Angels, heartbreak and murder

Like they did most mornings, Constance and David Johnston sat down for breakfast in their Richland home about 9:30 a.m. on Feb. 19, 2013. Connie read the comics as she ate, her husband of 51 years next to her.

Their adult grandson walked in, and without looking up, David said, “Good morning, Levi.”

The 26-year-old didn’t return the greeting. That wasn’t unusual — for years, Levi Staver’s schizophrenia had prevented him from having typical interaction with his family.

Instead, he shouted, “This has got to stop!” and plunged a 6-inch-long black Bowie knife into his grandmother’s back.

David leaped to his feet — trying to disarm Levi with one hand while trying to steady Connie, who was attempting to help him, with his other.

Ruth Johnston, the couple’s daughter — and Levi’s mother — had been in the basement when she heard scuffling upstairs. She raced up to find her mother bleeding and her father trying to get the knife away. She immediately called 911.

“Drop the knife,“ David demanded.

“I can’t. It’s attached to my wrist,“ Levi answered. “You’ll have to let me go.“

David finally wrestled Levi to the kitchen door and threw him down the concrete steps to the outside.

Ruth watched as her son’s face smashed off the ground, and then turned to see her father pulling his wife off the couch and into his lap on the living room floor.

A short time later, police officers arrived with their guns drawn and pointing at Levi, who was standing on the outside steps.

“Put your hands up,“ they demanded.

“Why?“ Levi responded. “I‘m not dangerous.“

“Levi, just do what they say so you don’t get hurt,“ Ruth yelled from the kitchen door.

She watched as the officers handcuffed her son. Then Ruth fled back down to the basement like a scared cat.

It wasn’t until hours later, when she had been taken to the police department to give a statement and saw her father there that she learned what happened.

“I said, ‘Dad, has anyone gone to the hospital to be with mom?’“

“Mom never left the house,“ David responded. “It was a murder.“

Levi was charged with criminal homicide, and nearly four years after he killed his grandmother, he pleaded guilty but mentally ill to third-degree murder. In June, despite argument that Levi’s schizophrenia had been stabilized in jail, as well as during an eight-month stay at Torrance State Hospital and expert reports suggesting he would be better served by obtaining mental health treatment in the community, he was ordered to serve 10 to 20 years in prison. Although pleading guilty but mentally ill assures that Levi will be evaluated for mental illness and receive medication in prison, it does not guarantee him intensive treatment like he’d receive in a hospital.

Ruth and David, who said they have forgiven him for his actions, believe that had Pennsylvania’s involuntary treatment laws had a lesser standard than “clear and present danger,” Levi would not be facing a decade of incarceration.

David and Connie Johnston on their wedding day, Dec. 24, 1961. Photo courtesy of Ruth Johnston.

Levi was the oldest of three brothers and grew up near Schenectady, N.Y. Ruth was a stay-at-home mom who home-schooled her children, and her husband, Randy Staver, was an optical physicist.

They enrolled Levi in public school in fifth grade, but Ruth described it as an awful experience, with Levi constantly being bullied.

Levi Staver in 1997. Courtesy of Ruth Johnston.

“Kids would back away. They didn’t like him,” she said. But adults around her son couldn’t see that, she continued. They saw what she saw, a friendly, outgoing boy who was a great artist and could recite the names of all of the world’s penguins species by age 3.

But at age 13, Ruth said, Levi was diagnosed with Asperger’s syndrome.

By the next year, she said, his expressions started to change. He stopped smiling. He stopped interacting.

And by 18, it was clear to Levi’s family that he was mentally ill.

Even though Levi had three semesters worth of college credits by that point — he excelled at science and lab work — he could no longer concentrate on his classes. As his parents divorced, he moved to an apartment in State College, where his aunt lived, and got a job doing construction work. He managed for a while, Ruth said, but was also self-medicating with marijuana and the occasional use psychedelic mushrooms and LSD.

As time progressed, Levi became more and more disorganized: He started eating out of dumpsters, crashed his car and could no longer work.

He moved back to Pittsburgh in 2007 — where Ruth, who for years has had a degenerative muscle disorder, had returned to stay with her parents in their Richland home — where his family urged him to get treatment. But Levi didn’t understand he was developing psychosis.

Ruth told him he had schizophrenia, but he refused to listen, telling his mother it was impossible, that his IQ was too high to have that diagnosis, and that he’d rather be thought of as a jerk than disabled. Instead, Levi left Pittsburgh and returned to New Hampshire to live with his dad.

