Source: https://vermont.lexroll.com/re-g-g-2017-vt-10-2017/
Timestamp: 2019-04-19 16:16:40+00:00

Document:
G.G., Pro Se, Berlin, Appellant.
Rebecca T. Plummer, Vermont Legal Aid, Inc., Montpelier, for Appellant.
William H. Sorrell, Attorney General, Bridget C. Asay, Solicitor General, and Benjamin D. Battles, Assistant Attorney General, Montpelier, for Appellee State.
¶ 1. EATON, J. At the center of this appeal is the issue of whether mental health patients have a due process right to waive counsel and represent themselves in proceedings on continued treatment or involuntary medication. The patient in this case, G.G., appeals from the court’s denial of requests by him and his counsel to let him represent himself in his mental-health proceedings and from the court’s subsequent orders of continued treatment and involuntary medication. We hold that the Due Process Clause of the Fourteenth Amendment precludes G.G. from proceeding without representation in his involuntary medication and involuntary commitment hearings, given the State’s exceedingly strong interest in an accurate determination on the merits of those hearings. Accordingly, we affirm the trial court’s denial of G.G.’s motion to waive counsel and his attorney’s motion to withdraw. Additionally, we affirm the decisions on the merits of G.G.’s continued treatment and involuntary medication orders.
¶ 2. G.G., the appellant, has been hospitalized at the Vermont Psychiatric Care Hospital (VPCH) since September 18, 2015, and has been subject to a sequence of renewed orders for involuntary medication since December 2015. On May 24, 2016, the State filed an application for G.G.’s continued treatment and hospitalization. On June 1, 2016, in light of the pending expiration of a ninety-day involuntary medication order dated March 4, 2016, the State filed an application seeking to involuntarily medicate G.G. with twenty milligrams of Prolixin Decanoate (Prolixin) by intramuscular injection every two weeks. The family court consolidated the State’s applications for continued treatment and involuntary medication and scheduled a hearing on June 8, 2016.
¶ 3. Prior to the hearing, G.G. filed a motion seeking to dismiss his attorney and proceed pro se, and his attorney simultaneously filed a motion to withdraw. The court informed G.G. of his right to counsel and “of the value of counsel in this highly technical arena” and “engaged in a colloquy similar to that employed in criminal cases to determine the propriety of [G.G.’s desired] waiver.” Noting the “lack of controlling Vermont precedent” and taking account of another Vermont family court decision it called “persuasive,” the court found that G.G.’s proffered waiver “was not knowing, intelligent and voluntary; and that [self-representation] was not in [G.G.’s] best interest.” Additionally, because G.G. requested to represent himself shortly before the scheduled hearing, the court found that granting the request would have delayed the proceedings. The court therefore denied G.G.’s motion for self-representation and his attorney’s motion to withdraw.
Nevertheless, the court permitted G.G. to participate in cross-examination of the State’s witnesses after his attorney concluded her examinations and allowed G.G. to make closing arguments.
¶ 5. The court found that G.G.’s schizophrenia significantly impaired his capacity to exercise self-control, judgment, or discretion in the conduct of his affairs and social relations and that he therefore represented a danger and a potential danger to others. The court credited Dr.
Richards’s testimony regarding her own fear of G.G., the “great lengths” to which she went in avoiding areas of disagreement during therapy, and her opinion that G.G.’s illness caused him “to view reality in a distorted manner and to react with violence.” For example, G.G admitted to a situation in which a VPCH nurse encouraged him to engage in more eye contact and he responded by grabbing her and slapping her face because, he later explained to Dr. Richards, “the nurse wanted physical contact, and she got it.” Prior to his admission at the VPCH, G.G. acquired a machete, a stun gun, and pepper spray and told Dr. Richards that he was angry when his parents took those articles from him. The court also found that if G.G. were discharged, he would soon become a danger to himself, in part because he was refusing to take Prolixin, which controlled his malignant catatonia. Specifically, G.G.’s past catatonic episodes left him unable to speak or walk for hours at a time, causing muscle degeneration and rendering him incapable of caring for himself, and after one episode, G.G. suffered hypothermia from self-exposure to the elements.
¶ 6. Despite the danger that catatonia poses to G.G.’s wellbeing, he has been adamant that he does not wish to take Prolixin because he “does not believe he needs it for any condition, does not believe it has improved his condition, [and] does not like how it makes him feel.” Instead, G.G. has made it clear to Dr. Richards that he would, if released, take other medications that he has stockpiled but that have failed to control his symptoms in the past and resulted in his present hospitalization. He maintains that he will not take Prolixin if not subject to court order and has actively attempted to interfere with its administration at the VPCH. When the VPCH began using injectable Prolixin, G.G. squeezed his arm so hard that the nurse was unable to administer the shot effectively, and when he was taking daily oral doses of Prolixin, the administration of the medication caused him and the staff great anxiety and stress. Although Dr. Richards did not ask G.G. directly whether he would voluntarily take Prolixin while at the hospital, the court credited her opinion that she did not need to ask in light of G.G.’s “long-held antipathy to Prolixin and his clear plan to cease its use once released and free of court compulsion.” Thus, the court concluded, G.G. would represent a danger to himself if discharged because of the risk that he would discontinue his medication and again suffer the effects of malignant catatonia.
