Court Opinion

ID: 9898501
Source: CourtListenerOpinion
Date Created: 2023-11-14 19:31:07.96645+00
Date Added: 2024-06-11T09:15:08.338781
License: Public Domain

Filed
                                                                                        Washington State
                                                                                        Court of Appeals
                                                                                         Division Two

                                                                                          June 13, 2023
     IN THE COURT OF APPEALS OF THE STATE OF WASHINGTON

                                          DIVISION II
 In the Matter of the Detention of:                                 No. 56491-2-II
                                                                      Consol. w/
 A.N.                                                               No. 56629-0-II

                                 Petitioner.                  UNPUBLISHED OPINION

        LEE, J. — A.N. appeals orders committing him to a 180-day civil commitment and

authorizing involuntary treatment with antipsychotic medications. A.N. argues that there is

insufficient evidence to support the jury’s finding that A.N. is gravely disabled. A.N. also argues

that the superior court commissioner failed to make a substantive finding regarding medical

appropriateness and made an inadequate substituted judgment in its order authorizing involuntary

treatment with antipsychotic medications.

        We hold that substantial evidence supports the jury’s finding that A.N. is gravely disabled,

and the superior court commissioner did not err in ordering involuntary treatment with

antipsychotic medications. Therefore, we affirm both orders.

                                               FACTS

A.      BACKGROUND

        In December 2019, A.N. was arrested and charged with felony stalking for allegedly

stalking a victim for over two years despite there being an active no-contact order in place. A.N.

told authorities that the victim was his girlfriend.

        In June 2020, the superior court ordered A.N. be admitted to Western State Hospital (WSH)

for competency restoration. A.N.’s June 2020 admission was his third admission to WSH since
No. 56491-2-II (Consol. w/No. 56629-0-II)

2013. A.N.’s prior admissions were also the result of competency restoration orders following

arrests for stalking, violation of an anti-harassment order, and criminal trespass. A.N. has never

been convicted of any crime; rather, he has a “history of being charged with, and then found

incompetent on,” various criminal charges. Clerk’s Papers (CP) at 6.

          At the time of his June 2020 admission to WSH, A.N. had exhibited “paranoid thoughts

regarding the legal system and delusional beliefs that painted himself as being the victim.” CP at

65. A.N. “claimed that his girlfriend had called the police in an effort to help him expose judges

who act as though they were above the law and that being in jail would help him with the task of

exposing their options(sic) to the world.” CP at 65. Additionally, A.N. wanted his case to “go to

the Supreme Court” and to sue the Supreme Court. CP at 65. WSH diagnosed A.N. with

“Delusional Disorder—Grandiose, Persecutory, and Erotomanic Type.” CP at 9.

          In July 2020, the superior court ordered a second period of competency restoration and for

an evaluation to determine if A.N. was competent to stand trial for the felony stalking charge.

WSH determined A.N. to be incompetent to stand trial, and the court dismissed the felony stalking

charge.

          In November 2020, A.N.’s treating psychiatrist and psychologist jointly filed a petition for

a 180-day involuntary treatment pursuant to chapter 71.05 RCW. The petition stated that A.N.

was both gravely disabled and presented “a substantial likelihood of repeating similar acts” to that

of his criminal charge. CP at 2. However, A.N. agreed to stipulate to a 90-day civil commitment

if WSH proceeded with its petition on the basis of grave disability only. WSH accepted A.N.’s

stipulation.

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No. 56491-2-II (Consol. w/No. 56629-0-II)

       In April 2021, A.N.’s treating psychiatrist and psychologist jointly filed a 180-day

involuntary treatment petition. The petition alleged that A.N. was gravely disabled and that he

required continued treatment at WSH. A.N. requested a jury trial, which the court set for

September.

       Prior to trial, A.N.’s new psychiatrist, Dr. Mary Zesiewicz, and psychologist, Dr. Elwyn

Hulse, filed an amended 180-day involuntary treatment petition and joint declaration. According

to the joint declaration, A.N. did not have anywhere to go if released, did not “‘agree to be released

if [he didn’t] have a place to go,’” would not take medication, and did not believe he was mentally

ill. CP at 66. A.N. compared himself to George Floyd and stated it was unfair that George Floyd’s

family had been compensated when A.N. had not been compensated for his suffering. A.N.

insisted that he continued to be in a relationship with his stalking victim and would attempt to see

her upon his release. Additionally, A.N. asserted that he wanted to “‘fight corrupt judges,’” he

stays at WSH to “‘get justice,’” his stalking victim “‘put [him] in prison’” when she called the

police, and the judge “put [him] in jail illegally.” CP at 69, 71, 73.

B.     JURY TRIAL

       In September 2021, the superior court held a three-day jury trial on the amended

involuntary commitment petition. Dr. Zesiewicz, Dr. Hulse, and A.N. testified.

       1.      Dr. Zesiewicz’s Testimony

       Dr. Zesiewicz, a clinical psychiatrist at WSH, testified regarding her interactions with A.N.

Dr. Zesiewicz began treating A.N. in June 2020, and had extensive sessions with him each time

they met. In preparation for trial, she reviewed A.N.’s records and collaborated with other

members of his treatment team.

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No. 56491-2-II (Consol. w/No. 56629-0-II)

       Dr. Zesiewicz testified that while A.N. presented well and was intelligent, “there are

several areas of his life that he has honed in on to the exclusion of everything else . . . what [she]

would consider to be an excessive preoccupation.” Verbatim Rep. of Proc. (VRP) (Sept. 15, 2021)

at 125. Specifically, A.N. believed the purpose of his jury trial was to “expose the truth” of the

world’s injustice and corruption and he would “exclusively focus[] on two women.” VRP (Sept.

15, 2021) at 126-27. Dr. Zesiewicz also testified:

       So, [A.N.] has told me numerous times that if he’s released from the hospital . . .
       [“]I will commit a crime because the police will pick me up, they’ll take me to jail,
       and then I will come back to [WSH.”] And then another time he told me; [“]I will
       send this woman flowers and she will call the police, and I will get picked up and I
       will be brought right back to jail.[”] And so he has said it in different ways but the
       theme is the same.

