Court Opinion

ID: 4636556
Source: CourtListenerOpinion
Date Created: 2020-11-24 22:38:09.369678+00
Date Added: 2024-06-11T07:58:33.647949
License: Public Domain

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                               Appellate Court                               Date: 2020.06.01
                                                                             11:49:42 -05'00'

                  In re Robert M., 2020 IL App (5th) 170015

Appellate Court    In re ROBERT M., a Person Found Subject to Involuntary Medication
Caption            (The People of the State of Illinois, Petitioner-Appellee, v. Robert M.,
                   Respondent-Appellant).

District & No.     Fifth District
                   No. 5-17-0015

Filed              February 28, 2020

Decision Under     Appeal from the Circuit Court of Madison County, No. 16-MH-148;
Review             the Hon. Donald M. Flack, Judge, presiding.

Judgment           Affirmed.

Counsel on         Veronique Baker and Laurel Spahn, of Illinois Guardianship &
Appeal             Advocacy Commission, of Hines, for appellant.

                   Thomas D. Gibbons, State’s Attorney, of Edwardsville (Patrick
                   Delfino, Patrick D. Daly, and Sharon Shanahan, of State’s Attorneys
                   Appellate Prosecutor’s Office, of counsel), for the People.
     Panel                    JUSTICE WHARTON delivered the judgment of the court, with
                              opinion.
                              Presiding Justice Welch and Justice Moore concurred in the judgment
                              and opinion.

                                              OPINION

¶1        The respondent, Robert M., raises two arguments in this appeal from an order finding him
      to be subject to the involuntary administration of psychotropic medication. First, he argues that
      there was insufficient evidence to prove by clear and convincing evidence that he was
      suffering, one of the statutory requirements for the involuntary administration of psychotropic
      medication. See 405 ILCS 5/2-107.1(a-5)(4)(B)(ii) (West 2016). Second, he argues that there
      was insufficient evidence to prove that less restrictive treatments were explored and found to
      be inappropriate, another statutory requirement. See id. § 2-107.1(a-5)(4)(F). In particular, he
      points out that there was evidence that he was willing to take an antianxiety medication, one
      of the types of medication his treating psychiatrist wanted to administer. He argues that there
      was no evidence that voluntarily administering an antianxiety medication would have been
      inappropriate. We affirm.

¶2                                           I. BACKGROUND
¶3        Robert was 32 years old at the time of the proceedings in this matter. He had a history of
      mental illness that dated back to when he was 10 years old, which required several previous
      admissions to psychiatric facilities.
¶4        On July 21, 2016, Robert was admitted to Alton Mental Health Center (Alton) after being
      found unfit to stand trial. His treating psychiatrist at Alton was Dr. Jagannath Patil. On August
      12, 2016, the State filed a petition seeking to involuntarily administer psychotropic medication
      to Robert. In a supporting affidavit, Dr. Patil indicated that he wanted to administer
      medications to control anxiety and symptoms of psychosis, including paranoid delusions.
¶5        At the time of his admission to Alton, Robert was experiencing pain from several infected
      teeth. He attributed his anxiety to his dental pain. While at Alton, Robert received dental care
      for his problem. He took two rounds of antibiotics for the infection and had two teeth filled.
      The dentist also recommended that five teeth be extracted. At the time of the hearing in this
      matter, Robert was still awaiting an appointment at Southern Illinois University School of
      Dental Medicine to have the teeth extracted.
¶6        On September 1, 2016, the court held a hearing on the petition for involuntary
      administration of psychotropic medication. Dr. Patil testified that he diagnosed Robert with
      schizoaffective disorder, bipolar type. As a result of this disorder, Robert experienced paranoid
      delusions, anger, hostility, increased speech, and increased psychomotor activity. Dr. Patil
      stated that Robert also experienced somatic preoccupations. Asked to explain, he noted that
      Robert believed that taking antibiotics helped him to think more clearly because they “slow[ed]
      down his brain.” He also noted that Robert told him that the fever from his infected teeth was
      interfering with his ability to think clearly.

