O Hear the Angel Voices

An interesting case, In re Stephen O. (Alaska Dec. 17, 2013), dealing with the recurring question of how religious claims can be relevant to mental commitment proceedings. From the three-Justice majority (some paragraph breaks added):

Shortly after Christmas 2009 Stephen O. experienced what he believed to be a religious conversion and, as he described it, “got [his] relationship back” with Jesus. In the weeks leading up to the holiday that year, Stephen had been “a little nervous” because his children were about to depart for a visit to their mother in Seattle for their Christmas vacation, the first Christmas he had spent without the children in a decade. Stephen and his wife of eleven years had separated in May 2009, when she left their home in Haines to live with her mother….

Stephen testified that when the children returned from their visit shortly after Christmas, he began to hear the voice of Jesus speaking to him, telling Stephen that his sins were forgiven and he should “get on a path of repentance.” According to Stephen, Jesus told him to go to church and, in particular, to talk to a neighbor across the street who attended a Pentecostal church. Stephen visited and prayed with the neighbor, who put Stephen in touch with his pastor. The pastor invited Stephen to attend his church.

Around this same time, Stephen’s father became concerned about him after Stephen’s 12–year–old daughter reported that Stephen’s behavior was “creeping her out.” Stephen had awakened his daughter at night and talked to her about Jesus, going to church, and following “a path of repentance.”

Stephen’s father and daughter were alarmed because they believed Stephen’s behavior was similar to behavior he had exhibited about six years earlier, in 2004, when he heard voices that led him to jump off a ledge approximately 16 to 18 feet high. [It was unclear from the evidence whether the voices were said to be of Jesus or of Lucifer. -EV] He broke his ankle, gashed his head, sustained a concussion, and was temporarily wheelchair-bound as a result. This incident occurred at a hospital in Olympia, Washington; Stephen had been taken to the hospital by members of a church after he asked them to take him to a doctor because he was experiencing “total fear” as a result of hearing voices. Following this incident, Stephen was prescribed Resperdal, an antipsychotic medication, which he took for approximately one to two years. Stephen also began receiving Social Security disability benefits for psychiatric illness.

On January 8, 2010, a petition for initiation of involuntary commitment was filed at the prompting of Stephen’s family members. The petition for commitment alleged that Stephen had been “presenting with psychotic features” and exhibiting behaviors “similar to those he has exhibited in the past, prior to a suicide attempt.” Specifically, the petition alleged that Stephen had been “hearing the voice of Jesus.” On the basis of this allegation, the Haines Police Department took Stephen into emergency custody under AS 47.30.705(a). [More details omitted. -EV] …

“[I]n order to be constitutional, [Alaska involuntary commitment law] must be construed so that the ‘distress’ that justifies commitment refers to a level of incapacity that prevents the person in question from being able to live safely outside of a controlled environment.” … “[T]his construction of the statute is necessary not only to protect persons against the massive curtailment of liberty that involuntary commitment represents, but also to protect against a variety of dangers particular to those subject to civil commitment. For example, there is a danger that the mentally ill may be confined merely because they are physically unattractive or socially eccentric or otherwise exhibit some abnormal behavior which might be perceived by some as symptomatic of a mental or emotional disorder, but which is in fact within a range of conduct that is generally acceptable.”

The superior court cited the following facts in support of its conclusion that Stephen was gravely disabled: (1) Dr. Pappenheim’s recollection of Stephen’s father’s statement that Stephen’s 12–year–old daughter complained Stephen was “creeping her out”; (2) Dr. Pappenheim’s discussion of the similarities between Stephen’s 2004 prior psychotic break, hospitalization, and apparent suicide attempt as recounted by Stephen’s father; (3) Stephen’s diagnosis of bipolar affective disorder, current manic with psychotic features, and his eligibility for and receipt of Social Security disability benefits for a psychiatric condition; (4) Dr. Pappenheim’s testimony that Stephen believed that Jesus was telling Stephen that he did not need mental help. These findings together cannot support a firm belief or conviction that Stephen was “gravely disabled” for purposes of involuntary commitment.

First, as the superior court itself acknowledged, the meaning of Stephen’s daughter’s comment that he was “creeping [her] out” was unclear. The quote from Stephen’s daughter came from Dr. Pappenheim’s testimony relaying what Stephen’s father told Dr. Pappenheim the daughter said to him. Dr. Pappenheim admitted he never directly spoke to Stephen’s children and only spoke to Stephen’s father. The superior court is certainly not required to ignore this hearsay-upon-hearsay statement, but its reliability and probative value do not meaningfully contribute to the elevated evidentiary burden in this case.

