In Re The Detention Of J.r.p.

IN THE COURT OF APPEALS OF THE STATE OF WASHINGTON
DIVISION II
In the Matter of the Detention of, No. 48300-9-II
J.R.P.,
Appellant. UNPUBLISHED OPINION
MAXA, A.C.J. – JRP appeals the trial court’s 180-day involuntary civil commitment order
following a jury trial. A person may be involuntarily committed if he or she is “gravely
disabled” under one of two definitions in RCW 71.05.020(17)(a) and (b)1. We hold that the
State presented sufficient evidence under both subsections (a) and (b) to support the jury’s
finding that JRP was gravely disabled.2 Accordingly, we affirm the trial court’s 180-day
involuntary civil commitment order.
1 RCW 71.05.020 has been amended since the events of this case transpired. However, these
amendments do not impact the statutory language relied on by this court. Accordingly, we do
not include the word “former” before RCW 71.05.020.
2 The general verdict did not specify whether its finding was based on subsection (a), subsection
(b), or both subsections. JRP argues that if the evidence is sufficient under only one of the
subsections of RCW 71.05.020(17), we must reverse because we cannot determine the basis of
the jury’s verdict. Because we hold that the evidence was sufficient under both subsections, we
do not address this argument.
Filed
Washington State
Court of Appeals
Division Two
January 31, 2017

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FACTS
JRP has been diagnosed with schizoaffective disorder, bipolar type. He has been
hospitalized eight times at Western State Hospital since 2006 and several times at other facilities
since 2003.
Petitions for Involuntary Commitment
At some time in 2014, JRP was charged with third degree assault after allegedly
assaulting a nurse in a treatment center. The charge was dismissed in January 2015 after the trial
court concluded that JRP lacked legal competency. In February 2015, JRP stipulated to a civil
order committing him to Western State Hospital for 180 days.
In August 2015, Antonio Gutierrez, M.D. and Mallory McBride, Ph.D. filed a second
petition and declaration in support of committing JRP to an additional 180 days of continued
involuntary treatment. The petition alleged that JRP was gravely disabled and that less
restrictive treatments were unavailable. JRP requested that his case be heard by a 12-member
jury. A jury trial was held in October 2015.
Gutierrez Testimony
Gutierrez’s diagnosis of JRP’s mental disorder was schizoaffective disorder, bipolar type.
This disorder manifested itself in destructive hostility, a disproportionate emotional response to
external events, psychomotor agitation with verbalized threats, elements of paranoia and
delusions. Gutierrez also diagnosed JRP with an antisocial personality disorder. Finally, the
diagnosis included his history of “polysubstance abuse, such as cannabis, alcohol, [and]
methamphetamine.” Report of Proceedings (RP) at 19.

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Gutierrez noted that JRP’s most pronounced symptom was episodic hostility, which had
led to his multiple hospitalizations. Gutierrez explained that as a result of his mental disorder,
JRP experienced violent reactions – involving screaming, demanding, pushing, banging, or
kicking – that had required hospital staff to respond to control his behavior. Gutierrez stated that
members of his treatment team had felt intimidated by JRP’s behavior “quite often,” and that
twice since June 2015 he had to run from JRP and hide behind a locked door because he was
convinced JRP would not be able to control his actions. RP at 63. JRP’s most recent incident
had been on October 5, 2015. Gutierrez testified that if JRP was released and was not
supervised, JRP’s interactions within the community would bring him into conflict with
community members, including law enforcement.
Gutierrez further testified that JRP’s participation in his treatment was inconsistent and
that he failed to participate in setting goals for himself regarding his release. JRP’s medications
were crushed and mixed into his food up until September 21, 2015. Following that time, JRP
was placed under a medication watch, which required hospital staff to watch him to ensure that
he actually took his medication. JRP did not permit medical staff to take blood draws to monitor
the medicine level in his system. Gutierrez testified that JRP believed that he did not have a
mental illness, did not need medication, and did not connect his medication to managing his
mental illness. Gutierrez testified that he believed JRP would immediately stop taking his
medication without hospital staff supervision. Without medicine, Gutierrez testified that JRP’s
symptoms would become more volatile.
Gutierrez concluded that JRP would be unable to meet his basic health and safety needs if
released from Western State Hospital. Gutierrez opined that upon being released from the

