Duncan Maccourt, MD

Dr. Charles Sell, a Missouri dentist, has been trapped in the limbo between law and psychiatry for almost a decade. His troubles began with allegedly fraudulent Medicaid billings and related white-collar crimes. But the criminal charges against him subsequently escalated as he quarreled with FBI agents, hurled racial insults and spat at a federal magistrate, and purportedly threatened to kill both a prosecution witness and a federal agent. The unfortunate man has a long history of mental illness and has been diagnosed by both prosecution and defense psychiatrists as suffering from the persecutory type of delusional disorder, which contributed to his unreasonable and belligerent reactions to his legal predicament. Unfortunately, while Sell believed the FBI and the government had been conspiring against him when the first criminal charges were filed in 1997, the intervening years of confinement, maltreatment and legal machinations have only reinforced and intensified these delusions. As of today, federal prosecutors have levied almost 70 criminal counts against him, and recently the St. Louis newspapers reported that he had been the victim of cruel and sadistic harassment by federal prison guards.

Despite its supposed rarity--its prevalence in the United States is estimated to be 0.025% to 0.03%--delusional disorder has played an important role in forensic psychiatry. We believe that German psychiatrist Robert Gaupp's 1938 case history of the infamous multiple murderer Ernst Wagner is the benchmark study in the European literature on paranoia and the insanity defense. Reconsideration of notable U.S. cases (e.g., John Hinckley Jr., Prosenjit Poddar, Sirhan Sirhan on the criminal side and Kenneth Donaldson on the civil side) might highlight the importance of this disorder in the modern U.S. context. Sell is yet another example of a patient with delusional disorder whose case has earned a place in the annals of law and psychiatry.

From a clinical perspective, psychiatrists know that it is particularly difficult to establish a therapeutic alliance with patients who suffer from the persecutory form of delusional disorder. Typically, such patients lack insight into their disorder, feel they are the victims of injustice and antagonize even those who would like to help them. As a result, they often prove highly resistant to treatment, and their course once in treatment is often protracted. Although there are no good double-blind studies of efficacy, most psychiatrists now believe that antipsychotic medications are helpful in the treatment of this disorder. In Sell's case, his symptomatic behavior--e.g., literally spitting in the face of the magistrate who was to decide whether he was dangerous enough to require confinement for his competency to stand trial evaluation--seems to have provoked ill will at every level of the criminal justice system and led to years of unproductive confinement.

Initially found competent to stand trial and released on bail in 1997, Sell's ill-considered threats and racist confrontation with the magistrate resulted in the revocation of his bond and an order for an inpatient evaluation. Psychiatrists on both sides of the case agreed on the diagnosis of delusional disorder and significant impairment; the federal court accordingly found Sell incompetent to stand trial in 1999 and remanded him to the federal medical facility in Springfield, Mo., for treatment. At Springfield, psychiatrists proposed that he be medicated with atypical antipsychotics and not unexpectedly Sell refused, raising the question whether he could be involuntarily treated to restore his competency to stand trial. That legal issue wound its way through the federal court system until in 2003 the U.S. Supreme Court decided 

, holding that in certain limited circumstances the government may forcibly medicate criminal defendants charged with serious but nonviolent offenses in order to restore their competency to stand trial. However, the standard to medicate is fairly strict, and requires that any forced medication be "substantially likely" to restore competence to stand trial and "substantially unlikely" to possess side effects undermining the trial's fairness, as well as being "in the patient's best medical interest."

While this decision has engendered much debate among legal scholars and mental health attorneys because it allows involuntary drug treatment without a finding of danger to self or others, it did not rescue Sell. He has remained in federal custody and has made no real progress either toward mental health or the resolution of the criminal charges. He not only continues to refuse antipsychotic medication, but also has never been involuntarily treated, as the government has not satisfied the Supreme Court's criteria for involuntary medication first enunciated in the case bearing his name.

As a clinical matter, we assume that Sell's delusions are encapsulated and that patients with this disorder would be competent by most legal standards. But the intensity of delusional convictions varies over time, as does the extent of mental impairment. Such patients present a shifting target for a forensic evaluation leading to fluctuating findings of competence, and assessing their potential for violence is a worrisome and often insoluble task.

Courts have struggled with these questions during the years of Sell's confinement. Despite his continued insistence that he is competent to stand trial, he has at different times been found by the federal court to be incompetent, although at other times he has been found competent. Most recently, the court found him presumptively competent in July 2004 after a group of his friends brought in another forensic expert who contradicted both the government's and the defense team's psychiatric experts. And in recent weeks a new set of government psychiatrists re-evaluated him and purportedly deemed him competent once again; a new hearing on this issue was originally set for late March 2005. (

went to press, Sell's case had not been heard in court--Ed.

) Meanwhile, he has been offered a plea bargain by the prosecution requiring him to plead guilty to one count each of mail fraud and conspiracy to murder, the latter due to alleged threats made against an FBI agent and a former employee who planned to testify against him. His own attorneys have urged him to accept the plea. But believing that he is a victim of both government conspiracy and abuse, Sell has refused the government's offer and agreed only to plead to the mail fraud count, a counteroffer unacceptable to the prosecution. And while he most recently has begged the federal judge hearing his case to put him on trial, his own attorneys continue to question his competence, leading to the court's appointment of yet another attorney to represent him solely on the competence issue.