¶ 7. Additionally, the court found that G.G. lacks insight into his own illness and is not competent to decide whether to take medication. G.G. denied having malignant catatonia and denied that any of his physical ailments were related to his mental illness. The court credited Dr.
Richards’s testimony that “[G.G.]’s condition causes a distorted view of reality that skews his perception as to his condition and the need for appropriate medication,” and renders him “unable to balance the need for medication against the possible risks.” The court considered those potential risks—which include tardive dyskinesia, tremors, muscle rigidity, seizures, in rare cases neuroleptic malignant syndrome (NMS), and pain with injection—relative to the benefits of continued administration of Prolixin, and concluded that the benefits to G.G. outweighed the potential risks. Specifically, the court found that since being subjected to forced medication orders in December 2015, G.G. has improved significantly and that Prolixin has been the cause of his improved mental condition, but without Prolixin G.G.’s prognosis was not good and his condition would worsen. The court credited Prolixin with helping G.G. “emerge from his catatonic state” and begin to engage in social activities like Scrabble and karaoke and found that if G.G. remains on Prolixin, his symptoms may be managed and he may eventually be able to return to the community in a supervised setting. The court found that the alternative drugs that G.G. preferred were ineffective and that the risk of G.G. suffering Prolixin’s most severe side effects could be mitigated and the less severe side effects effectively managed. Thus, the court concluded, there was no alternative effective treatment to Prolixin, and given G.G.’s inability to balance the benefits of Prolixin against its risks, he was not competent to decide whether to take the medication.
person, shall be adjudged by the selectmen and civil authority aforesaid (or the major part of them) to be incapable of taking care of him or herself, and shall certify the same under their hands, to the judge of probate; the said judge is hereby empowered to appoint some suitable person or persons, to be guardian or guardians. . . .
1808 V.S. ch. 40, No. 1, § 1 (March 2, 1797) (emphasis added). We quote the language from the 1797 statute because the wording of the statute is relevant; we intend no disrespect in using this language. See In re Guardianship of A.S., 2012 VT 70, ¶ 2 n.1, 192 Vt. 631, 57 A.3d 716 (mem.) (noting that quoted language was repeated from prior version of statute and was not intended to be disrespectful). The fact that the statutory law that displaced the common law of 1793 provided for adjudication of mental illness by the courts—not by a jury—furthers what other states and the federal courts have recognized: the common law did not recognize a right to a jury trial in civil commitment proceedings, and no such right exists now.
The Sixth Amendment to the U.S. Constitution is made applicable to the states, including Vermont, through the Fourteenth Amendment. See State v. Paquette, 146 Vt. 1, 4, n.3, 497 A.2d 358, 361, n.3 (1985) (citing Pointer v. Texas, 380 U.S. 400, 406 (1965)).
Bean, 171 Vt. 290, 297, 762 A.2d 1259, 1264 (2000) (noting that “[m]ost courts have held that the right to self-representation must be invoked before trial to be considered timely per se”). If the party attempting to assert the right to self-representation raises the issue before trial, the invocation is timely per se. Id. The sole case that the State cites in support of its argument, In re A.B., 2013 VT 66, ¶¶ 9-11, 194 Vt. 279, 79 A.3d 42, involved an untimely effort to assert a right of selfrepresentation in a termination-of-parental-rights hearings. The mother whose rights were at issue attempted to dismiss her appointed counsel after the termination hearing had begun. Id. ¶ 12. The family court therefore appropriately considered “the potential for disruption and delay.” Id. ¶ 10. This Court, in affirming the family court on appeal, emphasized that the impact of delay is heightened in the juvenile context because the parent’s right to self-representation must be weighed against a child’s right to a prompt custody determination. Id. ¶ 11. The State’s reliance on In re A.B. is therefore misplaced for two reasons. First, G.G.’s attempt to assert a right to selfrepresentation was timely. Second, even if G.G.’s motion had been untimely, the risk of delay and prejudice on the facts of this case were not heightened, as the State claims. This is because although the involuntary medication order to which G.G. was subject expired on May 31, 2016, the medication was effective for two weeks after its administration. Thus, even if the family court had delayed the hearing by several days to permit G.G. to prepare, G.G. would not have necessarily been unmedicated.
In re E.T., 2004 VT 111, ¶ 7, 177 Vt. 405, 865 A.2d 416 (describing “the Vermont Constitution’s presumption that freedom from restraint is a fundamental, inalienable right”); see also Bell v.
Wayne Cty. Gen. Hosp., 384 F. Supp. 1085, 1093 (E.D. Mich. 1974) (“[W]e hold that a respondent has the right to legal counsel [in civil commitment proceedings] and, if indigent, to appointed counsel, to assist him [or her] at every step of the commitment proceedings; and further that he must be notified of this right at the outset of the proceedings.”).
¶ 11. “[O]nce it is determined due process applies, the question remains what process is due.” Morrissey v. Brewer, 408 U.S. 471, 481 (1972); see also Washington v. Harper, 494 U.S.
210, 228 (1990) (“Having determined that state law recognizes a liberty interest, also protected by the Due Process Clause, which permits refusal of antipsychotic drugs unless certain preconditions are met, we address next what procedural protections are necessary to ensure that the decision to medicate an inmate against his will is neither arbitrary nor erroneous. . . .”). Thus, to answer the question that is before this Court—whether a mental health patient has the right to waive representation in a proceeding that implicates due process—we must look to the three factors that guide any procedural due process inquiry: (i) the interests of the individual; (ii) the governmental interest affected; and (iii) the risk of erroneous deprivation of the individual’s interests if the right he or she asserts is not recognized, and the probable value, if any, of recognizing that right.
