies, procedures, systems, and operations of agencies including those for mental health. Dr. Sood was intimately involved in all aspects of the panel and, in particular, had personal access to Cho's family members and the involved faculty and administrators at Virginia Tech. (Cho's family authorized the release of their son's health and education records, and they willingly participated in multiple interviews by the Virginia Tech Panel). The co-editor of the book, Dr. Cohen, is an expert in policy and program development.

Although much of the story about Seung-Hui Cho's progression from a “fragile, solitary, and silent young man who inspired sympathy” to the dark, ruminative, and rageful murderer he became has been reported in the press, the book provides greater insight into the failings of the mental health system prior to and during his time as a college student at Virginia Tech. Co-author Stambaugh, a policy/systems analyst for emergency, security, and crisis management in Arlington Virginia created a table that includes the 17 “red flags” regarding Seung-Hui Cho's potential for harm and the limited network of individuals and agencies in academics, student affairs, law enforcement, mental health centers, and the courts who knew about them. The panel determined that much of the poor communication was the result of widespread lack of understanding and conflicting implementation of poorly designed privacy laws. The laws do provide exceptions that allow for disclosure in some instances, but the complexity leads most to maintain privacy when it would be legal and safest to disclose.

The book is comprehensive in defining the failures of the various systems that touched Seung-Hui Cho over his lifetime. The series of missed opportunities and dropped balls will be all too familiar to most clinicians, especially those who treat college-age youth. However, what is most appreciated in this book is the best practices and resources chapter by Drs. Martel and Sood relating to national models for college mental health care services. They review the annual results of the National Survey of Counseling Center Directors and the findings of the 2010 American College Health Association National College Health Assessment Survey. These surveys confirm that there is a persistent increase in the numbers of students who are attending college with preexisting mental health problems and that 6 of the 10 factors impacting academic performance listed by students were psychological or emotional in character. The description of the key principles of the development of a comprehensive campus mental health plan includes discussion of individual development, culture, legal issues, evidence-based treatments, training of mental health professionals, and the importance of embedding this plan within an larger community/public health system. Primary and secondary prevention strategies that were identified by the authors include helping students develop life skills and improve social networks, and enhancing the ability of the college to improve identification and screening for students with mental health needs. Of interest to most clinicians is the discussion of models from a Midwest university of mandated professional assessments for any student who threatened or attempted suicide. This practice remains somewhat controversial because of the conflicting roles it imposes on the mental health professionals and the administrators involved. The chapter discussing this ends with several case examples that highlight best practices for all who are involved with mentally ill students transitioning to college.

The authors' attempt to shed some new light on predicting violence in public places is a nearly impossible task, because of the challenge of identifying “one common predisposing factor that leads to a violent act.” The summary of lessons learned from the litany of violent acts by diverse individuals in the United States and abroad is generally interesting, and likely familiar to most readers who are mental health professionals.

One of the greatest disappointments for the authors of the book, and for most readers, will be that the tragic events on April 16, 2007 did not lead to substantive change, even though there was an explosion of bills to improve many aspects of college safety and college mental health in Virginia. The 2008 recession was partly to blame, but the narrow focus on public safety and not on improvement in mental healthcare stands out also. Dr. Sood laments, “Even after the Virginia Tech tragedy there is little evidence of uniform improvement in mental health systems of university counseling centers.” Stigma, inefficient delivery systems, and understaffed work forces continue to limit progress in mental health. Dr. Sood blames the elected policy makers whose conflict of interest between retaining political power and making scientifically informed decisions that may be costly, and produce delayed outcomes.

The scenario at Virginia Tech in 2007 has been played out in several other tragedies since 2007 including in Newtown, Connecticut. The pace of legislative change is maddeningly slow and erratic. I agree with Dr. Sood's final comment in her postscript. “We must not wait for repeated tragedies to drive rational policy.” This book is a must for all who want to move the bar closer to a more optimal system of care for all children and adolescents including college-age youth.