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You can search the entire site. or go to the recent opinions, or the chronological or subject indices. In Re Necessity for the Hospitalization of Jeffrey E. (7/27/2012) sp-6701
Notice: This opinion is subject to correction before publication in the PACIFIC REPORTER .
Readers are requested to bring errors to the attention of the Clerk of the Appellate Courts,
303 K Street, Anchorage, Alaska 99501, phone (907) 264-0608, fax (907) 264-0878, email
corrections@appellate.courts.state.ak.us.
THE SUPREME COURT OF THE STATE OF ALASKA
In the Matter of the Necessity ) Supreme Court No. S-14419
for the Hospitalization of: )
) Superior Court No. 3AN-11-01224 PR
JEFFREY E. )
) O P I N I O N
)
) No. 6701 - July 27, 2012
)
Appeal from the Superior Court of the State of Alaska, Third
Judicial District, Anchorage, John Suddock, Judge.
Appearances: Marjorie Allard, Assistant Public Defender,
and Quinlan Steiner, Public Defender, Anchorage, for
Appellant. R. Scott Taylor, Senior Assistant Attorney
General, Anchorage, and John J. Burns, Attorney General,
Juneau, for State of Alaska.
Before: Carpeneti, Chief Justice, Fabe, Winfree, and
Stowers, Justices.
WINFREE, Justice.
I. INTRODUCTION
A respondent appeals his 30-day involuntary commitment order, arguing
the evidence was insufficient to support the superior court's conclusion that he was
gravely disabled. Because the superior court did not err in concluding that the
respondent was gravely disabled under the required clear and convincing evidence
standard, we affirm the 30-day commitment order.
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II. FACTS AND PROCEEDINGS
In June 2011 Jeffrey E.1 was 20 years old, had recently lost his job due to
behavioral difficulties, was in the process of divorcing, and was staying with family
members. Jeffrey's family members became concerned about his behavior and brought
him to a hospital. Jeffrey's family reported Jeffrey had not been eating, drinking,
sleeping, or performing any self-care for several days - he had more or less remained
seated in a catatonic state,2 to the point of urinating on himself. Jeffrey's family also
reported Jeffrey had made comments about others being able to read his mind, had
responded aggressively to challenges, and had a family history of mental illness.
Jeffrey remained in the emergency room overnight for observation. He
spent most of the night sitting awake in a chair and refusing medication, food, and drink.
Because Jeffrey was uncommunicative, hospital staff could not determine if he was
actively psychotic. Although unable to articulate how he would behave differently,
Jeffrey wanted to go home and "denied thoughts or plans of self harm or harm to others."
Hospital staff concluded Jeffrey "may be experiencing symptoms of psychosis but it is
difficult to assess" and that "[h]e could benefit from further assessment and stabilization
. . . as it is possible he is experiencing psychosis."
The next day hospital staff filed a Petition for Initiation of Involuntary
1 We use a pseudonym to protect the respondent's privacy.
2 "Catatonia" is defined as a "phase of schizophrenia in which the patient is
unresponsive . . . [a] tendency to assume and remain in a fixed posture and inability to
move or talk are characteristics of this phase." TABER 'S CYCLOPEDIC MEDICAL
DICTIONARY 305 (16th ed. 1989).
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Commitment and an Application for Examination.3 The superior court granted an ex
parte order requiring Jeffrey's transport to Alaska Psychiatric Institute (API) for
examination. A few days later API staff filed a petition for an involuntary 30-day
commitment, and the court held a hearing on this petition.4
Dr. Kennedy Cosgrove, an API psychiatrist, testified at the hearing about
his diagnosis of Jeffrey's mental illness - specifically psychotic disorder not otherwise
classified. This diagnosis was based on behavior described by Jeffrey's family members
and the hospital emergency room staff, as well as on Dr. Cosgrove's own observations
at API. Dr. Cosgrove stated that Jeffrey's catatonia had "resolved rather quickly" after
he took medication in the emergency room. Dr. Cosgrove stated Jeffrey had resumed
adequate eating and drinking, and that he had stopped responding to internal stimuli -
auditory hallucinations and delusional thoughts - by the day before the hearing.