Mathews v. Eldridge, 424 U.S. 319, 335 (1976). We address each Mathews factor in turn.
834 (citation omitted), and protecting his desire “to affirm [his] dignity and autonomy,” McKaskle v. Wiggins, 465 U.S. 168, 176-77 (1984).
Edwards, 554 U.S. at 170-71 (quoting Faretta, 422 U.S. at 817-34) (final alteration in original).
Thus, while we recognize that the Fourteenth Amendment and not the Sixth Amendment governs the scope of G.G.’s rights because his case is a civil, not criminal, proceeding, the Faretta factors guide our understanding of the weight that ought to be afforded to G.G.’s interest in selfrepresentation in the context of an involuntary commitment or medication proceeding.
(finding no statutory right to proceed pro se), with In re D.Y., 95 A.3d 157, 169-71 (N.J. 2014) (interpreting state statute governing civil commitment proceedings as permitting selfrepresentation), and In re J.S., 159 P.3d 435, 440 (Wash. Ct. App. 2007) (finding right to selfrepresentation in civil commitment proceedings and applying “unequivocal, intelligent, and knowing” standard to waiver), and In re S.Y., 469 N.W.2d 836, 840 (Wis. 1991) (locating right to self-representation in state constitutional provision granting any citizen right to “prosecute or defend his suit either in his [or her] own proper person or by an attorney of the suitor’s choice”).
This fact is relevant because when the U.S. Supreme Court has looked to the underlying motivations for recognizing a right to counsel in other contexts, it has given weight to the existence of a state-level consensus in favor of recognizing such a right. See Faretta, 422 U.S. at 817 (quoting Justice Jackson for idea that “[t]he mere fact that a path is a beaten one is a persuasive reason for following it” (quoting R. Jackson, Full Faith and Credit—The Lawyer’s Clause of the Constitution, 45 Col. L. Rev. 1, 26 (1945)). The lack of a national consensus among state courts about recognizing a right to waive counsel in civil commitment and involuntary medication proceedings, thus, is an indication that recognizing a right to waive in those proceedings would not further the same fundamental interests as in the criminal context. See id.
Amendment, concluded that it “grants to the accused personally the right to make his defense” and “the right to self-representation—to make one’s own defense personally—is thus necessarily implied by the structure of the Amendment.” Id. at 819. However, the right to self-representation, even in a criminal trial, is not absolute: “the Constitution permits judges to take realistic account of the particular defendant’s mental capacities by asking whether a defendant who seeks to conduct his own defense at trial is mentally competent to do so.” Edwards, 554 U.S. at 177-78; see also State v. Burke, 2012 VT 50, ¶ 27, 192 Vt. 99, 54 A.3d 500 (discussing Edwards and Faretta). In reaching that conclusion, the Edwards Court gave particular weight to its view that “a right of selfrepresentation at trial will not ‘affirm the dignity’ of a defendant who lacks the mental capacity to conduct his defense without the assistance of counsel.” Edwards, 554 U.S. at 176 (quoting McKaskle, 465 U.S. at 176-77, for proposition that “ ‘[d]ignity’ and ‘autonomy’ of individual underlie self-representation right”). “To the contrary, given that defendant’s uncertain mental state, the spectacle that could well result from his self-representation at trial is at least as likely to prove humiliating as ennobling.” Id. Therefore, even in the criminal context, the Sixth Amendment right to counsel is not absolute, and the limitations that exist for a criminal defendant whose liberty is at stake carry an even greater weight for a mental health litigant like G.G. whose liberty and bodily integrity are at stake.
“flexible” and its overarching purpose is to ensure that there exists adequate process to protect substantive rights. See Morrissey, 408 U.S. at 481. Thus, as the U.S. Supreme Court has concluded, the Sixth Amendment’s focus on the rights of the specific individual to whom its protections extend supports the right to waive counsel when the Sixth Amendment is implicated.
See Faretta, 422 U.S. at 819. In contrast, the Due Process Clause’s broader concern for adequate procedure does not implicate the same dignity and autonomy considerations, and the interest that G.G. asserts when he seeks to dismiss his appointed attorney finds no support in the structure of the Due Process Clause.
¶ 17. Additionally, while it is true that a patient like G.G., who is the subject of an involuntary medication or commitment proceeding, retains an interest in preserving his or her dignity and autonomy, that interest is tempered by the fact that the patient’s competency has been called into question. As is true of a mentally ill criminal defendant, a mentally ill patient who engages in self-representation at a civil hearing runs the risk of undermining his or her dignity and autonomy by presenting the case ineffectively as a result of the underlying mental illness. See Edwards, 554 U.S. at 176 (citing American Psychiatric Association amicus brief filed in support of neither party in that case for proposition that “[d]isorganized thinking, deficits in sustaining attention and concentration, impaired expressive abilities, anxiety, and other common symptoms of severe mental illness can impair the defendant’s ability to play the significantly expanded role required for self-representation”). Thus, while we recognize that individuals like G.G. undoubtedly have an interest in affirming their dignity and autonomy by representing themselves, we also recognize that “given [their] uncertain mental state[s], the spectacle that could result from [their] self-representation [at the family court] is at least as likely to prove humiliating as ennobling.” Id. G.G.’s interest in self-representation in these mental-health proceedings, then, is a limited interest.
