Pretty much everyone who knew Robert Card was surprised when doctors let him walk out of a New York psychiatric hospital last August.
The 40-year-old from Bowdoin, Maine, had been acting strangely for months. He told friends and family members that everywhere he went strangers were whispering about him behind his back, accusing him of being a pedophile.
He was getting sick of it. And he was getting angrier.
Finally in July, Army Reserve leaders ordered Card to go to the hospital after he tried to fight a fellow soldier he believed was in on the conspiracy. The medical staff who evaluated him said he appeared to be suffering from psychosis. He admitted to having a growing “hit list.” And when he resisted psychiatric treatment, hospital staff took the first steps toward committing him against his will.
But he promised doctors he would take his meds and attend follow-up care. So on Aug. 3, 19 days after arriving at the hospital, they let him go. Nobody made more than limited attempts to reach him when he almost immediately broke those promises.
Eighty-three days later, Card committed the deadliest mass shooting in Maine’s history, killing 18 people and shooting another 13.
The massacre in Lewiston was the worst possible outcome of a pattern that mental health experts say they see all too often across the country. For generations, they argue, we have failed to adequately treat millions of people with serious mental illness until they reach a point of crisis.
It was once routine to commit unwilling patients to psychiatric hospitals — but that approach was largely abandoned decades ago because of widespread abuse. And, in Maine, one program set up to be a less intrusive alternative has never been widely used.
Like nearly every other state in the nation, Maine has a law that can compel people with serious mental illnesses to comply with outpatient treatment while still living in their own communities. Proponents of this law, called the progressive treatment program (PTP), believe it could have pushed Card to accept help before he became violent.
Yet many law enforcement officials, including the Sagadahoc County deputy who responded to the last and most serious warnings about his behavior, didn’t even know it existed.
Though PTP has been on the books for well over a decade, it remains a little-used tool, especially by law enforcement. The Maine Department of Public Safety and the Department of Health and Human Services both say they are not responsible for training police on how the law works. And while state legislators have consistently indicated support for the statute in theory, they’ve never adequately funded programs that would make it easier to use.
The conversation around PTP and similar laws is part of a long simmering debate around the ethics and efficacy of involuntary treatment — a debate that’s often stoked after high-profile mass shootings.
Patient rights advocates warn that pushing for more involuntary care is misguided and dangerous. They fear that forcing people to take medication they don’t want is a step down a slippery slope toward re-institutionalization and the abuses of the asylum system.
And they say there’s little evidence that it will do anything to improve patient outcomes or public safety — most mass shooters are never diagnosed with the types of serious mental illnesses that warrant involuntary treatment.
“We knew the narrative was going to be ‘crazy person off their meds,’” and not one of the many other root causes of violence including widespread access to guns, said Carlene Mahaffey, a member of Maine’s Intentional Peer Support Advisory Committee and advocate for the rights of patients with serious mental illnesses. “That’s not what we’re talking about here. We’re talking about realizing the reality that forced treatment, a majority of time, doesn’t work.”
But proponents of PTP insist that Maine’s failure to properly implement the law endangers patients and puts the public at risk.
“We have a wall in Maine between law enforcement and the mental health community,” said John Nutting, a former state legislator who sponsored the PTP bill. “This wall is killing people. Tormenting hundreds of families and the state of Maine. And it’s just continuing.”
‘Playing the game’
Card’s experience in New York demonstrates the difficulty of forcing even an obviously disturbed person to stay in the hospital under modern involuntary commitment laws.
When he reported to West Point in July 2023 for his unit’s annual training, he charged at a fellow soldier who he believed was insulting him behind his back.
The next morning, after Card refused to leave his room, his Army colleagues were concerned enough to call New York state troopers for help. But police decided they didn’t have the authority to bring him to the hospital against his will because he hadn’t directly threatened himself or others.
“Unless he gets combative, physically combative … or if he says the things that I was talking about earlier,” a trooper says, according to body camera footage. “We don't have a lot of gray areas, unfortunately, the way that the laws are written in the state.”
Instead, after his commanders ordered him to submit to an evaluation, Card went to Keller Army Community Hospital. In the eyes of New York law, he went voluntarily.
