Opinion
AP-20-39
05-16-2021
In Re: Kari G.
ORDER
THOMAS MCKEON, JUSTICE MAINE
Before the Court is Appellant's appeal from the District Court's Order for Hospitalization in a Mental Hospital. For the forgoing reasons, the judgment of the District Court is affirmed.
I. Factual Background:
The Appellant reported to Franklin Memorial Hospital's emergency department on October 22, 2020, exhibiting disorganized, paranoid, and manic behaviors. Based on the Appellant's mental condition, doctors committed the Appellant to Spring Harbor Psychiatric Hospital on an emergency basis pursuant to 34-B M.R.S. § 3863. The Appellant was committed to Spring Harbor for the maximum period allowed for psychiatric emergencies. Spring Harbor then petitioned the District Court to commit the Appellant to Spring Harbor for further inpatient treatment pursuant to 34-B M.R.S. § 3863(5-A)(C). A hearing on the petition was held on November 4, 2020, after which the District Court ordered that the Appellant undergo both inpatient and involuntary treatment for a period of forty-five days. The Appellant appeals that decision here.
During her initial emergency treatment, the Appellant was treated by Spring Harbor's attending psychiatrist, Dr. William Brennan. Dr. Brennan testified at hearing that the Appellant denied having a mental illness and resisted psychotropic medications. Dr. Brennan also detailed that the Appellant was aggressive with Spring Harbor staff, appeared manic, and suffered from delusional forms of thought. Dr. Brennan testified further that the Appellaut had been hospitalized over mental health concerns on at least eight prior occasions. Dr. Brennan stated that he believed the Appellant's mental illness had caused her to previously engage in certain dangerous behaviors, which iucluded an incident where Appellant reportedly drove her car over ninety miles per hour based on her belief that the car was a bomb that was about to explode. Dr. Brennan concluded that the Appellant suffered from a mental illness, including elements of bipolar and schizoaffective disorders, which were exacerbated by her unwillingness to engage in appropriate outpatient treatment over the previous twelve months.
Dr. Brennan gave his opinion that it was essential for someone suffering from Appellant's mental illness to engage in consistent outpatient care. Dr. Brennan further described that it was difficult to treat the Appellant's illness during her three-day emergency commitment, namely because the Appellant refused to take medications orally and also because the medication being administered was designed to treat the mental health emergency itself, not the Appellant's underlying mental illness. Although the Appellant made progress during her three-day emergency treatment, Dr. Brennan stated that Appellant's treatment was indeed focused primarily on her mental health emergency, not her underlying mental illness. Dr. Brennan expressed concern that in order to adequately threat Appellant's mental illness, the Appellant would need to have thoughtful discussions regarding active treatment and commit to taking certain medications. However, the Appellant maintained throughout her emergency treatment that she does not suffer from a mental illness and refused to take medications orally. Dr. Brennan testified that it was likely that the Appellant's illness would regress if she were released.
Dr. Brennan also submitted a report to the District Court which outlined a proposed treatment plan for the Appellant. The treatment plan specifically requested that the District Court authorize the use of certain medications, which the Appellant had refused to take during her emergency treatment period. Dr. Brennan testified that the side effects of the requested medications included drowsiness, weight gain, and sedation, which could be monitored daily during her involuntary treatment. Dr. Brennan also gave his opinion that the benefits provided by the requested medications outweighed the risks, stating that without the medications, the Appellant would likely end up in the hospital again and that the longer the Appellant remained in a manic state, the more difficult her situation could become.
Dr, Brennan further explained his concern for the Appellant's safety if she were to be released from the hospital. Dr. Brennan described that the longer a patient remains in a manic state, the harder it becomes to restore the patient to their "baseline." In regards to Appellant specifically, Dr. Brennan expressed concern that the Appellant would not engage in appropriate treatment if she were released, which could further exacerbate her mental illness and complicate her likelihood of recovery. Dr. Brennan was specifically concerned that the Appellant had reportedly told her housemate that she wanted to retrieve a gun and shoot herself. Dr. Brennan also reiterated his concern over the Appellant's reported delusions, including the incident where the Appellant thought her car was a bomb. Dr. Brennan concluded that, in his opinion, the Appellant presented a number of concerning symptoms that made her a threat to herself and others if she were to be released without further treatment.
Dr. Brennan also testified that there were no adequate community resources available to care for or treat the Appellant if she were released. Dr. Brennan stated that in his opinion, inpatient treatment was the best available and least restive means to treat the Appellant. Dr. Brennan also testified that Spring Harbor had the ability to carefully monitor and adjust Appellant's medications as needed. Dr. Brennan testified that he did not think that the Appellant would engage in an appropriate level of treatment outside of the Spring Harbor facility.