Dr. Cosgrove was concerned that Jeffrey lacked insight into his prior
condition. Jeffrey had told Dr. Cosgrove "that he [had] no problem other than
daydreaming and drinking alcohol and [did] not see anything wrong with him[self]."
Dr. Cosgrove also was concerned that Jeffrey's lack of insight would result in Jeffery
3 See AS 47.30.700 (regarding initiation of involuntary commitment
proceedings based on probable cause to believe person is mentally ill and gravely
disabled or likely to cause harm to self or others); AS 47.30.705 (establishing procedures
for emergency evaluation detention); AS 47.30.710(b) (authorizing hospitalization if a
mental health professional "has reason to believe that the respondent is (1) mentally ill
and that condition causes the respondent to be gravely disabled or to present a likelihood
of serious harm to self or others, and (2) is in need of care or treatment," and requiring
application for an ex parte order if no judicial order has been obtained under AS
47.30.700).
4 See AS 47.30.730-.735 (setting forth requirements for 30-day commitment
petition and 30-day commitment hearing).
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discontinuing his medication, causing a return of his prior symptoms. Dr. Cosgrove
testified to the serious consequences that would result if Jeffrey went off medication:
"Catatonia returns often very quickly when someone stops the [medication] for it," and
could return "in a matter of hours, certainly within a day." Dr. Cosgrove testified that
Jeffrey's mental illness would worsen if not treated, and that the catatonia caused Jeffrey
mental and physical distress.
Jeffrey also testified at the hearing. He described his condition upon
arriving at the hospital as "positive," described his issues as "daydreaming" or "anxiety,"
and thought his stay at API was "kind of helpful." He said that if released, he would
return to his brother's house, or a local homeless shelter if his brother would not let him
return. He planned to contact his prior employer about re-employment and had enough
savings to tide him over in the meantime. He stated he had been given the telephone
number of a mental health clinician, whom he planned to contact on release. He also
stated he planned to keep taking his medication if the clinician recommended it.
But Jeffrey also answered "no" when asked if he was "going to follow up
for treatment for mental illness." He stated that he would be "furthering the process of
getting medication for anxiety," but did not "really notice that much of a difference"
once he began medication for catatonia. Jeffrey later stated he "possibly" would "consult
with another physician regarding the need for ongoing medication."
The superior court found that: (1) Jeffrey was mentally ill; (2) Jeffrey was
gravely disabled; and (3) no less restrictive facility than API would adequately protect
Jeffrey. The court noted Jeffrey was a "functioning human being" at the time of the
hearing, but was still vulnerable. The court found Jeffrey would not continue to take his
medication on his own and that there were "catastrophic consequences of ceasing to take
the medication."
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Jeffrey appeals the superior court's finding that he was gravely disabled.
He does not appeal the mental illness finding or the finding that API was the least
restrictive alternative. Although Jeffrey was released from API shortly after being
committed and the issue he raises is moot under the standard established in Wetherhorn
v. Alaska Psychiatric Institute,5 because this was Jeffrey's first involuntary commitment
we consider his appeal under the collateral consequences exception to mootness recently
adopted in In re Hospitalization of Joan K .6
III. STANDARD OF REVIEW
"We review fact findings in involuntary commitment proceedings for clear
error, reversing only if we are left with a 'definite and firm conviction that a mistake has
been made.' "7 We apply de novo review to related legal questions, "including whether
the fact findings meet the statutory standards for involuntary commitment."8
IV. DISCUSSION
Before the superior court can involuntarily commit a person it must find,
by clear and convincing evidence, that the person is "mentally ill and as a result is likely
5 156 P.3d 371, 380 (Alaska 2007) (holding an evidentiary-based challenge
to an expired 30-day commitment order is moot and will not be reviewed absent an
exception to the mootness doctrine).
6 273 P.3d 594, 598 (Alaska 2012) (concluding "that there are sufficient
general collateral consequences, without the need for a particularized showing, to apply
the [collateral consequences exception to mootness] in an otherwise-moot appeal from
a person's first involuntary commitment order").
