2.8 “A Rumor in My Own Mind”

Book Two / 8

Terence Myers, the man before us for the assault of his brothers, had expressed a self-awareness of his illness, and his belief that the illness had motivated his violence.  In a letter to the judge, handwritten from his jail cell, Myers wrote perceptively of the problems involved in prosecuting and incarcerating the mentally ill, but at the same time he revealed a popular misunderstanding of the laws he confronted:

As a defendant, I’ll be the first to say, I’m not looking for an easy way out, but prison is not the answer for someone who has a deep rooted mental health problem.  If this problem isn’t taken care of, I’ll simply end up committing a more violent act the next time.  Killers go free because they have been judged as having mental health issues which have been cured through treatment.  I want the very same opportunities so that I can continue to walk among society, or at least live among my fellow human beings without worrying about having to snap and hurt someone if my boiling point reaches a certain level.  

From self-reflection, Myers had reached the conclusion that his best chance for obtaining treatment, restoring his mental health, and enjoying the freedom he believed he deserved was through the state’s insanity defense.  If killers could “go free” after receiving treatment, then he wanted the same opportunity.

Killers, however, did not simply go free, even those very few who were successful with an insanity defense.  In fact, even non-killers did not go free.  A year before Myers had assaulted his brother, our court had been assigned the case of a woman who’d attacked a worker at a public health clinic.  On a July morning Mary Williams, a 44 year-old African American woman, walked into the street-level clinic for a dental appointment.  She had earlier tucked a butcher knife into a bag.  The bag was with her that morning.

As she sat in a chair with the clinic’s admission forms to fill out, Williams began watching one of the clinic’s workers nearby.  Voices in her head — what she would later call “a rumor in my own mind” — confirmed a suspicion that the worker was actually a person who had been following her.  Williams’ voices convinced her that the woman was attempting either to kill her or make her prostitute herself, and that Williams needed to “take her out.”  She got up from her chair, went to the desk where the clinic worker was seated, pulled out her butcher knife and began stabbing.

Medical reports would indicate that the clinic worker had been stabbed in the head, both eyes, and her chest, including penetrating wounds to her heart, in the lungs, stomach, buttocks, and vagina.  She sustained wounds to her liver and bowels, both hands and arms, and an artery was severed.  She lost her left eye entirely, and was permanently blinded in her right eye.  Upon admission to the hospital she had initially died in the operating room but was resuscitated.  A mother of three, she had moved to the area fourteen years earlier from Puerto Rico to raise a family in a safe environment.

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Not surprisingly, Williams had a medical history of schizophrenia, with recurring hallucinations and paranoid delusions.  A series of hospitalizations for evaluation and treatment had begun eleven years earlier, but a history of noncompliance with that treatment had also begun.  Once released from the hospital and freed from its institutional oversight, Williams would gradually stop taking her medicine and symptoms of her illness would return.

Five years before her attack at the public health clinic Williams had been admitted to the state’s mental hospital after assaulting a roommate and a police officer, and attempting to set on fire a tax preparer with H&R Block.  On that occasion she’d been released from the hospital after two years, with the requirement to report regularly to a community mental health clinic for treatment and medication.

Despite information in Williams’ file documenting her risk of future violence and her need to remain medicated, staff at the community clinic lowered Williams’ medication dose when she complained about the way the medicine made her feel.  The lowered dose gradually aggravated her psychosis.  Without sufficient insight into her illness to recognize the downward spiral of symptoms, Williams slipped again into psychosis and stopped taking the drugs altogether.  Eventually the rumors in her mind returned.

Williams’ case would never reach a jury.  Based on the examination and evaluation of the state’s psychologist, the prosecutor decided not to oppose a defense motion for the court’s judgment of acquittal based on Williams’ legal insanity at the time of her crime.

The court’s final judgment of Williams’ acquittal would recite the required legal findings for that defense and for her hospitalization:  that Williams had been charged with attempted first degree murder; that she was legally insane at the time of the attempt; that she remained a substantial present danger to other persons; and she presented a substantial likelihood of committing crimes that jeopardize public safety if not controlled.  With those words, the attorneys had supported their agreed recommendation that the court commit Walker to the highest level of confinement at the state’s mental hospital for her “care and custody.”

