Court Opinion

ID: 6800833
Source: CourtListenerOpinion
Date Created: 2022-07-22 17:02:56.683969+00
Date Added: 2024-06-11T16:03:13.530906
License: Public Domain

Notice: This opinion is subject to correction before publication in the PACIFIC REPORTER.
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                THE SUPREME COURT OF THE STATE OF ALASKA

In the Matter of the Necessity                       )
for the Hospitalization of                           )   Supreme Court No. S-17810
                                                     )
JONAS H.,                                            )   Superior Court No. 3AN-20-00831 PR
                                                     )
                                                     )   OPINION
                                                     )
                                                     )   No. 7607 – July 22, 2022

               Appeal from the Superior Court of the State of Alaska, Third
               Judicial District, Anchorage, Herman G. Walker, Jr., Judge.

               Appearances: George W. P. Madeira, Jr., Assistant Public
               Defender, and Samantha Cherot, Public Defender,
               Anchorage, for Jonas H. Anna Jay, Assistant Attorney
               General, Anchorage, and Treg R. Taylor, Attorney General,
               Juneau, for State of Alaska.

               Before: Winfree, Chief Justice, Maassen, Carney, and
               Henderson, Justices. [Borghesan, Justice, not participating.]

               CARNEY, Justice.

I.     INTRODUCTION
               A man appeals superior court orders authorizing his involuntary
commitment for mental health treatment and the involuntary administration of
psychotropic medication, asking us to vacate both orders. He argues that the superior
court relied on erroneous facts to find that he was gravely disabled and that the court did
not adequately consider the constitutional standards established in Myers v. Alaska
Psychiatric Institute before authorizing medication.1 Because the evidence supports the
court’s finding that the man was gravely disabled, we affirm the commitment order. But
we vacate the medication order because the court’s analysis of the Myers factors was not
sufficient.
II.    FACTS AND PROCEEDINGS
       A.     Facts
              In April 2020, Jonas’s2 mother petitioned the superior court to order her son
hospitalized for evaluation of his mental health. She wrote in the petition that he had
been diagnosed with schizophrenia in 2002 and that his illness had been successfully
controlled by medication until he stopped taking it in 2015. Jonas’s mother asserted that
he “ha[d] progressively gotten worse” and was “[u]nable to take care of his basic needs.”
The superior court granted the petition the next day, and Jonas was transported to the
Alaska Psychiatric Institute (API) for evaluation. A few days later, API filed petitions
requesting an order to commit Jonas to API for 30 days and an order authorizing API to
involuntarily administer psychotropic medication to Jonas.
       B.     Proceedings
              In early May, a superior court master held two separate hearings to address
the commitment and medication petitions. The court first addressed the commitment
petition. Jonas’s mother testified about his deteriorating condition. She testified that
Jonas’s behavior had become “much more erratic” in the past year, he had threatened his
father with a knife, and he had started sending her alarming emails. While she once had
contact with Jonas every other week, he had largely stopped communicating with her,
and she had become afraid to go to his apartment. On the day she filed the petition, she

       1
              138 P.3d 238 (Alaska 2006).
       2
              We use a pseudonym to protect Jonas’s privacy.