The troopers suggested this would be for the best.
“Those guys (at Keller) will be able to handle it a lot better than any of these civilian hospitals ‘cause they'll just let them walk right out. I guarantee that,” one trooper says in the footage.
The reservist ended up in a private facility anyway, where his Army orders, not New York commitment laws, again bound him to submit to treatment — at least in the short term.
According to the final report of the Maine commission investigating the shooting, doctors at Four Winds Hospital considered involuntarily committing Card when his Army orders were due to expire in early August. But they reversed course after determining that he was safe to be released and that a court likely wouldn’t agree to hold him.
In order to involuntarily hospitalize a person with a serious mental illness in New York for an extended period of time, doctors must convince a court that the person’s welfare depends on them being treated in a hospital and that they pose a substantial threat to themselves or others.
Card’s treating psychiatrist, Dr. Sarah Klagsbrun, told the commission in closed-door testimony that he was compliant with his medication and that the hospital had seen improvements in his condition during his stay.
Yet the people who knew him best said the version of Robert Card who walked out of the hospital on Aug. 3 was just as angry and convinced of his persecution as the version who walked in.
He told his closest friend and fellow soldier, Sean Hodgson, that he had merely been “playing the game” — he talked his way out of the hospital by telling doctors what he thought they wanted to hear, even though he didn’t believe there was anything wrong with him.
Hodgson, who picked Card up in New York when he was released, later told the commission that his friend spent their hours-long drive home running through the list of people he believed were conspiring against him.
“He was like, ‘I wish they would just tell me to my face so I could punch them in the face.’ He just kept going on and on the whole way back.”
Klagsbrun, who canceled the hearing to have him involuntarily committed, has only spoken to the commission investigating the shooting behind closed doors, citing “New York privacy law concerns.”
She and other doctors and administrators at Four Winds have for months refused to return messages from the Portland Press Herald asking to discuss the case or their policies and practices around involuntary commitment more generally. When a reporter visited their campus in Katonah in September, he was asked to leave the property and referred to an attorney, who also did not answer messages.
There is also no evidence anyone ever considered a less drastic court order to compel Card to receive outpatient treatment back in Maine — not when he was released from Four Winds, and not a month later, when Hodgson warned their commanders that he might be planning a mass shooting.
Progressive treatment program
Natasha Irving says she regularly sees the consequences of a failing mental health system as the district attorney of several Maine counties, including Sagadahoc, where Card lived. This spring, she publicly criticized a Rockport hospital after doctors discharged a 23-year-old woman who had threatened to kill a family member with a gun and a screwdriver.
To Irving’s team, it seemed clear that the woman belonged in a hospital, not jail. But when doctors declined to pursue a court order to commit her, Irving felt that she had no choice but to arrest her for domestic assault and terrorizing just to protect the community.
According to Irving, the case is just one example of a pattern she regularly sees: people with mental illnesses put themselves or others in serious danger or otherwise cause problems in the community, get picked up by police and brought to the hospital, receive immediate stabilizing treatment, then walk out and begin the cycle again.
Only when they succeed in hurting someone can law enforcement intervene. That outcome fails the public and the patient, Irving said.
“I understand that we just shouldn’t take somebody’s freedom away,” she told the Press Herald this summer. “(But) I can’t believe we treat the most ill, most vulnerable people like this.”
Nutting, the former state lawmaker, believes the solution lies in the legislation he sponsored 14 years ago.
His group, the Maine chapter of the National Shattering Silence Coalition, promotes the expanded use of assisted outpatient treatment laws like PTP. These laws, which require patients to comply with treatment while living outside of a hospital, are meant to be compromises that impose fewer restrictions on personal liberties than inpatient psychiatric commitment.
Several groups are empowered to begin the PTP application process in Maine, including legal guardians, medical practitioners and police officers. The petitioner must prove several facts, including that the patient suffers from “severe and persistent mental illness,” that they pose a likelihood of serious harm, and that they are unlikely to follow a treatment plan voluntarily.
If a court agrees, a community provider monitors the patient to ensure they are complying with their treatment plan. If they aren’t, the patient can be committed in an inpatient setting until they return to compliance.