The court’s final judgment also included three critical paragraphs.  Each paragraph contained one of the three elements required to prove legal insanity under the state’s criminal statutes.  Combined, the elements were the state’s modern version of the words and phrases inherited from the British justices who had crafted M’Naghten’s Rule nearly one hundred and seventy years earlier.  They read:

“At the time the defendant committed the act with which she is charged, she was suffering from a mental disease or defect.

“As a result of the proportion and magnitude of her mental disease or defect, the defendant’s mind was affected to such an extent that she was unable to appreciate the nature and quality of her acts . . .

“As a result of the proportion and magnitude of her mental disease or defect, the defendant’s mind was affected to such an extent that she was unable to know right from wrong . . .”

If there are magic words in the law, these would be some of them.  Whatever the words might have meant at another time or in another country, when the judge entered his order in Williams’ case he had to wave his gavel-wand and recite the language from M’Naghten’s case in order to make a record that would sustain this rare acquittal.  He could enter his order only if he found that Williams, at the time of the attack, had been suffering from a mental disease or defect, and the disease or defect caused her to be unable to appreciate the nature and quality of her act, or to know it was wrong.

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A defendant in our state could be found not guilty on account of legal insanity only if, like Williams, she had been so psychotic at the time of the crime that she had no idea what she was doing, or that it was even wrong.  Everyone else — all those with a serious mental illness that substantially impairs their judgment and self-control but does not render them completely senseless — everyone else must be subject to criminal responsibility and punishment:  conviction followed by prison, not treatment.

As M’Naghten’s Rule defined these individuals, so long as they knew the nature or illegality of their actions, however ill or delusional they might have been, they could not avoid punishment in order to obtain treatment.

Very few individuals are so ill at the time of a crime that they do not know, on some level, what they are doing or understand that it’s wrong.  The prosecutor, however, had agreed that Mary Williams had been that severely impaired.  She may have known that she was stabbing a woman, and may even, on some level, have understood it was wrong.  Witnesses report that Williams had fled a few blocks down the street after tucking the knife back into her bag, attempting to elude police in pursuit.  But the psychologist was convinced that Williams genuinely believed that her victim was not a clinic worker but someone pursuing and persecuting her.  She’d believed that her acts were in self-defense.

Nine months after Mary Williams attacked the public health clinic employee she appeared in our court for resolution of the charges against her.  She had been hospitalized long enough for medication to restore her present competency.  In the meantime her attorney and the prosecutor had been negotiating the terms of a joint recommendation to the court for entry of a judgment of acquittal based on the requirements of the state’s insanity defense laws.

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States that retain the insanity defense have statutes with detailed requirements for the detention and treatment of a defendant who’s been acquitted on the basis of insanity.  The verdict form may even direct jurors to make specific findings about the defendant’s present and future dangerousness, and about the treatment that would best protect society and the defendant going forward.

In our court, once the judge accepted the recommended findings proposed by counsel, he was required by law to impose the corresponding level of detention and treatment based on the risks of danger that Mary Williams’ illness still posed.  In all cases the primary options are hospitalization in a state mental hospital, conditional release, or full release.

If a defendant is hospitalized, he must remain there until the court orders otherwise, based upon regular evaluations and reports on the success of treatment.  He may be required to remain hospitalized and under treatment for the entire time he’d have served in prison had he been convicted of the crime.  Even then, if he remains seriously ill and poses a continuing threat to public safety, procedures for an additional term of civil commitment are available.

If, on the other hand, a court releases a defendant based on findings of non-dangerousness, the order of release can impose conditions of counseling, treatment, and periodic review hearings.  If the defendant fails to abide by the conditions and presents a risk of danger, the court can revoke the release and order the defendant confined again.

In Williams’ case, the court’s judgment of acquittal ordered simply that she be committed for treatment to the state’s mental hospital for the criminally insane, but with those words all of the law’s requirements for the public’s protection attached.  From that day forward, Williams would be completely confined, required to attend counseling, and placed on a medication regimen with close supervision until the court ordered a different arrangement.  Hospital staff would submit regular reports on her progress and compliance.  If any modification were recommended or requested, Williams would have to travel from the institution to appear in person before the judge for his review and decision.

Over the years, regular updates to the court would report that Williams consistently maintained her relapse prevention plan to monitor for triggers and warning signs, and to develop personal coping skills.  She attended weekly counseling sessions to discuss signs of decompensation, and to develop cognitive skills of self-awareness and insight into her illness.  She remained fully compliant with her psychotropic medications.  And she was able to recognize that medication compliance and, as staff described it, “maintaining a healthy balance in her daily schedule” supported the psychiatric stability she enjoyed.

