Opinion
No. A03-1754.
Filed April 27, 2004.
Appeal from District Court, Fillmore County, File No. PX-03-594.
Aaron M. Lorentz, Baudler, Baudler, Maus Blahnik, (for appellant Susanna Smith Grant).
Todd E. Pierce, Assistant Fillmore County Attorney, (for respondent Fillmore County).
Considered and decided by Shumaker, Presiding Judge; Kalitowski, Judge; and Minge, Judge.
This opinion will be unpublished and may not be cited except as provided by Minn. Stat. § 480A.08, subd. 3 (2002).
UNPUBLISHED OPINION
Appellant challenges the district court's judgment that she be civilly committed to the St. Peter Regional Treatment Center as mentally ill and chemically dependent. Appellant claims that the district court erred (1) in finding clear and convincing evidence that she is mentally ill and (2) in committing her because there were less restrictive alternatives available. Because the district court did not err, we affirm.
FACTS
Fillmore County Social Services filed a petition for judicial commitment in October 2003, alleging that appellant Susanna Grant is mentally ill and chemically dependent. The petition also alleged that appellant posed a threat of serious imminent physical harm to herself or others unless she was held in a treatment facility. At that time, appellant was being held at St. Mary's Hospital after attempting suicide on September 29, 2003. Since her stay, she has been diagnosed as having opiate dependence; opiate-induced mood disorder during withdrawal, which constitutes a major mental illness; chronic pain disorder; personality disorder; and significant depression with suicidal ideations. It is not disputed that appellant has been chemically dependent due to her use of opiates for managing her chronic pain. She was initially diagnosed with opioid dependence in 1994. She also previously received chemical dependency treatment in 1993, at which time she was diagnosed with dysthymia (a form of depression), generalized anxiety disorder, and personality disorder.
On the morning of September 29, 2003, appellant attempted suicide. She left home with a rifle on her way to her therapist appointment. Her husband notified the police, who found appellant and confiscated the weapon. Later that day, appellant drove to a field where she connected a garden hose to her car exhaust and placed the other end of the hose in her mouth. Appellant called her therapist during this suicide attempt. The therapist believed that she sounded drowsy, and he was able to determine her location. When the police arrived, they found that appellant was barely responsive and transported her to the emergency room.
After her admission to St. Mary's, appellant maintained her suicidal intent, stating that she would kill herself if she was released from the hospital without being able to continue taking her chronic pain medication. At the hospital, appellant was uncooperative by refusing to eat or drink for a number of days and requiring intravenous feeding, and refusing to take her medication. At one point, she used a syringe and injected her urine into her body, which caused a septic infection and required antibiotic treatment. Appellant previously in 1988 had injected herself with contaminated material causing illness.
In addition to appellant's threat of harm to herself, she has threatened others. Appellant has been charged with terroristic threats due to an incident in June 2003, in which she fired a rifle twice into the air to prevent her neighbors from putting up a no trespassing sign along the driveway they shared with appellant. She told the responding officer that next time she would put shots through her neighbor's "engine block and through him." In addition, she held assaultive thoughts against a psychology staff member at St. Mary's with whom she dealt with ten years ago during a child custody hearing.
The district court heard testimony from the court-appointed psychologist, appellant's treating psychiatrist, appellant's husband, and appellant. Kenneth Dennis, the court-appointed psychologist examined appellant several times in October 2003. He diagnosed appellant as having "opiate dependence and flowing from that a period of time of withdrawal from opiate-induced mood disorder and, of course, she has a pain disorder that [was] the basis for the prescription for opiates in the first place." He testified that until appellant moves beyond the withdrawal phase, he is unable to determine specifically whether her mental illness is solely dependent on addiction or dependence on the opiates. Nonetheless, he does not believe that her symptoms are simply part of withdrawal; her gun incidents and the urine-syringe incident are signs of a major mental illness of significant mood disorder. He noted that withdrawal was not the basis of her terroristic threats act in June. And during the time of her withdrawal her mood disorder is considered a major mental illness. He stated that he was "not recommending outpatient treatment to start with," but that she would have to first take care of pain management followed by chemical dependency treatment, after which any additional treatment could indicate that she be treated on an outpatient basis. He recommended that appellant have a stay of commitment during which she can receive an individualized and effective treatment plan. He also stated that she must have 24-hour supervision, which her husband might be able to provide for a couple of weeks, until she goes into an inpatient treatment program.