                                                  -2-
¶7         Dr. Patil testified that Robert exhibited a deterioration in his ability to function. Asked to
       explain, he noted that Robert typically only slept four to five hours a night. He described Robert
       as being always “on guard” and frequently argumentative. Dr. Patil described some of the
       paranoid beliefs expressed by Robert. For example, he testified that Robert believed that staff
       members were “messing up with his locked toothbrushes.” He further testified that Robert
       asked to shower alone due to paranoid fears. Dr. Patil testified that on one occasion, Robert
       refused to take Tylenol for his tooth pain even though he had requested it. He testified that
       Robert spit out the tablet, insisting that it was not really Tylenol. When a staff member showed
       him the box, Robert continued to insist that the tablet was something other than Tylenol, and
       he accused staff members of conspiring against him to turn him into a “zombie.”
¶8         Dr. Patil opined that Robert was suffering as a result of his symptoms. He noted that Robert
       reported to his treatment team that he was “in duress with anxiety.” Dr. Patil testified that
       Robert complained that the staff was neglecting his pain, anxiety, and medical needs, but when
       staff members asked him what they could do to help, Robert accused them of being “too
       aggressive.”
¶9         When asked if Robert exhibited threatening behavior, Dr. Patil described three incidents.
       In one incident, Robert threw a chair against the wall during an argument with a nurse. The
       following night, he was awake most of the night slamming doors and talking loudly. During
       this incident, Robert threatened to “write up” staff members so they would be fired. Another
       time, Robert could be heard yelling and cursing angrily while he took a shower. Dr. Patil
       testified, however, that it was not necessary to medicate Robert on an emergency basis during
       any of these incidents or at any other time.
¶ 10       Dr. Patil testified that Robert reported suffering from depression and posttraumatic stress.
       Robert indicated to Dr. Patil that he “might” need to take Klonopin, an antianxiety medication
       he had taken prior to his admission to Alton. Dr. Patil testified, however, that Robert felt he
       did not need to take antipsychotic medications because he was “ ‘in control of [his] own
       paranoia.’ ”
¶ 11       Dr. Patil did not have access to all of Robert’s medical records. Instead, he elicited
       information from Robert on what medications he had taken in the past, although he testified
       that he did not know whether Robert was an “accurate historian.” Robert told Dr. Patil that he
       previously took risperidone, haloperidol (Haldol), Invega, Thorazine, and Seroquel. Robert
       reported that he had “bad experiences” with risperidone, Haldol, and Invega. When asked what
       kind of bad experiences Robert had with these medications, Dr. Patil replied, “I mean, he did
       not elaborate, but I’m sure he may have experienced some side effects.”
¶ 12       Dr. Patil was asked whether less restrictive treatments had been explored. In response, he
       noted that Robert participated in classes and therapy sessions. However, he opined that these
       alternatives were not adequate to treat Robert’s symptoms unless used in conjunction with
       medication.
¶ 13       On cross-examination, Dr. Patil acknowledged that Robert was eating and taking showers
       and that his hygiene had improved. He further acknowledged that Robert’s progress reports
       included entries indicating that he was interacting with others and cooperating with unit
       expectations. Dr. Patil testified that although Robert indicated that he might need to take
       Klonopin, he did not sign a consent form. We note that Dr. Patil did not indicate whether
       Robert was ever asked to sign a consent form.

                                                   -3-
¶ 14       Robert testified in his own behalf. Asked which medications he has taken in the past,
       Robert replied, “I’ve been on a whole variety of medications that there was no success because
       *** there has been no solid proof of any of the illnesses that they’ve accused me of having.”
       He testified that he has taken Ativan, Invega, Risperdal, Thorazine, Zyprexa, Haldol, and “a
       lot of antibiotics. A whole lot of antibiotics.” Robert was asked what side effects he
       experienced while taking these medications. He testified that Thorazine and Invega caused
       fever and rashes and that he experienced swelling in his throat after receiving injections.
       However, he could not remember which medications caused the swelling because they were
       administered a long time ago. He also testified that he blacked out and experienced redness in
       his eyes, but he did not specify which medications caused these side effects.
¶ 15       Robert acknowledged that he banged on the window to the nurses’ station in order to get
       the attention of the nurses so he could request Tylenol. He explained that he was “desperate
       for Tylenol” because he was running a fever, which he believed was “cooking [his] brain.” He
       further testified that the infection from his teeth was spreading though his blood and that no
       one had “thoroughly checked” for infection throughout his system.
¶ 16       Robert testified that he was currently willing to take an antianxiety medication because the
       pain from his teeth was making him irritable. He indicated, however, that he did not believe he
       would need to take an antianxiety medication once his dental treatment was complete. Finally,
       Robert accused staff members of threatening to tell the doctors to medicate him against his
       will.
¶ 17       The last witness to testify was Anne Crane, Robert’s mother. She testified that Robert lived
       with her prior to his admission to Alton. Crane described her son as being able to function
       reasonably well at home. She testified that he was able to take care of himself with no
       assistance and that he was also able to assist her due to her physical disability. She noted that
       he also worked on the family’s vehicles. Crane did not believe that Robert should be medicated
       with antipsychotic medications, but she did believe he needed an antianxiety medication. She
       testified that there were several recent stressors in Robert’s life. She explained that a year
       earlier, she was on life support in the emergency room, and emergency room personnel
       recommended that her husband execute a do not resuscitate order. In addition, she testified that
       Robert’s father and brother both died and that his dental problems had been going on for a few
       years because he had no insurance to pay for the necessary care.
¶ 18       After hearing the arguments of the parties, the court ruled from the bench. The court began
       by finding that the State did not present clear and convincing evidence that Robert exhibited
       either threatening behavior or a deterioration in his ability to function. See 405 ILCS 5/2-
       107.1(a-5)(4)(B) (West 2016). The court therefore turned its attention to the issue of suffering.
       See id. The court noted that there is an “ongoing issue in the Appellate Courts as to what is
       sufficient to constitute suffering.” The court then highlighted Dr. Patil’s testimony describing
       “the level of anxiety and mood symptoms” experienced by Robert. The court emphasized that
       “the word ‘duress’ was used.” The court found that this “level of symptomology is sufficient
       in and of itself to constitute suffering under the law with or without manifestation of physical
       symptoms.”
¶ 19       The court noted, however, that it was “possible that there [was] a manifestation of physical
       symptoms in this case caused by mental suffering.” This was so, the court explained, because
       some of Robert’s beliefs regarding “all of his physical symptomology [were] not supported by
       the medical testimony and evidence in the record.”