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hospital, JRP would indulge in substance abuse and fail to take his psychiatric medication.
Based on JRP’s failure to cooperate with treatment at the hospital, Gutierrez opined that JRP
would not follow through with his mental health treatment outside the hospital. Gutierrez did not
believe that a less restrictive setting would be able to adequately manage JRP’s medication or
treatment needs.
In addition, Gutierrez testified that JRP suffered from esophageal tears, known as
Mallory-Weiss Syndrome. The condition presented itself in May 2015 when JRP began
vomiting blood. JRP was uncooperative in receiving treatment for the tear at a nearby hospital
and had to be sedated. Once JRP returned to Western State Hospital, JRP did not cooperate with
staff attending to his medical needs, which Gutierrez believed was a result of JRP’s mental
disorder. JRP began treatment for the esophageal tears by taking a stomach acid reducing
medication. Gutierrez testified that he was concerned that JRP would not seek medical care if
the esophageal tears happened again. Gutierrez testified that JRP’s resistance to medical
treatment was a result of his lack of adherence to treatment for his mental disorder.
McBride Testimony
McBride echoed Gutierrez’s diagnosis of schizoaffective disorder, bipolar type and also
believed that JRP’s psychotic symptoms likely included auditory hallucinations. She testified
that JRP had participated in active treatment groups 25 to 50 percent of the time during the
month preceding the hearing. However, when JRP attended groups, he failed to participate in
treatment and was frequently preoccupied with internal stimuli. Other times, JRP would lose
control, become angry with group leaders, and leave. McBride explained that JRP suffered from

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ongoing delusional beliefs, including that his father remained alive and that he had 20 to 80
brothers residing in the community.
In McBride’s opinion, JRP would not seek out mental health services or cooperate with
treatment if released from the hospital. She based this opinion on her observations that JRP had
been uncooperative with treatment, had a pattern of refusing to take medication, failed to
consistently attend treatment groups, and stated his belief that he does not have a mental illness
or need for treatment or medication. McBride felt that she and her treatment team were unable to
develop a rapport with JRP in part due to his paranoid ideation that others were out to get him.
McBride testified that she did not believe that JRP would be able to meet his basic needs
of health and safety if released in the community. She based this conclusion, in part, on JRP’s
ongoing symptoms of mental illness, which included extreme anger and frustration and an
inability to meaningfully control those emotions. McBride expressed her opinion that there was
a very high likelihood that JRP would discontinue his medications after his release and that JRP
would cope with his symptoms by using substances.
Due to JRP’s ongoing psychotic symptoms, McBride also believed that JRP’s paranoia
would cause him “to be so suspicious of the treatment providers that it would be a very high
likelihood that he would leave that placement, [whether it be with his mother or in a group home
and] that he would go back to the streets.” RP at 134. And based on her opinion that JRP would
fail to adhere to a medication regime, McBride testified that JRP’s symptoms, post release,
would “become so overwhelming that it’s possible that he could completely lose any type of
connection to reality.” RP at 153-54.

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McBride stated her belief that JRP would have a problem finding both food and shelter
because JRP had no internal resources to manage the symptoms of his mental disorder. In
McBride’s opinion, the high level of structure provided by Western State Hospital, along with
JRP’s medications, permitted JRP to function “at a most basic level.” RP at 135. However, she
also noted that JRP had neglected his self-care even in the structured hospital environment. His
body odor became so intense that his roommates requested to be moved.
McBride testified that without the structure of the hospital and hospital staff ensuring that
he take his medications, upon JRP’s release “he would not engage in any hygiene, not eat, [and]
not have normal sleeping patterns.” RP at 136. McBride expressed her concern that without
JRP’s medications, he could forget to sleep, forget to eat, forget where he was, and forget to not
wander into traffic. She believed that JRP, without the high level of structure in the hospital,
would show severe deterioration in routine functioning if released from treatment.
McBride also discussed that JRP experienced a loss of volitional or cognitive control
while at the hospital. She explained that JRP became verbally aggressive with staff on an almost
daily basis. And she testified that JRP had also become physically aggressive on several
occasions.
JRP Testimony
JRP also testified. He recognized that he “might have certain problems I might need help
with,” including “maybe” hearing voices. RP at 167. He testified that his medication helped
him a lot. He also stated that if he was released, he would go back to a prior mental health
service provider in Seattle and take his medication.