On cross examination, Dr. Brennan acknowledged that the Appellant did have a support system outside of Spring Harbor. This system included a prescribing primary care doctor, a behavioral health specialist, and peer support therapist. Dr. Brennan admitted that he had not spoken with these supports directly before coming to his conclusions. However, Dr. Brennan maintained that in this opinion, the Appellant still required medication and expressed concern that the Appellant was refusing such medications. Dr. Brennan stated that he felt that Appellant's established support group was almost irrelevant in the absence of medication because it would be unable to provide the support necessary when the Appellant was in a manic state. Dr. Brennan also admitted that some of the medications he sought authorization for had been administered to the Appellant previously, but gave his opinion that the medications prior lack of efficacy was likely due to the Appellant's refusal to stay on those medications.
Nurse Practitioner, Constance Jordan, also testified at the District Court hearing. Jordan was appointed by the court to perform a mental examination of the Appellant. Jordan met with the Appellant via zoom on October 28, 2020.
Jordan testified that the Appellant's mental health symptoms prevented the Appellant from engaging in a substantive narrative conversation during the examination. Jordan testified further that the Appellant appeared exceedingly disorganized, exhibited loose associations, and paranoid delusions. Jordan also stated that the Appellant continued to assert that she did not suffer from a mental illness, but rather a personality disorder. Jordan testified that the Appellant's explanations of events that lead to her hospitalization were not consistent with the medical or physical symptoms the Appellant displayed.
Jordan also testified that in her opinion, the Appellant suffered from a mental illness and concurred with Dr. Brennan's opinion that the Appellant had an evolving diagnosis of schizoaffective disorder. Jordan explained that it takes time to fine tune the etiology of psychotic symptoms in situations similar to Appellant's.
Jordan also testified that, in her opinion, the Appellant posed a substantial risk of harm to herself or others if she were to be released without further treatment because she appeared unable to care for herself outside of the structured environment that the hospital could provide. Jordan explained that her opinion was based on the fact that the Appellant lacked the insight and judgment necessary to pursue appropriate voluntary treatment. Jordan testified further that she felt there were no appropriate community-based resources to care for the Appellant if she were released and that inpatient hospitalization was the least restrictive means of treatment.
Jordan also testified that she had reviewed Dr. Brennan's proposed treatment plan. Jordan stated that she felt that the proposed medications were adequate to get the Appellant's symptoms under control and that she would benefit from the proposed medication plan. Jordan also stated that, in her opinion, the Appellant was unable to make informed decisions about treatment in her present state. Jordan agreed that the Appellant's need for treatment outweighed the risk and side effects of the treatment plan.
On cross examination, Jordan admitted that her examination of the Appellant took place a week prior to the District Court hearing. Jordan also testified that her examination of the Appellant lasted for approximately fifteen to twenty minutes.
The Appellant also testified at the hearing. The Appellant gave her opinion that both Dr. Brennan and Jordan were wrong in their diagnosis. The Appellant also stated that she had never met with Jordan. The Appellant detailed her current support system, which included: immediate family; a social worker whom Appellant meets with every week; a weekly peer group therapy session; a nurse practitioner; endocrinologist; and psychiatrist and therapist. Although the Appellant admitted that she did have a mental illness, she maintained that she had been misdiagnosed by Dr. Brennan and Jordan.
The Appellant testified further that she has previously tried the medications that Dr. Brennan sought authorization for. The Appellant stated that although these medications do work, the side effects always left her feeling worse off than she had previously. The Appellant detailed that the medications sought by Dr. Brennan make her extremely drowsy and unmotivated, and caused her to gain approximately sixty five pounds. The Appellant further explained that she felt she had a borderline personality disorder, not a paranoid or schizophrenic illness. The Appellant stated that her disorder demands therapy, not just medications, and that she has benefited from the use of her therapy dog. The Appellant disputed that she was ever abusive with Spring Harbor staff, and testified that she has been compliant throughout her emergency treatment period. The Appellant also testified that she believed that the Spring Harbor staff was lying about her emergency treatment, and stated that she has not been treated by Dr. Brennan.
At the end of the testimony, the District Court made the following determinations on the record:
"The hospital has proven by clear and convincing evidence that there's a mental illness here. I know the patient doesn't agree with that. It appears that with bipolar and now may be evolving into schizoaffective disorder. And it's also proven that her recent actions and behaviors show that there is a likelihood of serious harm to
herself or others based on the testimony of the history given by both experts.
She may have some supports outside the hospital, buy they are not available to her right now or adequate in light of the advanced stage of her mental illness. And she needs hospitalization right now in the hospital in ... internally. In a hospital, not outside getting outpatient treatment, is the best available means to treat the mental illness I mentioned earlier.
She also lacks the capacity to make informed decisions regarding treatment. And the need for the treatment, largely based on medication, the benefits of that certainly outweigh the risk that exist with any medication. I know she says she's had some side effects, but without the medication she is unable to get out of the hospital and function appropriately based on her current symptoms.