                                           -2­                                       7607
went to his apartment with two police officers, but Jonas did not answer the door. She
said she went inside the apartment because she “was afraid that he had killed himself.”
She testified she was “shocked” because there were “[h]oles in every door[,] . . . holes
punched in every wall, [and] garbage everywhere,” as well as signs that Jonas had lit
fires inside the apartment.
              Jonas’s mother also testified that she and other family members did not feel
safe around Jonas. In response to questioning, she explained that she deposited money
into Jonas’s account every month and paid for his apartment but that she would not lease
a different apartment for Jonas because she was afraid of the damage he would do. She
stated that she did not believe Jonas could provide food or housing for himself if she did
not help him, that he had a car but he would not use it, and he had taken apart his cell
phone. And she was not aware of any friends and family who would be willing to help
him.
              The State then called Jonas’s treatment provider from API. She testified
that Jonas had one prior admission to API and had been diagnosed with schizoaffective
disorder, bipolar type. She testified Jonas was “acutely psychotic,” “exhibit[ed] manic
symptoms,” and had “delusion[s]” such as “believing he [was] God” and “that [his] food
[was] drugged.” The treatment provider testified that “the severity of his delusions”
would “affect his ability to care for himself” and that because he had “no insight into his
mental illness . . . he probably [wouldn’t] be able to . . . find help if he need[ed] it.” She
stated that Jonas’s mental illness would interfere with his ability to keep himself safe if
he were released. Jonas interrupted her testimony, asserting, “I actually am the Lord.
I actually am God. I have to deal with a lot . . . . But it doesn’t mean that it’s a disorder.
A lot of people have intense spiritual lives.”
              The provider testified that Jonas told her he wanted a new apartment
because the current one was “cursed.” She had been unable to discuss the process for

                                             -3-                                        7607
obtaining a new apartment with Jonas because “usually[] the conversation [went] into
a tangent about religion.” She acknowledged that at API Jonas had been eating all of his
meals, had not acted in a violent or unsafe manner, and had been having appropriate
interactions with his peers. But she believed he was doing well because API provided
his food and prompted him to eat, shower, and socialize. She believed that his condition
could improve if he stayed at API and took his medications.
               When asked where he would go if he were released from API, Jonas
testified:
               I would . . . go to my address to gather my things. And then
               I would sort it out from there. I’m not too worried about such
               things actually. I know there’s a shelter. I’ve actually stayed
               at the shelter a few nights before when I got locked out of my
               house . . . .
He also testified that he was “not worried about walking overnight” and could buy
groceries at a gas station.
               Jonas testified that his mother had not provided him enough money to live
on and that she was cruel to him. He also declared that he “would definitely leave” his
apartment because it was cursed and “the curse is tied to the premise[s].” He stated he
was getting “a lot more rest” at API “because the house is cursed.” When asked what
he would do if released, he responded, “I cannot predict the future like this. You’re
asking me to do something that I’m incapable of doing at this time. I think it’s
ridiculous.”
               The master made findings on the record. The master found that Jonas’s
mother had testified she could not provide him an apartment any longer, “especially
given the condition that the last apartment was left in.” And the master found that Jonas
was “very intelligent and very articulate” but had been so focused on “curses and
religion,” he was not able to discuss “basic discharge planning . . . even when it was

                                            -4-                                    7607
rephrased in a very simple fashion.” The master concluded that Jonas was mentally ill
and gravely disabled, and recommended granting the commitment petition.
              The master held a hearing on the medication petition the following day.
The court visitor3 testified that Jonas was “oriented in all spheres” but that Jonas denied
having a mental illness and believed instead that he was “being spiritually attacked.” She
testified that Jonas had both reasonable and unreasonable objections to medication.
Jonas told the visitor that the medication was unhelpful and caused several negative side
effects, which the court visitor believed were reasonable objections. But she also stated
Jonas had unreasonable objections that the medications made him feel he was “about
to . . . enter into death” and left him “spiritually threatened”; he also believed that the
doctors were “trying to overprescribe him.” The court visitor testified that Jonas
“exhibited pressured speech,” an irrational thought process, and a concern that “people
[were] trying to harm him through the administration of medication.” The court visitor
also testified that Jonas’s mother had said while Jonas was living with her, he recognized
he needed treatment and had been taking Seroquel. But his mother told her that after he
moved out he had stopped taking medication and decompensated. She concluded that
Jonas did not have the capacity to give informed consent.
              Jonas’s treatment provider again testified. She clarified that although the
medication petition contained multiple medications, she would prescribe only one mood
stabilizer and one antipsychotic medication at a time. She explained the medications and
dosages and how possible side effects would be treated. She testified that she had not
been able to have a reasonable conversation with Jonas because he claimed to have “been
on all of these medications before” but was “very nonspecific about what he’s taken,

       3
            The court must appoint an independent visitor to investigate whether the
respondent to an involuntary medication petition has capacity to give or withhold
informed consent to administration of medication. AS 47.30.839(d).

