The Trouble With Spikol has a post titled “Cho Docs Released” about the release of documents involving the mass shooting and murder at Virginia Tech University by a student Seung-Hui Cho. The blogger Liz Spikol copies some of the pages from the psychological evaluation onto the post for review. Here is an excerpt:

As we know now, the man who committed mass murder at Virginia Tech, Seung-Hui Cho, was subject to psychological and psychiatric intervention several times while on campus. Some of what disturbed professors were plays like Richard McBeef, a takeoff on Macbeth that took things a little too far.

On Wednesday, the university finally released the documents that were “lost” after the shootings. They reveal a great consistent gap in the psychiatric system, and one that can’t easily be remedied. Though the documents attest that Cho was interviewed several times, he was lucid and able to say that he wasn’t a threat to himself or others. This is typically the standard that merits commitment, and if a person avers that he’s not a danger, we have to take that at face value. We can’t just go around virtually incarcerating people for being strange.

In the case of one incident, a roommate reported concerns of suicidal ideation on Cho’s part. But Cho voluntarily went to the counseling center to discuss it, and was clearly not psychotic or delusional. He was, to all appearances, under control. Much of what was done (physical tests, etc.) is standard and mandatory, and some might say detracts from really engaging. But on the other hand, if the person is suffering due to a physical problem, this must be discovered.

When reviewing the documentation you can see the limitations of psychological assessments and the power of confidentiality clauses that keep mental health professionals and outside institutions from digging deeper to find out what in fact may be going on with an individual who is being thought of as disturbed or a danger to himself or others. Cho’s word apparently held enough weight in the evaluation process to keep mental health professionals from going any further than a cursory response of recommending therapy for a possible mood disorder. The documents she posts are standard fare for what we see in so many psychological assessments, which can represent a very limited snapshot, or better yet a distorted picture of what may really going on with an individual.

In order to get a more accurate picture of someone who has the potential to cause harm to themselves and others a clinician and/or investigator needs time and access to more history, family, friends, peers, employers, faculty, coworkers and others who have come in contact with him over the years. Obviously, this kind of investigative/analytical approach is mostly unrealistic because of the time it will take, who is in fact willing to talk and the limited access to private information. So an assessment and/or investigation has to gather as many perspectives and history as possible to make a determination about how at-risk a person is and whether he or she will harm themselves and/or others. Being able to rely mostly or only on the person being assessed is the greatest fault in the system of mental health.

Confidentiality in regards to private information plays a large factor here as does the limited resources available to mental health professionals. Add to this the hit or miss results that are achieved through making clinical diagnoses, enforcing interventions and implementing treatment strategies as discussed in the previous post “Cultural Symptoms: What We Don’t Know.” Any statements made by a person being assessed and/or investigated must be corroborated by others and found within existing documentation. Again this takes time, resources and an ability to get passed confidentiality clauses that hide information from those trying to get answers.

One other important aspect of assessments and investigations is having a system wide critical risk threshold assessment for determining who is potentially in crisis and in need of more serious and invasive interventions and treatment. It is an assessment tool that evaluates and scores who has reached a critical at-risk threshold and then triggers how aggressive mental health and law enforcement professional need to be. I have mentioned this critical risk threshold process in the post “Critical Risk Thresholds: Finding The Right Balance.” Read also about the challenges associated with using psychological evaluations in the post “Rorschach Test Exposed and Other Thoughts on Psychological Evaluations.”

Health Insurance Portability and Accountability Act (HIPAA) protects personal information held by doctors, hospitals, and mental health providers and the rights of patients. This is an important act that has much merit. But, as important as this act is in protecting our personal information it makes it extremely difficult to get or share information about a person who is at-risk of harming themselves and others. In the case of Cho and so many others the ability to dig deeper, reach out to others, collect data is hampered by this act. Mental health, social workers and law enforcement professionals can’t do an investigation if a person who is at-risk has not committed a serious enough act. It is literally a wait and see dilemma.

But, it is not only confidentiality standards and clauses and an inability to dig deeper that can cause us to miss someone’s symptoms and behaviors. The ways in which families, friends, peers, coworkers and neighbors will keep important information from those who might be able to help or protect the person who is disturbed and/or others and themselves from possible harm also comes into play. Families and friends, especially in certain cultures, will protect their member and friend from outsiders or may not possess a real understanding of what to look for in terms of mental illness. Shame also plays a role in withholding information. Friends and peers may not want to intrude, invade someone’s privacy or may think that it is no big deal and that he or she will get over what is bothering them. In most cases regardless of the family dynamic, or the involvement of friends and peers it is hard to determine how far a person who seems disturbed will go.

Even with a more invasive investigative process and procedures including the use of critical risk threshold assessment tools to determine who poses a threat to themselves and others, an ability to get through the red tape of confidentiality acts and find important information from family, friends, peers, coworkers, neighbors and in existing documentation, and aggressive clinical interventions that can help address and contain the person in need of this kind of help, so many who are out there will still fall through the cracks. The kind of approach we are talking about is just too invasive and risks violating so many fundamental personal rights. This leads us back always to the fact that a person at-risk in the majority of cases will have to cause harm to themselves and/or others before we can step in. In the meantime, as family members, friends, peers, coworkers and professionals in the field we have to stay aware of the people around us who are falling through the cracks. Our communities depend on each of us, layman and professional, to know the warning signs and to how to act upon them when they occur.

(An amazing indepth article and case study worth the time of those interested in the serious problems associated with using psychological assessments in investigations is from the New Yorker titled “Trial by Fire: Did Texas execute an innocent man?” by David Grann. See gin able’s photostream here.)