But by November 2011, Levi said he could no longer live with his father and returned to Pittsburgh.

Levi Staver in 2000. Courtesy of Ruth Johnston.

“He was just as schizophrenic as they come,” Ruth said.

By that point, Levi was actively hallucinating — hearing angels talking to him, commanding him to do things, warning him that his grandmother was evil.

From that point until Connie’s death, the family struggled to get Levi the help he needed.

April 28, 2012: David Johnston called re:solve Crisis Network and reported that Levi was referring to himself as “second in command of the angelic army” and talking about “’sacrificing himself to God’ and running a blade on his neck.”

A mobile crisis team arrived at the home at 4:12 p.m. to find superficial wounds on Levi’s neck. Ruth described to them her son’s behavior, telling them that Levi believed his grandmother was best friends with the devil, that the woman was poisoning their food and that he said “he would be willing to attack the person acting as his grandmother with a knife or pipe that he carries on him.”

When Levi met with the team that day, according to their notes, he was pleasant and cooperative. He told them he was fine and apologized repeatedly for cutting himself.

Levi told them he was not willing to go to a hospital for a psychiatric evaluation, but based on what the staff observed, they discussed with Ruth having him involuntarily committed at Western Psychiatric Institute and Clinic. The county delegate approved, and the Northern Regional police transported Levi to the hospital.

It was the one and only time in his life — before his incarceration for killing his grandmother — that Levi was involuntarily committed. His behavior that day — cutting himself — was enough to qualify Levi  as a “clear and present danger of harm to others or to himself” under Pennsylvania law.

While at Western Psych, Levi was diagnosed with psychosis — not otherwise specified. He was kind to those around him, offered to pray for them and folded his casework book into paper airplanes, according to Ruth.

Although the Section 302 commitment authorizes a 21-day stay, Levi was released after only 10.

He called home to Ruth, begging her to pick him up.

“I won’t cut myself again,“ Levi pleaded. “Please come get me.“

Connie Johnston, Levi Staver’s grandmother, in 2006. Courtesy of Ruth Johnston.

Ruth agreed, and the hospital discharged him, with instructions to follow up with a talk therapist that same day. He was taking a small dose of Risperdal, an anti-psychotic, which he quickly stopped.

On the way to the counselor, Levi again pleaded with his mother.

“Please, don’t talk about the angels,“ he urged.

And, despite her better judgment, she didn’t.

“You already know they’re mad at you,” Ruth said years later in an interview. “So, I soft-pedaled.”

So that therapist, who at the time didn’t know about Levi’s hallucinations, concluded Levi needed more socialization — friends.

Over the next nine months, Levi, his mother and grandfather contacted mental health professionals more than a dozen times, and Levi voluntarily went to a walk-in clinic operated by re:solve three times, staying a total of 10 days.

Levi Staver’s artistic talent showed in the illustrations he made for a book his mother wrote on Beowulf. This is one of those illustrations. (Nate Guidry/Post-Gazette)

May 28, 2012: Levi called re:solve himself, telling them that his grandmother had stolen his knife and was trying to kill everyone in the house. He agreed to go to the walk-in center, and while there told a clinician that a couple of days earlier, he had awakened to his grandmother standing in his room with a knife. He called police about his concerns, as well. Levi reported that he was not delusional or paranoid and not psychotic.

“He reports that everyone else in his house has [mental health] concerns and they are the ones that are delusional and dealing with psychosis,” one clinician wrote in a report.

Levi was discharged the next day.

Aug. 26, 2012:  Ruth called the crisis team and reported that Levi had taken his brother’s car to a local store but then couldn’t find it in the parking lot. He called the police, who located the car, and returned Levi to his home with a request that he receive mental health treatment. When the team from re:solve arrived, they noted that Levi appeared to be high and had unusual hand movements. On evaluation, Levi reported having paranoid delusions, including that others were attacking him. He reported hearing God and having other auditory hallucinations. He agreed to go to the walk-in clinic, where he remained until Aug. 28.

Again, on discharge, Levi refused medication.

Sept. 8, 2012: Ruth asked that the crisis team visit Levi because she had found him at 5 a.m. burning a Bible page by page in a steel mixing bowl in his bedroom. When she told him to stop, he took the Bible outside, she reported, and used a blowtorch.