In addition, the recommended treatment plan is the least intrusive treatment that's available to her. And without it, her commitment could be significantly extended. And she needs to, at this point, cooperate with the plan."(Hearing Transcript: pgs. 41-42, ¶¶13-13.) The District Court ordered that the Appellant be committed for involuntary treatment for a period of 45 days.
II. Standard of Review
An appeal from a District Court Judgment is limited to questions of law and the District Court's factual determinations shall not be set aside unless clearly erroneous, M. R. Civ. P. 76D. A fact finding court is the "sole arbiter of witness credibility" and is "free to selectively accept or reject portions or all of any witness's testimony[.]" Efstathiou v. Efsathiou, 2009 ME 107, 5T 12, 982 A, 2d 339. The reviewing court "will reverse a finding only if there is no competent evidence in the record to support it, if the factfinder clearly misapprehends the meaning of the evidence, or if the finding is so contrary to the credible evidence that it does not represent the truth and right of the case[.]" In re Henry B., 2017 ME 72, ¶ 18, 159 A.3d 824 (citations and quotations omitted). The presence of conflicting evidence is not sufficient to overturn a fact finder's determination when there is other competent evidence in the record to support those determinations. See Efstathiou, 2009 ME 107, J 12, 982 A.2d 339 (holding that there was competent evidence in the record that supported the court's findings, "[notwithstanding the significant conflicting evidence").
III. Discussion:
The Appellant here challenges only the District Court's factual determinations that there was clear and convincing evidence to: (1) involuntarily commit the Appellant for forty-five days; and (2) order the Appellant to undergo involuntary treatment. Accordingly, the issue before this court is whether there is competent evidence in the record to support the District Court's factual determinations on each issue.
A. Involuntary Commitment
A person may be admitted to a psychiatric hospital on an emergency basis according to certain procedures. See 34-B M.R.S. § 3863 et seq. "If there is need for further hospitalization of the person" beyond the time allowed under the emergency procedures, a qualified individual "may seek involuntary commitment" from the District Court. 34-B M.R.S. § 3863(5~A)(C). The District Court may order involuntary commitment if it determines that: (1) there is clear and convincing evidence that the person is mentally ill and that the person's recent actions and behavior demonstrate that the person's illness poses a likelihood of serious harm; (2) that adequate community resources for care and treatment of the person's mental illness are unavailable; (3) that inpatient hospitalization is the best available means for treatment of the patient; and (4) that the court is satisfied with the individual treatment plan offered by the psychiatric hospital to which the applicant seeks the patient's involuntary commitment. See 34-B M.R.S, §§ 3864(6)-(7).
1. Mental Illness and Likelihood of Serious Harm
There is competent evidence in the record to support the District Court's determination that the Appellant has a mental illness and that her recent behavior posed a likelihood of serious harm. Two mental health experts testified that the Appellant suffered from a mental illness. Moreover, there is testimony that the Appellant has expressed suicidal thoughts, and a reported incident where the Appellant engaged in highly reckless driving based upon a delusion that her vehicle was a bomb. Additionally, the Appellant reportedly refused to meaningfully engage with appropriate mental health treatment. Although the Appellant disputes the testimony provided, there is also competent evidence to suggest that her resistance to treatment is further evidence of mental illness and could exacerbate her manic behaviors.
The District Court, as fact finder, is the arbiter of witness credibility. It is therefore in the purview of the District Court to accept or reject the Appellant's testimony. See Efsathiou, 2009 ME 107, ¶ 12, 982 A, 2d 339. Other than the Appellant's testimony and opinion, there is no other evidence that contradicts the expert testimony provided. Accordingly, there is competent evidence to support the District Court's conclusion that the Appellant suffered from a mental illness and posed a likelihood of serious harm.
2. Availability of Community Resources
There is competent evidence in the record to support the District Court's determination that there were no adequate community resources available to treat the Appellant. The expert testimony provided indicated that treatment for the Appellant required a structured environment that was not otherwise available outside of Spring Harbor. Although the Appellant does have a support system outside of Spring Harbor, Dr. Brennan specifically stated that this support group was irrelevant in the absence of more structured treatment. The only evidence that contradicts this expert testimony is the assertion that the Appellant's outside support group does indeed exist.
There is nothing in the record that details how or why this support group was actually equipped to treat the Appellaut's mental illness. Accordingly, there is competent evidence in the record to support the District Court's decision that there were no adequate community resources available to treat the Appellant.
