WINFREE, Justice.
An adult woman diagnosed with a mental illness appeals her already completed 30-day
In February 2010 Joan K. disappeared from her mother's house.
The next day a FMH staff physician applied for an ex parte order authorizing Joan's involuntary hospitalization for a mental health evaluation.
The superior court held a 30-day commitment hearing on March 1, 2010.
The superior court also found that as a result of her mental illness Joan was likely to cause harm to others, based on an incident at FMH and evidence of her unstable emotions. The court said Joan might "present aggressively out in the public in front of lay people who may not know of [Joan's] mental disability and who may react violently or who may be hurt by her, may not know how to talk her down and certainly are not going to have drugs available [such as Valium] to ameliorate her mood as was true here."
The superior court found no less restrictive facility than API would adequately protect Joan and the public. Finding Joan had refused voluntary treatment, the court ordered her committed to API for a period not to exceed 30 days. Although the record does not indicate when API actually released Joan, 30 days from her commitment date was April 1, 2010.
Joan appeals the superior court's 30-day commitment order.
Mootness is a matter of judicial policy and its application is a question of
In Wetherhorn v. Alaska Psychiatric Institute we established that commitment-order appeals based on assertions of insufficient evidence are moot if the commitment period has passed, subject to the public interest exception.
In her supplemental briefing, Joan suggests we should overrule Wetherhorn because it mistakenly focused on release from commitment, rather than vacating the commitment order, as the relief sought in a commitment-order appeal. She also argues the public interest exception to mootness applies because "[u]nless this court reviews commitment orders for sufficiency of the evidence, the masters and trial court judges hearing these cases will have no standards by which to measure the cases before them." Finally, she argues that we should adopt the collateral consequences exception to mootness in commitment-order appeals. The State responds that Wetherhorn mandates dismissal of Joan's appeal as moot because: (1) the public interest exception to mootness does not apply; and (2) Joan has not established any actual collateral consequences resulting from her commitment order.
We ordered oral argument on the mootness question, directing that the parties be prepared to discuss the authority and appropriateness of issuing a vacatur order to remedy possible collateral consequences arising from an otherwise-moot commitment order.
In response to our supplemental briefing order, Joan asserts that in Wetherhorn we "erred in focusing on the period of the commitment rather than the relief that Wetherhorn sought" when we held that an evidentiary-based challenge to a completed commitment is generally moot. Joan asserts the true relief Wetherhorn sought was vacating the "gravely disabled" finding; although not expressly stating it, she suggests the true relief she seeks is vacating the finding that she is a danger to herself or others.
Our order for supplemental briefing did not anticipate questioning Wetherhorn's fundamental
Joan also argues her evidentiary-based appeal of her 30-day commitment should be considered under the public interest exception to mootness. She contends that given her bipolar disorder, she is likely to face future commitment proceedings and the issues of this case are likely to be repeated. She also contends we "must provide guidance to the trial courts" on the evidence necessary to meet the legal standards for: (1) finding someone a danger to self or others; and (2) least restrictive treatment alternatives. In connection with this latter argument, Joan cursorily asserts in her supplemental opening brief that her statutory right to appeal her commitment order is "meaningless" if we choose not to review the order.
Joan notes that several other courts have applied the collateral consequences exception to mootness in the involuntary commitment context. She points to social stigma,
The State acknowledges there are collateral consequences from an involuntary commitment order, but argues that: (1) an exception from the general rule of mootness requires a case-specific analysis; and (2) Joan has not established any actual collateral consequences arising from her involuntary commitment order. At oral argument the State also argued that certain collateral consequences from an involuntary commitment order, such as restrictions on the right to possess a firearm, are important, and we therefore should consider an appeal's merits rather than simply vacate the underlying commitment order.
We have previously recognized that the collateral consequences doctrine "allows
We conclude that there are sufficient general collateral consequences, without the need for a particularized showing, to apply the doctrine in an otherwise-moot appeal from a person's first involuntary commitment order. But we do note that some number of prior involuntary commitment orders would likely eliminate the possibility of additional collateral consequences, precluding the doctrine's application.
Based on our adoption of the collateral consequences exception to mootness in the involuntary commitment order context, we agree that Joan's commitment order, her first, is reviewable.
To involuntarily commit someone to a treatment facility for up to 30 days, a court must first find, by clear and convincing evidence, that the person "is mentally ill and as a result is likely to cause harm to [self] or others or is gravely disabled."
The court must also consider whether a less restrictive alternative would provide adequate treatment.
As discussed below, we affirm the superior court's findings by clear and convincing evidence that Joan suffered from a mental illness and that as a result she posed a substantial risk of bodily harm to herself under AS 47.30.915(10)(A).