                                                   -4-
¶ 20       The court then addressed the question of whether Robert lacked the capacity to make a
       reasoned decision regarding his treatment. See id. § 2-107.1(a-5)(4)(E). The court found that
       Robert’s beliefs about his physical symptoms interfered with his ability to make a reasoned
       decision regarding his care. It later clarified that Robert’s “inability to properly distinguish
       between the physical and mental issues that he’s having” rendered him unable to make a
       reasoned decision regarding the proposed treatment.
¶ 21       The court next considered whether less restrictive treatments had been explored and found
       to be inappropriate. See id. § 2-107.1(a-5)(4)(F). The court found that clear and convincing
       evidence showed that less restrictive treatments had been considered. The court stated, “[i]t’s
       not that they’re inappropriate, but [they are not] sufficient to treat this without the medication.”
¶ 22       The court further found that Robert suffered from a serious mental illness that had been
       marked by the continuing presence of symptoms (see id. § 2-107.1(a-5)(4)(A), (C)) and that
       the benefits of the proposed treatment outweighed the risk of harm (see id. § 2-107.1(a-
       5)(4)(D)). The court therefore granted the petition and entered an order authorizing the
       involuntary administration of psychotropic medication that day.
¶ 23       On September 27, 2016, Robert filed a motion to reconsider. He argued that the State failed
       to prove by clear and convincing evidence that he exhibited suffering.
¶ 24       The motion to reconsider did not come before the court for a hearing until December 22,
       by which time the order had expired. The court therefore asked the parties to address the
       question of mootness.
¶ 25       Counsel for Robert M. argued that two exceptions to the mootness doctrine applied—the
       public interest exception and the collateral consequences exception. She then turned to the
       merits, pointing out that suffering is a subjective question. Counsel argued that in this court’s
       then-recent decision in In re Debra B., 2016 IL App (5th) 130573, we reversed an involuntary
       medication order, in part because we held that the psychiatrist’s “mere recitation of [the
       respondent’s] symptoms” was insufficient to support a finding that she exhibited suffering
       where the psychiatrist did not also “explain how [the] symptoms caused her to feel grief,
       anxiety, depression, or any other type of emotional distress.” Id. ¶¶ 41, 45. Although counsel
       acknowledged that Dr. Patil provided more of an explanation in this case than he did in
       Debra B., 1 she argued that anxiety alone is not enough to demonstrate that a respondent is
       suffering.
¶ 26       Counsel for the State noted that the order authorizing involuntary medication had expired
       and that Robert had been discharged from his commitment at Alton. As such, she argued, the
       order was moot. Counsel did not address exceptions to the mootness doctrine or the merits of
       Robert’s arguments.
¶ 27       The court found that the motion to reconsider was moot and that no exception was
       applicable. In so holding, the court noted that trial courts, unlike appeals courts, do not set
       public policy. Despite this finding, the court went on to discuss the merits of the motion. The
       court first explained that this case is distinguishable from Debra B. because here the treating
       psychiatrist testified that Robert felt anxiety that was “not just ordinary daily anxiety ***, but
       an intense type and [he] was actually under duress.” The court further noted that Robert’s
       paranoid delusions caused him to refuse pain medication while he was experiencing physical

          1
           We note that Dr. Patil was also Debra B.’s treating psychiatrist.

                                                     -5-
       pain, which added to his suffering. Finally, the court noted that despite its earlier ruling to the
       contrary, the court believed the evidence was sufficient to support a finding that Robert
       exhibited a deterioration in his ability to function. The court reiterated that it found the issues
       raised in the motion to be moot but stated that it would find that both criteria were met if it
       were to rule on the merits. The court dismissed the motion to reconsider. This appeal followed.