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While testifying, JRP expressed beliefs of having been shot by police while at
Harborview, a denial that he had ever vomited blood in relation to his esophageal tear, and a
denial that his father had passed away. JRP testified that he did not believe he was gravely
disabled.
Verdict and Commitment Order
The jury was instructed on both definitions of gravely disabled under RCW
71.05.020(17). The verdict form asked whether JRP was “gravely disabled as a result of his
mental disorder.” Clerk’s Papers (CP) at 52. The verdict form did not ask the jury to specify
whether JRP was gravely disabled under subsection (a) or (b) of RCW 71.05.020(17) or under
both subsections.
The jury returned a verdict finding that JRP was gravely disabled and that further
detention at Western State Hospital for evaluation and treatment was in JRP’s best interest. The
trial court entered an order detaining JRP at Western State Hospital for a period not to exceed
180 days.
JRP appeals the trial court’s commitment order.
ANALYSIS
A. SUFFICIENCY OF THE EVIDENCE
JRP argues that the State failed to present sufficient evidence that he was gravely
disabled under either of the two alternative definitions of RCW 71.05.020(17).3 We hold that the
3 Initially, JRP argues that his appeal is not moot even though he now has been released because
he will suffer collateral consequences as a result of the 180-day involuntary commitment order.
The State does not address this argument. We have recognized that because an involuntary
commitment order may have adverse consequences on future involuntary commitment
determinations that an appeal of an involuntary commitment order is not moot. See In re Det. of

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State presented sufficient evidence that a reasonable jury could find clear, cogent, and
convincing under both subsections of RCW 71.05.020(17).
1. Legal Principles
The State sought JRP’s involuntary commitment based on former RCW 71.05.320(4)(d)
(2013). Under that statute, a person who currently is involuntarily committed for 90 days can be
recommitted involuntarily at the end of the commitment period for up to 180 days if he or she
continues to be “gravely disabled.” Former RCW 71.05.320(4)(d), (6).
RCW 71.05.020(17) defines “gravely disabled” as a condition in which a person, because
of a “mental disorder”:
(a) Is in danger of serious physical harm resulting from a failure to provide for his
or her essential human needs of health or safety; or (b) manifests severe
deterioration in routine functioning evidenced by repeated and escalating loss of
cognitive or volitional control over his or her actions and is not receiving such care
as is essential for his or her health or safety.
This statute provides two alternative definitions of “gravely disabled,” and either provides a basis
for involuntary commitment. In re Det. of LaBelle, 107 Wn.2d 196, 202, 728 P.2d 138 (1986).
In a voluntary commitment proceeding, the State has the burden of proving that a person
is gravely disabled by clear, cogent, and convincing evidence. RCW 71.05.310; Labelle, 107
Wn.2d at 209. This standard means that the State must show that it is “highly probable” that the
person is gravely disabled. Labelle, 107 Wn.2d at 209.
After a trial, our review is limited to determining whether the jury’s verdict is supported
by substantial evidence, considered in light of the highly probable test. Id. In other words, we
M.K., 168 Wn. App. 621, 625, 279 P.3d 897 (2012). Accordingly, we exercise our discretion
and address the merits of JRP’s appeal.

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will not disturb a finding of grave disability if supported by substantial evidence that the jury
could have reasonably found to be clear, cogent, and convincing.4 Id.
2. Subsection (a) – Failure to Provide for Essential Human Needs
JRP argues that the State failed to provide clear, cogent, and convincing evidence that as
a result of his mental disorder he was gravely disabled under subsection (a) of RCW
71.05.020(17). We disagree.
a. Scope of Definition
RCW 71.05.020(17)(a) states that a person is gravely disabled if because of a mental
disorder he or she “[i]s in danger of serious physical harm resulting from a failure to provide for
his or her essential human needs of health or safety.” The risk of danger of serious physical
harm must be “substantial.” LaBelle, 107 Wn.2d at 204. But there is no requirement that the
danger of harm be “imminent” because the effect of care and treatment received in a hospital
usually will eliminate the imminence of the danger. Id. at 203.
Under subsection (a), danger of harm need not be evidenced by recent, overt acts. Id. at
204. Instead, the danger usually arises from passive behavior, such as when a person fails or is
unable to provide for his or her essential needs. Id.
[T]he State must present recent, tangible evidence of failure or inability to provide
for such essential human needs as food, clothing, shelter, and medical treatment
which presents a high probability of serious physical harm within the near future
unless adequate treatment is afforded. Furthermore, the failure or inability to
provide for these essential needs must be shown to arise as a result of mental
disorder and not because of other factors.
Id. at 204-205.
4 LaBelle involved a trial court’s findings of fact and conclusions of law. But there is no reason
that a different standard of review should apply to a jury verdict. Labelle, 107 Wn.2d at 209.