Sell's delusions directly focus on persecution by the government and although we have no confidential information, we would speculate that Sell wants to use his trial to expose the government's persecution even if that is not in his best legal interest. However, his delusional thinking has taken a new direction as a result of the abusive treatment he has actually endured at the Springfield federal prison hospital--mistreatment that he maintains is somehow connected to the Abu Ghraib prison scandal in Iraq.

According to a recent news article in the 

, which is based on a leaked confidential report to the court, Sell has been victimized brutally while in federal custody. The article recounts how a prison hospital surveillance videotape shows guards in riot gear forcibly removing a nonviolent Sell to an isolation room where his clothes are cut from his body and he is "seemingly unnecessarily" injected with a sedative and left handcuffed to a concrete slab for 19 hours. Another tape reveals Sell being led to a prison shower while a female staff member looks on. Next he violently lurches to the floor, either as the result of a fall or having been pushed. He is then forcefully dragged, wearing only his underpants, across the floor and pushed back to his cell by a prison guard. The prison's own subsequent internal investigation has revealed that the guard had purposefully devised a form of torture whereby he--after first calling a female staffer to watch--sprayed the near-naked Sell in the shower with scalding water at 120 degrees from a hose, causing first-degree burns on Sell's back, legs and chest, and then manhandled him causing numerous scrapes and contusions. The offending guard was reportedly disciplined for this outrageous action by being given only a brief suspension, as the authorities supposedly were unwilling to prosecute him due to Sell's status as a "mental patient."

The longer Sell stays in federal custody under the conditions that have prevailed, the more his delusional thinking is reinforced. And the more he will be without a hope of recovery and the ability to assess his choices and make a reasoned decision about his trial or the plea bargain offer. The government's position becomes therefore more and more punitive and smacks of retribution rather than a sincere desire to see Sell brought to trial or even to serve an adequate and fair sentence. Certainly after eight years in federal confinement, the argument can be made that Sell has served such a sentence already, at least for the mail fraud charges if not the conspiracy to murder charges as well.

We also wonder if Sell's continued confinement may have verged on the unconstitutional. He appears to be in a situation extremely similar--if not in all pertinent aspects identical--to that of the appellant in the landmark Supreme Court opinion 

 (1972), which held that a criminal defendant "committed solely on account of his incapacity to proceed to trial cannot be held more than the reasonable period of time necessary to determine whether there is a substantial probability that he will attain that capacity in the foreseeable future." Although Sell's capacity may well have fluctuated, we question whether that "reasonable period of time" has not expired.

From our own clinical perspective, we might observe that the federal prosecutors seem as adamant as Sell. They apparently refuse to recognize either that his mental disorder has played a part in their mounting tally of criminal counts against him--including the charges of conspiracy to murder--or that inadequate care and abuse have prolonged his confinement. Based on what we have been able to learn about the Sell case, it seems to have degenerated into a contest of wills. On the one side, the prosecution has insisted that Sell is incompetent, that he be involuntarily medicated, and that he acknowledge his wrongdoings; on the other side Sell steadfastly refuses the prescribed medication, insists on his competence, and demands that the government acknowledge its transgressions. Lost in all of this is the realization that the needs of the patient have been subordinated to the needs of the court system, resulting in a standoff serving neither the cause of justice nor rehabilitation.

We do not intend to suggest that Sell should be forgiven or found not responsible for his symptomatic offenses. Our concern is that, in the limbo of law and psychiatry, his mental disorder has become the basis for increasing his punishment, which, in turn, has exacerbated his illness. One hopes that the recently reported forensic re-evaluation of Sell is correct and that he has now some modicum of competence that will allow the judicial process to move forward and put an end to the endless debate about his mental stability. If not, then one can only hope that at some point in this human tragedy a better considered plea bargain will be offered to Sell and he will accept it. Although there are lessons to be learned from Sell's story, there is unlikely to be a happy ending. His experiences in federal custody may well have reinforced his delusions and provided him with new grievances, making any future treatment that much more difficult. Clearly he will need extensive psychiatric care when and if he does get released. One hopes he then will be provided the supportive therapeutic relationship he requires, his legitimate grievances will be acknowledged, and he will accept voluntarily the medication he has long refused. To move toward that conclusion and away from the no-man's land of law and psychiatry in which Sell has been trapped--and which threatens to trap other defendants suffering from this highly refractory condition--seems in the best traditions of both "helping" professions.

Dr. MacCourt is a resident in psychiatry at Cambridge Hospital and chief resident in legal psychiatry at Massachusetts Mental Health Center.

Dr. Stone is Touroff-Glueck Professor of Law and Psychiatry in the faculty of law and the faculty of medicine at Harvard University.

Sell v United States, 539 U.S. 166 (2003).

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The case of dentist Charles Sell, who suffers from delusional disorder, still awaits resolution. In the meantime, Sell remains incarcerated while his competency to stand trial is debated. Does this serve justice?

Duncan Maccourt, MD

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Caught in Limbo Between Law and Psychiatry