VRP (Sept. 15, 2021) at 129. According to Dr. Zesiewicz, A.N. adamantly denies having any

behavioral health disorder. This denial, she stated, “limits his ability to look at issues related to

what’s in his best interest.” 2 VRP (Sept. 16, 2021) at 15. Dr. Zesiewicz further testified that A.N.

responds to internal stimuli, “meaning [A.N.’s] own reality. There’s a lot going on within him,

and he is talking in response to what’s going on in his own mind.” 2 VRP (Sept. 16, 2021) at 33.

       At WSH, A.N. is in the highest level of psychiatric care with “extensive staff support.” 2

VRP (Sept. 16, 2021) at 44. Dr. Zesiewicz stated, “[A.N.] is very dependent on the [WSH]

structure of the day to have [his] basic needs met.” 2 VRP (Sept. 16, 2021) at 44. Dr. Zesiewicz

further stated she did not believe a less restrictive placement was appropriate for A.N. because of

“his almost exclusive intent on escaping and doing something—in his word, like he says, ‘To go

to jail,’ that . . . is putting—it puts him at risk; it puts the community at risk.” 2 VRP (Sept. 16,

2021) at 48.

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No. 56491-2-II (Consol. w/No. 56629-0-II)

       2.      Dr. Hulse’s Testimony

       Dr. Hulse is a psychologist at WSH. As a staff psychologist, Dr. Hulse monitors the

behavior of patients on his ward, which includes A.N. Dr. Hulse sees A.N. every day and speaks

with A.N. more thoroughly approximately once a month where Dr. Hulse would assess A.N.’s

behavioral health condition.

       Dr. Hulse testified that A.N. has “delusional disorder multiple types,” specifically

erotomania, grandiose, and persecutory. 2 VRP (Sept. 16, 2021) at 86. Dr. Hulse stated:

       The erotomania is the delusion that someone above you in status is in love with you
       and you have a relationship with them even though they may not even know that
       you’re alive.

       ....

       . . . [W]ith regard to the grandiose delusions he has told me that he wants to be a
       Nelson Mandela or George Floyd type person in history, and that he is . . . following
       in their footsteps.
                With regard to persecution . . . he consistently tells me about corrupt police
       officers . . . good judges and bad judges . . . . [W]e have an enclosed patio . . . where
       we have a camera so we can, kind of, see what goes on out there. . . . [A.N.] was
       staring up at the camera, gesturing and talking to the camera. So I followed up with
       him and I asked him . . . who were you talking to? What were you saying? And he
       said he was talking to the police because this was a direct line to the police, that
       camera.

2 VRP (Sept. 16, 2021) at 87-88. Dr. Hulse also shared other examples of A.N.’s delusional

symptoms, including that A.N. believes “women are in love with him. They are part of his anti-

conspiracy program because they are helping him stay in jail.” 2 VRP (Sept. 16, 2021) at 88. Dr.

Hulse further testified that A.N.’s delusions impact his perception of reality, along with his ability

to reason and think clearly. Additionally, A.N.’s delusions affect his ability to abstain from certain

actions, such as contacting the woman he stalked.

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No. 56491-2-II (Consol. w/No. 56629-0-II)

       Dr. Hulse also testified that A.N. does not have insight into his behavioral health disorder

and “continues to act on his distortion of reality.” 3 VRP (Sept. 20, 2021) at 119. Dr. Hulse stated

that A.N. would likely be able to obtain food if on his own; however, Dr. Hulse expressed concern

that, if released from WSH, A.N. would not be able to meet other basic health and safety needs.

Specifically, A.N. has “very limited cognitive control” and A.N.’s “laser focus[] on psychotic

thoughts and action” evidences a loss of volitional control. 3 VRP (Sept. 20, 2021) at 129-30.

Furthermore, Dr. Hulse testified, “[T]he biggest need is safety. It’s community safety.” 3 VRP

(Sept. 20, 2021) at 130.

       3.      A.N.’s Testimony

       A.N. testified he does not believe he has a behavioral health disorder. He further testified

that he would have the ability to feed himself, but whether he could or would seek shelter was

“[his] business.” 3 VRP (Sept. 20, 2021) at 156. A.N. also stated:

       The corrupt justices are covering up their bad behavior, their bad actions. And
       they’re the—they said that I’m mentally ill so that they could throw me in here and
       close my case. If you’re mentally ill you have to take medicine for your whole life
       but I haven’t taken any medicine. It’s very easy. I am asking the Court to release
       my records for the entire country to be able to see them. That’s what I’m asking
       the jury to do.

3 VRP (Sept. 20, 2021) at 157.

       A.N. shared that he believed himself to be a victim of “the bar association,” “corrupt

judges,” “several of the doctors [at WSH],” and “US bank,” among other groups and individuals.

3 VRP (Sept. 20, 2021) at 158. He testified:

               I’m here in order to raise my voice against all 50 governors of the United
       States and all 100 senators, all 435 US representatives and all of the presidents,
       including all of the past presidents of this country. All of them are domestic
       criminals, and I would like to declare that I am not mentally ill.

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No. 56491-2-II (Consol. w/No. 56629-0-II)

       ....

               I have the cognitive ability in order to stand up and resist the corrupt
       justices. The corrupt judges are trying to hide their evil crimes and so that’s why
       they said that I am mentally ill.

3 VRP (Sept. 20, 2021) at 159-61. A.N. further testified that upon release, he would immediately

“go look for [his] girlfriend in order for the police to arrest [him] so [he] can be put in jail and

continue to bring charges or to resist the corrupt judges.” 3 VRP (Sept. 20, 2021) at 161.

       4.      Jury Instructions

       During trial, the trial court requested that both parties submit proposed jury instructions.

The State submitted proposed jury instructions, and the trial court asked the parties if there were

any exceptions or objections to the State’s proposed jury instructions. A.N. stated that he had no

objection to the State’s proposed jury instructions nor did he wish to propose any additional jury

instructions. The superior court adopted the State’s proposed jury instructions.