In the report on the visit, the clinician wrote, “Delusions included believ[ing] he is a six-winged seraphim [angel] and that angels speak to him and tell him what to do.”

The team stayed at the home for two hours and then left, urging Levi to call re:solve if necessary.

Nov. 24, 2012: The Johnston family had relatives over for for an after-Thanksgiving holiday dinner, and Levi, believing that the house was full of poison gas, sat outside in the 30-degree temperatures for hours with his arms held out in front of him. When he finally went inside, he tumbled down the basement stairs, breaking his nose and causing a compression fracture in his vertebra in his back. At UPMC Presbyterian, he tried to teach the staff how to salute in the angelic army — by curling the toes up inside their shoes and moving their shoulders. He told a nurse aliens pushed him down the stairs. The hospital released him the next day with the staff telling the family “It’s not illegal to be delusional,” which Ruth said she had been told repeatedly by others who had treated her son.

Nov. 25: The same day he was released from Presbyterian, Ruth picked Levi up and told him he had to go to the re:solve walk-in clinic, where he was admitted voluntarily but still refused anti-psychotic medication.

Nov. 27: A doctor said that Levi still did not meet the criteria for involuntary, in-patient treatment. He was discharged from the walk-in clinic on Nov. 30.

In an email Levi wrote to a family friend after the Thanksgiving day incident, he explained that he was a cyborg and credited his quick healing to having “impact absorbing cerebrospinal fluid from the Archangels.”

Jan. 3, 2013: Levi was arrested for shoplifting a bottle of cough medicine from a Walmart in Butler County. “He told me the angels had done it so he could tell the cops about Jesus,” Ruth said.

The preliminary hearing on the retail theft charge was scheduled for Feb. 21.

“Two days before that hearing, Levi killed my mom,” Ruth said.

The Northern Regional police were familiar with Levi and his mental health history from having been called to the family home repeatedly about him over the years.

The day of “the tragedy,” as the Johnstons now refer to it, Levi told the first responding officers that he stabbed his grandmother because he was told to by the Archangel Michael. He called the 76-year-old woman a witch.

David Johnston poses for a portrait at his home in Richland. (Nate Guidry/Post-Gazette)

For what seemed like hours that day, David was kept out of his living room by a strip of crime-scene tape across the entryway as detectives did their work.

During their investigation, officers discovered Levi’s 302-page diary kept on his laptop computer.

On the fourth page, they found these words:

GRRRRR My grandmother is SUCH A COMPLETE WITCH.

She abuses her husband and takes control of things. She is THE Beast Vibrator.

I might have to go and stab her to death.

Would I get permanently committed, or sent to prison

SHE MUST DIE

aLIEN capital ship turret fire hopefully will take her down though

Commander of a fleet of Alien capital ships is not so dumb as to go and stab his

evil grandmother to death without a legal reason

Apologies, she’s up, and she drains away all the energy from her surroundings

She’s so fat and ugly and she has quite the tongue

ick she send vibes at me

She has Altzheimers

I’m going to kill her

Apologies

I will just go and stab her in the heart and get arrested

Should I do it now

please save me

The family had hoped that Levi might be able to plead not guilty by reason of insanity, which would have allowed him to be institutionalized in a forensic hospital for whatever length of time would be necessary to stabilize him and ensure his safety — and that of those around him — in the community. But that type of plea was never discussed because of the threatening words in the diary. He and his family contemplated having a jury trial and seeking an insanity verdict, but Allegheny County Common Pleas Judge Donna Jo McDaniel, two weeks prior to trial, granted a prosecution motion precluding Levi from presenting any evidence of his mental illness.

An example of Levi Staver’s writings, indicating his state of mind.

Assistant District Attorney Michael Pradines wrote in his motion that Levi had gone through three previous attorneys who had postponed the case 10 times -— and still failed to provide him with any written expert report on Levi’s diagnosis.

Ruth acknowledges much frustration in dealing with the attorneys who represented her son during the nearly four years the case was pending. When she finally hired an attorney from Philadelphia, she thought he would be able to help her son.

But Benjamin Cooper was only retained Dec. 30, 2016, and the case was scheduled for trial on Jan. 30. Mr. Cooper asked for a postponement to pursue a mental health defense, and asked for time to prepare for trial.

The request was denied on both counts.

Levi, faced with no other choice, Ruth said, pleaded guilty but mentally ill.

