Opinion ID: 2336032
Heading Depth: 3
Heading Rank: 2

Heading: Merits of Joan's Appeal

Text: To involuntarily commit someone to a treatment facility for up to 30 days, a court must first find, by clear and convincing evidence, that the person is mentally ill and as a result is likely to cause harm to [self] or others or is gravely disabled. [19] Although the statute does not define harm, we have found AS 47.30.915(10) relevant, [20] defining likely to cause serious harm as when a person: (A) poses a substantial risk of bodily harm to that person's self, as manifested by recent behavior causing, attempting, or threatening that harm; (B) poses a substantial risk of harm to others as manifested by recent behavior causing, attempting, or threatening harm, and is likely in the near future to cause physical injury, physical abuse, or substantial property damage to another person; or (C) manifests a current intent to carry out plans of serious harm to that person's self or another[.] The court must also consider whether a less restrictive alternative would provide adequate treatment. [21] Alaska Statute 47.30.915(9) defines least restrictive alternative as treatment conditions that: (A) are no more harsh, hazardous, or intrusive than necessary to achieve the treatment objectives of the patient; and (B) involve no restrictions on physical movement nor supervised residence or inpatient care except as reasonably necessary for the administration of treatment or the protection of the patient or others from physical injury[.] As discussed below, we affirm the superior court's findings by clear and convincing evidence that Joan suffered from a mental illness and that as a result she posed a substantial risk of bodily harm to herself under AS 47.30.915(10)(A). [22] We therefore do not need to discuss the evidence or the superior court's finding that Joan posed a substantial risk of harm to others.
Dr. Bell testified Joan suffered from bipolar disorder, a serious mental illness which caused Joan to suffer mixed emotional states with manic elements, depressed elements, and psychotic manifestations. Joan told Dr. Bell that she could sense other people's feelings, that Fairbanks was the center of the galaxy and the separation point between heaven and hell, and that she was responsible for maintaining the balance between heaven and hell. Joan also told him he was prescribing the wrong medicines because she needed amphetamines and OxyContin to deal with the stress of sensing others' thoughts. Dr. Bell was unable to determine whether Joan had organic brain damage because her manic bipolar disorder symptoms prevented a complete examination. Dr. Bell thought Joan had been abusing drugs for the three weeks she disappeared because her admission drug screens were positive for amphetamines and cocaine and because she appeared to be in a state of lethargy or torpor, which typically follows prolonged stimulant abuse. Dr. Bell was primarily concerned Joan would harm herself by further illegal drug use. He thought Joan would use drugs if she left the hospital because she believed she needed amphetamines and OxyContin to manage the stress associated with her delusions. Dr. Bell testified that using illegal substances in Joan's mental state would make her thought process so completely disorganized that she would not know what she was doing. Using drugs would also cause further de-stabilization of [Joan's] mental and mood state, which would aggravate her ability to conform ... to reasonably safe behaviors. Dr. Bell testified there was not a less restrictive facility than API that could meet Joan's needs. He testified Joan needed a very secure mental health unit that would very closely control[] her and provide a lot of emotional support, with careful control of her sleep pattern and regular appetite. Dr. Bell thought Joan would need a long period of treatment, though it could be concluded within 30 days were she to accept medication reliably and begin to understand how drugs and alcohol impact on the exacerbation of her mental illness. Dr. Parker testified he had not personally diagnosed Joan, but her records indicated she had bipolar disorder and a history of attention deficit hyperactivity disorder, polysubstance abuse, and alcohol abuse. In Dr. Parker's opinion, Joan was at risk of causing herself bodily harm through drug use if she were not committed. He said Joan's mental stability can change very rapidly due to her bipolar disorder. He also noted she had disappeared for three weeks and used drugs prior to her hospital admission. Dr. Parker testified Joan locked herself in a bathroom and threatened to blow herself up in November 2009. When the superior court asked what danger, if any, illegal drug use posed for Joan, Dr. Parker replied it would not be good for the system and was self-destructive, but he could not say it posed imminent danger. Dr. Parker acknowledged Joan had not expressed suicidal ideations after her February hospital admittance, nor did she directly indicate any intent to harm herself or others. Like Dr. Bell, Dr. Parker testified there was not a less restrictive facility than API that could meet Joan's needs. Dr. Parker thought Joan needed to come out of her current manic episode and return to her baseline before release, otherwise she would continue her uncontrolled manic behavior and substance abuse. Dr. Parker noted that the day before the hearing nurses had to medicate Joan after an incident at the nurses' station. He also thought outpatient treatment was not a viable option for Joan because outpatient psychiatry or psychology requires patients to have some kind of insight on their behavior and some ... sort of consistency of behavior. Joan had denied to him that she had any mental illness or needed treatment; due to her lack of insight, Dr. Parker thought it very unlikely Joan would follow through with outpatient treatment even if she said she would. Dr. Parker also testified that for a family wrap-around plan or 24-hour surveillance by a family member to work Joan would have to agree, and Joan changed her mind too frequently for such plans.
