On June 20, 2006, William Bruce approached his mother as she worked at her desk at home and struck killing blows to her head with a hatchet.
Two months earlier, William, a 24-year-old schizophrenic, had been released from Riverview Psychiatric Center in Augusta, Maine, against the recommendations of his doctors. "Very dangerous indeed for release to the community," wrote one in William's record.
Shoshananh White for The Wall Street Journal
William Bruce, left, with his father, Joe Bruce, who feared his son's release from a psychiatric facility.
But the doctor's notes also show that William's release was backed by government-funded patient advocates. According to medical records, the advocates -- none of them physicians -- appear to have fought for his right to refuse treatment, to have coached him on how to answer doctors' questions and to have resisted the medical staff's efforts to contact his parents. As one doctor wrote, William told him his advocates believed he is "not a danger, and should be released."
William's father, Joe Bruce, obtained his son's medical records from Riverview eight months after the killing. "I read through the records and I just remember crying all the way through," Joe Bruce says. "My God, these people knew exactly what they were sending home to us."
Helen Bailey, one of William's advocates, declined to discuss the details of his case but says the handling of it was consistent with her professional duties. "My job is to get the patient's voice into the mix where decisions are made," says Ms. Bailey, an attorney with Maine's Disability Rights Center in Augusta. "No matter how psychotic, that voice is still worthy of being heard. I have not had the person who is so out of it that they can't communicate what they want." She added that the records reflect the doctors' perception of what happened.
The story of William Bruce -- based on medical records made available to The Wall Street Journal -- as well as interviews with relatives, doctors, advocates and hospital administrators brings into sharp focus the impact of a little-known government-funded advocacy program for psychiatric patients.
Attempt to Curb Abuses
Congress created the national Protection and Advocacy for Individuals with Mental Illness program, or PAIMI, in 1986 to curb abuse and neglect of the mentally ill, primarily in institutions. In the 1960s and 1970s, many abuses were uncovered at hospitals, where patients were physically restrained, neglected or overmedicated.
The PAIMI program, operated by the Substance Abuse and Mental Health Services Administration with a 2008 budget of $34.8 million a year, funds protection-and-advocacy agencies in each state. Typically nonprofits, these groups sometimes receive supplemental funding from states. According to a 2007 SAMHSA report, the agencies served 19,000 people in 2006.
Some doctors, hospital administrators and mental-health veterans argue that advocates are endangering the mentally ill and the public by too often fighting for patients' right to refuse treatment. Many advocates "have a strong bias," says Robert Liberman, a director of a psychiatric rehabilitation program at the University of California, Los Angeles.
"I don't know if they are doing people a service when they assert the right of mentally-ill individuals to remain psychotic," says Ron Honberg, director of policy and legal affairs for the National Alliance on Mental Illness, an education, support and advocacy group.
Proponents of patient advocates say they're essential to protecting the rights of the mentally ill. The National Disability Rights Network, which provides lobbying and other services for the patient-advocacy system, says advocates play a critical oversight role.
With the help of government-funded advocates, William Bruce was discharged from a psychiatric hospital against his doctor's wishes. Two months later he killed his mother. WSJ's Nathan Koppel and Elizabeth Bernstein report. (Aug. 15)
They cite the 2006 sentencing of the owners of a Kansas treatment facility on charges that they subjected patients to forced labor and involuntary servitude, and a class-action lawsuit alleging that female patients of the Lincoln Regional Center in Nebraska were raped and assaulted by a male staff member. The latter case was settled in 2007 with the hospital, which denied liability, agreeing to more thoroughly investigate assault complaints.
The mentally ill are "very vulnerable," says Curt Decker, executive director of the National Disability Rights Network. "There needs to be an external, independent, legally based advocacy system to make sure they are being treated fairly, equitably and safely."
John Morrow, senior public health advisor at SAMHSA, declined to discuss the Bruce case. But he says advocates serve a very important function, and that the organization has resolved thousands of cases of abuse and neglect.
In recent years, there has been a wave of legislative efforts, many inspired by violent crimes, to make it easier to mandate treatment for the mentally ill. Advocates have blunted those efforts in California, New Mexico and Michigan.
In Michigan, advocates successfully pushed for limits to a 2005 law -- proposed after a schizophrenic killed a young man -- mandating outpatient treatment. "They have a left-wing, individual-rights-at-all-costs agenda," says Virg Bernero, mayor of Lansing, Mich., who helped pass the law when he was a state legislator.
