Opinion
No. C9-02-1981.
Filed: April 22, 2003.
Appeal from the Olmsted County District Court, File No. P5023801.
James M. Hansen, Bagniefski Murakami, P.A., (for appellant).
Raymond F. Schmitz, Olmsted County Attorney, Geoffrey A. Hjerleid, Assistant County Attorney, (for respondent).
Considered and decided by Shumaker, Presiding Judge, Randall, Judge, and Wright, 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This opinion will be unpublished and may not be cited except as provided by Minn.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UNPUBLISHED OPINION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 his commitment as mentally ill, arguing that (1) the district court erred in finding that he posed a substantial likelihood of harm to another, (2) there were less restrictive alternatives than commitment to the St. Peter Regional Treatment Center, and (3) the district court erred in finding that he lacks capacity to make informed decisions regarding treatment and medication. We affirm.
FACTS
Appellant Randy Carlson has a history of schizophrenia. In May 1999, he was committed to St. Peter Regional Treatment Center (St. Peter). Upon his discharge from the treatment center in May 2002, Carlson moved to Rochester, Minnesota.
On May 24, 2002, Carlson went to urgent care and demanded an emergency colostomy. Following an evaluation by a psychiatrist, he was admitted to the psychiatric unit of St. Mary's Hospital and placed on a 72-hour hold. Because of his disruptive behavior, Carlson spent part of his stay in seclusion. Although he denied having a mental illness, he agreed to take medication prescribed to treat mental illness upon discharge.
Two social workers from Olmsted County Social Services (OCSS) visited Carlson at his home on May 31, 2002. They reported that he appeared disheveled and became agitated upon learning that the visitors were from social services. He refused any mental health services, refused to take any medication, and reported that he had only pretended to take his medication in the past.
Carlson called OCSS on August 1, 2002. Carlson, who was very upset, requested assistance in moving out of town but again refused any mental health services.
The next day, OCSS received a phone call from the Olmsted County Government Center, because Carlson was demanding his money and refused to leave until he received his check. After law enforcement officers were called, Carlson left the building.
On August 5, 2002, two OCSS social workers visited Carlson at his home and observed that his arm was in a cast. Carlson reported that he had injured his arm in a fight at the Community Food Response, he had been kicked out of the Civic Inn, and he had received a citation for trespassing at a bookstore. When OCSS social workers visited Carlson again on August 22, 2002, Carlson refused any assistance from the Olmsted County Community Treatment Team.
Approximately one week later, Carlson called OCSS and reported that he had received a citation for fifth-degree assault, because he struck a man in a wheelchair with his cast. Later that day, Carlson met with a psychiatrist. During the appointment, Carlson told the psychiatrist that he felt like "blow[ing] someone's head off," but added that he would never do it.
Carlson subsequently pleaded guilty to the assault charge.
Following the meeting with the psychiatrist, Carlson was admitted to the psychiatric unit of St. Mary's Hospital and held in seclusion. When he was discharged on August 29, 2002, Carlson refused to take any medication. The psychiatrist felt that Carlson was at risk and contacted OCSS. A petition for early intervention, pursuant to Minn. Stat. § 253B.064 (2002), was filed. The psychiatrist also filed a Jarvis petition for involuntary administration of neuroleptic medication.
The OCSS screening team evaluated Carlson on September 11, 2002. After the interview, Carlson went to the psychiatric unit of St. Mary's Hospital demanding to see the doctor who submitted a letter in support of the petition. Security officers had to be used to remove Carlson from the hospital.
One week later, Carlson was jailed for disorderly conduct. He was transferred to St. Peter, where the staff reported that Carlson displayed antisocial behavior. Specifically, his appearance was unkempt, his mood was hostile, his speech was rambling, he spoke of having a deformed forehead and eyebrows, and he was fixated on his bowels, demanding tap water enemas three times a week. Carlson was demeaning and vulgar to the staff, and he threatened psychiatrists on the unit. Because Carlson continued to deny having a mental illness and refused to take medication, emergency medication was administered. Carlson subsequently agreed to take medication only after being advised of the intention to continue emergency administration.
During a psychological evaluation with Dr. Rosemary Linderman, Carlson's appearance was disheveled and he spoke loudly, sometimes screaming about being abused by the mental health system. Dr. Linderman noted that Carlson appeared to be an extremely paranoid individual who was prone to misrepresenting social situations. She diagnosed him with acute symptoms of schizophrenia and recommended that Carlson be committed as mentally ill.
On September 24, 2002, OCSS filed a petition for involuntary civil commitment supported by a Jarvis petition requesting authorization for involuntary administration of neuroleptic medication. The district court dismissed the petition for early intervention and set a hearing on judicial commitment. Following that hearing, the district court ordered Carlson to be confined at St. Peter for observation, evaluation, diagnosis, and treatment pending the commitment hearing.
