IN THE COURT OF APPEALS OF IOWA

No. 17-1591

Filed March 7, 2018

IN THE MATTER OF S.M.,

Alleged to be Seriously Mentally Impaired,

S.M.,

Respondent-Appellant.

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Appeal from the Iowa District Court for Johnson County, Chad A. Kepros, 

Judge.

An inmate diagnosed with schizophrenia appeals the district court order 

finding him to be seriously mentally impaired under Iowa Code chapter 229 (2017). 

AFFIRMED.

Sandra R. Hart of Hart Law, North Liberty, for appellant.

Thomas J. Miller, Attorney General, and Gretchen W. Kraemer, Assistant 

Attorney General, for appellee State.

Considered by Doyle, P.J., and Tabor and McDonald, JJ.
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TABOR, Judge.

Convicted of first-degree murder nearly forty years ago, S.M. is serving a 

life sentence in the custody of the Iowa Department of Corrections (DOC). S.M. 

has been treated for schizophrenia during his prison stay. From 2000 until 2016 

he was subject to a civil commitment order as a means to enforce medication 

compliance. Without that enforcement, S.M. resisted taking his prescribed antipsychotic drug and grew increasingly delusional. When S.M.’s conspiracy theories 

progressed to include prison staff and other inmates, and he discussed “retaliation” 

against them, his treating psychiatrist sought to renew the civil commitment. The 

district court ordered S.M. to receive treatment within the DOC at the outpatient 

level of care. S.M. appeals that order, contending the State did not prove he posed 

a danger. In light of his past actions, S.M.’s current threats and physical posturing 

signaled the probable commission of a harmful act upon himself or others likely to

result in physical injury; we find the dangerousness element satisfied.

I. Facts and Prior Proceedings

S.M.’s diagnosis of schizophrenia dates back to 1977 when he was 

discharged from the military. S.M. admitted killing his mother in 1978 by striking 

her head with a large concrete lawn ornament. At his trial, S.M. claimed he 

suffered from a psychosis aggravated by drug and alcohol use. He nevertheless 

received a sentence of life without parole. Early in his prison term, around 1984, 

S.M. engaged in self-mutilation, cutting his testicles with a razor. He also got into 

two fights with fellow inmates during the 1980s. He attempted suicide in the late 

1990s. The DOC records indicate S.M. has exhibited ongoing delusions and 

fixations involving “biker gang wars” and “rock and roll wars,” as well as conspiracy 
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theories about murders across the country. At times, his delusions have been 

categorized as hyper-sexual and hyper-religious, including his declaration of a 

“holy war” in which he was the leader of his own church.

DOC psychiatrist Gary Keller noted S.M. had “a long history of not 

complying with medications and treatment, so had been on a long acting injectable 

medication, haloperidol, for many years.” Because of his non-compliance, from 

2000 until 2016, S.M. was under a mental health civil commitment at the Clarinda 

Correctional Facility, where he was incarcerated. In May 2017, the DOC 

transferred S.M. back to the Iowa Medical and Classification Center (IMCC) so that 

his mental illness could be better monitored and managed. According to Dr. Keller, 

since the commitment ended, S.M. “has refused his medication for treatment of his

schizophrenia” and “has deteriorated in regard to his delusional system.” Dr. Keller 

found S.M.’s illness has grown “much more prominent in his interactions.” 

In early August 2017, S.M. became convinced a corrections officer on his 

unit, as well as other inmates, were involved in a conspiracy involving the death of 

S.M.’s father. While on the prison yard, staff overheard S.M. discussing the 

conspiracy and bringing up “retaliation.” S.M. also spoke of a “genocide scenario.” 