After his arrest, he was taken to the Allegheny County Jail, where he remained for about seven weeks. Levi was then transferred to Torrance State Hospital because he was not competent to participate in his court case. He remained there for seven months before he was considered to be stabilized and competent, taking anti-psychotic drugs. He was returned to the jail in November 2013.

In a report completed for Levi’s sentencing, Robert G. Thompson, a psychologist, wrote, “There is ample evidence to conclude that he was gravely mentally ill, that his reality testing was compromised, and that his actions were the direct result of his psychotic condition.”

Judge McDaniel did not doubt Levi’s mental illness, but she worried that he could, at any time, stop compliance with his mental health treatment and medication. If he did that, she said, it could be dangerous.

She ordered him to prison.

Levi Staver’s written apology to his grandfather for killing his grandmother.

During his stay in the Allegheny County Jail, Levi penned a hand-written letter to his grandfather, asking him for forgiveness.

It was unnecessary, because David, a Presbyterian pastor for nearly 50 years, had almost immediately forgiven the grandson who took from him his wife of so many years.

Ruth Johnston at the home she shares with her father in Richland. (Nate Guidry/Post-Gazette)

On Feb. 20, 2015, David wrote back to Levi.

“Thank you for writing that letter. I am sure it was difficult to do. But it was the right and kind thing to do.

“I am writing this letter to tell you that you are forgiven.”

David went on to tell his grandson that he does pray for him.

“I wish that this had not happened, and that you were not in jail,” he wrote. “But it isn’t possible to change what happened. All we can do is forgive and then faithfully live out God’s plan for us.”

For David, that has been easier than most might think. He takes solace in the fact that Connie died quickly and with no indication she felt any pain. In the last few years of her life, she had been having memory loss and other medical issues that were frustrating to her. The couple feared what could have been a years-long decline.

That morning, just moments before she was stabbed, Connie turned to David as they headed downstairs for breakfast and said, “I want to thank you for all the years of wonderful, loving care you’ve given me.” They hugged.

He focuses on that and the fact that his wife got her wish “to be with the Lord.”

Her two most fervent prayers were answered when she was killed, said David, who is 78.

“Connie went up to Jesus, and prayers came down like wonderful raindrops,” he said, noting that Levi, almost immediately, got the mental health care his wife had prayed for.

David visited his grandson at the Allegheny County Jail a handful of times. In late July, Levi was transferred to the state prison system.

“It’s a nightmare for the people who have to live with this as family members,” David said.

“By the time you get to ‘clear and present danger,’ it’s too late,” Ruth said.

In the months leading up to the stabbing, the only remedy for the Johnston family was kicking Levi out of their home, which Connie said they would never do.

“All we could do was make him homeless,” David said. “That’s appalling. That’s Godlessness in a nation that deserves better.”

Instead, they kept Levi at home and continued to try to convince him to get treatment.

“We never really expected it to be violent,” Ruth said. “But he had pickled in the delusion for so long, it became real to him. It took him that much psychosis — five years — to get him to do something violent. He never punched a wall. He never raised his voice.

“He was never violent until he was.”

Is clear and present danger enough?

At its peak, in 1955, there were 555,000 people with mental illness in public hospitals.

Now, there are about 40,000.

And even though it was clear for decades — up through the 1970s — that too many people were being thrown away in institutions under the guise of mental illness, experts say, it is equally clear that the changes in the law made it far too difficult to get involuntary, inpatient treatment for those people who most needed it — like Levi Staver.

“We swung the pendulum too far,” said Frankie Berger, director of advocacy for the Treatment Advocacy Center in Washington, D.C., which focuses on legislative and policy issues for the most seriously mentally ill.

So now, little by little, across the country, individual states have been moving to swing it back.

Pennsylvania, however, is among the last to make any change.

The state’s Mental Health Procedures Act was passed in 1976, and 41 years later, it remains mostly unchanged. It sets the standard for involuntary commitment for a person who is “severely mentally disabled when, as a result of mental illness, his capacity to exercise self-control, judgment and discretion in the conduct of his affairs and social relations or to care for his own personal needs is so lessened that he poses a clear and present danger of harm to others or to himself.”

That criteria, “clear and present danger of harm,” is too high, experts say.

“It’s the strictest that I know of in the country,” Ms. Berger said. “We have to figure out a way to get these people help.”

