In re Tonja P.
| Docket Number | Supreme Court No. S-18077 |
| Decision Date | 17 February 2023 |
| Parties | In the MATTER OF the Necessity for the Hospitalization of TONJA P. |
| Court | Alaska Supreme Court |
Julia Bedell, Assistant Public Defender, and Samantha Cherot, Public Defender, Anchorage, for Tonja P.
Laura Fox, Senior Assistant Attorney General, Anchorage, and Treg R. Taylor, Attorney General, Juneau, for State of Alaska.
Before: Winfree, Chief Justice, Maassen, Carney, and Borghesan, Justices. [Henderson, Justice, not participating.]
A woman appeals court orders authorizing her involuntary commitment and administration of psychotropic medication. She argues the superior court erred by relying on a cursory report from the court visitor and by failing to make specific findings that involuntary medication was in her best interests. She also contends that it was error to commit her to a psychiatric hospital instead of to a less restrictive facility. We affirm the superior court's orders.
Tonja P.1 suffers from schizophrenia
; before March 2021 she had previously been committed to the Alaska Psychiatric Institute (API) six times. Between 2016 and 2021 Tonja lived with her parents and was able to manage her illness with outpatient treatment. In March 2021 her health deteriorated after she stopped taking medication. She became unable to care for her hygiene and other needs and became aggressive with her parents. Tonja went to API voluntarily but after she was admitted she declined medication. API petitioned for an order authorizing Tonja's hospitalization for evaluation. Tonja's father, who is her legal guardian, supported API's request. The superior court granted the evaluation order.
A day later API filed a petition to commit Tonja for 30 days for treatment2 and a petition to authorize the involuntary administration of psychotropic medication.3 The commitment petition alleged Tonja was mentally ill and was "[c]urrently psychotic, responding to internal stimulation (hallucinations) and unable to communicate effectively." It also alleged she was gravely disabled because she was unable to make an informed decision or to communicate her needs. The petition asserted that Tonja would not be safe and would be unable to obtain shelter or food outside of API. The involuntary medication petition sought authorization to treat Tonja with two psychotropic medications.
A combined hearing on both petitions was held before a master on March 11. API presented Tonja's treating psychiatrist, Dr. Laura Swogger, as an expert witness in psychiatry. Dr. Swogger testified that Tonja initially had been aggressive at API and had bitten one of the officers who brought her in. She testified that Tonja had since become withdrawn and isolated, and was not able to organize her thoughts or communicate in a coherent manner. She acknowledged that Tonja was taking care of her basic needs but required "a lot of supervision and prompting." Dr. Swogger testified that Tonja had voluntarily taken medication when she first arrived at API, but that she began refusing medication shortly after her admission. Dr. Swogger testified that she spoke with Tonja's father, who stated he and her mother wanted her to return home but not until her condition improved.
Dr. Swogger also testified that Tonja would not be able to function if released to a homeless shelter because she would be unable to care for her basic needs and would easily be victimized because of her "confused" and "disoriented" mental state. Dr. Swogger explained that API offered a variety of types of therapy but that Tonja would not benefit from them until her psychosis
improved, which required medication. She testified that a similar treatment plan had worked for Tonja in the past. Dr. Swogger also stated that she was unaware of any outpatient provider that would accept someone with Tonja's level of need.
Tonja was provided with an opportunity to testify, but she was unable to speak coherently and eventually declined to speak. Because Tonja was unable to communicate her wishes, her attorney took no position on the commitment petition4 except to emphasize API's high burden.
The superior court next addressed the medication petition. The court-appointed visitor5 testified that Tonja could not follow a conversation; was confused about her name, what year it was, and where she was located; and denied having a mental illness. The court visitor described Tonja as "confused and disorganized" and "actively delusional." She stated that Tonja had not expressed any reasonable objections to medication or identified any side effects that concerned her. The court visitor concluded that Tonja did not have the capacity to give consent, to assimilate information regarding her diagnosis and treatment, to make treatment decisions or participate in treatment, and lacked insight or the ability to rationally engage in treatment decisions. She testified that she attempted to reach Tonja's father but was unsuccessful, and that Tonja "does not appear to have an advance[ ] health care directive."
Dr. Swogger was called again. She agreed with the court visitor's conclusions. Dr. Swogger testified that she planned to administer the antipsychotic medication risperidone
to Tonja, but to have a second medication, haloperidol, as a backup in case Tonja did not tolerate risperidone. She testified that the medication plan was within the standard of care for schizophrenia, that Tonja had successfully been treated with both medications in the past without negative effects, and that her risk for side effects was low. Dr. Swogger also testified that API took the potential for side effects very seriously, and she detailed measures to monitor and address potential side effects. Finally, Dr. Swogger testified that medication was in Tonja's best interest because her condition would "probably stay the same or ... potentially worsen" without it. Tonja's attorney again took no position on the petition except to reiterate API's high burden and emphasize that granting the petition would be a "serious intrusion."
The court granted the medication petition. It found that Tonja lacked the capacity to give informed consent, that the court visitor could not locate an advance health care directive for Tonja, that medication was in Tonja's best interest, and that there were no other reasonable and less restrictive alternatives to medication. The court concluded that "the benefits of these medications clearly outweigh the minimally anticipated risks[,]" and that "Dr. Swogger ha[d] articulated a plan of treatment that includes close monitoring" for side effects.
Several weeks later API petitioned for a 90-day commitment order6 and for continued authorization to administer medication. A hearing was held on April 8 on both petitions. Dr. Swogger again testified. She stated that Tonja had improved and was able to communicate but did not make much sense. She testified that Tonja continued to exhibit "symptoms of a thought disorder," including hallucinations and minor delusions. She also testified that Tonja still needed prompting to take care of her basic needs and that she was "not in any way able to procure her own food." She reported that Tonja's parents still wanted her to return home but wanted her to be more stable before she came home. She opined that returning Tonja to her family was "the strongest discharge plan" for her.
Dr. Swogger explained that Tonja's current treatment plan was to transition
Tonja from oral medication to long-lasting injectable medication. Dr. Swogger testified that outpatient facilities or assisted living facilities were not viable alternatives because they were not able to involuntarily administer the injectable medication that Tonja needed and could not prevent Tonja from leaving.
The superior court granted the petition for a 90-day commitment. Based on Tonja's continued hallucinations and delusions and her inability to meet her needs, the court concluded that she remained gravely disabled as a result of her mental illness.
The master then considered the medication petition. The same court visitor testified. She reported that Tonja was "oriented in all spheres," but that she still struggled to identify her exact location, continued to be confused and disorganized, denied having a mental illness or need for medication, and was still unable to articulate reasonable objections to medication or identify any concerning side effects. The court visitor concluded Tonja still did not have capacity to give consent nor the ability to engage rationally in treatment. The visitor also testified that she again attempted to contact Tonja's father and was again unsuccessful, but this time the court visitor informed the court that Tonja "does not have an advance health care directive."
Dr. Swogger was called to testify about Tonja's need for medication. She agreed with the court visitor's testimony and added that Tonja's next treatment step was to transition
her from daily pills to one injection every 14 days. She testified that Tonja would benefit from continued medications and that Tonja had not experienced any side effects so far. She explained that Tonja would be unable to benefit from other therapies without further medication and that she "would go back to the way that she presented"...
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