¶ 18. The State’s interests in precluding mental health patients from representing themselves in involuntary commitment and involuntary treatment proceedings are manifold. First and foremost, the State has an “a concomitant, constitutionally essential interest in assuring that the [patient’s hearing] is a fair one.” Sell v. United States, 539 U.S. 166, 180 (2003). This is especially true in the case of involuntary medication, where “ ‘[a] compelled surgical intrusion into an individual’s body . . . implicates expectations of privacy and security’ of great magnitude,” and where the patient “cannot undo [the] harm” of involuntary medication, even if he or she is adjudicated competent to refuse. Id. at 176-77 (quoting Winston v. Lee, 470 U.S. 753, 759 (1985)). The State has no recognized interest in injecting therapeutic medication into the bloodstream of a patient who is competent to refuse the medication, and the State’s interest in not allowing mental- health patients to proceed unrepresented flows directly from that fact: the State has a strong interest in not exercising the most profound governmental power—the power to invade the body of a citizen—when that exercise of power is unwarranted. See 18 V.S.A. § 7629(b) (explaining Legislature’s intention to enact involuntary medication laws in accordance with principle that involuntary medication “should be avoided whenever possible because the distress and insult to human dignity that results from compelling a person to participate in medical treatment against his or her will are real”); In re L.A., 2008 VT 5, ¶ 16, 183 Vt. 168, 945 A.2d 356 [hereinafter In re L.A. II] (“The Legislature expressed deep concern over coerced medication and wanted procedures in place to assure that it was done only when necessary.”); cf. Edwards, 554 U.S. at 176-77 (“Moreover, insofar as a defendant’s lack of capacity threatens an improper conviction or sentence, self-representation in that exceptional context undercuts the most basic of the Constitution’s criminal law objectives, providing a fair trial.”); In re Conservatorship of Joel E., 33 Cal. Rptr. 3d at 710 (“[A]ffording an individual the right of self-representation generally does little if anything to further the fairness or accuracy of the proceedings.”).
Judicial Court of Maine reasoned that the statute’s “explicit requirement” that mental-health patients be represented was “grounded on sound public policy.” Id. ¶ 10. Specifically, the court considered that “involuntary commitment hearings inevitably involve substantial questions regarding the mental status of the person who is the subject of the application” and selfrepresentation “runs the risk of giving those who may be incompetent the task of proving their own competence.” Id. We find the Maine court’s reasoning in the context of our constitutional analysis persuasive: when the Legislature has evinced an intention to make a statutory provision mandatory, and where that intention is grounded in sound public policy, the State has a strong interest in seeing the policy carried out.
¶ 20. The State also has an interest in avoiding outcomes in mental-health proceedings that undermine the integrity of the process. Specifically, self-representation in an involuntary medication or commitment hearing creates a circularity problem: a mental health patient who represents him or herself and who is adjudicated in need of commitment or medication would then be in a position to challenge the initial waiver of counsel as not knowing, intelligent or voluntary and thereby claiming a right to a new hearing with counsel. See, e.g., In re B.S., No. 32-2-06, Wymh, slip op., at 4 (Vt. Super. Ct. Mar. 27, 2006) (finding no right to self-representation and reasoning that “if [B.S.] proceeds pro se, [and] if he is subsequently found to be a person in need of treatment he will then have grounds for arguing that he could not waive counsel due to his mental state, thereby invalidating the court’s ruling and requiring a new hearing with counsel”); In re R.Z., 415 N.W.2d 486, 488 (N.D. 1987) (reversing commitment order and remanding to trial court for new competency hearing because patient alleged that initial waiver was not knowing and intelligent); In re Mental Commitment of Aaron J., No. 03-3349, 2004 WL 2249951, at *4 (Wis.
Ct. App. Oct. 7, 2004) (“Even if a subject gave the ‘right’ answers to the court’s questions during a colloquy, the subject could plausibly later maintain that he or she was not thinking clearly at the time. . . .”). The lack of finality that is threatened by a continuous review of a mental-health patient’s competency to waive counsel also implicates other government interests, including expedient resolution of cases of this nature, economic efficiency, and the maintenance of an effective and uninterrupted treatment plan for the patient. Thus, the State’s interest in requiring that patients like G.G. be represented by counsel is significant.
Mathews, 424 U.S. at 321. “Numerous courts have commented that, in most cases, the right of self-representation is the equivalent of a right to a poor defense.” In re Conservatorship of Joel E., 33 Cal. Rptr. 3d at 710 (citing Faretta, 422 U.S. at 834); see also Martinez, 528 U.S. at 161 (“No one, including Martinez and the Faretta majority, attempts to argue that as a rule pro se representation is wise, desirable, or efficient.”). This is because, as a rule, “it is reasonable to assume that counsel’s performance is more effective than what the unskilled [litigant] could have provided for himself [or herself].” Martinez, 528 U.S. at 161. As the California Supreme Court has noted, “[i]t is manifest” from the language of Faretta that the rule announced in that case was not intended “to enhance the reliability of the truth-determining or fact-finding process” and selfrepresentation “will most likely have the directly opposite effect.” People v. McDaniel, 545 P.2d 843, 849 (Cal. 1976). We agree. Rather than enhancing the fairness or accuracy of a proceeding, allowing a mental-health patient to represent him or herself runs the risk of undermining the accuracy of the proceeding. This factor, too, weighs against permitting self-representation in an involuntary commitment or medication hearing.