She is talking about people with schizophrenia or severe bipolar disorder -— in Pennsylvania that’s about 111,000 and 222,000, respectively, her group estimates. They often fail to recognize the need for treatment, experts say, making it difficult for them to seek help voluntarily.

“Many people with severe mental illness who are not engaged in treatment because they deny anything is wrong would benefit from involuntary hospitalization,” said Dr. Paul Appelbaum, a psychiatry professor at Columbia University and past president of the American Psychiatric Association.

He supports an “awareness of illness” standard, which would recognize that a person is decompensating but not threatening, and notes that that criteria would allow the system to intervene in the most heart-rending of family cases.

Dr. Appelbaum noted, though, that changing to that more broad standard would also open the system up to a large group of people who previously were not getting treatment, and that would require increasing resources.

“If you’re not willing to do that, there’s no reason to expand your commitment law,” he said.

Ms. Berger, whose organization has been lobbying in Pennsylvania for years, called the involuntary treatment laws here “a convoluted, strange system,” that “have been fiercely protected by the legislature.

“There’s very little political will, and a lot of opposition, to changing the inpatient threshold,” she said. “A couple of people killing their grandmas is not providing the impetus they need to change the criteria on the inpatient side.”

Assisted Outpatient Treatment

But, Ms. Berger notes with satisfaction, her organization, working with many others in Pennsylvania, may see movement this year on involuntary, outpatient treatment, known as Assisted Outpatient Treatment, or AOT.

AOT already exists in Pennsylvania, but those who work in the mental health field have rarely been able to use it on its own. That’s because it requires the same high burden,  “clear and present danger of harm to others or to himself” as the in-patient law.

“If there is a concern for dangerousness, those folks are going to an in-patient commitment,” said Denise Macerelli, the deputy director for the Office of Behavioral Health, Allegheny County Department of Human Services.

Instead, as AOT in Pennsylvania stands now, it is most often used as a follow-up to inpatient commitment.

But that could change in coming months. The state House passed legislation 189-0  in June changing the criteria for involuntary, out-patient treatment, and it has now been referred to the state Senate (see state House Bill 1233). The new standard would require “establishing by clear and convincing evidence that the person would benefit from [AOT] as manifested by evidence of behavior that indicates all of the following:

• The person is unlikely to survive safely in the community without supervision, based on a clinical determination;
• The person has a history of lack of voluntary adherence to treatment for mental illness and has either: twice within the last three years been involuntarily committed because of a failure to adhere to treatment; or within the last four years has acted on or threatened serious violence to self or others;
• The person is unlikely to voluntarily participate in treatment;
• The person is in need of treatment to prevent a relapse or deterioration that would be likely to result in a substantial risk of serious harm to the others or himself. The initial process of evaluation would be similar to what exists now, including the same due process, and if a person is found to meet the standards, a judge would issue a civil court order calling for outpatient treatment.

That treatment includes community psychiatric supportive treatment, medication assistance, individual or group therapy, financial services, housing services, and any other service prescribed to assist the patient.

But, those advocating for the change, note that there are no punitive measures attached to the law. If a participant doesn’t follow the treatment plan, they cannot be fined or jailed or involuntarily committed to a hospital, or anything else. Instead, they are asked to report back to their judge, explain why they’re no longer compliant, and the treatment plan gets adjusted.

“It’s tremendously successful,” said Ms. Berger, whose organization has been working on AOT legislation in Pennsylvania for 10 years.

Right now, 46 states have existing AOT laws.

“The data are quite positive,” Dr. Appelbaum said.

AOT, he continued, is effective in treatment and in preventing relapse, and is cost-effective. It’s also, he added, one of the least coercive interventions that exists, and the structure it provides to patients leads to better outcomes.

But there are other groups, like the National Coalition for Mental Health Recovery, that argue against involuntary outpatient treatment.

Joseph Rogers, whose organization, Mental Health Partnerships, based in Philadelphia, participated in developing a fact sheet on the issue, said that they believe the vast majority of people can be treated voluntarily in the community.

As for the proposed change to Pennsylvania law, Mr. Rogers said, there is no funding source attached to it.

“We take the position that the law is not the issue,” he said. “It’s the lack of services, cutting the budget, a lack of insurance coverage for long-term mental health care.

“[It will] make it easier to commit somebody to something that doesn’t exist. It’s a false solution.”

