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The Kennebec Journal/Morning Sentinel

June 27, 2006

Reprinted with permission of the author. All rights reserved. Visit the newspaper online.

It is human nature when confronted with horrible and tragic events to want to do something. Pass a law, strengthen existing ones, do something -- anything -- to help people avoid a repeat of the incident.

Such is the case with the death of Amy Bruce last week. Bruce's 24-year-old son, William, diagnosed at various times with schizophrenia and bipolar disorder, is accused of bludgeoning his mother to death in their Caratunk home.

William Bruce was a classic case of a very ill person who refused to take medication that could have prevented a tragedy.

"Why on earth wasn't this man locked up before he hurt someone?" is the question on many people's minds. "Couldn't we do something more to prevent this? Couldn't someone have forced him to take medication."

The questions do not lend themselves to simple, reactive responses.

This is what we did in the old days: Lock 'em up and throw away the key. Centuries ago, we used leeches and exorcisms to treat mental illness. In the 19th and 20th centuries, we had women committed to institutions by their husbands when they did not behave in socially acceptable ways; children were likewise vulnerable to parents who could not control their behavior. Genuinely mentally-ill people were virtually sentenced to life inside institutions where they were lobotomized, given endless shock therapy or even ice baths. There was serious abuse and neglect of the mentally ill, which began to be exposed in the 1960s and 1970s.

The pendulum shifted very far in the other direction over the last few decades. This country has a strong commitment to civil liberties, and advocates for the mentally ill worked effectively to extend those liberties to them. Courts and legislatures reflected the position that patients should direct their own treatment in cases of mental illness, even when family members made the argument that an individual was not capable of making those decisions. In making up for decades -- centuries -- of paternalistic and wrongheaded and often criminal treatment of the mentally ill, our society made the decision to err on the side of freedom and autonomy. The battle was hard-won, and the absolutists have long held sway in its aftermath.

But what to do about someone who is deeply disturbed, paranoid, delusional, potentially violent and refuses treatment, as was apparently the case with William Bruce?

For years, the mantra of those seeking enlightened treatment for the mentally ill has been the statistic that the vast majority of the mentally ill are not more violent than the population at large -- and thus involuntary institutionalization should be the absolute last resort and only after many hurdles have been passed.

The law in Maine is designed to protect patients' civil rights. It says people -- even those with severe mental illness -- have the right to direct their own treatment. That can be a challenging task for persons whose illness prevents them from making wise decisions that could aid their return to health.

Even advocates for the mentally ill acknowledge that the law is overly rigid and can make it nearly impossible for caring families to get help for sons, daughters and parents. As the latest tragedy demonstrates, that failure can leave patients, family members, friends -- even strangers -- in danger.

The Treatment Advocacy Center, a highly-regarded mental health think tank in Virginia which has received the American Psychiatric Association's Presidential Award, produced a study this year that links violence and schizophrenia.

"Although most individuals with mental illnesses are not violent, violence by a subgroup of individuals with schizophrenia is far from rare. And the violent behavior is almost always associated with the person not having received treatment for their illness," the center reported.

While involuntary commitment laws exist in many states, they are not often used. What has become the preferred option is something called "assisted outpatient treatment." That allows a court to order a noncompliant person into treatment outside of an institutional setting. Patients are required to work with a comprehensive and around-the-clock list of supporting staff, they must take medication and their families are included in their treatment to a much greater extent.

Last year, Maine passed an assisted outpatient law, championed by Sen. John Nutting, to provide assisted outpatient treatment in this state. The law has not been fully implemented.

Mental health advocates say the new law, combined with greater attempts to diagnose early, to reach out and include families in an individual's treatment and to keep severely mentally ill patients receiving treatment, should help prevent such terrible acts of violence as was seen in Caratunk last week.

That's good, but it's tragically late.

We understand the concern for the civil liberties of people with mental illness, but this case shows the greater need for the patients like William Bruce is to keep ahold of them -- not necessarily in institutions -- but within a system that can treat the symptoms that lead to such tragedies.

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