Dr. Bell testified Joan suffered from bipolar disorder, a serious mental illness which caused Joan to suffer mixed emotional states with manic elements, depressed elements, and psychotic manifestations. Joan told Dr. Bell that she could sense other people's feelings, that Fairbanks was the center of the galaxy and the separation point between heaven and hell, and that she was responsible for maintaining the balance between heaven and hell. Joan also told him he was prescribing the wrong medicines because she needed amphetamines and OxyContin to deal with the stress of sensing others' thoughts. Dr. Bell was unable to determine whether Joan had organic brain damage because her manic bipolar disorder symptoms prevented a complete examination. Dr. Bell thought Joan had been abusing drugs for the three weeks she disappeared because her admission drug screens were positive for amphetamines and cocaine and because she appeared to be in a state of "lethargy or torpor," which typically follows prolonged stimulant abuse.
Dr. Bell was primarily concerned Joan would harm herself by further illegal drug use. He thought Joan would use drugs if she left the hospital because she believed she needed amphetamines and OxyContin to manage the stress associated with her delusions. Dr. Bell testified that using illegal substances in Joan's mental state would make her thought process "so completely disorganized" that she would not "know what she was doing." Using drugs would also cause "further de-stabilization of [Joan's] mental and mood state, which would aggravate her ability to conform ... to reasonably safe behaviors."
Dr. Bell testified there was not a less restrictive facility than API that could meet Joan's needs. He testified Joan needed a "very secure mental health unit" that would "very closely control[]" her and provide "a lot of emotional support, with careful control of her sleep pattern and regular appetite." Dr. Bell thought Joan would "need a long period of treatment, though it could be concluded within 30 days were she to accept medication reliably and begin to understand how drugs and alcohol impact on the exacerbation of her mental illness."
Dr. Parker testified he had not personally diagnosed Joan, but her records indicated she had bipolar disorder and a history of attention deficit hyperactivity disorder, polysubstance abuse, and alcohol abuse. In Dr. Parker's opinion, Joan was at risk of causing herself bodily harm through drug use if she were not committed. He said Joan's mental stability "can change very rapidly" due to her bipolar disorder. He also noted she had disappeared for three weeks and used drugs prior to her hospital admission. Dr. Parker testified Joan locked herself in a bathroom and threatened to blow herself up in November 2009. When the superior court asked what danger, if any, illegal drug use posed for Joan, Dr. Parker replied it would not be "good for the system" and was "self-destructive," but he could not say it posed "imminent
Like Dr. Bell, Dr. Parker testified there was not a less restrictive facility than API that could meet Joan's needs. Dr. Parker thought Joan needed to come out of her current manic episode and return to her baseline before release, otherwise she would continue her "uncontrolled manic behavior" and substance abuse. Dr. Parker noted that the day before the hearing nurses had to medicate Joan after an incident at the nurses' station. He also thought outpatient treatment was not a viable option for Joan because outpatient psychiatry or psychology requires patients to "have some kind of insight on their behavior and some ... sort of consistency of behavior." Joan had denied to him that she had any mental illness or needed treatment; due to her lack of insight, Dr. Parker thought it "very unlikely" Joan would follow through with outpatient treatment even if she said she would. Dr. Parker also testified that for a family wrap-around plan or 24-hour surveillance by a family member to work Joan would have to agree, and Joan changed her mind too frequently for such plans.
Joan does not contest the superior court's finding of a mental illness. Joan instead contends the superior court erred by finding that due to her mental illness she was likely to cause harm to herself, arguing: (1) there was no evidence illegal drug use physically harmed her and she did not make affirmative statements that she would use illegal drugs if released; and (2) she did not manifest a current intent to carry out a plan to seriously harm herself.
We decided a similar issue in E.P. v. Alaska Psychiatric Institute.
The superior court's finding is amply supported by Dr. Bell's testimony.
The superior court also heard evidence that illegal drug use would "pose a substantial risk of bodily harm" to Joan by exacerbating her mental illness.
Finally, the superior court heard evidence regarding Joan's "recent behavior causing, attempting, or threatening" harm to herself by illegal drug use.
Based on these findings, the superior court did not err by finding clear and convincing evidence that, under AS 47.30.735 and AS 47.30.915(10)(A), Joan was likely to cause harm to herself due to her mental illness.
An important principle of civil commitment in Alaska is to treat persons "in the least restrictive alternative environment consistent with their treatment needs."