¶ 28                                          II. ANALYSIS
¶ 29                                            A. Mootness
¶ 30        Before addressing the merits of this appeal, we note that it is technically moot. Because the
       order authorizing the involuntary administration of psychotropic medication has expired, our
       decision in this case will not grant Robert effective relief from that order. See In re Joseph M.,
       398 Ill. App. 3d 1086, 1087 (2010). Illinois courts ordinarily lack jurisdiction to decide moot
       questions, render advisory opinions, or address issues where our decision will not affect the
       result. In re Alfred H.H., 233 Ill. 2d 345, 351 (2009). Although most mental health cases fall
       within one or more of the recognized exceptions to the mootness doctrine, “there is no per se
       exception to mootness that universally applies to mental health cases.” Id. at 355.
¶ 31        The three recognized exceptions to the mootness doctrine are (1) the public interest
       exception, (2) the capable-of-repetition-yet-evading-review exception, and (3) the collateral
       consequences exception. In re Beverly B., 2017 IL App (2d) 160327, ¶ 19. Robert argues that
       all three exceptions apply to both of his claims. The State agrees that the collateral
       consequences exception applies to both claims. The State also agrees that the public interest
       exception applies to the question of whether a respondent’s willingness to voluntarily take
       some, but not all, of the proposed medications must be considered as a less restrictive
       alternative to involuntary medication. The State argues, however, that the public interest
       exception does not apply to Robert’s arguments concerning the evidence that he exhibited
       suffering and that the capable-of-repetition-yet-evading-review exception is not applicable to
       either claim. We find that the public interest exception is applicable to both claims.
¶ 32        The public interest exception allows us to consider issues that are otherwise moot if (1) the
       case presents questions of a public nature, (2) there is a need for an authoritative determination
       to guide public officials, and (3) the questions presented are likely to recur. Alfred H.H., 233
       Ill. 2d at 355. The procedures courts must follow before authorizing the involuntary
       administration of psychotropic medication are “a matter of ‘substantial public concern.’ ” In re
       Evelyn S., 337 Ill. App. 3d 1096, 1102 (2003) (quoting In re Mary Ann P., 202 Ill. 2d 393, 402
       (2002)). Challenges to the sufficiency of the evidence “are inherently case-specific” and thus
       do not generally “present the kinds of broad public interest issues” that are present in other
       mental health cases. Alfred H.H., 233 Ill. 2d at 356-57. However, claims that “relate to the type
       of evidence the State must present to meet its statutory burden, rather than the weight of the
       evidence presented,” have “ ‘broader implications than most sufficiency-of-the-evidence
       claims.’ ” In re H.P., 2019 IL App (5th) 150302, ¶ 17 (quoting In re Joseph M., 405 Ill. App.
       3d 1167, 1173 (2010)).
¶ 33        Both of Robert’s claims challenge the sufficiency of the evidence. However, his first claim
       turns on what type of evidence will support a finding that a respondent is exhibiting suffering.
       Similarly, his second claim turns on the question of whether, and under what circumstances, a
       respondent’s willingness to voluntarily take some of the proposed medications constitutes a
       less restrictive form of treatment. These questions are matters of great public concern. There

                                                    -6-
       are few Illinois cases addressing either issue. This court has not previously considered the
       questions raised in Robert’s less-restrictive-treatment argument. Although we addressed the
       issue of suffering in Debra B., we believe it would be appropriate to clarify some of the
       language in that decision. We therefore find that an authoritative determination of both issues
       is needed. Finally, because of the short duration of orders authorizing the involuntary
       administration of psychotropic medication, these issues are likely to recur without the
       opportunity to be fully litigated before becoming moot. See id. ¶ 18 (citing Mary Ann P., 202
       Ill. 2d at 402-03). We will therefore consider both of Robert’s arguments under the public
       interest exception.

¶ 34                                        B. Applicable Law
¶ 35        Turning to the merits, we begin by emphasizing the fundamental nature of the rights at
       issue in this appeal. As our supreme court has stated, the administration of any involuntary
       mental health services to an unwilling patient entails a “ ‘massive curtailment of liberty.’ ”
       In re Barbara H., 183 Ill. 2d 482, 496 (1998) (quoting Vitek v. Jones, 445 U.S. 480, 491
       (1980)). Involuntary administration of psychotropic medications is especially intrusive due to
       the “ ‘substantially invasive nature’ ” of these medications, their risk of serious side effects,
       and the potential for such medications to be misused as a means of managing patients rather
       than treating their symptoms. H.P., 2019 IL App (5th) 150302, ¶ 20 (quoting In re C.E., 161
       Ill. 2d 200, 214-15 (1994), and citing In re Robert S., 213 Ill. 2d 30, 46 (2004)). For these
       reasons, Illinois courts recognize that mental health patients have a constitutionally protected
       right to refuse psychotropic medications. C.E., 161 Ill. 2d at 213-14.
¶ 36        We also recognize, however, “that the state has a legitimate parens patriae interest in
       furthering the treatment” of mentally ill patients who are incapable of making reasoned
       decisions regarding their treatment. Id. at 217. The procedures in the Mental Health and
       Developmental Disabilities Code (Mental Health Code) (405 ILCS 5/1-100 et seq. (West
       2016))—including the statute authorizing the involuntary administration of psychotropic
       medication—were “enacted by our legislature to ensure that Illinois citizens are not subjected
       to [involuntary mental health] services improperly.” Barbara H., 183 Ill. 2d at 496. The statute
       provides that a patient may not be medicated against his will unless a court finds by clear and
       convincing evidence:
                   “(A) That the recipient has a serious mental illness or developmental disability.
                   (B) That because of said mental illness or developmental disability, the recipient
               currently exhibits any one of the following: (i) deterioration of his or her ability to
               function, as compared to the recipient’s ability to function prior to the current onset of
               symptoms ***, (ii) suffering, or (iii) threatening behavior.
                   (C) That the illness or disability has existed for a period marked by the continuing
               presence of the symptoms set forth in item (B) *** or the repeated episodic occurrence
               of these symptoms.
                   (D) That the benefits of the treatment outweigh the harm.
                   (E) That the recipient lacks the capacity to make a reasoned decision about the
               treatment.
                   (F) That other less restrictive services have been explored and found
               inappropriate.” 405 ILCS 5/2-107.1(a-5)(4)(A)-(F) (West 2016).