Nutting believes assisted outpatient treatment could have ensured that Card got the help he needed. But that was unlikely to happen.
He likely wouldn’t have qualified for a court ordered treatment plan under New York’s version of the law. It requires a petitioner to show that the patient has a demonstrated lack of compliance with his treatment plans — that was not true of Card at the time of his release from Four Winds.
He might have qualified for PTP in Maine after he made threats against his Army Reserve base in September because by that time, he had told Army caseworkers that he was not taking his prescribed antipsychotics or attending follow-up care. But Sgt. Aaron Skolfield, the Sagadahoc deputy who responded to the call, did not know the law existed.
He says he’s not alone.
“It’s never been brought up in any of my training,” Skolfield said. “I don't know of any other cop that's ever heard of it — because (when) I bring it up in conversation with my colleagues around the state, they don't know what (I’m) talking about.”
Ideally, Nutting said, Skolfield would have started the PTP process and collaborated with Card’s doctor to complete certain elements of the paperwork that require a professional medical opinion. Had the deputy filed a completed application, Card would have been legally required to submit to a medical examination and then a court hearing.
But even though the statute technically says police can initiate the PTP process, several people who spoke with the Press Herald said that, in practice, it is only ever initiated by medical providers when an already hospitalized patient is being discharged.
A spokesperson for DHHS said they don’t regularly track the total number of Mainers on active PTP orders, but as of Oct. 4, there were 78 people on PTPs that had been initiated by Maine’s two state-run psychiatric hospitals.
Dan Wathen, who chaired the state commission investigating the shooting, said the group talked about PTP behind closed doors but decided not to include any mention of the law in its final report. He said it was not relevant to the Lewiston case because PTP has typically only been initiated by doctors when a patient is already in a hospital. But he acknowledged that PTP “doesn’t necessarily have to operate this way.”
Nutting says his group has tried for years to get DHHS to train prosecutors and law enforcement leaders on PTP.
DHHS says that’s not their responsibility.
Lindsay Hammes, a spokesperson for the department, said no one was available for an on-the-record interview. She said in an email that DHHS “has implemented the Progressive Treatment Program in accordance with the law,” but added that the department has no statutory authority to oversee the PTP process, train law enforcement or report PTP data to the National Institutes of Health.
Under state law, DHHS is responsible for “the promotion and guidance of mental health programs within the communities of the State,” but Hammes said PTP is a “legal process,” not a DHHS program. And the original version of the PTP law said the department must “develop and distribute educational and training materials … for distribution to the courts, judges, providers of mental health services, law enforcement officials, consumers, family members and the general public.” But that section appears to have lapsed in 2010 under a sunset provision.
Shannon Moss, a spokesperson for the Maine Department of Public Safety, said the Maine Criminal Justice Academy’s more than 20 hours of training on mental health and behavioral health issues does not include specific instruction on PTP – partly because PTP assessments “extend beyond the scope of law enforcement training and are more appropriately handled by clinicians and other specialists who are better positioned to manage these responsibilities.”
Without training, police have been mostly cut out of the PTP process entirely — if they’re even aware of the law’s existence.
Multiple law enforcement leaders in Maine who responded to questions from the Press Herald had little to no knowledge of the PTP law and thought a reporter was referring to the state’s emergency involuntary hospitalization process, usually called “blue papering.”
Sanford’s deputy police chief Matthew Gagné said his department’s dedicated mental health team is aware of the program but rarely, if ever, initiates PTP petitions.
“I’m sure that this program could be beneficial,” he said. “It’s that there isn’t really this paved road for law enforcement to follow.” “
Nutting rejects DHHS’ claim that it is not responsible for overseeing PTP across the state. He remains adamant that the tool should be a central part of how both doctors and law enforcement respond to patients with serious mental illnesses before they reach the point of needing to be committed to a hospital.
He said the national movement toward court-ordered outpatient treatment comes from a recognition that some people suffering from psychosis will not accept treatment because they suffer from a neurological condition called anosognosia that renders patients unaware of their own illness, and thus their need for help.