In the same time period, S.M. wrote a note discussing his father’s death which, 

according to Dr. Keller’s recollection, stated “quote, they should pay for what 

they’ve done.” S.M. named a particular offender in the note and also 

“incorporated” officers in S.M.’s living unit and acute mental health unit into his 

conspiratorial thinking. In a follow-up discussion with Dr. Keller, S.M. engaged in 

“even more delusional talk.” Meanwhile, fellow inmates expressed unease about 

S.M.’s compulsive pacing and his aggressive demeanor. Dr. Keller also received 
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reports S.M. displayed “increased irritability” and intimidated other inmates when 

he “often flexes and tenses up in mannerisms as if he is ready to strike out.” Dr. 

Keller opined S.M. was “starting to act on his delusional thinking.”

Dr. Keller feared not only for the inmates and staff who came in contact with 

S.M. at the prison but also was concerned that S.M.’s manifestations of his 

schizophrenia were threatening S.M.’s own health. S.M. would exercise to the 

point of developing sores on his hands and feet and allowed his personal hygiene 

to decline. S.M. also was reluctant to rehydrate because he believed the water at 

the prison was contaminated. According to Dr. Keller, S.M. was not only refusing 

his anti-psychotic medication, but S.M.’s compliance with taking other prescribed 

medications for physical maladies had waned.

On August 7, 2017, a social worker at the IMCC filed an application for an 

order of involuntary hospitalization with S.M. as the respondent. Dr. Keller filed a 

physician’s report outlining his concerns about S.M.’s mental health and increasing 

threats toward staff and fellow inmates. After a hearing, a judicial hospital referee 

found S.M. to be seriously mentally impaired within the meaning of Iowa Code 

chapter 229 (2017). S.M. appealed and the district court held a hearing on 

September 12, 2017. Dr. Keller testified that the point of the mental-health 

commitment was to enable staff to administer medication notwithstanding S.M.’s

objection. Dr. Keller said S.M. had “incorporated” different officers on the living 

unit and on the acute mental-health unit into his conspiracy theories. Plus, peers 

indicated they were concerned about S.M.’s demeanor and avoided interactions 

with him. S.M. also testified, telling the court he “doesn’t believe [he] is 
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schizophrenic.” S.M. testified he dislikes the side effects of the anti-psychotic 

medication, which makes him lethargic, shaky, and restless. 

The district court affirmed the finding of the judicial hospitalization referee, 

noting that during S.M.’s testimony “he quickly reverted to the delusional and

conspiratorial thinking that Dr. Keller had described in his testimony. The Court 

agrees with Dr. Keller that [S.M.] represents a danger to himself and others at this 

time due to his mental illness.” S.M. appeals the district court’s findings.

II. Scope and Standards of Review

We review challenges to the sufficiency of the evidence in involuntary 

commitment proceedings for the correction of legal error. In re B.B., 826 N.W.2d 

425, 428 (Iowa 2013). The State must prove an allegation of serious mental 

impairment by clear and convincing evidence. Iowa Code § 229.13(1). “Clear and 

convincing evidence is less burdensome than evidence establishing proof beyond 

a reasonable doubt, but more burdensome than a preponderance of the evidence.” 

B.B., 826 N.W.2d at 428. Clear and convincing proof leaves “no serious or 

substantial doubt about the correctness of a particular conclusion drawn from the 

evidence.” Id. (quoting In re J.P., 574 N.W.2d 340, 342 (Iowa 1998)). The district 

court’s factual findings are binding on us if they are supported by clear and 

convincing evidence. J.P., 574 N.W.2d at 342. 

III. Analysis of Endangerment Component

Involuntary hospitalization requires proof of a “serious mental impairment.” 

See Iowa Code §§ 229.1(20), 229.6(2)(a)(2), 229.13(1). The code defines “serious 

mental impairment” as:
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[T]he condition of a person with mental illness and because of that 

illness lacks sufficient judgment to make responsible decisions with 

respect to the person’s hospitalization or treatment, and who 

because of that illness . . . [i]s likely to physically injure the person’s 

self or others if allowed to remain at liberty without treatment.