                                                   -7-
       The court may not authorize the involuntary administration of psychotropic medication unless
       it finds that all six of these factors are present. In re Gail F., 365 Ill. App. 3d 439, 446 (2006).
¶ 37        On appeal, we review the trial court’s factual findings to determine whether they are against
       the manifest weight of the evidence. Debra B., 2016 IL App (5th) 130573, ¶ 24. However, we
       conduct a de novo review of the court’s rulings on questions of law. See In re Andrew B., 237
       Ill. 2d 340, 348 (2010); In re Alaka W., 379 Ill. App. 3d 251, 259 (2008). Whether a patient’s
       willingness to take some medications voluntarily is a “ ‘less restrictive’ ” treatment within the
       meaning of the statute is a question of law. In re Torry G., 2014 IL App (1st) 130709, ¶ 33.
       We will therefore consider that question de novo.

¶ 38                                            C. Suffering
¶ 39        Robert first argues that there was insufficient evidence to support the court’s finding that
       he was suffering. There are three components to this argument. First, Robert correctly points
       out that the State must demonstrate something more than the fact that a respondent is mentally
       ill before a court may authorize the involuntary administration of psychotropic medication.
       Beverly B., 2017 IL App (2d) 160327, ¶ 43; Debra B., 2016 IL App (5th) 130573, ¶ 36. He
       emphasizes the court’s finding that his “level of symptomology” was “sufficient in and of itself
       to constitute suffering.” He argues that this finding was “tantamount to holding that any patient
       with a serious mental illness is subject to involuntary administration of medication,” a holding
       we found to be “untenable” in Debra B. See Debra B., 2016 IL App (5th) 130573, ¶ 45. Second,
       Robert points to his own belief that his anxiety was related to the pain from his infected teeth.
       He argues that because neither the physical pain nor the anxiety related to his dental problems
       were caused by his mental illness, they could not support a finding that he was suffering
       “because of [his] mental illness.” See 405 ILCS 5/2-107.1(a-5)(4)(B) (West 2016). Third, he
       points to the court’s statements regarding the “possibility” that his mental illness caused a
       “manifestation of physical symptoms.” He argues that a mere possibility is not sufficient to
       support a finding of suffering by clear and convincing evidence. We find all three arguments
       unavailing. We address them in turn.
¶ 40        Robert relies heavily on our holding in Debra B. to support his claim that the court’s
       reliance on his symptomology was, in essence, a finding that he was subject to the involuntary
       administration of psychotropic medications based solely on the fact that he is mentally ill. We
       find Debra B. to be distinguishable.
¶ 41        There, the respondent’s symptoms included racing thoughts, pressured speech, increased
       psychomotor activity, florid mania, and grandiose delusions. Debra B., 2016 IL App (5th)
       130573, ¶ 4. At the hearing on a petition for involuntary administration of psychotropic
       medication, Debra’s treating psychiatrist (Dr. Patil) was asked to explain why he believed that
       she was suffering. He replied, “ ‘All the symptoms that she exhibited is a suffering basically.’ ”
       Id. ¶ 7. He then testified that Debra was “ ‘incessantly writing,’ ” and he opined that her
       writings indicated that she was suffering. Id. Dr. Patil described the contents of some of
       Debra’s writings—letters addressed to Alton staff members, the St. Louis Cardinals, and Prince
       William and Kate Middleton. The letters were signed by “God,” “The Mother of the Holy
       Ghost,” “Witchpoo,” and “Queen Debra of Czechoslovakia.” Id. ¶¶ 8-10. In one letter, Debra
       wrote, “ ‘I am tired of this bull***. Get it together.’ ” Id. ¶ 8. However, nothing else in the
       contents of the letters gave any obvious indication that Debra was angry, sad, or fearful.