                                            -5-                                      7607
what the side effects may have been. So there really is no history.”
              The provider testified that it was “very important” for Jonas to receive
treatment and that his treatment needs could not be met without medication. She
believed the proposed medication plan was in his best interest because “without
medication, there . . . [was] no chance” that he would improve. She also stated that
Jonas’s symptoms were too severe to be treated with just one medication, even one that
could act as both a mood stabilizer and an antipsychotic.
              Jonas testified that he had taken every medication listed in the petition
“extensively.” And although he was “desperate to get rid of [his] condition,” the
medications and side effects “made [him] more dysfunctional than functional.” He
testified that he had tried to find psychologists to help him, but because they did not have
similar religious beliefs they were unable to understand what was psychosis and what
was religion. And he testified that he was not mentally ill, that it was “a spiritual
phenomenon” and “not really a problem with the mind.”
              The State argued that Jonas was not competent to consent to a medication
plan because he lacked capacity4 due to his failure to appreciate that he had a mental
illness, and that medication was in his best interests because he would otherwise
“decompensate and get worse.” The State further argued that Jonas did not have capacity
to make an informed decision, because he was not rational about his treatment plan
despite being intelligent and well-spoken. Jonas urged the court to deny the petition
because he had clearly articulated his reasons for not taking medication. The master

       4
              See AS 47.30.837(d)(1) (defining “competent” for purpose of patient giving
informed consent to medication as “(A) has the capacity to assimilate relevant facts . . . ;
(B) appreciates that the patient has a mental disorder or impairment . . . ; (C) has the
capacity to participate in treatment decisions by means of a rational thought process; and
(D) is able to articulate reasonable objections to using the offered medication”).

                                            -6-                                       7607
found by clear and convincing evidence that Jonas was not competent to provide
informed consent, medication was in his best interests, and there was no less intrusive
alternative.
               The superior court adopted the master’s recommendations and granted the
petition for the 30-day commitment to API and the petition for involuntary
administration of psychotropic medication. In its commitment order, the court concluded
that Jonas was mentally ill and gravely disabled. It found his mother’s testimony and
photographic evidence credible and described “the state of the apartment . . . including
enormous amounts of garbage laying around, dirty pots and pans, burn marks to walls
in the kitchen, and extensive damage to doors and walls.”
               The superior court also concluded that involuntary medication was in
Jonas’s best interests because the medications were FDA-approved and the treatment
provider explained that “the benefits of these medications . . . outweigh the minimally
anticipated risks.” The court found the treatment provider’s testimony credible that
Jonas’s condition was “currently untreated and so acute that if he was released, he would
have no ability to secure basic food or shelter.” And the court found that Jonas “is not
now capable of meaningful participation in a plan of care for himself.”
               Jonas appeals both the commitment and medication orders.
III.   STANDARD OF REVIEW
               “ ‘Factual findings in involuntary commitment or medication proceedings
are reviewed for clear error,’ and we reverse those findings only if we have a ‘definite
and firm conviction that a mistake has been made.’ ”5 “Whether those findings meet the
involuntary commitment and medication statutory requirements is a question of law we

       5
            In re Hospitalization of Jacob S., 384 P.3d 758, 763-64 (Alaska 2016)
(quoting Wetherhorn v. Alaska Psychiatric Inst., 156 P.3d 371, 375 (Alaska 2007)).