7 Id. at 596 (quoting In re Hospitalization of Tracy C. , 249 P.3d 1085, 1089
(Alaska 2011)).
8 Id . (citing E.P. v. Alaska Psychiatric Inst. , 205 P.3d 1101, 1106 (Alaska
2009)).
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----------------------- Page 6-----------------------
to cause harm to [self] or others or is gravely disabled."9 Clear and convincing evidence
is "that amount of evidence which produces . . . a firm belief or conviction about the
existence of a fact to be proved."10 Gravely disabled is defined in AS 47.30.915(7)(B):
"gravely disabled" means a condition in which a person as a
result of mental illness
. . . .
will, if not treated, suffer or continue to suffer severe and
abnormal mental, emotional, or physical distress, and this
distress is associated with significant impairment of
judgment, reason, or behavior causing a substantial
deterioration of the person's previous ability to function
independently.
We have noted that this subsection of the statute "is concerned with a more
passive condition, whereby the respondent is so unable to function that he or she cannot
exist safely outside an institutional framework due to an inability to respond to the
essential demands of daily life."11 To preserve the constitutionality of the statute, we
have interpreted "distress" in AS 47.30.915(7)(B) as referring "to a level of incapacity
that prevents the person in question from being able to live safely outside of a controlled
environment."12 In sum, for Jeffrey to be committed to API there had to be evidence
producing a "firm belief or conviction" that he would be unable to exist "safely outside
of a controlled environment."
9 AS 47.30.735(c).
10 In re Johnstone , 2 P.3d 1226, 1234-35 (Alaska 2000) (quoting Buster v.
Gale, 866 P.2d 837, 844 (Alaska 1994)).
11 Wetherhorn v. Alaska Psychiatric Inst., 156 P.3d 371, 376 (Alaska 2007)
(citing In re LaBelle , 728 P.2d 138, 144 (Wash. 1986)).
12 Id. at 378.
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Jeffrey argues the superior court erred in finding him gravely disabled at
the time of the commitment hearing. He concedes he was gravely disabled when he was
admitted to the emergency room days before the commitment hearing. But he contends
that to be committed, he had to be gravely disabled at the time of the commitment
hearing.13 He maintains the superior court contradicted itself by acknowledging he had
"crossed the line" back to being a functioning human being but finding he was gravely
disabled.
The State counters that the superior court made an "express finding" that
Jeffrey was gravely disabled at the time of the commitment hearing and that this finding
is entitled to "especially great deference" because it required the superior court to
evaluate conflicting oral testimony and witness credibility.14 The State adds that recent
behavior is relevant to whether a respondent is gravely disabled at the time of the
hearing, and Jeffrey had very recently been catatonic.15
Jeffrey responds that the superior court's factual findings are reviewed for
clear error but the ultimate legal conclusion of whether those facts meet the legal
standard of gravely disabled is a question of law reviewed de novo. He contends that a
lack of insight into his mental condition and a "realistic probability" that he would stop
13 See In re Hospitalization of Tracy C., 249 P.3d 1085, 1093 (Alaska 2011)
("We therefore conclude that although the superior court may only grant an involuntary
commitment petition if it finds by clear and convincing evidence that the patient is
mentally ill and likely to harm herself or others or is gravely disabled at the time of the
commitment hearing, when making that determination the court may consider the
patient's recent behavior and condition as well as the patient's symptoms on the day of
the hearing.").
14 See id. at 1089.
15 See id. at 1093.
-7- 6701
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taking his medication provide an insufficient basis to find him gravely disabled.
Regarding the standard of review, Jeffrey is correct; factual findings are
reviewed for clear error, but the ultimate legal conclusion of whether those facts meet the
"gravely disabled" criteria is reviewed de novo.16 Jeffrey and the State are each partially
correct in reading Tracy C. - a respondent must be gravely disabled at the time of the
commitment hearing, but recent behavior is probative of whether the respondent is
gravely disabled at the time of the hearing.17 And we add that the statutory subsection
is forward-looking with its concern that the respondent "will, if not treated, suffer or
continue to suffer" distress as a result of the respondent's mental illness.18
Dr. Cosgrove testified that in his opinion, Jeffrey "would probably go off
his medication and get back into the same situation rather quickly" without
hospitalization. Dr. Cosgrove based his prediction on Jeffrey's lack of insight into both
his condition and his need for treatment. He stated it was "not clear" to him whether
Jeffrey would be able to obtain food and drink if released. Dr. Cosgrove also expressed
"very significant concerns" about Jeffrey's ability to survive in the community if
released.