Card’s sister, Nicole Herling, said she saw that condition in her brother, though she didn’t have a name for it at the time. During the months she spent reaching out to his commanders and veteran helplines last year, she said no one ever told her about PTP. Now, she thinks it could have helped.
“I believe it would have been a game changer," she said. "You can't reason with a person with that type of psychosis."
Nutting believes any system that allows people with anosognosia to dictate their own treatment is destined to have tragic consequences.
Yet to opponents of involuntary psychiatric care, the use of assisted outpatient treatment programs is a tragedy of its own – one that threatens to return America to a dark era of institutionalization.
‘Original sin’
During Steve Sharfstein’s residency at Massachusetts Mental Health Center in the early 1970s, it was easy to get someone committed to a state hospital and to keep them there. Too easy, he said.
The system “was a lot cleaner when we had the big hospitals,” he said. “You went into a hospital, and you were there for the rest of your life.”
By the 1950s, more than half a million Americans lived in psychiatric institutions. For generations, they had been portrayed to the American people as bucolic campuses where their loved ones would receive care.
The reality was much darker.
Patients, often living in squalid conditions, could remain stashed away for years, even when it should have been apparent that the “treatment” they were receiving was not making them better. In fact, it often made them worse — some patients were pumped full of drugs to keep them sedated and left to languish alone, said Sharfstein. Later, as a resident, he helped close the psychiatric ward at Boston State Hospital, then went on to lead Maryland’s Sheppard Pratt Health System and the American Psychiatric Association before his retirement.
“It creates a kind of self-fulfilling prophecy,” he said. “These people can’t take care of themselves well because we’ve taken care of them.”
That lasted until several converging forces kicked off a reform movement in the mid-20th century.
Journalists and other whistleblowers exposed the rampant abuses within state-run facilities. Civil rights groups like the American Civil Liberties Union helped win landmark legal victories that bolstered the rights of individuals with mental illnesses.
The advent of more powerful antipsychotic drugs led to an optimism that a new system of outpatient psychiatric care could be successful — and at a cheaper price to the state.
President John F. Kennedy, whose sister Rosemary had been disabled by a lobotomy 22 years earlier, signed the Community Mental Health Act into law in 1963. The legislation provided states with federal dollars to build 1,500 community mental health centers around the country.
In this vision of psychiatric care, patients would receive just as much support as they needed to live productive lives at home.
Elements of this dream have come to pass.
Nationwide, doctors who could once commit patients for months or years without any real due process now need a court order to hold anyone against their will for an extended period. Commitments must be reviewed regularly to ensure no one is kept involuntarily if they don’t need to be.
By 2016, there were fewer than 38,000 staffed state psychiatric hospital beds in the U.S., down 93% from the peak totals of the 1950s, according to a 2016 report from the Treatment Advocacy Center.
But experts say the country has largely failed to invest in the community care that was supposed to replace the institutionalization system.
Half of the community mental health centers planned under the Community Mental Health Act were never constructed.
Brendan Saloner, a professor at the Bloomberg School of Public Health at Johns Hopkins, was one of several who mentioned the election of President Ronald Reagan as a key turning point. Months after taking office, Reagan helped gut the Mental Health Systems Act of 1980, a would-be landmark law intended to expand community mental health services.
His Republican administration believed that the federal government should leave psychiatric care to the states and the free market. But the states, recently freed from the expensive asylum system, were not eager to foot the cost of the community-based system reformers had envisioned. And research shows the private sector has been a bad fit for psychiatric patients, whose complex needs are expensive to meet.
As a result, Saloner said, there are not nearly enough mental health providers to meet the need across the country, which regularly leaves patients waiting for care. Hundreds of thousands of people who would have been confined to state institutions a generation ago have been left to struggle on their own. Many wind up homeless or in jail.
“Many people who had this very imperfect safety net were now just sort of thrown out into the world,” Saloner said. “I think a lot of problems that have emerged since then can be traced back to that original sin.”
A painful debate
The shadow of institutionalization still hangs over conversations about how to treat patients who don’t want help.
Patient rights advocates like Mahaffey, from Maine’s Intentional Peer Support Advisory Committee, say the argument that patients with mental illnesses don’t know what’s best for them is paternalistic.