Joan argues the superior court erred in finding commitment to API would be the least restrictive alternative placement. Joan also contends no testimony supported a finding that she refused outpatient treatment or a home placement, particularly in light of Dr. Bell's and Dr. Parker's decisions not to contact her family or prior psychiatrist to ask about Joan's potential success in such alternative settings. Joan's second argument reflects a misunderstanding of the superior court's findings—the court found outpatient treatment was not a viable option, and therefore
The superior court found there was "[n]o less restrictive facility [that] would adequately protect [Joan] and the public." The court explained:
The record supports the superior court's finding.
First, Dr. Bell and Dr. Parker both testified there was no less restrictive facility than API that could meet Joan's needs. Dr. Bell testified Joan needed a "very secure mental health unit" that would "very closely control[]" her and provide "a lot of emotional support, with careful control of her sleep pattern and regular appetite." Dr. Bell thought Joan "need[ed] a long period of treatment, though it could be concluded within 30 days were she to accept medication reliably and begin to understand how drugs and alcohol impact on the exacerbation of her mental illness." Dr. Parker testified Joan needed to come out of her current manic episode and return to her baseline before being released, otherwise she would continue her "uncontrolled manic behavior" and substance abuse.
Second, Dr. Parker testified outpatient psychiatry or psychology require a patient stable enough to have insight into one's behavior and some "sort of consistency of behavior." Joan was not stable because she had changeable emotions and could change her mind "from one minute to the next." Joan also lacked perspective regarding her bipolar disorder, denying she had any mental illness or needed treatment. Because of Joan's lack of insight, Dr. Parker thought it "very unlikely" she would follow through with outpatient treatment even if she said she would.
The superior court did not err by finding API was the least restrictive placement.
We AFFIRM the superior court's involuntary commitment order on its merits.
CHRISTEN, Justice, not participating.
STOWERS, Justice, dissenting.
In Wetherhorn v. Alaska Psychiatric Institute,
One of the orders that Wetherhorn appealed was the superior court's order approving her involuntary commitment for 30 days. We began our discussion by observing that "[t]he United States Supreme Court has characterized involuntary commitment for a mental disorder as a `massive curtailment of liberty' that cannot be accomplished without due process of law."
We then analyzed the Alaska statute that correlates with the requisite findings for both types of harm. We explained:
We emphasized the importance of the "clear and convincing" standard of proof. We noted that another Supreme Court case, Addington v. Texas,
As I will show, in Joan's case the superior court unfortunately failed to give meaning to the heightened "clear and convincing" standard of proof. Now, doubly unfortunate, this court also fails to meaningfully apply this heightened standard on review. In my view, the evidence adduced against Joan was conclusory and speculative, and may not have satisfied even the lower preponderance of the evidence standard. Because Joan was involuntarily committed to the Alaska Psychiatric Institute (API) by evidence that was far less than clear and convincing, I respectfully dissent from the opinion of the court.
In order to involuntarily commit Joan to API for 30 days, the superior court was required to find by "clear and convincing" evidence that she was "likely to cause harm to [herself] or others" due to her mental illness,
Clear and convincing evidence is evidence that produces "a firm belief or conviction
Dr. Parker testified that Joan was "potentially a risk to herself" due to her unstable emotional state (emphasis added), but admitted Joan had not directly expressed any intent to harm herself or anyone else during her present hospitalization and had not actually harmed herself or anyone else, other than by using drugs. When asked what danger, if any, Joan posed to herself based on the fact that she had used illegal substances, Dr. Parker responded, "amphetamines aren't good for the system, but ... I can't say there's some imminent danger from that. It's certainly self-destructive, but... plenty of people engage in self-destructive behavior." (Emphasis added.)
Dr. Bell testified that Joan had the "potential to cause harm" to herself and others due to her unstable emotions and "excessive anger," and "speculate[d]" that her anger was one of the reasons she had a bruise around her eye.
"Likely" is defined as "an equivalent to probably."
This court also relies on E.P. in affirming the superior court's finding. But E.P. is manifestly distinguishable from Joan's case in several respects—there was clear evidence that E.P. was addicted to huffing gas, that his addiction had caused organic brain damage resulting in dementia and personality disorder, and that he intended to continue huffing gas if released.