                                                    -8-
¶ 42        On the other hand, Debra herself testified that she was “suffering” because of her
       involuntary admission. Id. ¶ 17. She explained that she missed her daughter and that she was
       worried that her daughter would be unable to manage caring for Debra’s elderly mother, four
       dogs, and two cats in her absence. Id. The trial court found this evidence sufficient to prove by
       clear and convincing evidence that Debra was suffering. Id. ¶ 18.
¶ 43        In reversing this ruling on appeal, this court first noted that the term “suffering” is not
       defined in the Mental Health Code and must therefore be afforded “its plain and ordinary
       meaning.” Id. ¶ 38. After considering dictionary definitions for the word “suffering,” we held
       that “to prove that a respondent is suffering, the State must show that she is experiencing
       physical pain or emotional distress.” (Emphasis added.) Id.
¶ 44        We next considered the only two previous Illinois appellate decisions to address the
       question of suffering—In re Wendy T., 406 Ill. App. 3d 185 (2010), overruled on other grounds
       by In re Rita P., 2014 IL 115798, ¶¶ 33-34, and In re Lisa P., 381 Ill. App. 3d 1087 (2008).
       The respondent in Wendy T. often became angry because she was unable to communicate
       effectively or perform basic tasks. Debra B., 2016 IL App (5th) 130573, ¶ 39 (citing Wendy T.,
       406 Ill. App. 3d at 188). In Lisa P., the respondent experienced rage and paranoia as a result
       of her illness. Id. ¶ 40 (citing Lisa P., 381 Ill. App. 3d at 1090). In both of those cases, the
       appellate courts found the evidence sufficient to support the trial courts’ findings that the
       respondents were suffering. Id. ¶¶ 39-40.
¶ 45        We found “two significant distinctions” between both of those cases and Debra B. We
       explained, “First, both cases included at least some evidence that the respondents were
       suffering beyond a mere recitation of their symptoms.” (Emphasis in original.) Id. ¶ 41. We
       further explained, “Second, the symptoms experienced by both Wendy T. and Lisa P. lead
       more readily to an inference that they were suffering than do the symptoms described by
       Dr. Patil here.” Id. ¶ 42. In this case, Robert emphasizes the first of these two distinctions in
       arguing that Dr. Patil’s testimony here likewise provided no evidence of suffering “beyond a
       mere recitation of [his] symptoms.” As we stated in the second distinction, however, if there
       is a clear nexus between the symptoms themselves and a respondent’s suffering, the symptoms
       themselves may be enough to support a finding of suffering.
¶ 46        We went on to discuss the type of evidence that would support a finding of suffering. We
       explained:
                     “Although we do not believe that evidence of physical manifestations of depression
                is necessary to meet the clear-and-convincing standard, we do believe that the State
                must provide some factual basis for an assertion that a respondent is suffering. For
                example, the medical expert might testify that the respondent has reported feeling
                sorrow, frustration, anger, anxiety, or some other intense negative emotion, or that the
                respondent has behaved in a manner that indicates she is experiencing some sort of
                emotional anguish.” Id. ¶ 44.
       In Debra B., we found the record devoid of this type of evidence. Id. It is for this reason we
       concluded that holding that the evidence in that case was sufficient to support a finding of
       suffering “would be tantamount to holding that any patient with a serious mental illness is
       subject to involuntary administration of medication.” Id. ¶ 45.
¶ 47        In this case, by contrast, Dr. Patil testified that Robert experienced somatic preoccupations
       and paranoid delusions. As we discussed earlier, Robert believed that his fever was “cooking
       his brain” and that his dental infection was spreading throughout his bloodstream. It is easy to

                                                   -9-
       understand why such beliefs would cause fear and anxiety. Similarly, there is evidence that
       Robert believed that members of the staff at Alton were conspiring against him. As we noted
       in Debra B., paranoid delusions might “cause anyone to feel isolated and fearful.” Id. ¶ 42. It
       is worth noting that on at least one occasion, Robert’s paranoia led him to refuse pain
       medication, which would have alleviated the suffering from his tooth pain. Although we agree
       with Robert that the physical pain from his dental infection did not constitute suffering caused
       by his mental illness, his refusal to take medication to alleviate some of that pain was caused
       by his mental illness and did add to his suffering. While this incident, standing alone, might
       not be enough to warrant involuntary medication based on suffering, it does provide additional
       evidence in support of the trial court’s finding.
¶ 48       Moreover, Dr. Patil testified that Robert behaved angrily and reported feeling severe
       anxiety. This is precisely the type of evidence we said the State could present to support a
       finding of suffering in Debra B. See id. ¶ 44. We believe that this evidence—unlike the
       evidence presented in Debra B.—was sufficient to support the court’s finding that Robert was
       suffering.
¶ 49       The second component of Robert’s argument—concerning the sufficiency of the evidence
       that he exhibited suffering—revolves around his testimony that his anxiety stemmed from the
       pain he was experiencing due to his infected teeth. In addition, Robert’s mother indicated that
       he may have been feeling anxiety due to other outside events. As Robert correctly contends, a
       patient may not be medicated against his will based on a finding of suffering unless the State
       proves that he is suffering “because of [his] mental illness.” (Emphasis added.) 405 ILCS
       5/2-107.1(a-5)(4)(B) (West 2016). Here, however, as we have discussed at length, there was
       ample evidence to support a finding that much of Robert’s anxiety stemmed from his mental
       illness, particularly his paranoia and his somatic preoccupations. The fact that his feelings of
       anxiety may have been exacerbated by factors other than his illness does not alter our
       conclusion.
¶ 50       Finally, Robert points to the court’s statements opining that it was “possible” that Robert
       was experiencing physical manifestations of suffering as a result of the symptoms of his mental
       illness and that the evidence did not support all of the physical symptoms he described. We
       agree with Robert that a mere possibility is not enough to meet the clear-and-convincing
       standard. See In re Bontrager, 286 Ill. App. 3d 226, 230 (1997). We also agree that there is no
       indication in the record that Robert was not actually experiencing pain or a fever from his
       dental infection. Although it is not clear what the court was referring to when it referenced
       symptomology that was not supported by the evidence, this may have been a reference to
       Robert’s testimony that his fever was “cooking his brain” and that the infection from his teeth
       was spreading through his blood. However, there is no indication in the record that Robert
       experienced any psychosomatic symptoms or physical manifestations as a result of these
       beliefs. Nevertheless, the court did not rely on the possibility of physical manifestations in
       finding that Robert was suffering; as stated earlier, the court found that the evidence of his
       severe anxiety and paranoid delusions was sufficient to prove by clear and convincing evidence
       that he exhibited suffering. For the reasons we have already discussed, we find that this
       conclusion was supported by the evidence.