“It’s like punching you in the gut,” said Mahaffey, who has worked closely with psychiatric patients as a peer support specialist. “Instead of stepping back and questioning, ‘What’s wrong with these medications? Why doesn’t the person like them?’ They step back and they think, ‘What’s wrong with that person?’”
Mahaffey and others in the patient advocacy world believe involuntary care is wrong for several reasons: treating someone who doesn’t want to be treated isn’t effective; it’s dehumanizing; and it takes attention away from real steps that could improve the mental health system.
Lewis Bossing, a former attorney at the Bazelon Center for Mental Health Law in Washington, D.C., rejects the idea that there’s a sizable population of patients who won’t accept voluntary treatment because they have anosognosia, the condition that makes patients unaware of their own illness.
He said most patients who avoid the mental health system do so specifically because they feel that it does not meet their wants and needs — forcing them to accept treatment they don’t want only antagonizes them further, pushes them away from the system and makes it less likely that they will seek or accept help in the future.
Bossing fears that involuntary treatment advocates are taking attention and money away from the types of community-based reforms that mental health professionals have longed for since President Kennedy was in office: housing first models that help patients find stable living situations; assertive community treatment teams that act as a “hospital without walls”; and mobile crisis teams.
And skeptics say there’s little evidence that involuntary treatment programs improve public safety.
A 2018 analysis published by the FBI found that only 25% of active shooters in the U.S. between 2000 and 2013 had been diagnosed with a mental illness, and only three of the 63 shooters studied had been diagnosed with a psychotic disorder.
Given that the vast majority of patients with serious mental illnesses never become violent, advocates say they should have the right to decide whether to follow the advice of their doctors, just like smokers or others with unhealthy habits.
Bossing said he is troubled but not surprised that there have been efforts to expand involuntary treatment programs in several states in recent years. Whenever a case like Lewiston’s emerges, he said, a fresh wave of calls for a more forceful handling of the mentally ill soon follows.
When asked how the medical system should balance public safety against the rights of patients with mental illnesses, he rejected the question’s premise.
“Your question assumes that people with mental health conditions are so violent that we should have a system in which we care less about them,” Bossing said. “We care less about their liberty than we would about yours or mine. And we care less about whether they get to make their own decisions.”
No clarity
Nutting’s side has at times found momentum in the Maine Legislature.
The original version of the law that would become PTP was passed two decades ago. The current statute has been on the books for 14 years. And last spring, proponents of expanding resources for involuntary treatment found broad bipartisan support for a bill that would have allowed federal Medicaid dollars to cover the cost of inpatient psychiatric care in large facilities designated as “institutions for mental disease,” which is normally prohibited by federal law.
According to the Kaiser Family Foundation, 11 states and Washington, D.C., have been approved for these waivers and another 11 states have applications pending.
Maine state Sen. Joe Baldacci, who sponsored Maine’s bill, said it would have required the state to commit $1.3 million annually to bring in $3.6 million in matching federal dollars. The money could have been used to add to the state’s total number of inpatient psychiatric beds and paid for some of the community resources that are broadly popular among mental health reform advocates, including transitional housing.
Some of those resources, like assertive community treatment teams, are prerequisites for the PTP law to be effective because they are the groups that monitor patients to make sure they are complying with their court orders.
“It boggles the mind why we would say we would not do this,” Baldacci said. “Most people see the common sense of this approach.”
But even though the bill was popular, it died on the appropriations table. Baldacci blamed resistance from Maine’s Department of Health and Human Services.
“I think the administration has dragged its feet on this and given into the opposition of some relatively small groups versus the broader interest,” he said.
Patient’s rights groups have their own complaints about DHHS.
According to Mark Joyce, managing attorney of Disability Rights Maine's mental health advocacy program, his team accepts that involuntary treatment laws are on the books in Maine and are not actively working to undermine their use – they’re only opposed to the expansion of involuntary treatment, because he hasn’t seen any numbers proving there’s a need for it in the state.
Both proponents and skeptics of involuntary care say the department should be gathering and sharing more data that could paint a better picture of the state of involuntary care in Maine, including the average wait times of psychiatric beds in Maine and the number of days patients spend in jails or hospitals before and after they are placed on court-ordered treatment plans.