       Jury instruction no. 6 instructed jurors on the definition of “gravely disabled.” The

instruction stated:

              Gravely disabled means a condition in which a person, as a result of a
       behavioral health disorder:
              (1) is in danger of serious physical harm resulting from a failure to provide
                  for his or her essential human needs of health or safety, or
              (2) manifests severe deterioration in routine functioning evidenced by
                  repeated and escalating loss of cognitive or volitional control over his
                  or her actions and is not receiving or would not receive, if released, such
                  care as is essential for his or her health or safety.

CP at 113. Additionally, jury instruction no. 8 stated, in pertinent part:

              In order to answer any question on the verdict form, ten jurors must agree
       upon the answer. It is not necessary that the jurors who agree on the answer be the

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No. 56491-2-II (Consol. w/No. 56629-0-II)

       same jurors who agreed on the answer to any other question, so long as ten jurors
       agree to each answer.

CP at 116.

       5.      Jury Verdict

       The jury found that A.N. had a behavioral health disorder, that he was gravely disabled as

a result of his behavioral health disorder, and that he should be committed for involuntary treatment

at WSH for 180 days. The trial court polled the jury, and each juror confirmed that the verdict

was his or her verdict. The trial court entered an order for A.N. to be committed for 180 days at

WSH.

C.     ANTIPSYCHOTIC MEDICATION PETITION AND HEARING

       On October 29, 2021, Dr. Michele Hines, a psychiatrist at WSH, filed a petition to

involuntarily treat A.N. with antipsychotic medication. In the petition, Dr. Hines stated that A.N.

had been advised of his need for antipsychotic medication, but that A.N. refused, citing concerns

about the medications’ side effects in addition to a desire to stay at WSH “‘to overturn the current

U.S. Constitution.’” CP at 122. A.N. expressed concerns that the medication would cause him to

develop heart problems. But Dr. Hines stated that A.N. “already has atrial fibrillation, is on

medication for it, and has been deemed to be stable by his medical doctor and his cardiologist.

Antipsychotic medication is unlikely to worsen this problem and may actually improve it.” CP at

126.

       Dr. Hines also stated that A.N. would likely be able to return to the community if on

medication and that he had not been adequately treated due to his refusal to take medication.

Without medication, A.N.’s stay at WSH would likely be prolonged.

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No. 56491-2-II (Consol. w/No. 56629-0-II)

       On November 23, 2021, the superior court commissioner held a hearing on the medication

petition. Dr. Hines and A.N. testified.

       1.      Dr. Hines’ Testimony

       Dr. Hines, a licensed psychiatrist at WSH, assumed care of A.N. in December 2020. She

diagnosed A.N. with “[p]sychosis not otherwise specified” and stated that A.N.’s primary

symptom was a set of fixed delusions. VRP (Nov. 23, 2021) at 7. She testified:

               [A.N.] believes that he is the victim of the judicial system in the United
       States and that he has been put in the hospital for the purpose of revealing some
       sort of global injustice wherein his presence in the hospital is going to lead to
       millions of victimizations being revealed and ultimately overthrow [sic] of the
       United States government.

VRP (Nov. 23, 2021) at 7. She further testified that she believed treatment with antipsychotic

medication would be effective for A.N. because “most people who have psychosis and take anti-

psychotic medication respond to it.” VRP (Nov. 23, 2021) at 8. Dr. Hines provided verbal and

written information to A.N. about adverse side effects of the medication. As to A.N.’s concerns

regarding cardiac problems, Dr. Hines testified:

       [A.N.] has a cardiac history. He developed, first of all, atrial fibrillation, an
       arrhythmia of the heart, for which he now takes medication and which he has been
       stabilized. And he also had an episode of heart failure several years ago, 2016. But
       he has had several evaluations since then and all of that has improved.
       Nevertheless, he has regular followup [sic] ongoing and will have that as long as
       he is here.

VRP (Nov. 23, 2021) at 9-10.

       A.N.’s prior heart failure was secondary to a gastrointestinal bleed, and Dr. Hines testified

that once A.N.’s bleed was treated, “[h]e recovered so that he no longer has heart failure.” VRP

(Nov. 23, 2021) at 16. Dr. Hines stated that should A.N. take antipsychotic medication, WSH

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No. 56491-2-II (Consol. w/No. 56629-0-II)

would monitor him closely through “bio sign monitoring,” frequent check-ins, and reviews with

medical doctors and a cardiologist. VRP (Nov. 23, 2021) at 10. Dr. Hines also testified that A.N.

recently saw a cardiologist, who recommended an echocardiogram “as a followup [sic] even

though [A.N.’s] current cardiac condition is stable.” VRP (Nov. 23, 2021) at 10-11. WSH would

arrange for A.N. to get the echocardiogram. However, Dr. Hines was unaware if A.N. directly

discussed side effects of antipsychotic medication with the cardiologist as the cardiologist’s notes

did not indicate one way or the other.

       Dr. Hines stated she would not recommend A.N. for discharge as long as he continued

having delusions, and that without medication, his delusions were unlikely to go away on their

own. Dr. Hines also noted that A.N. “has had years of less restrictive alternatives and they have

not had any impact.” VRP (Nov. 23, 2021) at 14.

       2.      A.N.’s Testimony

       A.N. testified at the medication hearing. A.N. stated that he did not believe he had any

behavioral health problems and that he was at WSH because of “the corrupt judge and corrupt

officials.” VRP (Nov. 23, 2021) at 19. When asked if he had any concerns about the medication

side effects, A.N. stated: “Of course . . . I don’t have any mental problems. I should not be taking

[medication]. But also, it is affecting my heart—bleeding to death even, yeah. It is clearly shown

in my records.” VRP (Nov. 23, 2021) at 20-21.

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No. 56491-2-II (Consol. w/No. 56629-0-II)

       3.      Commissioner Ruling and Order

       The superior court commissioner found by clear, cogent, and convincing evidence that the

State had a compelling interest in involuntarily administering antipsychotic medication to A.N.

and that the proposed treatment was necessary. In its oral ruling, the commissioner referred to Dr.