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“[U]ncertainty of living arrangements or lack of financial resources will not alone justify
continued confinement in a mental hospital.” Id. at 210. The State must show that the person’s
mental condition “render[s] him unable to make a rational choice with respect to his ability to
care for his essential needs.” Id. (emphasis added). A key question is whether the person is able
to “form realistic plans for taking care of himself outside the hospital setting.” Id.
b. Analysis
The State presented evidence that if released, JRP would fail to provide for the essential
human need of medical treatment.
Both Gutierrez and McBride testified that their professional opinion was that because of
his mental disorder, JRP would discontinue taking his medication and receiving mental health
treatment upon his release. These opinions are supported by evidence that (1) JRP did not
necessarily believe that he has a mental disorder, that he needed medication, or that the
medication helped manage his symptoms; (2) JRP had failed to engage in meaningful treatment
while hospitalized; (3) JRP was suspicious of treatment providers and believes that they are
trying to harm him; (4) JRP had refused to cooperate with attempts at psychological and medical
care, including his hospitalization for the esophageal tear; and (5) JRP had developed no
resources during his treatment to manage the symptoms of his mental disorder. Gutierrez and
McBride also expressed their beliefs that it was highly likely that JRP would self-medicate
through substance abuse upon his release from the hospital.
The State also was required to produce evidence that JRP’s failure to seek medical care
caused a substantial risk of danger of serious physical harm. The State provided such evidence
regarding JRP’s mental disorder. Both Gutierrez and McBride testified that JRP would be

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unable to meet his basic health and safety needs if released. Further, Gutierrez expressed
concern that, because of JRP’s medical disorder, JRP would not seek medical care if JRP’s
substance abuse caused additional esophageal tears.
JRP argues that concerns regarding his potential failure to seek medical treatment were
too speculative and insubstantial to support the jury’s determination of grave disability. In
support of this argument, JRP cites to the Richardson case in LaBelle. 107 Wn.2d at 213. The
trial court held that appellant Richardson was at a substantial risk for serious physical harm
based on three factors: (1) he initially presented with a case of impetigo that he refused to get
treated, (2) he had tooth pain and had not seen a dentist in 12 years, and (3) he had not been
eating well prior to hospitalization but was unwilling to seek medical help regarding the issue.
Id. at 213-14. The Supreme Court held that this evidence was too speculative and insubstantial
to support the trial court’s finding of grave disability, reasoning that the impetigo no longer
required medical attention, no evidence was presented that the dental problem involved any risk
of harm to Richardson, and there was no evidence that Richard’s poor eating habits caused him
danger or resulted from his mental disorder. Id. at 214.
The facts here are different. While JRP’s Mallory-Weiss Syndrome was being treated
through medication, both of JRP’s medical providers believed that he would discontinue taking
all medication upon his release. Further, JRP would be at a substantial risk of harm upon his
release because evidence was presented that JRP would use drugs or alcohol to cope with the
symptoms of his mental disorder. Gutierrez testified that JRP’s “Superman complex,” and other
symptoms of his mental disorder, would cause JRP to fail to seek medical care for any resulting
esophageal tears caused by his substance abuse. RP at 88.