2008 VT 48, 184 Vt. 273, 959 A.2d 544, or In re L.G., No. 91-488, slip op. at 2 (Vt. Jan. 7, 1992) (unpub. mem.), those cases are overruled.
¶ 23. However, a patient who is the subject of one of these proceedings is not prevented from participating in preparing and presenting his or her case. First, Vermont Rule of Professional Conduct 1.14 provides that “[w]hen a client’s capacity to make adequately considered decisions in connection with a representation is diminished, whether because of minority, mental impairment or for some other reason, the lawyer shall, as far as reasonably possible, maintain a normal clientlawyer relationship with the client.” V.R.P.C. 1.14(a). Other rules of professional conduct in Vermont define the nature of “a normal client-lawyer relationship.” See V.R.P.C. 1.2 (“[A] lawyer shall abide by a client’s decisions concerning the objectives of representation and, as required by Rule 1.4, shall consult with the client as to the means by which they are to be pursued.”); V.R.P.C.
1.4(a) (“A lawyer shall . . . reasonably consult with the client about the means by which the client’s objectives are to be accomplished; keep the client reasonably informed about the status of the matter; [and] promptly comply with reasonable requests for information.”). We highlight these rules to emphasize that even when an attorney represents a client with diminished capacity, he or she has an ethical duty to “treat the client with attention and respect. Even if the person has a legal representative, the lawyer should as far as possible accord the represented person the status of client, particularly in maintaining communication.” See V.R.P.C. 1.14 cmt. 2.
¶ 24. Second, in Vermont the patient has a statutory right “to appear at the hearing to testify.” 18 V.S.A. § 7615(d); see also id. §§ 7621 (directing court to apply procedures set forth in §§ 7613-7616 in hearing for continued treatment), 7625 (directing court to apply procedures set forth in §§ 7613, 7614, 7616, and 7615(b)-(e) in hearing for involuntary medication). Even a patient who is incompetent may not, as a matter of Vermont law, be precluded from presenting the court with his or her perspective, from explaining why he or she should not be subjected to orders for treatment or involuntary medication, or from providing the court with any additional information that might aid in the resolution of the State’s application for an order.
¶ 25. Third, in recognition “that the right to speak for oneself entails more than the opportunity to add one’s voice to a cacophony of others,” we hold that a judge should allow additional participation by the patient when the court determines that it is appropriate under the circumstances. See McKaskle, 465 U.S. at 177. This may involve the kind of participation in which the court below permitted G.G. to be involved, including conducting limited crossexamination of witnesses and making closing objections or a closing statement. However, the judge must ensure an orderly and fair proceeding consistent with due process and the appropriate level of patient participation therefore depends on the circumstances of each case; there may be times where any level of participation would be disruptive to the integrity of the hearing process, and in those instances the judge may determine that no level of patient participation, beyond the opportunity to testify, is appropriate. Fundamentally, the level of patient participation allowed by the judge in any case must strike an appropriate balance between recognizing the patient’s significant dignity and autonomy interests, see id., at 176-77, and the State’s interest in ensuring the accuracy of the fact-finding process. See Sell, 539 U.S. at 180.
¶ 26. G.G. appeals the family court’s findings that he is in need of further treatment and that the State satisfied its burden for his continued hospitalization and involuntary medication. Specifically, G.G. challenges two aspects of the involuntary medication order. First, he argues that the State did not present sufficient evidence that he was refusing psychiatric medication, a prerequisite to the application of the involuntary medication statute. 18 V.S.A. § 7624(a). Second, he argues that the court applied an incorrect standard for competency and that under the correct standard, he was competent to make decisions about his course of treatment.
¶ 27. In judicial proceedings involving involuntary mental-health treatment and commitment, the State must prove its case by clear and convincing evidence. 18 V.S.A. § 7625(b).
“Clear and convincing evidence is a very demanding standard, requiring somewhat less than evidence beyond a reasonable doubt, but more than a preponderance of the evidence.” In re E.T., 2004 VT 111, ¶ 12, 177 Vt. 405, 865 A.2d 416. However, on appeal “our review of the family court’s decision is deferential” and is “based on all the evidence presented at the hearing.” In re M.C., 2005 VT 60, ¶ 4, 178 Vt. 585, 878 A.2d 284 (mem.). “The test on review is not whether this Court is persuaded that there was clear and convincing evidence, but whether the factfinder could reasonably have concluded that the required factual predicate was highly probable.” In re N.H., 168 Vt. 508, 512-13, 724 A.2d 467, 470 (1998).
