Vermonters have been watching in recent weeks as members of the state legislature consider proposed statutory changes related to timely access to judicial review for the small number of psychiatric inpatients being considered for court-ordered treatment. It's a difficult but necessary discussion that I think Vermonters are ready to have.

As a nurse who works in a psychiatric hospital that provides care for some of the most severely mentally ill patients in the state, my hope is that we don't lose sight of the actual patients whose lives are at the center of this discussion. With that in mind I offer the following true story. (I have been careful to alter or eliminate any identifying details that could compromise patient confidentiality.)

Joe was admitted to our unit by court order after spending weeks in the Department of Corrections waiting for a bed in a mental health facility. With a history of schizophrenia, he had been successfully holding down a job and living independently with support from a community out-patient mental health facility. Then Joe stopped taking his medication. He quickly developed extreme paranoia and delusions. He became involved in an altercation with a neighbor whom he believed was conspiring against him with help from the police.

When Joe arrived on the unit, the staff made sure to constantly reassure him that he was safe and that we were here to care for him and support him in his recovery. However, he would often become very agitated, pacing up and down the hallways and engaging in loud, angry conversations, mostly with himself and the voices he was hearing, about perceived wrongs. A fairly large man, when in this state Joe was frightening to other patients and staff, especially as his thinking grew increasingly disorganized and erratic.

Staff did their best to help him and others remain safe without resorting to the use of involuntary emergency procedures or restricting his movements. He clearly needed as much room as we could afford him in order to be able to work off some of his considerable energy. After many weeks of watching him steadily deteriorate into heightened paranoia and distress, we were still unable to convince him of the benefit of resuming the medication that had helped him so much in the past.

One evening, he unexpectedly walked up to a nurse and punched him in the head. The nurse collapsed to the ground. In an attempt to prevent him from kicking the fallen nurse, another staff member put herself between him and Joe. She was badly kicked in the arm and neck.

Although Joe had been involuntarily hospitalized, he continued to worsen for several more weeks while an application for involuntary medication slowly worked its way through the courts. During this time he would repeatedly call the police and the FBI, and frequently yell loudly at staff accusing them of things like killing his baby, raping him, stealing his car, violating his girlfriend, etc. It was obvious that Joe was suffering greatly, losing weight as he battled with the horrible ideas in his mind.

More than four months after he first fell ill, the Vermont courts finally authorized involuntary medications for Joe. Despite having repeatedly benefitted from them in the past, he was reluctant at first; but within a few days a remarkable transition started to take place. The angry, tormented Joe transformed into an articulate, intelligent, caring young man. When a week had passed he asked to meet with the nurse he had injured and apologized for his actions, explaining that he had not meant to hurt anyone, but that the voices in his head would just not give him peace.

Within two weeks, Joe was able to spend hours reading books, playing games with the staff, engaging in pleasant conversation, and planning for his future. We discovered, much to our delight, that he was a fan of Hemingway and jazz music and could engage in extensive and insightful discussions about a wide range of topics including local and international politics.

As he prepared for his discharge Joe's insight was restored to such a degree that he expressed a clear understanding of how early intervention would have spared him the horrible suffering he had endured by being allowed to refuse needed treatment for so long. Indeed, it had been a long and arduous four months for everyone; and on the day he walked off our locked unit to return to independent living, there was not a dry eye in the house.

Paul Capcara, RN, is the clinical manager at the Brattleboro Retreat.