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We hold that the State presented substantial evidence of grave disability under subsection
(a) that a reasonable jury could find was clear, cogent, and convincing.
3. Subsection (b) – Failure to Receive Care Essential to Health or Safety
JRP argues that the State failed to provide clear, cogent, and convincing evidence that as
a result of his mental disorder he was gravely disabled under subsection (b) of RCW
71.05.020(17). We disagree.
a. Scope of Definition
RCW 71.05.020(17)(b) states that a person is gravely disabled if, because of a mental
disorder, he or she “manifests severe deterioration in routine functioning evidenced by repeated
and escalating loss of cognitive or volitional control over his or her actions and is not receiving
such care as is essential for his or her health or safety.” This definition has two separate
requirements: (1) a severe deterioration in routine functioning and (2) failure to receive treatment
that is essential for health or safety. LaBelle, 107 Wn.2d at 205. The legislature added this
subsection in 1979 to broaden the scope of the involuntary commitment standards. Id. at 205-
206.
Subsection (b) is designed permit the State to “treat involuntarily those discharged
patients who, after a period of time in the community, drop out of therapy or stop taking their
prescribed medication and exhibit ‘rapid deterioration in their ability to function
independently.’ ” Id. at 206 (quoting Durham & LaFond, The Empirical Consequences and
Policy Implications of Broadening the Statutory Criteria for Civil Commitment, 3 YALE L. &
POL’Y REV. 395 (1985)). However, people cannot be involuntarily committed “solely because
they are suffering from mental illness and may benefit from treatment.” Id. at 207.

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Regarding the first requirement, the State must provide recent proof of “significant” loss
of cognitive or volitional control. Id. at 208. Regarding the second requirement,
the evidence must reveal a factual basis for concluding that the individual is not
receiving or would not receive, if released, such care as is essential for his or her
health or safety. 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. To
justify commitment, such care must be shown to be essential to an individual’s
health or safety and the evidence should indicate the harmful consequences likely
to follow if involuntary treatment is not ordered.
LaBelle, 107 Wn.2d at 208. The person must be “unable, because of severe deterioration of
mental functioning, to make a rational decision with respect to his need for treatment.” Id.
b. Analysis
Here, the State presented evidence of JRP’s severe deterioration in routine functioning as
demonstrated by repeated and escalating loss of volitional and cognitive control during his stay
in the hospital.
Gutierrez testified that JRP’s mental disorder manifested such that he reacted to situations
with hostility, a disproportionate emotional response, verbalized threats, and paranoia. Even in
the hospital setting, there had been several instances of JRP losing cognitive and volitional
control that required hospital staff to call for assistance to control JRP’s behavior. Gutierrez
described how he twice had to run from JRP and hide behind a locked door because JRP could
not control his actions, and that the most recent event had occurred approximately two weeks
before the hearing.
McBride gave more specific examples of what she characterized as a loss of cognitive
and volitional control, which involved JRP growing angry and yelling or swearing at his
treatment group or the hospital staff. She further explained that JRP would grow physically

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aggressive and take such actions as punching the window at the nurse station or throwing his
medication or food at hospital staff.
In addition, the State presented evidence that JRP would not receive treatment that was
essential for his health or safety if he was released. McBride testified that the highly structured
environment the hospital provided, along with JRP’s medications, permitted him to function “at
a most basic level.” RP at 135. As discussed above, both Gutierrez and McBride believed that
because of his mental disorder, JRP would discontinue taking his medication and receiving
mental health treatment upon his release. Without the hospital structure, and premised on the
informed belief that JRP would discontinue taking his medications, McBride believed that JRP’s
functioning would severely deteriorate such that he would forget to eat, sleep, or engage in
hygiene.
JRP emphasizes that he possessed an awareness of his medical issues, that he was taking
medication and believed that it was helpful, and emphasizes that he planned to live with his
mother. However, JRP’s own testimony indicated that he did not believe that his medication was
particularly helpful. And despite JRP’s claims on appeal, the evidence discussed above indicates
that upon his release, he would not be able to make a rational decision regarding his need for
treatment.
We hold that the State presented substantial evidence of grave disability under subsection
(b) that a reasonable jury could find was clear, cogent, and convincing.
CONCLUSION
We affirm the trial court’s 180-day involuntary civil commitment order.

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A majority of the panel having determined that this opinion will not be printed in the
Washington Appellate Reports, but will be filed for public record in accordance with RCW
2.06.040, it is so ordered.
MAXA, A.C.J.
We concur:
WORSWICK, J.
SUTTON, J.