Id. § 229.1(20)(a). Only the last element, commonly referred to as the 

endangerment component, is at issue in this appeal.

Proving endangerment requires “predictive judgment” that is built on “prior 

manifestations” but focuses on future rather than past danger. In re Mohr, 383 

N.W.2d 539, 542 (Iowa 1986). To deprive a person of their liberty through civil 

commitment, the State must show the person poses a danger to himself or 

others—evidenced by a “recent overt act, attempt or threat.” Id. (quoting Stamus 

v. Leonhardt, 414 F.Supp. 439, 451 (S.D. Iowa 1976)). Our supreme court has 

held in the context of civil commitment that an “overt act connotes past aggressive 

behavior or threats by the respondent manifesting the probable commission of a 

dangerous act upon himself or others that is likely to result in physical injury.” In 

re Foster, 426 N.W.2d 374, 378 (Iowa 1988).

S.M. argues the recent threats of “retaliation” attributed to him were too 

lacking in detail to show the likelihood that he would cause physical injury to 

another person. He contends writing down “they will pay” did not manifest a direct 

threat toward another inmate or prison staff. S.M. also insists his overt acts did 

not demonstrate he was likely to injure himself. 

S.M. correctly points out that “socially unacceptable, even repugnant 

behavior” is not enough to satisfy the endangerment element. See Mohr, 383 

N.W.2d at 542. Likewise, spouting bizarre delusions—without more—does not 

qualify as a recent over act. Foster, 426 N.W.2d at 379. 
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But the district court was allowed to view S.M.’s repulsive behavior and 

bizarre delusions in the context of the overall course of his schizophrenia. While 

S.M.’s murder of his mother, attempts at suicide and self-harm, and history of 

physical altercations with other inmates occurred years ago, they still provide a 

backdrop for his current threats. See United States v. Mikawa, 849 F.3d 445, 451 

(8th Cir. 2017) (noting committed person’s assault of his first wife was entitled to 

less weight because it occurred over twenty-five years ago but “need not be 

entirely discounted” (citing United States v. Evanoff, 10 F.3d 559, 563 (8th Cir. 

1993) (“[T]he recency or remoteness of any particular activity simply affects the 

weight the court will give to that particular evidence.”))); see also Mohr, 383 N.W.2d 

at 542 (noting attack involving Mohr’s father occurred many years ago but Mohr’s 

presently expressed view of it is was “ominous” and portrayed “a sadly twisted 

frame of mind” and holding “[w]ith this background his sexual overtures to total

strangers and his fantasies about sexual attacks take on a threatening nature”). 

Given S.M.’s violent past, his recent delusions and threats implicating other 

inmates and prison staff were sufficient to prove dangerousness even if he did not 

have the opportunity to act on them. See United States v. S.A., 129 F.3d 995, 

1001 (8th Cir. 1997) (“The violent nature of S.A.’s visual and auditory hallucinations 

and his actual prior violent behavior are sufficient to support a finding that he is 

dangerous.”). Even without action, S.M.’s physical posturing and aggressive 

stances made his fellow inmates nervous.

We likewise find no error in the district court’s conclusion S.M’s recent overt 

acts demonstrate a likelihood he would injure himself if not civilly committed. 

Beyond his threats to seek retribution against others, the record showed S.M. was 
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exercising to the point of injury, not drinking water, not regularly showering, and 

not taking prescribed medication for physical ailments. See generally In re B.T.G., 

784 N.W.2d 792, 798 (Iowa Ct. App. 2010) (finding substantial evidence to 

establish that inmate was likely to injure himself or others physically because of 

his mental illness when he threatened to harm prison staff and their children and 

was striking out at the walls and door of his cell).

The record contains substantial evidence to support the district court’s 

conclusion S.M. has a serious mental impairment. In particular, we find clear and 

convincing proof S.M. is likely to injure himself or others if allowed to remain at 

liberty without treatment. 

AFFIRMED.