¶ 28. A “patient in need of further treatment” is defined in 18 V.S.A. § 7101(16) as either “a person in need of treatment” or as “a patient who is receiving adequate treatment, and who, if such treatment is discontinued, presents a substantial probability that in the near future his or her condition will deteriorate and he or she will become a person in need of treatment.” “A person in need of treatment,” in turn, is defined in 18 V.S.A. § 7101(17) as “a person who has a mental illness and, as a result of that mental illness, his or her capacity to exercise self-control, judgment, or discretion in the conduct of his or her affairs and social relations is so lessened that he or she poses a danger of harm to himself, to herself, or to others.” The State may show a “danger of harm to others” by establishing that the individual at issue “has inflicted or attempted to inflict bodily harm on another” or that by his or her “threats or actions he or she has placed others in reasonable fear of physical harm to themselves.” Id. § 7101(17)(A)(i), (ii). The State may show a “danger of harm to himself or herself” by establishing that the individual at issue “is unable, without supervision and the assistance of others, to satisfy his or her need for nourishment, personal or medical care, shelter or self-protection and safety,” to an extent that “death, substantial physical bodily injury, serious mental deterioration, or serious physical debilitation or disease will ensue unless adequate treatment is afforded.” Id. § 7101(17)(B)(ii). The court’s inquiry into dangerousness need not be focused purely on present danger; the statutory scheme recognizes that with effective treatment a patient may not be currently dangerous and thus focuses on “predictions about the effect of discontinuing treatment, rather than dangerousness.” In re P.S., 167 Vt. 63, 71, 702 A.2d 98, 103 (1997). Upon making a determination that a patient is in need of further treatment, the court may enter an involuntary treatment order only after examining appropriate alternatives “to ensure that the patient receives treatment in the least restrictive manner.” In re R.L., 163 Vt. 168, 172-73, 657 A.2d 180, 183-84, (1995) (citing 18 V.S.A. § 7617(c)).
¶ 29. Here, the State presented sufficient evidence for the trial court to conclude that G.G.
¶ 30. With respect to the danger that G.G. poses to himself, the court credited Dr.
Richards’s testimony that G.G. was presently refusing to take Proxlin and found that it was “likely” that, if released, he would discontinue his course of medication, that his condition would deteriorate, and that he would become a danger to himself “in short order.” As an example of how he might become a danger to himself, the court described an incident in which G.G., prior to his admission at the VPCH, suffered a catatonic episode that left him with hypothermia as a result of exposure to the elements. Dr. Richards testified that catatonia “can be life-threatening in and of itself when not treated” and that in her opinion, “[G.G.’s] life is at risk” if he is not medicated.
¶ 31. Although G.G. disputes that he has a mental illness, there is sufficient evidence in the record to support the court’s conclusion that G.G. suffers from schizophrenia. Specifically, the court had before it evidence that G.G. has had at least fifteen hospitalizations since March 2006, that prior to his current hospitalization he was diagnosed with childhood-onset schizophrenia, and that he ended up in the VPCH because of dangerous and violent behavior that required his admission to the emergency room. Dr. Richards testified at the hearing that she had been G.G.’s treating psychiatrist since his admission at the VPCH in September 2015, and she explained that she has been meeting with G.G. on a regular basis since that time, that she is familiar with G.G.’s medical history, and that she has consulted with multiple colleagues in the medical profession, outpatient providers, and G.G.’s family members regarding his illness. Dr. Richards’s medical opinion, to a reasonable degree of certainty, was that “G.G. has schizophrenia.” She explained that she had never “met anyone with such a rigid perspective before,” described how when G.G. arrived at the hospital his “ability to function” was severely impaired, and testified to her opinion that G.G. suffered from auditory hallucinations. Thus, given that there was ample evidence that G.G. suffered a mental illness, the question before this Court is whether the family court could reasonably have concluded that, “as a result of that mental illness,” it was highly probable that his “capacity to exercise self-control, judgment, or discretion in the conduct of his . . . affairs and social relations is so lessened that he . . . poses a danger of harm to himself . . . or to others.” 18 V.S.A. § 7101(17).
in need of further treatment.
¶ 33. Additionally, the court considered a less restrictive alternative placement for G.G.
at the Middlesex Therapeutic Community Residence, but it found—based on Dr. Richards’s testimony at the hearing—that “[G.G.] does not wish to go there” and concluded that “[t]he VPCH provides appropriate services to treat [G.G.]’s condition. It can ensure that [he] is offered treatment in a safe environment and that he has ready access to necessary support services. The hospital can offer him medications, group and individual counselling, and activities, all in a secure environment.” Additionally, the court credited Dr. Richards’s opinion that “there is no less restrictive alternative to hospitalization.” Based on the evidence in the record, we cannot conclude that the court erred in determining that there was no alternative, less restrictive placement for G.G. other than at the VPCH. See In re R.L., 163 Vt. at 173, 657 A.2d at 183-84. Accordingly, we affirm the trial court’s decision to grant the State’s application for a year-long hospitalization order.
¶ 34. Under 18 V.S.A. § 7624(b)(1), the State may file a petition with the family court for the involuntary medication of a patient who refuses to accept medication if the patient is, among other things, subject to an order of hospitalization pursuant to 18 V.S.A. § 7619. In a hearing in which the State seeks to involuntarily medicate a patient subject to an order of hospitalization, the State bears the burden of proving by clear and convincing evidence that: (1) the patient is refusing medication; (2) the patient is not competent to refuse; and (3) based on the factors outlined in § 7627(c), involuntary medication is warranted. See In re L.A., 2006 VT 118, ¶¶ 8, 11, 181 Vt. 34, 912 A.2d 977 [hereinafter In re L.A. I].
¶ 35. As a threshold matter, G.G. argues that there was insufficient evidence to support the court’s finding that he was currently refusing medication. The involuntary medication statute provides that the State may seek to involuntarily medicate a patient who is the subject of a hospitalization order only if the patient “is refusing to accept psychiatric medication.” 18 V.S.A.