Dr. Linda Marshall conducted a psychological evaluation of Carlson approximately two weeks later. During the interview, Carlson did not recognize Dr. Marshall, even though he had met with her several times in the past. Dr. Marshall reported that Carlson denied having a mental illness and complained about being abused by the mental health system. Although he was fixated on his physical pain, he wanted to forego any medication. Dr. Marshall recommended Carlson's commitment as mentally ill and concluded that he lacked the capacity to make informed decisions regarding his treatment and medication.
During the judicial commitment hearing on October 10, 2002, both Dr. Linderman and Dr. Marshall testified. They agreed that Carlson met the criteria for involuntary civil commitment as a mentally ill person. Minn. Stat. § 253B.02, subd. 13 (2002). Dr. Marshall diagnosed Carlson as suffering from paranoid schizophrenia. Both doctors agreed that, based on Carlson's recent behavior, he posed a substantial likelihood of physical harm to others and that he lacked the capacity to make informed decisions regarding his treatment and medication. The doctors also observed that Carlson had a long history of refusing medication and concluded that it was not in his best interests to stop taking medication, because his mental health would deteriorate.
The district court found Carlson to be mentally ill, ordered him committed to St. Peter, and authorized the treatment center to administer 240 mg of a neuroleptic medication daily for the duration of one year.
DECISION
On review from civil commitment, we determine whether the district court complied with the statute and whether the evidence in the record supports the findings of fact. In re Knops, 536 N.W.2d 616, 620 (Minn. 1995). We review the record in the light most favorable to the district court's decision. Id. Findings of fact justifying commitment "shall not be set aside unless clearly erroneous, and due regard shall be given to the opportunity of the trial court to judge the credibility of the witnesses." Minn.R.Civ.P. 52.01. Whether the evidence is sufficient to meet the standard for civil commitment is a legal question, which we review de novo. Knops, 536 N.W.2d at 620.
I.
Civil commitments are governed by the Minnesota Commitment and Treatment Act, codified at Minn. Stat. §§ 253B.01-.23 (2002). To civilly commit a person as mentally ill, the district court must find by clear and convincing evidence that a person is "mentally ill" within the meaning of the civil commitment statute. Minn. Stat. § 253B.09, subd. 1 (2002) (standard of proof in judicial commitment by clear and convincing evidence); In re McGaughey, 536 N.W.2d 621, 623 (Minn. 1995). The statute defines a mentally ill person as
any person who 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 as demonstrated by:
(1) a failure to obtain necessary food, clothing, shelter, or medical care as a result of the impairment;
(2) an inability for reasons other than indigence to obtain necessary food, clothing, shelter, or medical care as a result of the impairment and it is more probable than not that the person will suffer substantial harm, significant psychiatric deterioration or debilitation, or serious illness, unless appropriate treatment and services are provided;
(3) a recent attempt or threat to physically harm self or others; or
(4) recent and volitional conduct involving significant damage to substantial property.
Minn. Stat. § 253B.02, subd. 13(a) (2002) (emphasis added). The determination of a substantial likelihood of physical harm is crucial, because there is no constitutional basis for confining mentally ill persons involuntarily if they are not dangerous to anyone and can live safely on their own. O'Connor v. Donaldson, 422 U.S. 563, 575, 95 S.Ct. 2486, 2493 (1975). A substantial likelihood of physical harm may be established by a recent attempt or threat to cause physical harm to oneself or another. Minn. Stat. § 253B.02, subd. 13(a)(3). Speculation as to whether a person "may, in the future * * * attempt or threaten to harm self or others is not sufficient to justify commitment as a mentally ill person." McGaughey, 536 N.W.2d at 623. But a person is not required to "either come to harm or harm others" before civil commitment is justified. Id. Instead,
[t]he statute requires only that a substantial likelihood of physical harm exists, as demonstrated by * * * a recent attempt or threat to harm self or others.
Id.
Carlson argues that there is insufficient evidence to establish that he posed a substantial likelihood of harm to himself or others. He contends that the incident when he assaulted the man in a wheelchair did not provide a sufficient basis to justify civil commitment, because it was an isolated occurrence, the victim provoked him, and the victim did not need medical treatment. A review of the record demonstrates, however, that the district court's conclusion that Carlson was mentally ill and posed a substantial likelihood of harm to himself or others was supported by ample evidence and was not based solely on Carlson's assault of the man in a wheelchair.
The evidence supporting the district court's conclusion includes Carlson's involvement in a physical altercation at the Community Food Response resulting in his broken arm, Carlson's outburst at the hospital when he demanded to see the doctor who submitted an early-intervention petition, and Carlson's disorderly conduct when he refused assistance from a police officer. The record also shows that Carlson threatened psychiatrists at St. Peter, where he was placed pending the judicial commitment hearing, and punched a door during a psychological evaluation. The district court also relied on Carlson's comments during an interview with a psychiatrist in which he stated that, even though he would not do it, he felt like "blowing someone's head off."