                                           -7-                                     7607
review de novo.”6
IV.    DISCUSSION
       A.     The Superior Court Did Not Clearly Err By Finding That Jonas Was
              Gravely Disabled.
              Jonas argues that the evidence before the superior court did not support a
finding of “grave disability” under AS 47.30.915(9)(B). The superior court may order
a person involuntarily committed to a treatment facility for up to 30 days if the court
finds by “clear and convincing evidence” that the person is “mentally ill and as a result
is . . . gravely disabled.”7 “Evidence is clear and convincing if it produces ‘a firm belief
or conviction about the existence of a fact to be proved.’ ”8 We have described this
standard “as evidence that is greater than a preponderance, but less than proof beyond
a reasonable doubt.”9
              Alaska Statute 47.30.915(9):
              “[G]ravely disabled” means a condition in which a person as
              a result of mental illness
                     ....
              (B) 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

       6
              Id. at 764.
       7
              AS 47.30.735(c).
       8
             In re Hospitalization of Luciano G., 450 P.3d 1258, 1262-63 (quoting In
re Hospitalization of Stephen O., 314 P.3d 1185, 1193 (Alaska 2013)).
       9
           In re Stephen O., 314 P.3d at 1193 (quoting Brynna B. v. State, Dep’t of
Health & Soc. Servs., Div. of Fam. & Youth Servs., 88 P.3d 527, 530 n.12 (Alaska
2004)).

                                            -8-                                       7607
             independently . . . .
In Wetherhorn v. Alaska Psychiatric Institute we held that an involuntary commitment
is constitutional only if the patient’s “distress” has reached “a level of incapacity that
prevents the person in question from being able to live safely outside of a controlled
environment.”10
             Jonas argues that the court erred by finding he could not secure food and
shelter for himself, and that the remaining evidence did not support a finding that he was
“gravely disabled.” He analogizes his case to In re Hospitalization of Stephen O.,
another case in which the respondent’s religious beliefs were the basis for finding that
he was gravely disabled.11 There, the respondent testified that Jesus spoke to him and
encouraged him to attend church.12 We reversed the superior court’s finding that he was
gravely disabled.13 We concluded that the court had clearly erred by relying “on partial
and unclear evidence.”14 We observed that Stephen’s symptoms (“a persistent sense that
Jesus [was] speaking to him,” directing him to attend church, follow his teachings, and
maintain an optimistic outlook) “would in no way compromise Stephen’s capacity to
function independently or live safely.”15 We noted that Stephen had “function[ed]
independently before and during the hearing,” and no evidence revealed anything

      10
             156 P.3d 371, 378 (Alaska 2007), overruled on other grounds by In re
Hospitalization of Naomi B., 435 P.3d 918 (Alaska 2019).
      11
             314 P.3d at 1193.
      12
             Id. at 1187.
      13
             Id. at 1197.
      14
             Id. at 1195.
      15
             Id. at 1196.

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“harmful or dangerous about Stephen’s religious beliefs or experiences.”16 Therefore we
concluded that the “concern that Stephen would decompensate and harm himself at some
time in the future was speculative.”17
             Even though Jonas’s religious beliefs featured prominently in the petition
hearings, that is as far as the comparison between his case and In re Stephen O. goes.
Jonas asserted that he was not mentally ill and instead was exhibiting a “spiritual
phenomenon.” The evidence before the court demonstrated that Jonas’s religious
experiences led him to believe that his family members were demons who cursed him
and his apartment, causing him to damage and leave his apartment and to prefer to stay
homeless. There also was testimony that Jonas had started a fire by burning notes about
his religious experiences. The fire was substantial enough to require a police response.
And Jonas testified that mental health professionals “would not be able to distinguish if
[his] thoughts are psychotic or not psychotic” unless they understood his religion,
leading him to abandon his treatment and medication. He also threatened his father with
a knife and made his family fear being around him. Testimony from his treatment
provider and Jonas’s statements revealed that he was unable to discuss anything except
his “intense spiritual li[fe]” and that he would be unable to care for himself if he were
released. These factual findings support the superior court’s conclusion that, unlike the
respondent in Stephen O., Jonas was gravely disabled under the statute.18 The superior
court did not err by finding that Jonas was gravely disabled, and granting the

      16
             Id. at 1195-96.
      17
             Id. at 1195.
      18
             Id. at 1195-96; see AS 47.30.915(9)(B).