We review the court’s factual finding that G.G. was refusing medication by asking whether there was sufficient evidence for the factfinder to have reasonably concluded, with a high probability, that G.G. was refusing medication. See In re N.H., 168 Vt. at 512-13, 724 A.2d at 470.
¶ 36. The evidence adduced at the hearing included the following. Dr. Richards testified that “G.G. has been very clear from before the first court order that he does not believe in taking [an antipsychotic]” and that he had never “expressed any kind of willingness to take the medication” she prescribed him. When the State’s counsel asked Dr. Richards whether she had asked G.G. directly if he would take Prolixin in the hospital, she testified that she did not need to because “it’s been so clear . . . that he does not want to take it, . . . [s]o, I guess I haven’t thought to go ahead and say, what about tomorrow.” Dr. Richards testified that the hospital had shifted to intravenous medication because G.G. had a history of “not taking medications and then storing them and then overdosing even in the hospital on those medications.” She described an incident after the hospital began administering intravenous medication to G.G. in which he “squeezed his arm so hard that the nurse was unable to administer the shot effectively.” And although Dr.
Court, he explained that the “episode of violence” in which he admitted to slapping a nurse was triggered by her “making very real threats” to administer “continued amounts of a horrid medication” and denied that he supports his attorney’s argument that he is not refusing medication.
¶ 37. Thus, although G.G. is correct that the involuntary medication statute requires that a patient “be refusing psychiatric medication” and G.G. is also correct that we must read the statute in light of the Legislature’s express intent “to work towards a mental health system that does not require coercion or the use of involuntary medication,” 18 V.S.A. § 7629(c), that does not equate to a requirement that the State obtain an express intention to presently refuse medication each time the medication is administered. The standard that the family court must apply is clear and convincing evidence, and circumstantial evidence of refusal is adequate evidence in involuntary medication hearings. That is not to suggest, however, that a past refusal, without more, is always sufficient to establish present refusal; prior to ordering involuntary medication, the court must still satisfy itself to a high degree of probability that the patient is presently refusing to take the medication. See In re N.H., 168 Vt. at 512-13, 724 A.2d at 470. As the court below observed, “it would have been advisable” for Dr. Richards or for the State’s attorney to ask G.G. “the direct question, either before or during the hearing,” and we agree that it is better practice in involuntary medication hearings to directly ask the patient, in reasonable proximity to the hearing, if he or she is refusing medication. However, we agree with the court that the State’s failure to ask the “direct question” is not fatal to its request for involuntary treatment because there was ample circumstantial evidence adduced at the hearing by which the court below could have reasonably concluded, with a high degree of probability, that G.G. was presently refusing Prolixin.
as is generally expected of medication—cannot be enough to conclude that the patient is incompetent.” Id. ¶ 12. “As long as [a] patient can understand the consequences of refusing medication, the statute permits him [or her] to do so, even if refusing medication will be to his [or her] detriment.” Id.
(emphasis added)). The court found that G.G. was “unable to balance the need for medication against the possible risks” and that his “condition causes a distorted view of reality that skews his perception as to his condition and the need for appropriate medication.” In particular, the court found that G.G. does not understand the consequences of not being medicated with Prolixin: (1) he does not believe that he should take antipsychotic medication because he claims that “[t]here is no evidence provided that [he] exhibited a mental illness”; (2) he denies that prior to being medicated with Prolixin he suffered from malignant catatonia and developed hypothermia as a result; (3) he does not acknowledge that prior to taking Prolixin he was “essentially mute, with very poor hygiene, no eye contact, withdrawn and unable to communicate effectively with others in any meaningful way,” and instead claims that “I think I would have remembered this if it occurred”; and (4) he has no capacity to recognize that his current and past hospitalizations have been the result of his mental illness nor that when he is “having a psychotic episode . . . he’s not able to process his own safety.” The court concluded that G.G.’s insistence that he is not ill is a product of his mental illness and reasoned that his inability to recognize and appreciate the danger that his symptoms present rendered him incompetent to make a reasoned decision about whether Prolixin is a reasonable form of treatment for his illness. See In re I.G., 2016 VT 95, ¶ 14.
re L.A. I, 2006 VT 181, ¶ 12.
¶ 42. Finally, G.G. argues that the merits of the involuntary medication issue, guided by the statutory factors outlined in § 7627, weigh against involuntary medication. Specifically, G.G. contends that “[t]here is not sufficient evidence” to sustain the trial court’s finding that he is in need of medication. Again, we apply the familiar standard in reviewing the court’s findings: was there sufficient evidence for the factfinder to have reasonably concluded, with a high probability and given its consideration of the statutory factors, that medication was warranted for G.G. See In re N.H., 168 Vt. at 512-13, 724 A.2d at 470.
¶ 43. Section 7627 of the involuntary medication statute directs the court to consider at a minimum, the following seven factors: (1) the patient’s competently expressed preferences, 18 V.S.A. § 7627(b) and (d); (2) the patient’s religious convictions, id. § 7627(c)(1); (3) the impact of medication or nonmedication on the patient’s relationships with his or her family or household members, id. § 7627(c)(2); (4) the “likelihood and severity of possible adverse side effects from the proposed medication,” id. § 7267(c)(3); (5) the risks and benefits of the proposed medication and its effect on the patient’s prognosis and his or her health and safety, id. § 7267(c)(4); (6) available alternative treatment, id. § 7627(c)(5); and (7) the need, if any, for long-acting medication, id. § 7627(f)(1). We address the court’s findings on each of these factors in turn.