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¶ 51                                    D. Less Restrictive Services
¶ 52       Robert next argues that there is no evidence that the less restrictive alternative of allowing
       him to voluntarily take Klonopin was explored and found to be inappropriate. We first note
       that Robert forfeited review of this question by failing to raise it before the trial court, either at
       the hearing or in his motion to reconsider. 2 However, forfeiture is a limitation on the parties,
       not the courts. See Wilson v. Humana Hospital, 399 Ill. App. 3d 751, 757 (2010). As we
       mentioned earlier, this court has not previously addressed this issue, and we believe guidance
       would be useful. We therefore choose to address Robert’s arguments.
¶ 53       Only one Illinois case has squarely addressed the precise question before us—In re
       Torry G., 2014 IL App (1st) 130709. However, in the context of admission to a facility, Illinois
       courts have repeatedly held that voluntary mental health services are preferable to involuntary
       treatment, if possible. In re James E., 207 Ill. 2d 105, 114 (2003) (explaining “that one of the
       purposes of the [Mental Health] Code was the encouragement of voluntary admissions”); In re
       Splett, 143 Ill. 2d 225, 233 (1991) (same); In re Hays, 102 Ill. 2d 314, 319 (1984) (stating that
       voluntary admission “generally is considered to be the preferred method of commencing
       treatment of mental illness”). There are two reasons for this preference. First, obviously,
       voluntary treatment does not involve the substantial intrusion on a patient’s liberty that is
       involved in involuntary treatment. Torry G., 2014 IL App (1st) 130709, ¶ 34. Second,
       voluntary treatment is more effective than involuntary treatment. See James E., 207 Ill. 2d at
       114; Splett, 143 Ill. 2d at 233-34; Hays, 102 Ill. 2d at 319; Torry G., 2014 IL App (1st) 130709,
       ¶ 34.
¶ 54       In Torry G., the First District considered this principle in the context of involuntary
       administration of psychotropic medication. The respondent in that case voluntarily admitted
       himself to a private hospital for mental health treatment. His treating psychiatrist filed a
       petition to involuntarily medicate him. Torry G., 2014 IL App (1st) 130709, ¶ 4. At a hearing
       on that petition, the psychiatrist testified that although Torry stated that he was willing to take
       medication willingly, he refused to take all of the specific medications the psychiatrist
       suggested. Id. ¶ 10. This led the doctor to believe that Torry “was only willing to take
       medication with no side effects, and no such medication actually existed.” Id.
¶ 55       Torry, by contrast, testified that he was willing to take medications with minor side effects,
       but he did not want to take medications with severe side effects. Id. ¶ 15. He further testified
       that, during his first admission for psychiatric treatment, he experienced side effects from the
       medications he was given. Id. ¶ 13. He noted that he was taken to the emergency room due to
       severe side effects on two occasions. Id. ¶ 14.
¶ 56       The trial court appeared to find Torry’s testimony concerning his willingness to take
       medication to be more credible than the testimony of the doctor on that point. Id. ¶ 38. The
       court explained, however, that although Torry was willing to take medication, he needed to
       “ ‘get on some kind of treatment plan to take the medications.’ ” Id. The court therefore granted
       the petition for involuntary administration of psychotropic medication. Id. ¶ 21.

           2
            We note that at the hearing, Robert did call to the court’s attention his willingness to seek treatment
       for anxiety. However, he did not explicitly make the argument that his willingness to take an antianxiety
       medication must be considered a less restrictive service. In the motion to reconsider and at the hearing
       on that motion, Robert only argued that the evidence was insufficient to prove that he exhibited
       suffering.