Hines’ testimony, citing A.N.’s refusal to consent to medication and the fact that other, less

restrictive treatments had been unsuccessful. The commissioner also addressed A.N.’s concerns

regarding the medication side effects in light of his current health condition:

               Now, [A.N.] has a heart condition that arose, I believe, in 2016, with a heart
       failure. He has an arrhythmia. The doctor has discussed with him the potential side
       effects of taking this medication both verbally and in written information form in
       his native language . . . and that was given to him in writing. He recently had a
       consultation with his cardiologist. The records don’t reflect whether or not the
       doctor spoke with him about the side effects but, certainly, [A.N.] had the
       opportunity to discuss the side effects of the medication with his cardiologist. . . .

               It is [Dr. Hines’] understanding from consulting with the records that
       [A.N.’s] arrhythmia resulted from some gastrointestinal disorder which was
       previously addressed and that there may have been some arrhythmia since that time
       but it was ultimately addressed at that time. The doctor has stated that without the
       prescription or the prescribing of the anti-psychotic medication that [A.N.’s] stay
       at [WSH] will be prolonged. [Dr. Hines] could not identify how long it would be
       extended. However, [A.N.] has had this fixed delusion since 2013 and no other
       treatment has been effective in addressing it.

VRP (Nov. 23, 2021) at 25-26.

       The superior court commissioner entered an order that incorporated the oral findings and

ruling, authorizing the involuntary treatment of A.N. with antipsychotic medications for 180 days.

The commissioner also noted that A.N. did not object to medication for any religious or moral

reasons, and that A.N.’s family did not object to use of antipsychotic medication.

       A.N. appeals.

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No. 56491-2-II (Consol. w/No. 56629-0-II)

                                            ANALYSIS

       A.N. argues on appeal that there is insufficient evidence to support the jury’s finding that

he is gravely disabled and the superior court commissioner erred in ordering involuntary treatment

with antipsychotic medications. We disagree.

A.     GRAVELY DISABLED1

       A.N. argues that the State did not sufficiently prove that he was gravely disabled under

either prong of RCW 71.05.020(24).2 The State argues that sufficient evidence supports the jury’s

verdict finding A.N. was gravely disabled and that either prong under RCW 71.05.020(24)

provides a basis for the jury’s verdict. We agree with the State.

       1.      Legal Principles

       Appellate courts review challenges to the sufficiency of the evidence in a light most

favorable to the State. In re Det. of B.M., 7 Wn. App. 2d 70, 85, 432 P.3d 459, review denied, 193

Wn.2d 1017 (2019). In 180-day commitment proceedings, the State bears the burden of presenting

clear, cogent, and convincing evidence. RCW 71.05.310; In re LaBelle, 107 Wn.2d 196, 209, 728

P.2d 138 (1986).

1
  The order at issue in this case has expired. However, because involuntary commitment orders
have collateral consequences for future commitment determinations, this appeal is not moot. In re
Det. of M.K., 168 Wn. App. 621, 622, 279 P.3d 897 (2012).
2
  RCW 71.05.020(24) has two alternative prongs under which a person can be found “gravely
disabled.” Under the first prong, “a person, as a result of a behavioral health disorder . . . [i]s in
danger of serious physical harm resulting from a failure to provide for his or her essential human
needs of health or safety.” RCW 71.05.020(24)(a). Under the second prong, a person, as a result
of a behavioral health disorder “manifests severe deterioration in routine functioning evidenced by
repeated and escalating loss of cognitive or volitional control over his or her actions and is not
receiving such care as is essential for his or her health or safety.” RCW 71.05.020(24)(b).

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No. 56491-2-II (Consol. w/No. 56629-0-II)

       An individual may be involuntarily committed for behavioral health treatment if, as a result

of a behavioral health disorder, that person is “gravely disabled.” LaBelle, 107 Wn.2d at 201-02.

Thus, the State must prove grave disability by clear, cogent, and convincing evidence. RCW

71.05.310; Morris v. Blaker, 118 Wn.2d 133, 137, 821 P.2d 482 (1992).

       When the standard is clear, cogent, and convincing evidence, “the ultimate fact in issue

must be shown by evidence to be ‘highly probable.’” LaBelle, 107 Wn.2d at 209 (quoting Pawling

v. Goodwin, 101 Wn.2d 392, 399, 679 P.2d 916 (1984)). “[A]ppellate review is limited to

determining whether substantial evidence supports the findings and, if so, whether the findings in

turn support the trial court’s conclusions of law and judgment.” Id. If substantial evidence

supports the trial court’s findings, then appellate courts will not disturb those findings. Id.

       There are two ways the State may prove that a person is “gravely disabled.” Id. at 202.

Under RCW 71.05.020(24), a gravely disabled person is one who

       as a result of a behavioral health disorder: (a) Is in danger of serious physical harm
       resulting from a failure to provide for his or her essential human needs of health or
       safety; or (b) manifests severe deterioration in routine functioning evidenced by
       repeated and escalating loss of cognitive or volitional control over his or her actions
       and is not receiving such care as is essential for his or her health or safety;

       Courts “must consider the symptoms and behavior of the respondent in light of all available

evidence concerning the respondent’s historical behavior.” RCW 71.05.245(1). Additionally,

certain symptoms or behaviors may support a finding of grave disability if they “are closely

associated with symptoms or behavior which preceded and led to a past incident of involuntary

hospitalization, severe deterioration, or one or more violent acts,” “these symptoms or behavior

represent a marked and concerning change in the baseline behavior of the respondent,” and

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No. 56491-2-II (Consol. w/No. 56629-0-II)

“without treatment, the continued deterioration of the respondent is probable.”               RCW

71.05.245(2).

                 a.   RCW 71.05.020(24)(a): Danger of serious physical harm from failure to
                      provide for essential health and safety needs

       Under RCW 71.05.020(24)(a), the State must show that an individual “is in danger of

serious physical harm as a result of his or her failure to provide for essential health and safety

needs.” LaBelle, 107 Wn.2d at 203. This requires a showing of a substantial risk of serious

physical harm, evidenced by

       failure or inability to provide for such essential human needs as food, clothing,
       shelter, and medical treatment which presents a high probability of serious physical
       harm within the near future unless adequate treatment is afforded. Furthermore,
       the failure or inability to provide for these essential needs must be shown to arise
       as a result of mental disorder and not because of other factors.