                                          -10-                                     7607
commitment petition.19
      B.     It Was Error To Fail To Make Adequate Findings On The Myers
             Factors.
             Jonas also argues that the master’s findings were not adequate to justify
involuntary medication.20 We held in Myers v. Alaska Psychiatric Institute that, because
“the right to refuse to take psychotropic drugs is fundamental,” “an independent judicial
determination of the patient’s best interests considered in light of any available less
intrusive treatments” was required before authorizing involuntary medication.21 Before
determining whether a patient has capacity to make an informed decision, a treatment
facility is required to provide certain information set out in AS 47.30.837(d)(2):
             (A) an explanation of the patient’s diagnosis and prognosis,
             or their predominant symptoms, with and without the
             medication;
             (B) information about the proposed medication, its purpose,
             the method of its administration, the recommended ranges of
             dosages, possible side effects and benefits, ways to treat side
             effects, and risks of other conditions, such as tardive
             dyskinesia;
             (C) a review of the patient’s history, including medication
             history and previous side effects from medication;

      19
               Jonas also points to the superior court’s “erroneous factual premise” that
his mother would not continue to provide an apartment for him and argues this error
fatally undermined the court’s finding that he was gravely disabled. Although it was
clear error to find that Jonas’s mother would not provide an apartment after she testified
that she would not provide him another apartment, the error was harmless in light of the
other evidence presented.
      20
             Because we affirm the superior court’s commitment order, we need not
address Jonas’s argument that the medication order was not appropriate because it was
based on an erroneous commitment order.
      21
             138 P.3d 238, 248, 252 (Alaska 2006).

                                          -11-                                       7607
              (D) an explanation of interactions with other drugs, including
              over-the-counter drugs, street drugs, and alcohol; and
              (E) information about alternative treatments and their risks,
              side effects, and benefits, including the risks of nontreatment
              ....
We suggested in Myers that courts consider these factors before making an involuntary
medication determination, and they now are known as the Myers factors.22 We have
since clarified that considering the Myers factors is a requirement.23
              The master made only a single finding related to the Myers factors: a
reference to Jonas’s mother’s testimony that Seroquel, an antipsychotic medication, had
“worked pretty well for approximately 13 years.” Beyond that, he found that although
Jonas did not want to be medicated, “for medical reasons and sometimes for psychiatric
reasons, some medications need to be taken on a regular basis . . . [to] allow[] somebody
to function safely.” The master found by “clear and convincing evidence that the
proposed treatment . . . is in [Jonas’s] best interest.” The superior court’s written order
was even more vague: the medication was “FDA approved to treat [Jonas]’s mental
illness” and “the benefits of these medications outweigh the minimally anticipated risks.”
              The State argues the court was not required to make specific findings on
each of the Myers factors, but only on contested and relevant ones. It contends that
because Jonas’s treatment provider addressed the Myers factors and Jonas did not
challenge her conclusions or offer contrary expert testimony, none of the factors were

       22
           See, e.g., Bigley v. Alaska Psychiatric Inst., 208 P.3d 168, 180 (Alaska
2009) (“We will here refer to these as the ‘Myers factors.’ ”).
       23
              See id. (clarifying that Myers factors “consideration by the trial court is
mandatory”); see also In re Hospitalization of Lucy G., 448 P.3d 868, 879 (Alaska 2019)
(reiterating mandatory consideration of Myers factors and distinguishing other non-
mandatory factors).

                                           -12-                                      7607
contested and the court was not required to make any findings. The State also argues that
the court addressed Jonas’s concerns about side effects when it referred to his mother’s
testimony that Seroquel had worked in the past and the treatment provider’s testimony
that she would carefully monitor and adjust the dosages in response to potential side
effects.
             Jonas counters that he contested two of the Myers factors at the petition
hearing. He presented evidence about his treatment history and his experience with
associated negative side effects. And he testified that “exercise,” “a good diet,” and “a
lot of sunlight” were alternative treatments he would prefer.
             The Myers factors delineate specific safeguards protecting respondents’
rights and allowing for meaningful appellate review.24 Although the State is correct that
this court has only required specific findings on “relevant, contested mandatory Myers
factors,”25 Jonas did testify with information relevant to several of the factors. But the
single finding that one medication had previously “worked pretty well” is the only
finding relevant to Myers factors. This testimony addressed the third Myers factor which

