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DEBORAH AMOS, host:

This is MORNING EDITION from NPR News. I'm Deborah Amos.

RENEE MONTAGNE, host:

And I'm Renee Montagne.

The community of Blacksburg, Virginia, continues to cope with Monday's shooting spree. And many are asking serious questions about whether it was appropriate to allow the shooter, Seung-hui Cho, to return to campus after he was released from a psychiatric facility in 2005. University officials defended their decision in a news conference yesterday. Christopher Flynn is director of the campus counseling service. He made a point to distinguish the university from the mental health system.

Dr. CHRISTOPHER FLYNN (Director, Cook Counseling Center, Virginia Tech University): This is not a law enforcement issue. He had broken no law that we know of. The mental health professionals were there to assess his safety, not particularly the safety of others. And so there is no necessity, perhaps, that they would notify everybody, whether it be the police or the university.

MONTAGNE: Behavioral changes and threats of violence can sometimes be difficult even for mental health professionals to read.

NPR's Joanne Silberner reports that it's nearly impossible to predict who is going to be violent.

JOANNE SILBERNER: Early in his medical career, psychiatrist Paul Appelbaum had a patient who worried him.

Dr. PAUL APPELBAUM (Psychiatrist, Columbia University): The patient was a young man in his early twenties who already had a long history of hospitalization for psychotic episodes.

SILBERNER: The young man had dropped out of high school. He had no friends. He got into fights. He lived alone in a boarding house.

Dr. APPELBAUM: One day, he told me how his landlady of the boarding house where he lived had been harassing him and how angry he was. And he said, in no uncertain terms, he was going to take her out.

SILBERNER: At the time, Appelbaum didn't know what to do. Today he heads the Division of Psychiatry, Law, and Ethics at Columbia University, and he knows every psychiatrist faces the challenge of predicting violence.

Dr. APPELBAUM: It's a routine part of psychiatric practice. I think every psychiatrist in every clinic in the country, and many psychiatrists in private offices in the country, go through that process everyday.

SILBERNER: So how do you tell who was going to be violent? There are risk factors. Those threats, for one. A history of being abused as a child. Prior acts of violence. But there haven't been enough cases of violence in the order of what happened in Blacksburg to come up with a clear profile. Forensic psychiatrist Philip Merideth says you can predict who is at risk of committing violence, but you can't say who actually will.

Dr. PHILIP MERIDETH (Medical Director, Brentwood Behavioral Healthcare): Psychiatric literature in the past has shown that efforts to "predict" - and using the word predict in quotes - violence is no better than flipping a coin.

SILBERNER: Merideth is a forensic psychiatrist and the chief medical officer for Brentwood Behavioral Healthcare in Mississippi, and he's a lawyer who teaches about mental health in the law. He says patient's rights have to be considered.

Dr. MERIDETH: The thing that I worry about is the deprivation of liberty that occurs with involuntarily hospitalizing someone against their will, and balancing that against the protection of the public.

SILBERNER: Merideth has his own stories to tell. Recently, he saw a student who was scaring the dickens out of classmates and teachers. The student had threatened others. Merideth could have made a case for involuntary hospitalization, but he didn't want to.

Dr. MERIDETH: I was worried that this student would go back to their educational setting and be identified as a, quote, "mental patient," close quote. Be further socially isolated, which might lead to an exacerbation of their psychiatric condition.

SILBERNER: Merideth recommended the student be required to get outpatient care in order to stay in school. And, much to his relief, it worked out. Years ago, Appelbaum could have hospitalized his patient who threatened his landlady. But Appelbaum, too, was worried about the patient's civil liberties when he had no way to prove the man would follow through on his threat. And there was another factor.

Dr. APPELBAUM: Psychiatric hospitalization is an expensive resource and a scarce one. To use it merely because we were afraid that he might represent some degree of threat at some point in the future to another person would not have been a good use of a hospital bed.

SILBERNER: After consulting with a supervisor, Appelbaum called the landlady in the presence of his patient to warn her. The landlady said she wasn't scared.

Dr. APPELBAUM: Meanwhile, my patient was sitting across the desk from me with a little bit of a smile on his face.

SILBERNER: Appelbaum realized his patient wasn't really planning on hurting his landlady. In this case, he just wanted the threat to be communicated. The fact is, it's easy to be suspicious of patients, but the vast majority don't hurt anyone.

Joanne Silberner, NPR News.

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