Id. at 204-05.

       The State need not show that an individual would fail to provide for all essential human

needs; rather, the State need only present evidence that an individual’s failure to provide for at

least one essential human need would result in a high probability of serious physical harm unless

adequate treatment is afforded. See In re Det. of A.F., 20 Wn. App. 2d 115, 126-27, 498 P.3d 1006

(2021), review denied, 199 Wn.2d 1009 (2022) (holding that an individual’s mental illness that

prevented him from seeking out and obtaining appropriate medical care supported a finding of

grave disability).

                 b.   RCW 71.05.020(24)(b): Severe deterioration in routine functioning

       Under RCW 71.05.020(24)(b), the State must show that (1) an individual manifests severe

behavioral health deterioration in routine functioning and (2) the individual would not receive, if

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No. 56491-2-II (Consol. w/No. 56629-0-II)

released, essential care for his or her health and safety. RCW 71.05.020(24)(b); LaBelle, 107

Wn.2d at 205. Evidence must provide a factual basis for concluding that an individual suffers

from severe deterioration. Labelle, 107 Wn.2d at 208.

       Such evidence must include recent proof of significant loss of cognitive or
       volitional control. In addition, the evidence must reveal a factual basis for
       concluding that the individual is not receiving or would not receive, if released,
       such care as is essential for his or her health or safety. It is not enough to show that
       care and treatment of an individual’s mental illness would be preferred or beneficial
       or even in his best interests. To justify commitment, such care must be shown to
       be essential to an individual’s health or safety and the evidence should indicate the
       harmful consequences likely to follow if involuntary treatment is not ordered.

Id. (emphasis in original). Furthermore, the individual must be unable to make rational decisions

regarding his or her treatment. Id.

       2.      Jury Verdict and 180-Day Commitment Order

               a.      RCW 71.05.020(24)(a)

       A.N. argues that the State did not prove that he would be unable to provide for his essential

needs as required under RCW 71.05.020(24)(a). Specifically, A.N. asserts that the State did not

present evidence that he could not feed himself, clothe himself, or find shelter. Additionally, A.N.

points to instances in the past when he has taken medication for health issues other than behavioral

health as evidence he would be able to obtain medical treatment.

       During the trial, while Dr. Hulse testified that A.N. would likely be able to procure food

for himself, Dr. Hulse expressed concerns that A.N. would not access behavioral health care. Dr.

Hulse stated that because of A.N.’s delusional disorder, he did not think A.N. would voluntarily

participate in behavioral health treatment, and A.N.’s failure to seek treatment would place A.N.

at risk of serious physical harm. Specifically, Dr. Hulse testified that A.N.’s expressed desire to

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No. 56491-2-II (Consol. w/No. 56629-0-II)

be arrested by the police and placed in jail would be detrimental to his treatment. Dr. Hulse also

testified that A.N.’s delusional disorder impacts A.N.’s ability to interact with others and A.N.

does not understand how his condition affects his behavior.

       Dr. Zesiewicz also testified that A.N.’s desire to go to jail was “the last thing he needs”

because jail is “not a safe place for . . . [A.N.] at his age and with his complex medical conditions,”

specifically his “cardiac problem and lung problem.” 2 VRP (Sept. 16, 2021) at 49.

       A.N. testified that he does not believe he has a behavioral health disorder and that upon

discharge, he would “go look for [his] girlfriend in order for the police to arrest [him] so that [he]

can be put in jail.” 3 VRP (Sept. 20, 2021) at 161.

       Here, Dr. Hulse’s testimony, Dr. Zesiewicz’s testimony, and A.N.’s testimony are evidence

that A.N. would not seek behavioral health care, an “essential human need” under RCW

71.05.020(24)(a). See LaBelle, 107 Wn.2d at 204-05. Thus, the evidence in the record shows that

it is highly probable that A.N.’s inability or failure to seek behavioral health care would result in

his arrest and placement in jail—indeed, A.N. stated his desire for such an outcome—which poses

a risk of serious physical harm to A.N. in light of his medical conditions.

       Furthermore, A.N.’s inability or failure to seek care is a direct result of his behavioral health

disorder. A.N. asserts that because he took medication for past medical conditions, he “has

demonstrated his ability to manage his health conditions by voluntarily taking medications and

working with his doctor.” Br. of Appellant at 26-27. However, A.N. stated, “I am not mentally

ill. . . . If you’re mentally ill you have to take medicine for your whole life but I haven’t taken any

medicine. It’s very easy.” 3 VRP (Sept. 20, 2021) at 157. Dr. Zesiewicz testified that A.N. “has

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been very clear that he will not accept any psychotropic medication.” 2 VRP (Sept. 16, 2021) at

42.

       The State need only show that an individual would fail to meet at least one essential need

which would risk substantial physical harm. See A.F., 20 Wn. App. 2d at 127. Here, the record

shows the State had met its burden. Therefore, we hold there is substantial evidence upon which

a jury could have reasonably relied on to find by clear, cogent, and convincing evidence that A.N.

is gravely disabled under prong (a).

               b.      RCW 71.05.020(24)(b)

       A.N. argues that there is insufficient evidence to prove that he is gravely disabled under

“prong (b).” Br. of Appellant at 30. Specifically, A.N. argues that the State did not sufficiently

prove that A.N.’s release would result in serious physical harm to him and that treatment at WSH

was essential to prevent the serious physical harm. Conversely, the State argues that the record

supports “civil commitment under prong (b) because A.N. has a history of repeated and escalating

loss of cognitive control.” Br. of Resp’t at 22. We agree with the State.