Dan Eisenhauer, the president of the Pennsylvania Association of County Administrators of Mental Health and Developmental Services, agrees there is a concern moving from county to county, where resources in more rural areas are less available.

But in Allegheny County, there are wrap-around services ready and available to address those needs, Ms. Macerelli said. People with mental illness or their families can call re:solve Crisis Network. That program takes calls, determines if a mobile team needs to be sent out to an individual, and can provide follow-up care — through calls, visits or voluntary admissions to its walk-in center.

It offers flexibility to those in need, Ms. Macerelli said, and “doesn’t have to be overwhelming [like] going into a mental health hospital.

“Families don’t need to figure it out, they just need to call and say ‘we need help.’”

But she also recognizes the frustration that comes for families whose loved one refuses treatment.

“You can’t force the mental health crisis response on an individual,” Ms. Macerelli said.

That’s why she thinks a change in the AOT law could be beneficial and will get more people who need it into treatment.

But, she’s also cautious.

“As a county, we have no way of anticipating what the volume need will be,” Ms. Macerelli said. Too, she said, it’s essential to make sure it is adequately funded and supported, and that the details are thought through to ensure successful implementation.

Mr. Eisenhauer’s organization worked with legislators on crafting the current bill and issued a white paper on the issue, promoting the relaxation of the dangerousness standard both for AOT and inpatient treatment. He called Pennsylvania’s laws on this issue “antiquated.”

“We do believe in voluntary treatment for most people, because it works,” Mr. Eisenhauer said. “But we can’t ignore that there are instances where the current construct of the law isn’t helpful to people because of the dangerousness standard.”

He believes the change in the AOT law will “absolutely help with that population.”

But, he continued, “I don’t see it being this big game-changer.”

That would come, Mr. Eisenhauer said, if the in-patient standard were changed.

Difficulty predicting violence

All of the experts agreed that the vast majority of seriously mentally ill people never become violent, and instead are much more likely to be the victim of crime.

Ms. Berger doesn’t dispute that. But the Treatment Advocacy Center, in a recent report, also found that in 2013, out of 16,121 homicides across the United States, 1,149 of them involved a seriously mentally ill person killing a family member. That equaled 7 percent of all homicides.

“It’s not that everyone with a mental illness is violent,” she said. “But when they are, it’s against their family members. In Pennsylvania, we’re forcing families to walk that line in a very dangerous way.”

Her organization worked with the family of Michael McDaniel after he tried to kill his grandmother in 2012, and with the family of Levi Staver after he did kill his in 2013.

“He doesn’t have this history of violence in his past, but what he does have is a very clear path in decline,” Ms. Berger said of Mr. Staver. “He is decompensating. He is very sick. He is having hallucinations. He is having paranoid thoughts.

“All of these things, even if he’s not actively harming himself or anyone else … we can see the writing on the wall.”

Had Mr. Staver been living in Ohio in the months leading up to his crime, Ms. Berger said, he likely would have gotten involuntary, inpatient treatment. There, and in several other states, they used the standard of “grave risk,” and “inability to provide basic needs.”

“In other states, there’s a lot more legal flexibility to get the treatment he clearly needed.”

Changing the dangerousness standard, Ms. Berger continued, would allow mental health professionals to treat gravely ill people as if it were a medical illness, “instead of [like] a philosophical debate about civil liberties,” Ms. Berger said.

She emphasized that her organization believes in protecting individuals’ rights to refuse treatment.

“But we also have the responsibility to provide care for vulnerable people,” Ms. Berger said. “They’re going to end up homeless, or in jail or killing themselves.

“This isn’t hyperbolic.”

Similar cases, much different outcomes

Michael McDaniel with his grandmother, Helen Badulak, on Aug. 10, 2017. Michael attacked her with her metal cane in January 2012 and was charged with attempted homicide. A judge found that he was insane at the time of the crime. Photo courtesy of Nina McDaniel.

Levi Staver and Michael McDaniel have remarkably, dreadfully similar stories.

Michael, who has schizophrenia, tried very hard to kill his grandmother on Jan. 23, 2012.

Levi, who has schizophrenia, succeeded in killing his grandmother on Feb. 19, 2013.

Michael, 35, whose case occurred in Berks County, was ordered to inpatient treatment at Wernersville State Hospital for at least one year after the judge granted a motion for judgment of acquittal, finding that Michael was insane at the time of his crime and therefore not criminally responsible. It is the equivalent in criminal law to being found not guilty by reason of insanity.