Dr. Alarcon is the medical director of the Mayo Psychiatry and Psychology Treatment Center, an acute intensive treatment unit. He has determined that appellant has a personality disorder reflected, for example, by her lack of self-control and low threshold for frustration. He stated that occasionally it may impair her perception of reality to the extent of losing control and acting impulsively, such as engaging in suicidal behavior or making homicidal threats. Based on her history, she is a threat of harm to herself and to others, and Dr. Alarcon recommends intensive treatment in an inpatient facility. His treatment recommendation for someone with chronic pain is initial inpatient treatment that encompasses mood, personality, potential addiction and chronic pain, after which treatment could be continued as an outpatient.
Appellant's husband, Wayne Grant, also testified. Grant and appellant had been separated for several years and living apart until a few months before her September 2003 suicide attempts. Grant is employed as a registered nurse at Mayo Clinic on the orthopedic surgical floor. He proposed a plan that appellant receive pain management and chemical dependency treatment on an outpatient basis. He was granted leave from work until she completed her pain-management program and would stay home with her 24 hours per day. He and appellant had already sent medical records to Fairview Medical Center in Minneapolis, which offers outpatient treatment for pain management, and signed the necessary releases. But his plan did not address treatment of her chemical dependency issues.
Appellant testified that she voluntarily signed the medical releases and wanted to participate in the Fairview Medical Center pain outpatient treatment program. She stated that she "made a big mistake, a big mistake." She attributed her change in attitude and behavior to the fact that she was taking a lesser dosage of her medication and had the opportunity to "sit down and think about things."
DECISION
On review of a district court's determination to civilly commit an individual as mentally ill, this court is limited to looking at whether the district court complied with the requirements of the Minnesota Commitment and Treatment Act (Act). Minn. Stat. ch. 253B (2002 Supp. 2003); see In re Schaefer, 498 N.W.2d 298, 300 (Minn. App. 1993) (limiting review to determine compliance with the requirements of the Act).
I
Before the district court may commit a person as mentally ill, the court must find that person mentally ill by clear and convincing evidence. Minn. Stat. § 253B.09, subd. 1 (Supp. 2003). This court will not set aside the district court's findings of fact unless they are clearly erroneous. In re McGaughey, 536 N.W.2d 621, 623 (Minn. 1995).
Under the Act, a person is mentally ill if he or she
has an organic disorder of the brain or a substantial psychiatric disorder of thought, mood, perception, orientation, or memory which grossly impairs judgment, behavior, capacity to recognize reality, or to reason or understand, which is manifested by instances of grossly disturbed behavior or faulty perceptions and poses a substantial likelihood of physical harm to self or others.
Minn. Stat. § 253B.02, subd. 13(a) (2002). Mental illness as defined can be demonstrated, among other behaviors, by a "recent attempt or threat to physically harm self or others." Id., subd. 13(a)(3). A person is not mentally ill if the impairment is solely because of "dependence upon or addiction to any alcohol, drugs, or other mind-altering substances." Id., subd. 13(b)(4) (2002).
Appellant argues that she is not mentally ill because any impairment in her judgment or behavior is due solely to her chemical dependence on pain killers. She argues that the court-appointed psychologist and the treating psychiatrist testified that her mood disorder could be attributed to her chemical dependence and chronic pain. She also argues that the district court could not determine whether her personality disorder constituted a major mental illness or whether it could be attributed to her chemical dependency.