       Dr. Hulse testified that A.N., without care and supervision at WSH, would begin to

decompensate. A.N. has grandiose delusions and “continues to act on his distortion of reality.” 3

VRP (Sept. 20, 2021) at 119. A.N. is unable to move beyond his fixed delusions despite attempts

to reason with him. Dr. Hulse also testified that A.N. has “very limited cognitive control” and a

“laser focus[] on psychotic thoughts and actions.” 3 VRP (Sept. 20, 2021) at 129, 130. For

example, A.N. was talking to a camera at WSH, believing that he was talking to the police because

the camera “was a direct line to the police.” 2 VRP (Sept. 16, 2021) at 88. A.N. does “not receiv[e]

feedback from the environment, and [he does] not back[] off of what he’s doing.” 3 VRP (Sept.

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No. 56491-2-II (Consol. w/No. 56629-0-II)

20, 2021) at 130. Also, Dr. Hulse does not believe there is a less restrictive setting that could meet

A.N.’s needs.

       Dr. Zesiewicz’s testimony corroborated Dr. Hulse’s testimony. Dr. Zesiewicz testified that

A.N. is “very preoccupied with [his girlfriend]. [A.N.] talks a lot about her.” 2 VRP (Sept. 16,

2021) at 57. A.N. has often stated that his plan and intent when he is discharged is to send his

girlfriend flowers or call her, “‘and she will call the police and I will immediately go to jail.’” 2

VRP (Sept. 16, 2021) at 57. Also, A.N. has an “almost exclusive intent on escaping and doing

something” to go to jail, putting him at risk. 2 VRP (Sept. 16, 2021) at 48. And A.N. responds to

internal stimuli, talking in response to what is going on in his own mind. Dr. Zesiewicz believes

that A.N. “is very dependent on the structure of the day [at WSH] to have [his] basic needs met.”

2 VRP (Sept. 16, 2021) at 44. At WSH, A.N. “is in a locked unit where there is monitoring 24/7.”

2 VRP (Sept. 16, 2021) at 44.

       Furthermore, when A.N. testified, he continually denied having a behavioral health

disorder. He stated, “I am not mentally ill. . . . The corrupt justices are covering up their bad

behavior, their bad actions. . . . [T]hey said that I’m mentally ill so that they could throw me in

here and close my case. If you’re mentally ill you have to take medicine for your whole life but I

haven’t taken any medicine.” 3 VRP (Sept. 20, 2021) at 157.

       Here, A.N.’s inability to move past his fixed delusions and his laser focus on psychotic

thoughts and actions is evidence of his significant loss of cognitive control. Substantial evidence

in the record shows that A.N.’s loss of cognitive control is a direct result of his delusion disorder.

A.N.’s continual denial of and lack of insight into his behavioral health disorder is evidence that

he would not access or receive behavioral health care essential for his health and safety.

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Furthermore, A.N.’s clear intention to do something to immediately get arrested is a harmful

consequence in the event of his release.

       A.N. currently resides in a locked ward where he has access to “extensive staff support.”

2 VRP (Sept. 16, 2021) at 44. Dr. Hulse’s and Dr. Zesiewicz’s testimony suggest that A.N. would

continue to decompensate without the support of WSH. Additionally, continued care at WSH

would prevent harmful consequences of A.N. doing something to get arrested and put into jail.

Thus, there is substantial evidence upon which a jury could have reasonably relied on to find by

clear, cogent, and convincing evidence that A.N. is gravely disabled under prong (b).

B.     JURY INSTRUCTIONS AND VERDICT

       A.N. argues that because the trial court did not require the jury to agree on the basis for its

finding of grave disability, the court violated A.N.’s procedural due process rights. We disagree.

       1.      Legal Principles

       Generally, an appellate court will not consider issues raised for the first time on appeal

unless there is a “manifest error affecting a constitutional right.” RAP 2.5(a)(3); B.M., 7 Wn. App.

2d at 88-89. “The appellant must demonstrate the error is manifest and ‘truly of constitutional

dimension,’” meaning “there must be a showing of actual prejudice.” B.M., 7 Wn. App. 2d at 89

(quoting State v. O’Hara, 167 Wn.2d 91, 98, 217 P.3d 756 (2009)). To demonstrate actual

prejudice, a party must show that the asserted error had practical and identifiable consequences

during the trial. State v. Mosteller, 162 Wn. App. 418, 426, 254 P.3d 201, review denied, 172

Wn.2d 1025 (2011). “In determining whether the error was identifiable, the trial record must be

sufficient to determine the merits of the claim.” O’Hara, 167 Wn.2d at 99.

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No. 56491-2-II (Consol. w/No. 56629-0-II)

       2.      Jury Instructions and Verdict Form

       A.N. argues that the trial court’s failure to require at least 10 jurors “make the finding of

grave disability under the same prong” in the jury instructions violated his procedural due process

rights. Br. of Appellant at 35. A.N. asserts he may raise the issue for the first time on appeal

because it is a “manifest constitutional error” under RAP 2.5(a). Br. of Appellant at 35. The State

argues that A.N. failed to preserve the issue for review and that we should decline to review it.

We exercise our discretion under RAP 2.5(a) to address the merits of A.N.’s argument.

       “Procedural due process prohibits the State from depriving an individual of protected

liberty interests without appropriate procedural safeguards.” State v. Lyons, 199 Wn. App. 235,

240, 399 P.3d 557 (2017). Due process guaranties in commitment proceedings are satisfied when

10 out of 12 jurors agree upon a verdict. RCW 4.44.380; Dunner v. McLaughlin, 100 Wn.2d 832,

845, 676 P.2d 444 (1984). Here, all 12 jurors agreed that A.N. was “gravely disabled.”