"Our legal mandate is to protect the rights of individuals," says Elmer Cerano, executive director of Michigan's PAIMI chapter. But, he says, "rights are limited when it comes to safety."
Despite advocates' objections, Joe Bruce -- with the help of his pro-bono attorney, Robert Owen of Fulbright & Jaworski LLP in New York -- successfully lobbied the Maine legislature to pass three bills. One gives mental-health professionals greater leeway to disclose patient information to those who may be affected by that person's conduct. Another makes it easier to medicate involuntarily committed patients.
Shoshananh White for The Wall Street Journal
William Bruce, who killed his mother in 2006 after he was released from Riverview Psychiatric Center in Augusta, Maine. He was found not criminally responsible by reason of insanity for the crime and was recommitted indefinitely. He takes classes online through Colorado Technical University.
William Bruce grew up in Caratunk, Maine, a picturesque town of about 110 residents nestled in the state's northern hills. His father, a rugged, talkative man, worked as a senior technician for the Maine Department of Transportation. His mother, Amy, served as the town's treasurer. The oldest of three boys, William grew up in a 100-year-old farmhouse that sits on the banks of the winding, rock-strewn Pleasant Pond Stream.
Even when Willy -- as he was known as a boy -- was young, "there was just something different about him," his father says. Although cute and energetic, William was hyperactive and deeply self-centered, his father says. And he could turn suddenly violent: When he was four, he pushed his younger brother down the stairs. At five, he broke the same brother's leg, his father says.
As an adolescent, William was handsome, popular with girls and deeply troubled, attempting suicide at 14. He would sometimes see therapists, but would quit and stop taking any prescribed medication, Joe says.
William's behavior particularly pained his mother. Tanned and athletic, Amy loved kids, often hugging her own and opening her home to neighborhood children. But Joe says she was seldom able to emotionally connect with her eldest son, and repeatedly blamed herself for his problems.
After dropping out of high school, getting his equivalency degree and serving in the Army, William bounced among low-level jobs and had a few minor brushes with the law. On Christmas Eve, 2003, Joe says William had his first psychotic episode in a Target store, telling his father that the security cameras were monitoring him.
But he refused to seek treatment, and his family couldn't insist. Maine, like many states, requires that the mentally ill pose a substantial risk of harm to themselves or others, based on recent evidence, to be involuntarily committed.
In March 2005, after William threatened two men with a loaded AK-47 assault rifle -- his father is a licensed gun dealer -- William went to a psychiatric facility in Bangor. He was eventually released but stopped taking his medicine.
William deteriorated. Sometimes he walked into neighbors' homes unannounced. Once he put his mother in a headlock. In January 2006, William punched his father in the face, screaming, "You have disobeyed direct orders from a superior officer in the CIA." He was sent on Feb. 6, to Riverview, an extended-care psychiatric facility.
'An Awful, Awful Feeling'
"We were certain he would be released," Joe Bruce says. Waiting for that day "was an awful, awful feeling."
A few weeks after William Bruce's admission, psychiatrist Jeffrey Fliesser wrote that William was hostile, paranoid and "dangerous to others without additional observation and active attempts to treat him," an opinion he reiterated over the next five weeks. The doctor also wrote that he urged William, now diagnosed with paranoid schizophrenia, to take medication, but William refused. Dr. Fliesser declined to comment about the case for this story.
William began working with advocates employed by the Maine Disability Rights Center, which receives funding from the federal PAIMI program as well as state and private sources.
According to a nurse's treatment record dated March 23, Ms. Bailey, the advocate, told Riverview administrators she saw no documentation showing that William should remain hospitalized. Trish Callahan, another advocate, suggested that William "may actually be getting worse by remaining here," the nurse's record says.
"I repeatedly explained to the patient, his advocates and other team members, his paranoid psychosis will not likely improve without medication therapy," Dr. Fliesser wrote in his notes. Ms. Bailey says she gives legal opinions, not clinical ones, and notes that her job is to represent the client's wishes.
By the beginning of April, William Bruce's case was "in a high state of contention," wrote Daniel Filene, a psychiatrist who had taken over the case. On April 6, Trish Callahan, another advocate, attended a meeting with William's treatment team. She stressed that William should be discharged and that his summer job prospects were being harmed by his continued hospitalization, Dr. Filene's notes say.