The hospital had a five-level security system of advancement through a series of increased privileges.  Eight years into her commitment, Williams had made it to the second level.  At level 2 she’d been allowed onto the grounds of the hospital for a couple of hours each day with a staff or peer escort, and she was permitted to work at the hospital’s library.

At a review hearing one day in Williams’ ninth year of confinement at the state hospital, she appeared in court with her attorney, hospital staff, and the prosecutor.  Based on her history of compliance with every imposed condition, she was seeking an additional modification:  ground privileges unescorted by staff.  As the hospital grounds were unsecured, it was possible that Williams could wander away.  She could have two hours of lead time before anyone would notice she was missing.

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Williams arrived for the hearing early and she sat alone on one of the wooden benches in the courtroom, waiting for her attorney to arrive.  Hospital staff who had transported her to court remained in the hallway.  Williams had recently celebrated her 53rd birthday.  On this day she appeared healthy, a little overweight in a solid rather than stodgy way, and she wore a beautiful dress that flowed around a middle-aged body whose carriage remained still and upright throughout the proceedings.

The attorneys answered most of the judge’s questions about Williams’ condition and compliance.  Near the end of the hearing, however, Williams asked her attorney to present a file folder to the judge for his consideration of its contents.  She seemed proud of her work, and wanted the judge to see her progress as he decided whether to grant the additional privilege with all the additional risks.

The manila folder was filled with the reports of her supervisor at the hospital library.  They indicated that as of the end of July that year Williams had successfully completed a full year of double shifts.  With exclamation marks scattered about the comments, as though Williams were a young school girl completing a year of kindergarten, the supervisor crowed about Williams’ accomplishments.  Not once had Williams called in sick, the report stated.  She re-shelved every item — over 10,000! — she created library displays, kept the plants healthy, assisted “customers,” and kept all the tables, chairs, and equipment clean.

It seemed that Mary Williams, in the right environment, was a model patient.  And despite the horrible crime she’d committed, she was also a model defendant for the insanity defense.

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Terrance Myers was not Mary Williams.  Both Myers and Williams had stabbed someone, and both of their victims had sustained life-threatening injuries.  But unlike Williams, no state psychiatrist had determined that Myers was one of those individuals who — as our supreme court described it — had “lost contact with reality so completely that they are beyond any of the influences of the criminal law.”*

Only the tiny minority of criminal defendants who had completely lost contact with reality were those contemplated by a state’s insanity defense if it were based on the case of M’Naghten, as ours was.  And if the prosecutor would not agree to recommend an insanity acquittal in order to trigger a regime of treatment in the state’s mental hospital, then the defendant would be on his own to prove his insanity to a jury.  If he could.

Unlike Mary Williams, Myers — though suffering from a mental disease or defect — surely knew what he was doing.  He knew that he was stabbing his own brother, and he knew it was wrong, that stabbing his brother was against the law.  It was unlikely that he would be able to convince a judge or a jury otherwise.

And yet Myers’ illness was real.  We’d been witnessing its effects on his behavior and on his self-control at every hearing, observing it in every letter or motion he wrote.  His family had likely experienced it all their lives.  One of its effects was to instill in him such a pernicious paranoia that he couldn’t trust or tolerate any support in his case.  His illness had created a character who was least capable of success with the rigors of self-representation, yet most insistent on trying.

It was hard to imagine Mary Williams ever wanting that responsibility given the manner in which her illness manifested.  Myers’ illness, on the other hand — what the psychologist had termed his “narcissistic and antisocial personality features,” — caused such an exaggerated sense of persecution that he would never see anything but corruption and conspiracy in the acts of others with any authority over him.

With Myers we were stuck in the mud of a legal landscape that wanted nothing to do with the problems presented by defendants like him — all those who were not legally insane, but not the opposite either.  They were the majority of mentally ill individuals we saw in court, those who fell somewhere in the middle of the scale that measured mental health and its impact on self-control.

Unfortunately, however, that landscape was defined exclusively by its extremes.  There simply was no gray area in the law on criminal insanity, no middle ground under M’Naghten’s Rule on which defendants like Myers could safely trod.

*State of Washington v. White, 60 Wash.2d 551, 590 (1962).

2.9 The Product Test