Staff psychiatrist Joseph Frieben, M.D., was in his office at the Cook Counseling Center at Virginia Tech University on April 16 as the campus was locked down after a gunman killed 32 students and professors in a dormitory and classrooms and then killed himself.

With no television in the center and little information coming from university officials, Frieben and other staff members remained in the dark for hours.

"Everyone wanted to just do something and be helpful in some way, but in reality there was absolutely nothing that we could do," he recalled in an interview a few weeks later. "Time moved very slowly."

When the scope of the tragedy finally became apparent, Frieben called his former residency training director at the University of Virginia, Edward Kantor, M.D., who also serves as the chair of the disaster committee of the Psychiatric Society of Virginia, a district branch of APA. Kantor and Frieben would consult half a dozen times that day and talk at least once a day during the following week as the university, the state, and the nation reacted to the mass killing.

According to the April 22 New York Times, the young man alleged to have committed the shootings was Seung-Hui Cho, a 23-year-old senior at Virginia Tech majoring in English literature. In 2005 Cho was involuntarily committed to Carilion St. Albans Psychiatric Hospital in Radford, Va., after two women students complained about his behavior to campus police and Cho sent friends an instant message implying he was suicidal. He was released after a doctor at the hospital said he was mentally ill but not an imminent threat. He was supposed to receive outpatient treatment, but it was not clear at press time if that had happened.

"In the first couple of days afterward, everyone felt numb," recalled Frieben, describing the feelings of the counseling center staff to Psychiatric News. "We wished we could be doing more. There weren't many walk-ins at first, even though we stayed open until 9 o'clock at night."

Over the phone on the day of the shootings, Frieben told Kantor that their colleagues around the state could best help by not driving to Blacksburg, where Virginia Tech is located. They could be more useful by remaining in their communities and making themselves available for students who would return home in the week after the tragedy, when the university was closed, or during the summer vacation. (See "APA Helps on Many Fronts" for information on APA's response to the tragedy.)

So Kantor, an assistant professor of psychiatry and emergency medicine at the University of Virginia School of Medicine, a few hours away in Charlottesville, decided what the district branch would—and would not—do in response to the shooting.

He sent an e-mail to the district branch's 500 members asking for volunteers to see Virginia Tech students who wanted a consultation. He later spread the net wider, to Maryland, North Carolina, New Jersey, and New York. Within a week, 140 psychiatrists had responded, although he did not know how many of those volunteers had been contacted yet by members of the Virginia Tech community.

"Ed Kantor was very helpful," said Frieben. "We were flooded with offers from people who wanted to come to Blacksburg."

Kantor did request support for the free clinic in Blacksburg to help persons not affiliated with the university and suggested that interested colleagues review the Psychological First Aid Manual published by the National Center for Posttraumatic Stress Disorder.

He asked the district branch's president, Lawrence Conell, M.D., to begin work on a request for a Lindemann grant from APA's Committee on Psychiatric Dimensions of Disasters to support the Virginia Tech counseling center's outreach and resilience activities and to expand the referral list he had compiled.

The district branch is also advising on a grant application to the Substance Abuse and Mental Health Services Administration to help fund outreach and supportive counseling, as has happened in the wake of other disasters.

In the meantime, Kantor counseled patience to his colleagues around the state.

"As hard as it is to wait, that's the best advice for the moment," Kantor e-mailed the members of the Virginia district branch." We all need to make sure that any response we make is for the needs of the Virginia Tech community rather than just our own desire to help, whether needed or not."

The September 11, 2001, attack on the Pentagon and the Washington-area sniper shootings in October 2002 had recently given Virginia's mental health community a lot of experience in dealing with mass tragedies and guided the district branch's response, said Kantor in an interview. He also consulted with S. Arshad Husain, M.D., and Anthony Ng, M.D., the current and former chairs, respectively, of the APA disaster psychiatry committee.

"The role of psychiatrists is limited in the early phases of any disaster," said Kantor. "Our role now is supportive. We shouldn't pathologize people's reactions, but we should emphasize resilience and assume they'll get better."

Despite public perceptions, disaster mental health is not about treating people with posttraumatic stress disorder, he told Psychiatric News." It's about treating `normal' people who are having an overwhelming response to a horrific event."

Two weeks after the shooting, Frieben said the staff was tired but trying to support each other. Calls and e-mails from friends and colleagues from around the country were encouraging.

"Students are acting appropriately and rationally, providing support and comforting each other," he said. "We haven't seen the worst of it yet."

The people most directly affected (such as the wounded or the people in other rooms in Norris Hall who heard screams and shots) probably went home after the shootings and stayed there, he said. About 75 percent of the students will leave campus for the summer vacation, so the counseling center staff has contacted other college counseling centers around the country, asking them to serve as referral points for area Virginia Tech students.

However, Frieben expects an increased demand for counseling services when students return in the fall. PTSD may take six to 12 months to appear, so adequate staffing at the center will remain an issue for the next few years.

The staff has already held outreach sessions for professors and others in the university community concerned about students' anxieties once classes resumed.

Besides requesting volunteers, Kantor also urged colleagues around the state and elsewhere to reserve public statements on the incident, explaining why he declined media requests for interviews or commentary (see "Ethics Reminder Offered About 'GoldwaterRule' on Talking to Media"). Any such comments, however well intended, might be seen as self-serving or implicitly critical by those closest to the tragedy, he wrote in the e-mail to his colleagues.

"I strongly believe that the Virginia Tech community deserves to control the information and discussion," he continued. "Control of self, surroundings, and even information is such an important part of early recovery from the loss and helplessness in such an event. I feel that we should support them but not overwhelm them, and support them on their terms."

Frieben expressed concern for the way in which some members of the media covered the events in Blacksburg.

"Some individual actions were very inappropriate and damaging to the recovery process," he said. "I want to follow the outcomes of students with the most exposure to the media."

Frieben detailed cases where members of the media entered dorm rooms or hospital units uninvited and demanded interviews with distraught students or their families. Another crew set up outside the counseling center and tried to talk to students as they left. Frieben said he put a quick stop to that.

And how was Joe Frieben doing a few weeks after the shootings?

"As well as possible," he said. "I'm finally getting back to doing some general clinical psychiatry."

Students say that tiny things are returning to normal in their lives, too. He tells them to hang on to those moments, that recovery will come bit by bit, not be snapped on like a light switch.

The National Center for Posttraumatic Stress Disorder's Psychological First Aid Manual is posted at<www.ncptsd.va.gov/ncmain/ncdocs/manuals/nc_manual_psyfirstaid.html>. Virginia Tech's information on counseling services for members of the university's community as well as the community at large is posted at<www.vt.edu/tragedy/support_resources.php>.▪