Levi, 31, whose case occurred in Allegheny County, was forbidden by the judge in his case from admitting evidence of his mental illness at trial, and therefore pleaded guilty but mentally ill to third-degree murder and was ordered to serve 10 to 20 years in prison.

The cases illustrate the difficulty in securing treatment in Pennsylvania before a person turns violent, and the wide range of discretion available to judges across the court system.

The McDaniel family’s first indication that something was wrong with Michael came in 2007 when he called his mom and simply said he didn’t feel like himself and needed to go to the emergency room. Within a month, he was having paranoia, and shortly after that auditory hallucinations that God and Satan were speaking to him.

Soon, he could no longer live by himself.

So began a five-year-long revolving door of inpatient hospitalizations and home visits and therapy appointments.

Michael’s case differed from Levi’s in that Michael sometimes showed signs or threats of violence before the attack on his grandmother, Helen Badulak: He threatened to kill his parents, asked them to hide the serrated knives in their kitchen and searched online for guns.

Paperwork to have Michael involuntarily committed was submitted for review five times, according to his mother, Nina McDaniel, starting in December 2008. Three times, he was hospitalized. Twice, after evaluation, Michael was sent home.

The last time he went to the emergency room, in October 2011, he stayed for just two hours before he called his mom and said he had been released.

“I gave up. I, literally, gave up,” Nina said. “No one was listening to us. We had no rights.

“He lost touch of reality completely.”

For the three years leading up to what she calls “the tragedy,” Nina slept on a sofa in the living room so she could keep an eye on Michael’s movements from where he slept in the pool room connected to the house.

“I thought I could protect the family because Michael wasn’t getting the help he needed,” she said.

Michael woke up early on the morning of Jan. 23, 2012, and walked past his mother on the couch — she thought he was just going to make coffee — and made his way down a long hallway to his grandmother’s bedroom.

According to an account Ms. Badulak, now 79, gave a psychologist evaluating her grandson, she awoke to Michael talking in a deep voice in “‘some kind of language, but it did not seem to be a language.’”

When she opened her eyes, she saw what looked like a pipe in his hand — it was actually her metal cane. She smiled at him, and he began to strike her, all the while talking in an unknown language.

“She states that he looked into the void beyond her, and then he started talking again in this unusual manner and hitting her,” the psychologist wrote.

“She fell down. She felt wetness all over. She could not get up.”

Suddenly, Michael walked out, he told the police, to search for a sledge hammer since his grandmother hadn’t died from the beating with the cane.

While he was out of the room,  now splattered with blood from ceiling to floor, Ms. Badulak was able to pull her cell phone by its charging cord down to the floor with her and called 911.

Then Michael returned, striking her again.

“He was not talking,” she told the psychologist. “He had a strange look in his eyes, and she said to him, ‘Michael, I love you, why are you hitting me?’

“She asked where his mother is, and he said that his mother is dead and ‘everyone is dead.’

“He then turned around and walked out.”

Michael, who also called 911 that morning and reported that he had killed his grandmother and wanted the police to come and shoot him, was arrested shortly after the attack.

He was charged with attempted homicide.

Michael was taken, at first, to Berks County Prison, where other inmates called him “Bobber,” referencing a side-to-side head movement he had had since he was just 9 months old. He was bullied for it throughout his childhood, and it was among the things that he fixated on throughout his illness.

Following a mental health evaluation on Feb. 13, 2012, Michael was deemed to be incompetent to stand trial.  A month later, he was transferred to Torrance State Hospital.

Michael remained at Torrance, where he got on a regular regimen of antipsychotic medication, for a few months, when he returned to the county prison, competent.

On Aug. 10, 2012, Michael had a nonjury trial before Berks County Senior Judge Stephen B. Lieberman Jr.

After listening to testimony from a psychologist and a psychiatrist who evaluated Michael, the judge determined that, although Michael may have understood the nature and quality of his act at the time of the offense, he did not know it was wrong.

Judge Lieberman said an important part of his decision in the case was Ms. Badulak’s statements about the crime.

“[S]he didn’t even recognize her grandson,” he said.

It appeared to her, the judge continued, that Michael was out of control, speaking in tongues.

“[T]his case is an example, I believe, of a failure of our mental health system in our country today,” the judge said.