3. Best Available Means for Treatment
There is competent evidence in the record to support the District Court's determination that inpatient hospitalization was the best available means to treat the Appellant's mental illness. As stated above, there is expert testimony that the Appellant required the sort of structured treatment that Spring Harbor could provide. Dr. Brennan also detailed that the Appellant had refused to meaningfully engage with appropriate treatments and resisted taking appropriate medications. Without more, the Appellant's mere disagreement with the proposed treatment, and assertion that she had been misdiagnosed, is not sufficient to contradict the expert testimony provided. Accordingly, there is competent evidence in the record to support the District Court's determination that inpatient hospitalization was the best treatment option available.
4. Individual Treatment Plan
There is competent evidence in the record to support the District Court's approval of the individual treatment plan offered by Dr. Brennan. Both experts agreed that the Appellant's mental illness should be treated with medication and that Appellant should receive support in a structured inpatient environment. Although there is evidence that the Appellant had previously taken several of the medications sought to be administered, Dr. Brennan detailed that such had not occurred in a structured setting, and there is evidence to suggest that the Appellant does not commit to taking these medications on her own. Dr. Brennan also stated that Spring Harbor could monitor the Appellant's medications on a daily basis and adjust their dosages as needed. Moreover, inpatient treatment would have provided the Appellant with an opportunity to engage in realistic and substantive discussions regarding her evolving mental illness, an activity which Dr. Brennan stated was necessary for effective treatment. All of this was detailed in Dr. Brennan's treatment plan, and was approved of by Jordan. Accordingly, there is competent evidence in the record to support the District Court's approval of the individual treatment plan offered.
B. Involuntary Treatment
In addition to involuntary commitment, the District Court may also "grant a psychiatric hospital power to implement a recorded treatment plan without a person's consent for up to 120 days or until the end of the commitment, whichever is sooner[.]" 34-B M.R.S. § 3864(7-A)(1). To order involuntary treatment, the District Court must find: (1) that the person lacks the capacity to make an informed decision regarding treatment; (2) that the person is unable or unwilling to comply with recommended treatment; (3) that the need for the treatment outweighs the risks and side effects; and (4) that the recommended treatment is the least intrusive appropriate treatment option. 34-B MRS. § 3864(7-A)(A)(1)-(4).
1. Informed Decisions Regarding Treatment
There is competent evidence in the record to support the District Court's determination that the Appellant lacked the capacity to make an informed decision regarding treatment. The evidence at hearing suggests that the Appellant was unwilling to consider that she suffered from a mental illness other than personality disorder. The evidence also showed that the Appellant refused treatment or to engage in meaningful discussions regarding her potential schizoaffective disorder. Accordingly, there is competent evidence showing that the Appellant would be unable to make informed decisions regarding treatment of her actual mental illness during her involuntary
I commitment and there is competent evidence in the record to support the District Court's conclusions, 2. Compliance with Treatment
The Appellant's refusal to acknowledge her schizoaffective disorder diagnosis, and express reluctance to take proscribed medications, has been thoroughly discussed. Accordingly, and for reasons discussed throughout this order, there is competent evidence in the record to support the District Court's determination that the Appellant was unwilling to comply with recommended treatment.
3. Need for Treatment Outweighs the Risk
There is competent evidence in the record to support the District Court's determination that the Appellant's need for treatment outweighed the risks, The Appellant testified about the side effects she has experienced while on the medications identified in the treatment, plan, including lack of motivation and weight gain. This court, as well as the District Court, has no reason to doubt that experience. However, Dr. Brennan was clear that the Appellant was likely to encounter further hospitalizations and more intrusive treatments in the event that she failed to receive proper treatment now. Moreover, Dr. Brennan detailed that the Appellant's failure to receive treatment now could negatively impact the Appellant's future ability to regain her baseline mental status. Finally, and for reasons stated above, there is evidence to suggest that the Appellant posed an immediate risk to herself and others if she were to be released. This court cannot say, based upon the record, that the side effects the Appellant has experienced outweigh the need for the Appellant to receive inpatient treatment for her mental illness. Accordingly, there is competent evidence in the record to support the District Court's determination the Appellant's need for treatment outweighed the risks.
4. Least Intrusive Appropriate Treatment Option
There is competent evidence in the record to support the District Court's determination that the involuntary treatment sought was the least intrusive appropriate treatment option. As stated elsewhere, there was evidence to support the determination that there were no community treatment options available for the Appellant. The Appellant also testified that she has undergone other forms of more intrusive treatment, such as electroshock therapy. Conversely, the plan proposed to the District Court was limited to medication and counseling, which Spring Harbor could have monitored on a daily basis. There is nothing in the record that suggests other, less intrusive treatment options were available. Accordingly, there is competent evidence in the record to support the District Court's determination that the involuntary treatment sought was the least intrusive appropriate treatment option.
IV. Conclusion:
For the reasons above, this Court affirms the judgment of the District Court and this case shall be remanded to the District Court and judgment shall be issued in favor of the Appellee, The Clerk is directed to incorporate this Order into the docket by reference pursuant to Maine Rule of Civil Procedure 79(a).