       24
             See In re Lucy G., 448 P.3d at 879 (“Because consideration of the Myers
factors ultimately may allow a court to deny a patient’s fundamental right to refuse
psychotropic medication . . . we emphasize the importance of such findings to both
patient due process and appellate judicial review.”); In re Hospitalization of Jacob S.,
384 P.3d 758, 772 (Alaska 2016) (“[W]e again emphasize the need for detailed findings
when making best-interests decisions.”); Bigley, 208 P.3d at 180 (“[The Myers] factors
are ‘crucial in establishing the patient’s best interests,’ which means that their
consideration by the trial court is mandatory.” (quoting Myers, 138 P.3d at 252)).
       25
             See In re Lucy G., 448 P.3d at 879 (“[S]uperior courts must make specific
findings on relevant, contested mandatory Myers factors before ordering involuntary
medication.”).

                                          -13-                                      7607
requires the court to review the patient’s prior medication history.26 The master stated
that he had “listened carefully” to witness testimony, but neither he nor the superior court
addressed Jonas’s concerns regarding side effects, as required by the second Myers
factor, or alternative treatments, as required by the fifth Myers factor.
                The State also argues that failure to consider the Myers factors was
harmless because the record clearly supports the court’s findings that medication was in
Jonas’s best interests and that we have previously upheld medication orders despite a
lack of detailed Myers findings. But all of the cases cited by the State contain more
detailed discussion of the Myers factors than this case. In In re Hospitalization of Rabi
R., we affirmed a medication order where the superior court addressed four of the five
Myers factors, and we concluded that the record contained enough support for the fifth
factor that failure to consider it was not clearly erroneous.27 And although the superior
court’s medication order was “sparse,” in In re Hospitalization of Jacob S. we concluded
the superior court had not clearly erred because it “considered Jacob’s objections to the
magistrate judge’s recommendation . . . [and] adopted the magistrate judge’s reasoning
that [the treatment provider’s] testimony supported the best interests finding.”28 We
emphasized, however, “the need for detailed findings when making best-interests
decisions.”29
                We have consistently required the superior court to “expressly make or
incorporate specific findings on each of these best interest factors in a case where

       26
                See Myers, 138 P.3d at 252; In re Lucy G., 448 P.3d at 881.
       27
                468 P.3d 721, 737 (Alaska 2020).
       28
                384 P.3d at 772.
       29
                Id.

                                           -14-                                       7607
involuntary medication is requested.”30 In Myers we underscored that a court must make
an independent determination about the respondent’s best interests to safeguard the
fundamental right to refuse unwanted psychotropic medication.31 Without specific
findings on the relevant, contested Myers factors, we are unable to adequately review a
medication order to ensure that a patient’s fundamental right is respected and that the
order is not merely acquiescence to a medical opinion — the exact outcome Myers
declared unconstitutional.32 Because the findings by the master and superior court did
not specifically address the Myers factors, they are not sufficient to allow for meaningful
judicial review.
V.     CONCLUSION
              We AFFIRM the superior court’s finding that Jonas was gravely disabled.
We VACATE the medication order.

       30
            In re Lucy G., 448 P.3d at 879; In re Hospitalization of Gabriel C., 324
P.3d 835, 840 (Alaska 2014); Bigley v. Alaska Psychiatric Inst., 208 P.3d 168, 180
(Alaska 2009).
       31
             Myers, 138 P.3d at 250 (holding because it “presents a constitutional
question,” decision to order involuntary medication must be decision “that hinges not on
medical expertise but on constitutional principles aimed at protecting individual choice”).
       32
             See id. (“[T]he right at stake here — the right to choose or reject medical
treatment — finds its source in the fundamental constitutional guarantees of liberty and
privacy. The constitution itself requires courts, not physicians, to protect and enforce
these guarantees.”).

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