04/18/2007 07:21 pm ET Updated May 25, 2011

National Security & Mental Health Intelligence: Cho Seung-Hui and the Virginia Tech Tragedy

This is an updated version from the author in response to recent evidence that has emerged from the case.

I know when people are depressed, I can feel it. They walk around like ghosts and only some of us choose to see them. They are a painful sight and are usually ignored because they scare us and make us feel so vulnerable.

Here's what we know so far about Cho Seung-Hui, the shooter at Virginia Tech. He was a 23-year-old student from South Korea majoring in English and has lived in the U.S. since 1992. He was also, "...a loner, and we're having difficulty finding information about him," according to school spokesman Larry Hinker. [Since writing this piece on the morning of 4/17/07, we have learned that the extent of Cho Seung-Hui's mental illness was severe and profound.]

Before I went to graduate school in clinical social work and completed institute training in psychoanalysis, I had been an editor. In the early 80s, I worked in a small publishing company where there was an older woman who haunted me. She was a loner and my co-workers knew very little about her. Let's say her name was Lena (to protect her identity).

She was petite, had deep lines in her face, wore a lot of make up and had platinum blonde, teased hair that finished in a flip. When she wasn't proofreading, she walked around the halls head down, sighed and smoked a lot of cigarettes. Sitting in the same bullpen, I overheard some of her telephone conversations--she was divorced and taking care of a frail, elderly mother. We developed a cordial--but not close--relationship.

My colleagues and I were young (early 20s). Lena was such a contrast to the environment, yet no one else noticed her. She tugged at the strings of my heart and soul and I wish I had had a better understanding of why. I would often confide in a close colleague, Ray, "I'm worried about her, let's ask her to lunch or take her to a movie." We never did either.

Years later in grad school, I learned from Ray that Lena's mother died. Later still, immersed in my internship counseling Vietnam Veterans and experiencing firsthand the ravaging effects of war-time trauma on psyche and soul, I received another call from Ray. He'd been reading the obituaries and learned that Lena passed away. I felt my heart get tugged hard one last time, I knew what happened. Ray confirmed she committed suicide. While on the phone with her brother, she cried out that life was too painful, she could no longer stand it and proceeded to stab herself to death.

Lena was a depressed, tortured soul who finally released all these feelings plus her enormous anger (against her brother, herself--all of us).

I can't tell you yet about Cho Seung-Hui, his "diagnosis" or the "motive" everybody is looking for. He could have been suffering from untreated clinical depression, psychotic depression or early stages of paranoid schizophrenia (which blossoms at his age marked by delusions, eg, he may have thought he had "special connections" with homicidal suicide martyrs and religious extremists); or the adverse reactions of poorly monitored anti-depressants (which Tom Cruise will surely jump on like Oprah's couch if Cho was on them).

A diagnosis is just a category used to justify prescribing drugs or obtain health insurance reimbursement. A person is so much more than that. That's why I was so offended by Maia Szalavitz's April 11th Op-Ed piece "When the Cure Is Not Worth the Cost."

Skilled, experienced mental health clinicians can often avert a mental health disaster--if you don't tie their hands. And, yes, there are also a few "quacks," inexperienced shrinks, and clinicians who are not well suited for their work--just like elected officials, surgeons, lawyers and teachers--we run the gamut. As a distinct group of professionals, none is held to a higher or special standard in their ability to make a living.

Szalavitz feels we should have, "mental health parity" and "coverage" only if "tied to evidence-based treatment" and "outcomes." Physical illnesses and medical treatments are not held to this ridiculous, naïve, reductionistic standard. I only wish we could judge and withhold payment for every poor outcome by politicians, surgeons and attorneys.

I went to three different MDs for a horrendous case of poison ivy. The first, an internist, gave me antihistamines. He got paid by my insurance company because he was an in-network provider of evidenced-based treatment. It didn't work. The second MD, a dermatologist, gave me low dose prednisone that I would have to taper. It didn't work. I had to pay for the visit myself. The third dermatologist gave me very high dose prednisone to be tapered for over a longer period. I paid for the visit. This treatment worked. The insurance company paid for all the drugs for all the visits.

It wasn't the drugs that finally cured me. It was the expertise of the third physician and no one telling him how to treat me.

Whether Cho Seung-Hui was ignored my his fellow students and suffered what Durkheim called anomie; was lonely, depressed and totally untreated; given psychotropic medication only and poorly monitored; not seen frequently enough by a culturally sensitive, experienced clinician (campuses often don't make it a priority to employ the best and the brightest and kids and their parents often can't afford better or long-term treatment because insurance won't pay)--one thing is clear there were signs that something was terribly wrong and these signs were not dealt with adequately.

Establishing a therapeutic alliance (an authentic relationship) between patient and clinician is what determines outcome. Also, outreach is key when there is poor patient compliance. Government, insurance companies and naïve laypersons who want to dictate policy, procedure and treatment need to get out of the way because there are lives to save.

Psychological suffering; poverty and other social injustices; horrible government (domestic and foreign) policies--including poor gun-control and naivety about the Middle East--these are our biggest threats to national security.

Who will help the victims of the traumatic events suffered at Virginia Tech? The same mental health professionals who helped the victims of 9/11. And, what will they have to demonstrate for Szalavitz to think insurance companies should reimburse them? They won't be reimbursed because they will probably volunteer and work for nothing, which is what you will often find we do in this field.

I wish I had had the courage and the expertise to do more for my late colleague, Lena, when I was Cho Seung-Hui's age. Now that I can do something please, Ms. Szalavitz, let me.

[One more update: There was a comment about analysts charging $200.00 per hour. If people only knew how many private practitioners--analysts and others--slide their fees to accommodate patients' financial situations, you would be astonished. Also, hundreds of social workers, psychologists, psychiatrists, psychiatric nurse practitioners and analysts from every orientation including myself flocked to the Red Cross after 9/11 and volunteered services in any capacity needed. It's not an issue of money, it's an issue of fairness, quality of service and professional integrity. I am not against evidenced-based treatment per se, I just don't think everyone agrees on exactly what it is and who determines what it is.]