Referencing the closure of state hospitals beginning in the 1970s, he continued, “It is an idea that seems to be working out a lot like communism — looks great on paper but in practice it’s leaving families of people that suffer from mental illness and leaves the person themselves that suffer from mental illness with virtually no resources and no help.”

Under Pennsylvania’s Mental Health code, Judge Lieberman ordered Michael to be committed to Wernersville State Hospital for at least one year.

At the end of his hearing, Nina said, Judge Lieberman addressed Michael directly and told him he believed in him and that he could turn his life around if he followed his treatment plan. “’Don’t let me down,’” the judge said.

And for Michael, that’s all he kept thinking about, his mother said.

“Now, he’s too scared to quit taking his medication.”

At Wernersville, medication wasn’t forced on Michael, Nina said, but it was part of a rewards system, and failure to take it would result in a loss of privileges — fewer family visits; fewer outings; fewer trips outside and losing good jobs in the hospital that paid the patients cash.

Michael remained at Wernersville longer than expected, Nina said. He was eligible for release after two years, but because it was difficult to find a program outside willing to take him because of his crime, he stayed six months after that.

More than two years after his release from the state hospital, Michael is doing well, his mother said.

He lives in a two-story house with two other men with severe mental illness through a program called Supportive Concepts for Families.

Michael sees a life coach on Mondays, has a psychologist and a caseworker. He drives himself to get his medication in an injection every other week.

He has lost 57 pounds and works out a lot. Michael bought a basketball hoop that he and his housemates can use. He enjoys music and journals every day.

Michael stays with his parents from Thursday to Saturday each week -—in the same home where his grandmother lives.

Their relationship remains close.

None of those things would be possible now if Michael had been sent to state prison, like Levi Staver was.

Paul Appelbaum, a psychiatry professor at Columbia University and past president of the American Psychiatry Association, said the criminal disposition of guilty but mentally ill came into being in the 1970s and ‘80s to give jurors an alternative to finding a defendant not guilty by reason of insanity.

“They recognize the defendant is mentally ill, but still punish him,” Dr. Appelbaum said. “But in many respects, guilty but mentally ill is a sham.”

The steps for an involuntary, inpatient commitment in Pennsylvania

• If a person is shown to have been a danger to self or others within the past 30 days, a petitioner must fill out a 302 request explaining knowledge of the dangerous conduct and be willing to attest to it at an emergency room, with a mobile crisis response team, or the county Office of Behavioral Health.
• Once the 302 petition has been authorized by the county delegate, the individual experiencing severe mental illness will be taken to an emergency room by police or ambulance for an evaluation by a physician to determine if involuntary inpatient treatment is necessary.
• If the person is admitted, the stay is limited to 120 hours unless a new petition, under Section 303 extending involuntary treatment, is filed by the hospital.
• Under Section 303, a hearing is held at the hospital to determine if additional, inpatient treatment time is necessary. At that hearing, the patient is represented by an attorney — which can be a public defender — and the hospital is represented by an attorney from the county law department. The hearing is presided over by the Mental Health Review Officer. If that officer finds there is sufficient dangerous conduct and the need for additional treatment, the officer can authorize a stay for up to 20 days.
• Source: Allegheny County

Under Pennsylvania law, a verdict of guilty but mentally ill guarantees the defendant will be evaluated for treatment, but that’s it. It does not guarantee treatment or placement in a secure setting.

“In general, these people are kept in prison for a substantial period of time,” he said. “It’s an unfortunate direction that our law went.”

Dr. Appelbaum noted that the more heinous a crime is, the more unlikely a judge or jury will find a defendant not guilty by reason of insanity.

“We seem to be stuck with substantial discretion on the part of the judges, and depending on which judge gets assigned to the case that day,” he said.

When Judge Lieberman returned his verdict that would, someday, allow Michael to return home, the family was in shock.

Nina, who now advocates for better mental health care for the seriously ill, has become friends with Levi’s mother, Ruth Johnston. They talk on the phone about the law, their struggles and lament how things could have been.

They compare stories.

“The positive thing is that we’re all alive,” Nina said. “We have deep wounds, but we’re all alive.”

And they compare their outcomes. Levi is now at the State Correctional Institution at Camp Hill. Michael is finding success in a group home.

“That’s what I wish would have happened for Levi,” Nina said. “Wow, what a difference it makes. [Michael] is even better than he was when he became ill.”

“Michael is not a schizophrenic first. He’s actually our Michael.”