Second, the record and testimony reveal marked differences between Stephen’s conduct, behavior, and experience in 2004 — six years before the present commitment hearings — and his conduct, behavior, and experience in 2010, such that the 2004 evidence is insufficient to form the basis for any firm conclusions about Stephen’s condition in 2010. As detailed above, both Stephen and Dr. Pappenheim testified concerning the differences between Stephen’s experience in 2004 — when he was “extremely fearful” and “knew something was not right” — and his experience in 2010, when he was calm, at peace, and optimistic about the future. Stephen testified that he was in “total fear” in 2004 “when the voices started” and ran to church so someone there could take him to see a doctor because he “didn’t want to hurt [anyone].” On direct examination Stephen was asked if he presently felt “any of the types of emotions or [heard] the types of voices” he experienced in 2004 or whether he felt “any pains or … internal sufferings” or “physical distress” as in 2004, and Stephen replied “no.” On the contrary, Stephen testified that he felt he was “doing good” and he was looking to the future because “[t]hings … always work out better.”

Moreover, Dr. Pappenheim acknowledged that his conclusions concerning the similarities between the two instances were substantially based on information from Stephen’s father that Dr. Pappenheim was unable to corroborate with the medical reports from the Olympia hospital….

Third, while the superior court was entitled to weigh the evidence of Stephen’s diagnosis of bipolar disorder in its gravely disabled determination, courts should proceed with caution when relying on mental illness as a basis for involuntary commitment…. “[M]ental illness, without more, ‘does not disqualify a person from preferring his home to the comforts of an institution.’” In order to involuntarily commit someone “it is not enough to show that care and treatment of an individual’s mental illness would be preferred or beneficial or even in his best interests.” Stephen’s diagnosis of illness and eligibility for Social Security benefits on the basis of his diagnosis likewise do not contribute much to the elevated burden of proof required in this case to justify commitment.

Fourth, Stephen did not express any general objections to “mental health help,” but only to psychotropic medication, particularly because of the side effects that he had previously experienced when taking such medication. Stephen stated that he was willing to comply with a court order for involuntary psychotropic medication if the court so decided.

A finding of gravely disabled by clear and convincing evidence in this case required the superior court to have a firm belief in the fact that Stephen could not live safely outside of a controlled environment, and had a condition of mental illness that, if left untreated, would cause him to suffer significant impairment of judgment, reason, or behavior. Stephen’s willingness to get treatment if the court so ordered demonstrates his ability to reason and make autonomous choices, contrary to the involuntary commitment ordered. Expressing a preference for treatment is not synonymous with refusing all mental help.

In sum, the superior court’s decision to commit Stephen was based on partial and unclear evidence, much of which was hearsay, and which the court acknowledged was in tension with significant evidence in favor of Stephen’s ability to function independently and live outside of a controlled environment…. Stephen was functioning independently before and during the hearing, and concern that Stephen would decompensate and harm himself at some time in the future was speculative….

Finally, there was much discussion at the January 20 hearing about Stephen’s religious background, belief, and practice. Dr. Pappenheim testified that Stephen’s religious beliefs were irrational and delusional, principally because they did not “come from a cultural, historical context” but rather came “out of the blue.” The superior court also seemed to regard Stephen’s religious background as important, noting that Stephen had not “regularly attended church,” although the court also commented that a person’s decision “in a time of stress” to find a “religious connection” and to proceed “to an active involvement with God” could not be regarded as “mental illness.”

In any event, even if Stephen’s beliefs did come about suddenly, this should not undermine their validity. More to the point, there was nothing harmful or dangerous about Stephen’s religious beliefs or experiences. Stephen testified that Jesus had forgiven his sins and told him to repent and to have a positive outlook on the future, messages that gave Stephen a sense of happiness and relief. Stephen also testified that he began to pray, that he wanted to pray with his children, and that, through his neighbor, he had been put in touch with the pastor of a local Pentecostal church. None of these activities or experiences rendered Stephen gravely disabled or interfered with his ability to live safely outside of a controlled environment.

Here’s an excerpt from the two-Justice dissent:

Dr. Pappenheim said … “Now, if somebody had a religious belief that they grew up with that was part of their culture, that is considered a rational means for that belief. However, in [Stephen]‘s case, the religiosity that he manifested started five years ago and led him to behave in a way that was substantially dangerous to himself, and could have killed him.” …

While Dr. Pappenheim emphasized the recency of Stephen’s religiosity, he appears to have relied at least as much on the notion that the voices directed Stephen to throw himself off a building. With regard to the superior court, the majority suggests that the superior court was unduly concerned with Stephen’s religious background. But the record shows that both parties had adduced substantial evidence on the subject and that Judge Collins merely made careful findings about it.

This was a difficult case. A troubled young man, suffering from mental illness, had a few years previously responded to voices directing him to leap from a building, seriously injuring himself. Again he was hearing voices. His worried family sought to obtain his hospitalization for his benefit and reported that he was behaving “in precisely the same fashion” now as he had in his previous psychotic episode.

An experienced trial judge, after hearing from the patient and a psychiatrist who reported the family’s concerns, found facts sufficient to support the determination that the patient was gravely disabled. Today’s majority reverses that finding by re-weighing the evidence and substituting its judgment for the trial court’s and by requiring a predictive capacity that no expert will be able to satisfy. Because I believe that the trial court did not clearly err, I respectfully dissent.