Carlson's documented violent behavior supports the district court's finding that he poses a substantial likelihood of harm to others. See In re Perkins, 404 N.W.2d 307, 309 (Minn.App. 1987) (determination of mental illness supported by person's assaultive behavior). Moreover, Carlson's continued denial of mental illness, despite being diagnosed with paranoid-type schizophrenia and being previously confined for three years in a treatment facility, along with his refusal to take prescribed medication that would control his behavior, supply additional evidentiary support for the district court's findings. See In re Schaefer, 498 N.W.2d 298, 300 (Minn.App. 1993) (refusal to take prescribed medications and denial of mental illness support finding of substantial likelihood of harm). From our review of the record, we conclude that the district court's findings are not clearly erroneous and provide sufficient support to justify Carlson's civil commitment as mentally ill.
II.
Carlson next challenges his commitment to St. Peter as the least restrictive alternative. In imposing an involuntary commitment, the district court must determine that the commitment is the only suitable disposition. Minn. Stat. § 253B.09, subd. 1 (2002); In re Brown, 640 N.W.2d 919, 922 (Minn. 2002). Reasonable alternative dispositions include dismissal of the petition, voluntary outpatient care, voluntary admission to a treatment facility, appointment of a guardian or conservator, and release before commitment. Minn. Stat. § 253B.09, subd. 1. If commitment is found to be the only suitable disposition, the district court must commit the person to the least restrictive treatment program or alternative programs that will meet the patient's treatment needs. Id. Carlson argues that the district court erred in concluding that St. Peter was the least restrictive alternative, because the psychiatrists who testified during the hearing agreed that outpatient monitoring of Carlson's medication would be acceptable.
The district court considered all of the alternatives to judicial commitment and specifically rejected those alternatives because of Carlson's history of mental illness, his denial of mental illness, and his refusal to take his medication. While the psychiatrists did agree that Carlson could be provisionally discharged from involuntary confinement, a provisional discharge is not an alternative to involuntary confinement. A patient may be provisionally discharged under certain conditions outlined in an aftercare plan after he or she has been confined in a treatment facility. Minn. Stat. § 253B.15, subd. 1 (2002). Such discharge may be revoked if the patient fails to meet the conditions. Id. The psychiatrists agreed that Carlson could be provisionally discharged, but they also reiterated that Carlson needed to continue taking his medication. The evidence demonstrates that Carlson's prior provisional discharge from St. Peter was revoked, because he failed to take his medication and he became agitated and abusive when his social workers offered mental health services. Carlson's lack of insight regarding his mental illness and refusal to cooperate with treatment efforts, such as taking prescribed medication to control his mental illness, provide ample support for the district court's finding that commitment is the only suitable disposition. See In re Melas, 371 N.W.2d 653, 655 (Minn.App. 1985) (patient's lack of insight into mental illness, inability to agree to voluntary treatment, and refusal to cooperate with treatment efforts justify trial court's rejection of alternatives). Thus, we conclude that the district court did not err when it rejected Carlson's argument and determined that commitment to St. Peter is the least restrictive alternative.
III.
Carlson next argues that the district court erred when it determined that he lacks the capacity to make informed decisions regarding the administration of neuroleptic medications. Neuroleptic medications may not be administered involuntarily without court approval. Minn. Stat. § 253B.092, subd. 8(a); Jarvis v. Levine, 418 N.W.2d 139, 148 n. 7 (Minn. 1988). The court must first find that the patient lacks the capacity to decide whether to take neuroleptic medication before authorizing involuntary treatment. Minn. Stat. § 253B.092, subd. 8(e) (2000).
The evidence supports the district court's finding that Carlson lacks the capacity to give or is not competent to withhold consent to take neuroleptic medications, as determined pursuant to Minn. Stat. § 253B.092, subd. 5 (2002). Carlson has continuously denied being mentally ill after 1993. But he was confined as mentally ill at St. Peter from May 1999 until May 2002. The undisputed evidence also establishes that Carlson has consistently refused to take medication prescribed for his mental illness. His provisional discharge from St. Peter in 2001 was revoked because he refused to take his medication. (He admitted pretending to take medication and later discarding it.) Yet, there is no doubt that Carlson needs to take the prescribed medication. In the past, Carlson's condition stabilized with neuroleptic medication. When Carlson refused to take his medication during his provisional discharge, his condition worsened, resulting in his involvement in numerous violent incidents. The evidence also establishes that the benefits to Carlson's mental health outweigh any side effects from the neuroleptic medication.
Because there is sufficient evidence to support the district court's conclusion that Carlson is mentally ill and in need of confinement in a structured treatment facility that can monitor his mental health and administer necessary medication, we affirm.