According to these notes, Dr. Filene suggested to William that he take trips outside the hospital. When William voiced reluctance to venture out, Ms. Callahan told William, "They want to see that you can play nicely in the community. Just say 'Yes.' " He did. Dr. Filene asked William if there was a risk he would refuse to return to the hospital from a community trip. "Ms. Callahan told him, 'Just say no,' and Mr. B. replied, 'No,' " the doctor wrote in his notes.
Dr. Filene wrote that he asked William for permission to speak to his mother and his previous mental-health providers. Ms. Callahan said there would be no benefit and that William's parents were "a negative force in his life." William refused to give consent, Dr. Filene's notes say. On April 11, Dr. Filene wrote that William said his advocates were telling him that he is "not a danger and should be released."
Ms. Callahan didn't respond to requests seeking comment. Dr. Filene declined to comment about the case for this story.
"I think the advocates overstepped their bounds," says Riverview Superintendent David Proffitt. William "was relying on the people whose purpose it was to ensure his civil rights were being exercised, and unfortunately that interfered with his other right, which was to get medical care."
Ms. Bailey, Ms. Callahan's superior, doesn't believe the advocates prevented William from getting medical care. "There is nothing in the William Bruce case that is contrary to the way we do business," she says, adding that it is the hospital's responsibility to try to have a patient committed or forcibly medicated.
William Gets Released
More generally, Ms. Bailey says it isn't a given that families of the mentally ill should be involved in decisions involving their care. "There are some God damn nasty families out there," she says. SAMHSA declined to comment on the case, as did the Maine Department of Health & Human Services.
In the end, Dr. Filene wrote that while he recommended William stay at Riverview, William appeared very unlikely to meet Maine's legal criteria for further involuntary hospitalization beyond his court-ordered commitment term, which expired at the end of April. On April 20, 2006, William was discharged.
William was soon back home. He hid steak and butcher knives in his bedroom and spent hours pacing in the driveway, giggling and babbling unintelligibly to himself. Joe began calling to check on his wife several times a day. "It was the worst we'd ever seen him," he says.
On June 20, two months after his son's release, Joe Bruce returned home from his office to find his wife's battered, bloodied body. William was gone.
"My son has killed my wife," Joe told the 911 dispatcher, later adding that he was arming himself in self-defense.
According to the medical examiner's report, Amy died of multiple blunt-force trauma and chop injuries to her head. She was 47 years old.
Police arrested William Bruce at his grandparents' house and later charged him with killing his mother. He told a psychologist that the Pope told him to kill his mother because she was involved with al Qaeda and Saddam Hussein. Joe Bruce became William's legal guardian and gained access to his medical records.
When police returned Amy Bruce's purse to Joe, he found an unsent letter she had written to her eldest son.
"I've always had this horrible feeling that I've let you down in some way," she wrote. "The only wish I have is that someday we can look each other straight in the eyes and say I'm sorry and I love you more than life itself." She added: "I will not give up on you ever."
In March 2007, William was found not criminally responsible by reason of insanity and was committed to Riverview again, this time indefinitely. At the end of 2007, faced with the possibility of being restrained and medicated against his will, William agreed to take Abilify, an antipsychotic drug. Within weeks, his mental status improved.
'I Blame Myself'
William Bruce, now 26, is strikingly handsome, his dark hair slicked back. Sitting in a Riverview conference room on July 23, he spoke courteously but deliberately. It was the first time he has been interviewed about his case.
"I blame the illness, and I blame myself," William said of his mother's death. "The guilt is...," he paused, struggling to find a word "...tough."
William said the first time he came to Riverview, he refused to believe he was mentally ill and approached the advocates because he wanted out.
"They helped me immensely with getting out of the hospital, so I was very happy," he said. He later added,
"The advocates didn't protect me from myself, unfortunately."
These days, William is taking criminal-justice classes online through Colorado Technical University. He points proudly to his 3.94 grade-point average and says he hopes to attend law school to learn more about mental-health laws. William and his father talk on the phone almost every day. "He stood by me the whole time despite the horrible tragedy...despite what I did," William said. "I am the man I am today because of my dad."
While William believes patients deserve some protection, he said he understands his father's fight to strengthen commitment and treatment laws. That fight took another turn last month, when Ms. Bailey and another attorney filed a lawsuit that could undermine portions of a law Joe supported. The suit, filed in U.S. District Court in Maine, is directed at the law which makes it easier for hospitals to compel patients to take medication.
"There are times when people should be committed," William said. "Institutions can really help. Medicine can help."
"None of this would have happened if I had been medicated."