The superior court explained its decision as follows:
The standard is clear and convincing evidence of a high level
of distress, impairing the person from being able to live
safely outside of a controlled environment. On these facts,
what you have is a gentleman who is - sounds like a very
nice person. He is articulate and well spoken. He is two days
16 In the Matter of the Necessity for the Hospitalization of Joan K ., 273 P.3d
594, 596 (Alaska 2012).
17 In re Tracy C. , 249 P.3d at 1091.
18 AS 47.30.915(7)(B).
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or so past his hunger strike, and he doesn't know - he
doesn't realize at an intellectual level that he was on a hunger
strike. In other words, he has no appreciation of what his
prior condition was, how much trouble he was in. What's
changed is that he's taken some medication that has brought
him out of frank catatonia where he was sitting on a couch
and if - without an intervention, he would literally pee on
himself, not eating, not drinking, and not able to lift himself
by his own bootstraps out of that condition. He's now moved
to a better condition, which is just across the line back to
being a functioning human being. But he's so vulnerable
right now, he's so fragile because he is just across the line.
And it's obvious that he has no insight that it's the
medication that has returned him to a state of lucidity able to
seemingly talk in a way that superficially sounds to have
sufficient normalcy to put him out in the community. But
what would clearly happen at this moment if he went out into
the community with his level of insight, he's not going to
take that medication. . . . And the catastrophic consequences
of ceasing to take the medication are so high that he simply
needs more time in the shelter of API to get himself together.
He may cross that line into having acceptable judgment
within a very short time. I agree . . . that his release may well
come well before 30 days are up. But it would be
irresponsible for me to say he's at that point three days in.
Jeffrey is incorrect that the superior court's findings and conclusion
contradict its own comments that Jeffrey had crossed the line back to being functional.
Jeffrey may have been "functioning" at the time of the hearing, but this does not preclude
him from also being "gravely disabled." As noted above, the statutory definition of
gravely disabled is forward-looking - even if Jeffrey were not suffering from distress
at the exact time of the hearing, he still could be gravely disabled at that time if he would
suffer distress in the near future as a result of his mental illness. It is noteworthy that the
trial court limited the commitment to 30 days or "until a moment when, in the best
judgment of [Jeffrey's] treaters there, [Jeffrey had] recovered enough resiliency, enough
-9- 6701
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judgment, that [he would] take the medication reliably that's going to protect [him] from
returning to a condition that [he didn't] recognize [he] had fallen into."
Because there is no dispute that Jeffrey's catatonia made him gravely
disabled, or that catatonia would reoccur shortly after the cessation of medication, the
outcome of this appeal hinges on whether the superior court's finding that Jeffrey would
not take his medication in the future is clearly erroneous. "We will grant especially great
deference when the trial court's factual findings require weighing the credibility of
witnesses and conflicting oral testimony."19 Jeffrey's own testimony at the hearing
supports Dr. Cosgrove's conclusion that Jeffrey lacked insight into his illness and
Jeffrey's equivocal and contradictory testimony about whether he would continue taking
his medication does not directly contradict Dr. Cosgrove's conclusion that Jeffrey would
not take his medication in the future. The finding that Jeffrey's existing condition would
cause him to not take his medication in the near future is not clearly erroneous. We
therefore affirm the conclusion that Jeffrey was gravely disabled.
V. CONCLUSION
We AFFIRM the superior court's 30-day commitment order.
19 In re Tracy C. , 249 P.3d at 1089 (quoting Bigley v. Alaska Psychiatric Inst. ,
208 P.3d 168, 178 (Alaska 2009)).
-10- 6701
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