Joan does not contest the superior court's finding of a mental illness. Joan instead contends the superior court erred by finding that due to her mental illness she was likely to cause harm to herself, arguing: (1) there was no evidence illegal drug use physically harmed her and she did not make affirmative statements that she would use illegal drugs if released; and (2) she did not manifest a current intent to carry out a plan to seriously harm herself. [23] We decided a similar issue in E.P. v. Alaska Psychiatric Institute. [24] E.P. had a history of inhaling gasoline fumes and other substances to get high (huffing), [25] which caused organic brain damage. [26] He was involuntarily committed to API several times and maintained that, if discharged from API, he [would] likely go back to huffing. [27] We held E.P.'s organic brain damage was a condition apart from, and more than, his drug addiction and met the statutory definition of mental illness under AS 47.30.915(12). [28] We also held the evidence supported the multiple masters' reports and superior court orders, which found huffing gas damaged E.P.'s brain and E.P. would continue huffing gas if released. [29] Thus E.P.'s continued intent to huff gas, as a result of his impaired judgment and understanding, [met] the standards of AS 47.30.915(10)(A) and (C). [30] E.P.'s intent to huff gas constitute[d] intent to cause himself bodily harm, and ... result[ed] from his mental illness. [31] Here, the superior court expressly stated it was not finding Joan was likely to harm herself based on drug addiction alone. The superior court noted E.P., and, as we did in E.P., distinguished Joan's case from one in which an addicted person with full mental capacity chooses to continue abusing harmful substances, no matter how unwise one might consider that choice. [32] The superior court stated: I find that [Joan] is suffering from a mental illness. She has bipolar disorder, which according to Dr. Bell's testimony, renders her unable to perceive reality. Her bipolar disorder is manifesting itself in psychosis right now. She is feeling that she is experiencing the feelings of other people, both close and far away, that Fairbanks is at the center point between heaven and hell and that she is responsible for maintaining balance between heaven and hell and keeping the universe centered. She has advised Dr. Bell that she believes that she must take [amphetamines] and oxycontin to manage the stresses that are caused by her current situation; that is, by the fact that she is responsible for balancing the equal point between heaven and hell. ... [Joan] is not being detained because she is a drug addict. She is taking drugs because of her perception of reality caused by her bipolar disorder and ... she's being detained because her mental illness is causing her to take the drugs. The superior court's finding is amply supported by Dr. Bell's testimony. The superior court also heard evidence that illegal drug use would pose a substantial risk of bodily harm to Joan by exacerbating her mental illness. [33] Dr. Bell testified if Joan used illegal drugs in her current mental state, her thought process would get so completely disorganized that she would not know what she was doing. Illegal drug use would also cause further de-stabilization of [Joan's] mental and mood state, which would aggravate her ability to conform ... to reasonably safe behaviors. In short, Dr. Bell's testimony supported the conclusion that Joan's continued illegal drug use would exacerbate her mental illness and cause a self-destructive downward spiral of her mental and physical health. Finally, the superior court heard evidence regarding Joan's recent behavior causing, attempting, or threatening harm to herself by illegal drug use. [34] Although Dr. Bell and Dr. Parker both acknowledged Joan neither articulated a desire to harm herself nor did so beyond using illegal drugs, both thought she would continue using illegal drugs if she were not committed. Joan's emergency room toxicology report showed traces of amphetamines and cocaine in her system. Dr. Bell testified Joan showed symptoms of lethargy or torpor that follow stimulant abuse. Dr. Bell also testified Joan showed symptoms of opioid withdrawal. The plain text of AS 47.30.915(10)(A) directs courts to consider recent behavior and does not, as Joan argues, require affirmative statements regarding future drug use. [35] Even if affirmative statements were required, Joan told Dr. Bell he was prescribing the wrong medicines because she needed amphetamines and OxyContin. [36] This is sufficient to support the superior court's finding that Joan was likely to continue using illegal drugs if released. Based on these findings, the superior court did not err by finding clear and convincing evidence that, under AS 47.30.735 and AS 47.30.915(10)(A), Joan was likely to cause harm to herself due to her mental illness.
An important principle of civil commitment in Alaska is to treat persons in the least restrictive alternative environment consistent with their treatment needs. [37] Joan argues the superior court erred in finding commitment to API would be the least restrictive alternative placement. Joan also contends no testimony supported a finding that she refused outpatient treatment or a home placement, particularly in light of Dr. Bell's and Dr. Parker's decisions not to contact her family or prior psychiatrist to ask about Joan's potential success in such alternative settings. Joan's second argument reflects a misunderstanding of the superior court's findingsthe court found outpatient treatment was not a viable option, and therefore the lack of evidence that Joan refused voluntary outpatient treatment is irrelevant. The superior court found there was [n]o less restrictive facility [that] would adequately protect [Joan] and the public. The court explained: API is an appropriate treatment facility, that there is no less restrictive facility that would adequately protect the respondent and the public at this time. The reason for that finding is Dr. Parker's testimony that in order for a family wraparound to work or 24-hour surveillance by a family to work, she would have to agree to it and he has witnessed her changing her mind rapidly about what she will do and what she will not do. So, I can't trust that committing her to her family's care would be a less restrictive alternative that would likely work for her. The record supports the superior court's finding. First, Dr. Bell and Dr. Parker both testified there was no less restrictive facility than API that could meet Joan's needs. Dr. Bell testified Joan needed a very secure mental health unit that would very closely control[] her and provide a lot of emotional support, with careful control of her sleep pattern and regular appetite. Dr. Bell thought Joan need[ed] a long period of treatment, though it could be concluded within 30 days were she to accept medication reliably and begin to understand how drugs and alcohol impact on the exacerbation of her mental illness. Dr. Parker testified Joan needed to come out of her current manic episode and return to her baseline before being released, otherwise she would continue her uncontrolled manic behavior and substance abuse. Second, Dr. Parker testified outpatient psychiatry or psychology require a patient stable enough to have insight into one's behavior and some sort of consistency of behavior. Joan was not stable because she had changeable emotions and could change her mind from one minute to the next. Joan also lacked perspective regarding her bipolar disorder, denying she had any mental illness or needed treatment. Because of Joan's lack of insight, Dr. Parker thought it very unlikely she would follow through with outpatient treatment even if she said she would. The superior court did not err by finding API was the least restrictive placement.