       A.N.’s argument is rooted in the unanimity requirement from criminal cases. But courts in

criminal cases distinguish between “multiple acts” cases and “alternative means” cases. A

“multiple acts” case is when an individual commits several distinct criminal acts, but is charged

with only one count. In re Det. of Halgren, 156 Wn.2d 795, 808, 132 P.3d 714 (2006). In such a

circumstance, the State must elect the act upon which it relies for conviction. Id. Alternatively,

“the jury must be unanimous as to which act or incident constitutes the crime.” State v. Kitchen,

110 Wn.2d 403, 411, 756 P.2d 105 (1988). If the State fails to make an election or the trial court

fails to instruct the jury regarding unanimity, there is constitutional error. Id. “The error stems

from the possibility that some jurors may have relied on one act or incident and some another,

resulting in a lack of unanimity on all of the elements necessary for a valid conviction.” Id.

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No. 56491-2-II (Consol. w/No. 56629-0-II)

       Conversely, in an “alternative means” case, “a single offense may be committed in more

than one way,” and “[u]nanimity is not required . . . as to the means by which the crime was

committed so long as substantial evidence supports each alternative means.” Id. at 410 (emphasis

in original). Halgren and Kitchen involve criminal acts. However, even if the underlying principle

of their holdings apply in an involuntary commitment case, A.N.’s unanimity argument fails.

       A.N. did not commit several distinct acts with the State failing to elect a particular act to

rely on for his commitment petition. Rather, A.N.’s case can be likened to an “alternative means”

case. Under RCW 71.05.020(24), an individual may be found “gravely disabled” either under

prong (a) or prong (b)—regardless of the means, the statute and outcome are the same. And, for

the reasons discussed in section A above, substantial evidence supports the jury’s finding that A.N.

is “gravely disabled” under both prong (a) and prong (b). Therefore, A.N. cannot show prejudice.

A.N.’s procedural due process argument fails.

C.     COURT’S SUBSTITUTED JUDGMENT FOR PROPOSED TREATMENT

       A.N. argues that he has a due process right to a “‘medical appropriateness’” finding, which

the commissioner failed to do. Br. of Appellant at 44 (quoting Riggins v. Nevada, 504 U.S. 127,

135, 112 S. Ct. 1810, 118 L. Ed. 2d 479 (1992)). A.N. also argues that the commissioner failed to

make an adequate substituted judgment when it ordered A.N. to be involuntarily medicated. We

disagree.

       1.      Legal Principles

       Under the Due Process Clause of the Fourteenth Amendment of the U.S. Constitution, an

individual “possesses a significant liberty interest in avoiding the unwanted administration of

antipsychotic drugs.” Washington v. Harper, 494 U.S. 210, 221, 110 S. Ct. 1028, 108 L. Ed. 2d

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No. 56491-2-II (Consol. w/No. 56629-0-II)

178 (1990); Lyons, 199 Wn. App. at 240 (“The liberty interest in avoiding the unwanted

administration of antipsychotic drugs gives rise to both substantive and procedural due process

considerations.”). An involuntarily committed individual has a right to refuse antipsychotic

medication. In re Det. of L.K., 14 Wn. App. 2d 542, 548, 471 P.3d 975 (2020). However, that

right is not absolute; an involuntarily committed individual may not refuse medication if “it is

determined that the failure to medicate may result in a likelihood of serious harm or substantial

deterioration or substantially prolong the length of involuntary commitment and there is no less

intrusive course of treatment than medication in the best interest of that person.”             RCW

71.05.215(1).

       Because of the liberty interest at stake, the Washington Legislature has outlined procedural

safeguards within RCW 71.05.215 and RCW 71.05.217. The petitioning party must prove by

clear, cogent, and convincing evidence a compelling state interest that justifies overriding a

patient’s lack of consent. RCW 71.05.217(1)(j)(i). There must be an attempt to obtain informed

consent prior to the administration of the medication and that attempt must be documented in the

record. RCW 71.05.215(2)(a), (e). Additionally, a court must

       make specific findings of fact concerning: (A) The existence of one or more
       compelling state interests; (B) the necessity and effectiveness of the treatment; and
       (C) the person’s desires regarding the proposed treatment. If the patient is unable
       to make a rational and informed decision about consenting to or refusing the
       proposed treatment, the court shall make a substituted judgment for the patient as
       if he or she were competent to make such a determination.

RCW 71.05.217(1)(j)(ii); see B.M., 7 Wn. App. 2d at 79.

       Compelling state interests include “‘(1) the preservation of life; (2) the protection of

interests of innocent third parties; (3) the prevention of suicide; and (4) maintenance of the ethical

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No. 56491-2-II (Consol. w/No. 56629-0-II)

integrity of the medical profession.’” McCarthy v. Schuoler, 106 Wn.2d 500, 508, 723 P.2d 1103

(1986) (quoting In re Guardianship of Ingram, 102 Wn.2d 827, 842, 689 P.2d 1363 (1984)).

Additionally, when a court makes a substituted judgment for the individual, “the goal is not to do

what most people would do, or what the court believes is the wise thing to do, but rather what this

particular individual would do if [he] were competent and understood all the circumstances,

including [his] present and future competency.” Ingram, 102 Wn.2d at 839. Courts should

consider the risk of adverse side effects, the ability of the individual to cooperate with post-

treatment therapy, the wishes of family and friends, and the individual’s religious or moral views,

among other factors. Id. at 840. Neither RCW 71.05.215 nor RCW 71.05.217 allow medical

professionals to substitute their judgment for procedures established by law. L.K., 14 Wn. App.

2d at 552.

         “When the standard is ‘clear, cogent and convincing . . . the findings must be supported by

substantial evidence in light of the highly probable test.’” B.M., 7 Wn. App. 2d at 85 (alternation

in original) (internal quotation marks omitted) (quoting LaBelle, 107 Wn.2d at 209).

         2.     Medical Appropriateness

         A.N. argues that the commissioner violated A.N.’s due process rights by not making a

“medical appropriateness” finding, which is part of the “substantive” substituted judgment the

court must make to order that A.N. be involuntarily medicated. Br. of Appellant at 52. A.N. cites

to Riggins and Sell v. United States3 to support his contention.

3
    539 U.S. 166, 123 S. Ct. 2174, 156 L. Ed. 2d 197 (2003).