But while Nutting and Baldacci have laid blame at the feet of DHHS, lawmakers in Augusta have not come through when given the opportunity to clarify the department’s responsibilities.
A 2022 bill would have designated a PTP monitor within DHHS whose duties would have included training police and medical providers to use the law and determining what data about the program should be collected in the future. But like Baldacci’s bill, it also died on the appropriations table after the Office of Program and Fiscal Review estimated the measure would cost just over $272,000.
Card’s sister, Herling, now believes that would have been money well spent.
"How much did (the Lewiston manhunt) cost? And all the therapy and the counseling?” she said. “What is that number in comparison to the $200,000 they weren't willing to put forward?"
Unanswered questions
When Card returned home to his trailer in rural Maine, he continued pushing away his loved ones until no one was left.
He had a treatment plan that he had no intention of following and a bubbling resentment of those who he believed had wronged him.
He stopped taking his antipsychotics and ignored messages from case managers — including one email he opened just a day before the shooting.
Several government probes have highlighted mistakes made by specific individuals — his Army commanders and Skolfield — as well as systemic weaknesses in laws to temporarily disarm potentially dangerous people. An Army investigation determined that those commanders should have done more to monitor his follow-up care; three of those leaders have been punished and face being discharged from the Army.
But the clinicians who treated Card have faced far less scrutiny.
What in his behavior made doctors believe he was well enough to be released? Were they correct that a court wouldn’t have agreed to involuntarily commit him? Who was responsible for his follow-up care, and why were they stymied by his simple refusal to answer their phone calls?
Though the state commission investigating the shooting met behind closed doors with the gunman’s psychiatrist, its final report devotes only a few paragraphs to her testimony and does not critically analyze the hospital’s decision to release him.
Four Winds staff refused to cooperate with the Army’s probe. Privacy laws have prevented even members of the shooter’s family from obtaining documents that detail his discharge and the follow-up treatment he never accepted. What documents state investigators have obtained are shielded from public records laws.
A group of attorneys representing more than 90 people have gone to probate court to kick-start the process to get those documents, and said they intend to file a lawsuit or lawsuits over the shooting. It’s not clear if they will target Four Winds.
At multiple press conferences, members of Nutting’s coalition called for the commission investigating the Lewiston shooting to look into whether Maine’s PTP law could have been used to stabilize the reservist. When the commission’s final report was released in August, PTP was never mentioned.
Wathen, the commission chair, said in an interview in September that he was satisfied that the group had found and reported the relevant facts about Card’s release. But he also said he expected the hospital would face civil litigation.
Frustrated by officials’ unwillingness or inability to promote the use of PTP — or to collect and publish basic data that would show whether the program actually improves patient’s lives — advocates like Bob Staples are taking matters into their own hands.
For years, he and his wife tried to get their son Brett into treatment for his schizoaffective disorder. On the rare occasions Brett accepted help, something always seemed to go wrong – the hospital wasn’t taking patients that day, or the doctors who were treating him decided he seemed better and let him out early, despite Staples’ warnings that his son would try to convince them he didn’t need help.
Like Card, Brett Staples knew “how to play the game,” his father said.
But for all his interaction with Maine’s mental health system, Bob Staples never heard of the progressive treatment plan until this August, when Nutting’s group reached out to him a week after Brett was killed by an Amtrak train while walking on the tracks in Portland. Now Staples thinks the program could have saved his son’s life.
“We went from shock to sadness to anger when we heard that,” Staples said. “My wife is an R.N. She’s never heard of it.”
Staples began researching the law. He said he’s had conversations with close to 70 law enforcement officers and medical providers since his son’s death. Only one knew about PTP.
He’s trying to change that. In September, he stepped down from his role as chair of the local school board so he can use his time to build a new nonprofit, named after his son, aimed at educating law enforcement about the law. If the state won’t get the word out, he said, he will.
Concerns that involuntary treatment violates the rights of people like his son are, to him, secondary.
“Until you take that box of remains and place it into the ground, you can’t say a word about it,” he said. “I would rather he be alive.”
Maine Public Deputy News Director Susan Sharon contributed to this report.