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¶ 57        Torry appealed that ruling. In relevant part, he argued that his willingness to take
       medication voluntarily should be considered a less restrictive alternative to involuntary
       medication, and that the State failed to prove by clear and convincing evidence that this less
       restrictive alternative had been explored and found to be inappropriate. Id. ¶ 32.
¶ 58        The appellate court first considered “the legal question of whether a respondent’s
       willingness to take medication voluntarily constitutes a ‘less restrictive service[ ]’ within the
       meaning of” the statute governing involuntary administration of psychotropic medication. Id.
       ¶ 33. In answering that question in the affirmative, the court emphasized that fact that, as we
       have already discussed, voluntary treatment has been held to be preferable to involuntary
       treatment in the context of proceedings for involuntary admission. See id. ¶¶ 34-35. The court
       found the same principle to be applicable in the case of proceedings for involuntary medication,
       explaining that “any treatment to which a mental health patient is willing to consent should be
       considered a ‘less restrictive service[ ]’ than forced treatment under section 2-107.1.” Id. ¶ 35.
       The court therefore held that
                “when a patient is willing to take some forms of psychotropic medication, but not
                others, and the State seeks to forcibly administer medication in the latter category, the
                State must first prove by clear and convincing evidence that the drugs that the patient
                is willing to take ‘have been explored and found inappropriate.’ ” Id. (quoting 405
                ILCS 5/2-107.1(a-5)(4)(F) (West 2012)).
¶ 59        The court then went on to apply this holding to the circumstances before it. The treating
       psychiatrist in that case sought permission to administer two primary medications and seven
       alternate medications to Torry. Id. ¶ 4. There was evidence that Torry refused to take one of
       these nine medications, and there was evidence that he had previously experienced unpleasant
       side effects from taking one of the other medications. Id. ¶ 39. However, there was no evidence
       concerning Torry’s willingness to take any of the other seven medications listed in the petition,
       and there was no evidence that any of the medications he “would have been willing to take
       were not appropriate as a substitute for the medications in the petition.” Id.
¶ 60        Significantly for our purposes, the Torry G. court also considered the differences between
       the circumstances of Torry G. and the circumstances of In re Israel, 278 Ill. App. 3d 24 (1996),
       a case cited by the State in this case. In Israel, the question before the court was whether the
       trial court had jurisdiction to enter an order authorizing the involuntary administration of
       psychotropic medications to a respondent who was willing to take some psychotropic
       medications but refused to take other medications. Id. at 31. The respondent’s treating
       psychiatrist testified that the respondent was voluntarily taking Valium to treat his anxiety. He
       testified, however, that the only medications that would treat the respondent’s other
       symptoms—delusions and paranoia—were Haldol and Risperdal. Id. at 32. Because Valium,
       Haldol, and Risperdal “treat very different problems,” the Second District concluded that “the
       State is not precluded from filing a petition seeking to administer another type of medication
       just because respondent consented to take one type of medication.” Id.
¶ 61        The Torry G. court found Israel to be distinguishable from the facts before it because in
       Torry G., unlike in Israel, “there was no testimony establishing that” the medications Torry
       was willing to take “could not effectively treat his mental illness.” Torry G., 2014 IL App (1st)
       130709, ¶ 39. For this reason, the court concluded that the State failed to meet its burden of
       demonstrating that the less restrictive alternative of allowing Torry to take medications
       voluntarily had been explored and found to be inappropriate. Id.

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¶ 62        We find the First District’s reasoning in Torry G. persuasive. We agree that if a patient is
       willing to take some medications voluntarily, treatment with those medications is a less
       restrictive form of treatment that must be explored and found to be inappropriate before a court
       may authorize involuntary medication of the patient. It is important to emphasize, however,
       that the question is not simply whether voluntarily taking those medications is appropriate for
       the patient at all, but whether taking those medications in lieu of the medications requested in
       the petition is appropriate. See id. (pointing out the lack of evidence that any of the medications
       Torry was willing to take could be substituted for the medications he was not willing to take).
       It is in this respect that we believe the instant case stands in stark contrast to Torry G.
¶ 63        Here, there was evidence that, in addition to severe anxiety, Robert experienced anger,
       hostility, paranoid delusions, and somatic preoccupations that caused him to believe that a
       dental infection had spread throughout his body through his bloodstream. Like the psychiatrist
       in Israel, Dr. Patil testified that these symptoms could only be treated with antipsychotic
       medications. Thus, while an antianxiety medication like Klonopin was appropriate for Robert
       to treat his anxiety, the record in this case establishes that it was not appropriate to administer
       only an antianxiety medication without also administering antipsychotic medication to treat
       Robert’s other symptoms. We therefore conclude that the evidence was sufficient to prove that
       less restrictive services were explored and found to be inappropriate.

¶ 64                                     III. CONCLUSION
¶ 65      For the foregoing reasons, we affirm the order of the trial court authorizing the involuntary
       administration of psychotropic medication to Robert M.

¶ 66      Affirmed.

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