Prolixin. The court’s findings on this factor were based on its conclusion, described above, that G.G. was not competent to make decisions about his own medication, and we affirm that conclusion. Next, the trial court found that G.G.’s aversion to Prolixin is not based on a religious preference and that there was no significant record evidence of any effects of medication or nonmedication on G.G.’s family or household members.
¶ 45. The court then considered the side effects, risks and benefits of Prolixin, and the availability of alternative treatment, again based on Dr. Richards’s testimony at the hearing. The court fully credited Dr. Richards’s testimony on these points, and because “[w]e rely on the factfinder’s assessment of the credibility of the witnesses and weighing of the evidence” it is therefore not for this Court to reassess Dr. Richards’s credibility. See In re N.H., 168 Vt. at 512, 724 A.2d at 470. The relevant findings include that: (1) G.G. “has and will continue to benefit greatly from administration of Prolixin”; (2) “he has made significant improvements since the hospital began to give him Prolixin”; (3) on Prolixin G.G.’s “symptoms may be managed and he may be able to return to the community in a supervised setting”; (4) “the VPCH is well aware of the potential side effects” of Prolixin; (5) as of the time of the hearing there was no “evidence of any side effects on [G.G.]”; (6) “Prolixin has been the cause of [G.G.]’s improved mental condition” and without Prolixin, “[G.G.]’s condition is likely to decline; and (7) “alternative drugs that [G.G.] has preferred in the past had not been effective in treating his condition and had resulted in his present hospitalization.” These findings were sufficient for a reasonable factfinder to conclude, by clear and convincing evidence, that the benefits of Prolixin for G.G. outweigh the risks and that there is no alternative available treatment. See id.
¶ 46. Finally, the court considered the need for long-acting medication and found that “a long-acting form of Prolixin is warranted in [G.G.]’s case.” In making that finding, the court credited Dr. Richards’s testimony that G.G. “does not wish to take [Prolixin]” and that “[w]hen daily oral doses were employed, most administrations of the drug resulted in conflicts between staff and [G.G.]” that “caused stress and anxiety for [G.G.] and for staff.” The court found, based on Dr. Richards’s testimony, that the stress associated with forcibly administering daily oral doses of Prolixin “adversely impacted [G.G.’s] condition,” but that G.G. “has made significant progress on the long-acting form of Prolixin.” These findings, too, were sufficient for a reasonable factfinder to conclude, by clear and convincing evidence, that for G.G., a long-acting form of Prolixin was necessary. See id.
¶ 47. We hold that the court had before it sufficient evidence from which to conclude that G.G. was refusing medication, that he was not competent to refuse his medication, and that the prescribed medication—long-lasting Prolixin—was warranted for G.G. Additionally, we hold that the court did not apply the wrong standard in evaluating G.G.’s competence to refuse medication.
Accordingly, we affirm the court’s grant of the State’s application for continued treatment and involuntary medication.
 The March 4, 2016 involuntary medication order gave the State leave to inject G.G. with 12.5 mg of Prolixin every two weeks. G.G. does not appeal the decision to increase the dosage, and we do not address the basis for that decision here.
 Since Faretta, when the U.S. Supreme Court has considered whether a right to selfrepresentation exists, it has looked to the Faretta factors for guidance. See, e.g., Martinez v. Ct. of App. of Cal., 528 U.S. 152, 164 (2000) (applying Faretta to appellate self-representation and concluding that there is no right to self-representation on appeal).
 The Sixth Amendment provides, in relevant part: “In all criminal prosecutions, the accused shall . . . have the Assistance of Counsel for his defence.” U.S. Const. amend. VI (emphasis added).
 Article 10 of the Vermont Constitution states: “nor can any person be justly deprived of his liberty, except by the laws of the land, or the judgment of his peers.” Vt. Const. ch. I, art. 10. This Court has interpreted that language as being “synonymous with ‘due process of law.’ ” State v. Messier, 145 Vt. 622, 627, 497 A.2d 740, 743 (1985).
 The statutes that control involuntary medication and treatment proceedings apply only to patients who have already been examined by a licensed physician and have been found to be in need of treatment. 18 V.S.A. §§ 7612(e) (involuntary treatment), 7624(c) (involuntary medication). The statute defines “a person in need of treatment” as an individual with a mental illness and who, “as a result of that mental illness,” has such a limited “capacity to exercise selfcontrol, judgment, or discretion in the conduct of his or her affairs and social relations” that “he or she poses a danger of harm to himself, to herself, or to others.” Id. § 7101(17). By law, then, any individual who is the subject of mental-health proceedings like those at issue in this case— concerning continued treatment and involuntary medication—has already been determined by a licensed physician to have a mental illness that severely impacts his or her self-control, judgment, or discretion. Id. Thus, although we limit this decision to the proceedings that are at issue here, we note that the process required in these proceedings may extend to other mental-health proceedings that require a preliminary finding of mental illness by a licensed physician.
 G.G., not his appointed counsel, raised this argument in his briefs to this Court. As discussed above, supra, note 2, we reach this issue because G.G. was permitted to participate alongside his attorney before this Court.
 Again, G.G., not his appointed counsel, raised this argument. See supra, note 2.

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