Though Joan's case is unlike E.P.'s case, E.P. reveals several relevant principles. We cautioned in E.P. that the statutory definition of "mental illness" does not include "drug addiction" in and of itself
It is undisputed that Joan has a diagnosis of bipolar disorder, thus meeting the statutory definition of mental illness. But there was no evidence that Joan was addicted to drugs; rather, it appears that she was simply an abuser of these harmful substances. There was also no evidence that Joan's drug use was caused by any organic brain damage, or even by her bipolar disorder. Joan's case thus appears to fall somewhere between the case of a person "with full mental capacity" (i.e., no mental illness) and E.P.'s case where he suffered organic brain damage from huffing gas and it was his brain damage that caused him to continue to huff gas. Dr. Parker's and Dr. Bell's testimony attempted to relate the risk of harm they argued Joan may cause to herself by her use of drugs to the potentially deleterious effect that these drugs could have on her mental condition. The superior court and this court rely on this testimony to conclude that Joan's case is like E.P.'s case and is not the kind of case that would be excluded because of the limiting definition of "mental illness" and the distinguishing
Both doctors also dismissed the possibility of a less restrictive alternative for Joan, even though they had not explored alternative options. Dr. Parker and Dr. Bell testified that they never communicated with any of Joan's family members to see if they could provide a wraparound plan for her. And even though Joan had previously been treated by Dr. Baker, a psychiatrist, neither doctor contacted Dr. Baker to discuss Joan's condition or to see if Dr. Baker could further treat Joan as an alternative to commitment to a psychiatric institution. Dr. Bell testified he did not know whether Joan would be an appropriate candidate for voluntary treatment, but he did not believe a less restrictive alternative would meet her needs because she was "liable to erupt with labile [i.e., changeable] emotions" and it was "possible she could injure another person in that state of mind." (Emphasis added.) Dr. Parker testified that he believed less restrictive options would not work for Joan because of her unstable temperament and because she had not acknowledged that she had a mental illness. Notwithstanding this testimony, the superior court found there were no less restrictive alternatives for Joan.
I start with the proposition that a mentally ill person's belief that she is not mentally ill cannot be the measure by which a court finds that there are no less restrictive alternatives; nor can a doctor's testimony that a person might display changeable emotions or "possibly" cause harm. Of greater significance, it is illogical and insufficient for a doctor to opine that there are no less restrictive alternatives when the doctor has done nothing to evaluate any less restrictive alternative. The doctors were aware, or should have been aware, that Joan was brought to the hospital by her mother. They were aware that Dr. Baker had previously provided psychiatric treatment to Joan. Their failure to contact family and Dr. Baker or to explore any other possible alternative should have caused the superior court to conclude that the State, which bears the burden of proof, failed to prove that there were no less restrictive alternatives.
In Wetherhorn we said:
Because there was no clear and convincing evidence that Joan presented a substantial risk of harm to herself or others, and that she was "helpless to avoid the hazards of freedom ... with the aid of willing family members or friends"
I also disagree with this court's resolution of the mootness question. The court today recognizes for the first time that the collateral consequences doctrine will permit an appeal of an otherwise moot order of involuntary commitment, provided that no previous commitments have been ordered. The court hedges on whether it will recognize in later cases the collateral consequences exception to the mootness doctrine for persons who have been involuntarily committed more than once. While I agree that collateral consequences justify not applying the mootness doctrine in involuntary commitment cases, I would go farther: it is my view that the supreme court must accept and decide on the merits every appeal of an order of involuntary commitment.
The mootness doctrine is a judicially constructed doctrine to give the courts a means to avoid addressing cases that no longer present "live controversies."
The right to appeal is no right at all if it is merely the right to pay the filing fee and file an appellate brief, only to be told that your appeal is moot and the court will not reach the merits. Even though the respondent will in every case have already completed her 30-day commitment by the time her appeal is ripe, and therefore the supreme court could not undo the commitment if the respondent's commitment order were wrongly issued, I contend that any order for involuntary commitment that is erroneously issued remains a "live controversy" for the respondent for the remainder of the respondent's life. Of first importance, the citizen's liberty has been alleged to have been wrongfully taken by court process; the court should afford the citizen the opportunity to prove the error and, if proven, obtain judicial acknowledgment that the order was erroneously issued. Giving the citizen this opportunity will assure the citizen that she will be heard, and that if a lower court has erred, that error will not go unnoticed or unremedied, at least to the extent that the erroneous order will be reversed and vacated. Public confidence in the
Second, in this age of prevalent information mining, collection, and storage into increasingly large, interconnected, and searchable data banks, the fact that a citizen has been involuntarily committed to a mental institution will follow that individual for all of her life. She should be given the means to effectively challenge that order through appeal regardless of the fact that by the time her appeal is ripe for decision, the 30 days will have long since expired and she will have been released from State custody. The injury inflicted by an erroneously issued order of involuntary commitment "lives" until the wrong is righted. I am at a loss to understand how a citizen can be ordered to be involuntarily committed for 30 days and be precluded from appealing this order merely because it is practically impossible to perfect an appeal of an order that by its terms will expire in 30 days.
Ending where I began, we—the Alaska Supreme Court—along with our legislature and the United States Supreme Court, have recognized that "involuntary commitment for a mental disorder [is] a `massive curtailment of liberty' that cannot be accomplished without due process of law."