The district court found that appellant has been diagnosed with "opioid dependence and with an underlying mood disorder, a major mental illness, and a diagnosis previous to this hospitalization of chronic pain disorder. [She] also has a suggested diagnosis of borderline personality disorder or factitious disorder." Appellant also suffers from a depressive disorder and, in addition to her attempted suicide in which she connected a garden hose to her car exhaust, she has "evinced a continuing and adamant plan and intent to commit suicide by shooting and was not willing to be engaged in treatment on a voluntary basis at that time." While she was hospitalized at St. Mary's, she refused to eat and drink, requiring intravenous feeding, and also injected herself with her own urine, causing a septic infection. She has also shown herself to be a harm to others; she has a "low tolerance for frustration and has used weapons in the recent past against her neighbors."
The record clearly supports the district court's detailed findings that appellant is mentally ill. And despite appellant's claim that her mental illness is due solely to her chemical dependence, neither the psychologist's nor the psychiatrist's testimony supports her claim. They testified that they were unable at this time to determine whether her behaviors were solely due to chemical dependency withdrawal. The treating psychiatrist testified that it is possible that the chronic pain and opioid dependence could be one component of the mood disorder. The psychologist testified that appellant could also have other mental disorders in addition to her chemical dependency and that during withdrawal, a mood disorder such as appellant's is considered to be a major mental illness. In addition, her terroristic threats against her neighbors, which relate to her low threshold for frustration, have nothing to do with her chemical dependency. Her inability to control herself may occasionally impair her perception of reality and result in her acting impulsively, such as attempting suicide or threatening others with physical harm. See, e.g., In re Martin, 458 N.W.2d 700, 704-05 (Minn. App. 1990) (stating that assaultive and threatening behavior presents a likelihood of harm to others). The record supports the district court's findings that under Minn. Stat. § 253B.02, subd. 13, appellant is mentally ill.
II
Appellant also argues that the district court erred by civilly committing her because there exist suitable less restrictive alternatives to judicial commitment. Appellant contends that her proposed plan that her husband watch her 24 hours a day and transport her to the Fairview Community Hospital in Minneapolis for outpatient pain management treatment is a suitable, less restrictive alternative. She claims to want to participate voluntarily and has signed the necessary release forms.
The district court must provide factual findings for any suitable, less restrictive alternative to judicial commitment that the court carefully considered and rejected, and reasons for the rejection. Minn. Stat. § 253B.09, subd. 2 (2002). This court will not reverse a district court's findings as to the least restrictive treatment program that can meet the patient's needs unless the court's findings are clearly erroneous. In re Thulin, 660 N.W.2d 140, 144 (Minn. App. 2003).
The district court made detailed findings to support its conclusion that judicial commitment is the least restrictive alternative to meet appellant's needs. The court rejected dismissing the petition because the evidence supports that appellant is mentally ill and chemically dependent. The court also considered and rejected voluntary outpatient care, voluntary inpatient care, informal admission to a treatment facility, and release before commitment. The court rejected these options based on appellant's history of impulsiveness and personality problems; her low threshold for frustration; lack of adequate supervision (the court did not believe that appellant's husband could provide adequate supervision based on his inability to prevent appellant's access to guns in the household even after a criminal hearing ordering guns to be taken from the home, his mischaracterization of an incident with the neighbors, and his inability as a registered nurse with limited psychiatric coursework to notice the opioid dependency). The court also found that appellant's proposed outpatient plan did not provide for behavioral therapy and psychotherapy.
The court rejected appointment of a guardian or conservator at this time because of her psychiatric instability, chemical dependency, and danger to herself and/or others. Finally, the court found that a stayed commitment did not provide appellant with the proper incentive to comply with a treatment program, nor did it provide for the safety of appellant and the public. Despite appellant's stated desire to voluntarily comply with an outpatient program, the district court noted appellant's prior lack of cooperation and unwillingness to help in her treatment.
Based on the record, including the testimony of the psychologist and psychiatrist, the district court did not make clearly erroneous findings that a judicial commitment is the most suitable, least restrictive alternative. Neither the psychologist nor the psychiatrist testified that an ongoing outpatient program was a suitable, less restrictive alternative. On the contrary, both the psychologist and psychiatrist testified that the treatment program best suited for appellant's needs was an inpatient program that treated her both for pain management and chemical dependency. Because the record supports the district court's determination that civilly committing appellant to the St. Peter Regional Treatment Center is the most suitable, least restrictive alternative, the court did not err.