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No. 56491-2-II (Consol. w/No. 56629-0-II)

       However, both Riggins and Sell involve the involuntary administration of medication for

competency restoration purposes so defendants could stand trial. See generally Riggins, 504 U.S.

at 129; Sell, 539 U.S. at 169. For instance, under Sell, the State may

       involuntarily . . . administer antipsychotic drugs to render a mentally ill defendant
       competent to stand trial on serious criminal charges if the treatment is medically
       appropriate, is substantially unlikely to have side effects that may undermine the
       trial’s fairness, and, taking account of less intrusive alternatives, is necessary
       significantly to further important governmental trial-related interests.

539 U.S. at 167. “This standard will permit forced medication solely for trial competence purposes

in certain instances.” Id. (emphasis added); accord Lyons, 199 Wn. App. at 238 n.2 (“Sell

establishes the requirements necessary for the State to obtain an order authorizing involuntary

medication in order to restore competency to stand trial.”). Riggins also addressed the involuntary

administration of medication to a defendant in order to stand trial. 504 U.S. at 127.

       Sell and Riggins, and the standards articulated therein, are inapplicable here. The issue of

whether A.N. is competent to stand trial is not before this court.

       2.      Substituted Judgment

       A.N. argues that the commissioner did not make an adequate “substituted judgment” for

A.N. to be involuntarily medicated. Br. of Appellant at 52. Specifically, A.N. asserts that the

commissioner’s substituted judgment “lacked a substantive discussion and consideration of A.N.’s

rational concerns concerning his health conditions,” and as a result, the medication order should

be reversed. Br. of Appellant at 43. We disagree.4

4
   The involuntary medication order expired in May 2022. However, the issue is not moot “because
like an involuntary commitment order, an order to involuntarily administer antipsychotic
medication can have collateral consequences.” B.M., 7 Wn. App. 2d at 76.

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No. 56491-2-II (Consol. w/No. 56629-0-II)

       During the medication hearing, Dr. Hines testified about A.N.’s delusions and the need for

antipsychotic medication. Dr. Hines described that A.N. believes “that he has been put in the

hospital for the purpose of revealing some sort of global injustice.” VRP (Nov. 23, 2021) at 7.

Additionally, A.N. told Dr. Hines that the woman who has a no-contact order against him is

“keeping him in the hospital in order to overthrow corruption,” and A.N. “plans to contact this

woman” if discharged. VRP (Nov. 23, 2021) at 12-13.

       Dr. Hines further testified that she had spoken with A.N. about the need for antipsychotic

medication while also discussing potential adverse side effects with him. Dr. Hines provided both

verbal and written information about the medication side effects to A.N., including written

information in his native language. She described how WSH would closely monitor the effects of

any medication on A.N. in light of his past cardiac issues and that A.N. had an opportunity to speak

with a cardiologist. Dr. Hines stated that without medication, A.N.’s delusions would not go away

on their own and that A.N. could remain at WSH indefinitely.

       The superior court commissioner made an oral finding that the State had proved by clear,

convincing, and cogent evidence A.N.’s need for antipsychotic medication. The commissioner

cited to Dr. Hines’ testimony and stated that “medications will assist [A.N.] in being more reality

based. And it has been explained to him that [WSH] cannot assist him with discharge until he has

addressed the delusions and to prevent the behaviors which led to hospitalization.” VRP (Nov.

23, 2021) at 25. The commissioner also discussed A.N.’s concerns about medication side effects,

noting that A.N. had the opportunity to speak with a cardiologist and that A.N. was no longer

experiencing his prior cardiac issues.

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No. 56491-2-II (Consol. w/No. 56629-0-II)

       In the written order, the superior court commissioner incorporated much of the same

testimony cited in the oral ruling, and found that less intrusive treatments were ineffective and

“[t]here is no other treatment available to address [A.N.’s] condition.” CP at 132. In the written

order, the commissioner also noted A.N.’s desires. The commissioner specifically noted that A.N.

refused medications because he does not believe he has a behavioral health problem and that A.N.

believed the medications “will [affect] his heart and will cause death.” CP at 132.

       Here, the superior court commissioner made specific findings concerning a compelling

State interest, the necessity and effectiveness of treatment, and A.N.’s own desires regarding

medication.    And the commissioner noted A.N.’s delusion regarding “a woman he was

previous[ly] involved with” and “that he would contact this woman upon discharge.” CP at 131.

       Also, the commissioner found that A.N. possessed the same delusion since 2013 and that

prior treatments without medication were ineffective. The commissioner’s order specifically

found that there is no other treatment available to treat A.N.’s condition.

       Finally, the record shows that the superior court commissioner considered the risk of

adverse side effects, A.N.’s desires, and A.N.’s competency to make rational decisions. In its oral

ruling, the commissioner stated that because of A.N.’s delusions, “he [was] not making rational

decisions concerning his treatment and, therefore, the Court has the ability to substitute [its]

judgment for [A.N.].” VRP (Nov. 23, 2021) at 26. The record also shows that the commissioner

took Dr. Hines’ testimony into consideration when the court made a substituted judgment. Thus,

the record shows that the court made findings as dictated by RCW 71.05.215 and RCW 71.05.217.

Because the commissioner followed the procedural safeguards of RCW 71.05.215 and RCW

71.05.217, the commissioner did not err in its substituted judgment.

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No. 56491-2-II (Consol. w/No. 56629-0-II)

                                        CONCLUSION

        Substantial evidence supports the jury’s finding that A.N. is gravely disabled, and the

commissioner did not err in ordering involuntary treatment with antipsychotic medications.

Therefore, we affirm the orders committing A.N. to a 180-day civil commitment and authorizing

involuntary treatment with antipsychotic medications.

        A majority of the panel having determined that this opinion will not be printed in the

Washington Appellate Reports, but will be filed for public record in accordance with RCW 2.06.040,

it is so ordered.

                                                    Lee, J.
 We concur:

 Glasgow, C.J.

 Cruser, J.

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