Rehabilitative Potential as a Basis for Involuntary Commitment

Facts of the Case

Mr. J. had a history of schizophrenia and substance use and was involuntarily committed to inpatient or outpatient treatment almost continuously from 1990 to 2008. Many of his hospitalizations occurred after he was noncompliant with medication, resulting in increased paranoia, agitation, rambling and pressured speech, and/or command hallucinations to kill himself or others. Mr. J. was released from prison in 2009 after serving an 18-month sentence for selling marijuana. At that point, he was adjudged to have mental illness and to be dangerous to others and was subjected to a new set of commitment orders that were renewed yearly.

In June 2015, the county filed a petition to extend Mr. J.'s involuntary outpatient commitment and treatment orders. At that time, he was living independently in the community, regularly attending appointments, and compliant with medications. During the prior 12-month period, Mr. J. had not required inpatient hospitalization; however, he continued to insist that psychotropic medications caused his mental health symptoms.

Mr. J. refused to participate in the commitment extension evaluation. Dr. Richard J. Koch, a licensed psychologist, who previously evaluated Mr. J. on five different occasions, reviewed Mr. J.'s medical records and other information. Dr. Koch opined that Mr. J. was mentally ill, dangerous, appropriate for outpatient treatment, and would continue to benefit from treatment. Dr. Koch concluded that Mr. J.'s status remained unchanged: his behaviors improved when he was compliant with medications, and he was unable to function in the community when he was noncompliant.

The circuit court extended the involuntary commitment and treatment orders for 12 months. It found that Mr. J. continued to have: … a mental illness (in the form of paranoid schizophrenia), he is a proper subject for treatment and benefits from it, he can function in the community in large part because of this treatment, and he satisfies the definition for “dangerousness” because if treatment were to cease, he would be a proper subject for commitment [J.W.J., p 787]. The court of appeals affirmed and stated that he was the proper subject for treatment because he had rehabilitative potential. Mr. J. appealed to the Wisconsin Supreme Court.

Ruling and Reasoning

The Wisconsin Supreme Court ruled that both lower courts properly applied its ruling from In the Matter of the Mental Commitment of Helen E.F., 814 N.W.2d 179 (Wis. 2012), to determine that Mr. J. is a proper subject for treatment because he has rehabilitative potential. Of note, Mr. J. did not dispute the findings regarding his mental illness or dangerousness. In Helen E.F. (a case involving a patient with Alzheimer's disease), the court separated treatment into two categories: those that bring about rehabilitation and those that do not. Citing Helen E.F., “if treatment will go beyond controlling activity and will go to controlling the disorder and its symptoms, then the subject individual has rehabilitative potential, and is a proper subject for treatment” (J.W.J., p 789). Mr. J. stated that this definition of “rehabilitation” did not take into account the unique features of schizophrenia and could lead to an inaccurate finding that the individual is a proper subject for treatment.

He asserted four problems with the court's framework in Helen E.F.:

• It is difficult to decide if treatment is controlling “behaviors” or “symptoms” in patients with schizophrenia.

• Which symptoms or how many symptoms treatment must be able to control before the patient is determined to have rehabilitative potential.

• A physician's word choice (as opposed to the patient's actual condition) could determine whether a person is a proper subject for treatment.

• Rehabilitative potential could be based on general characteristics of a class of disorders instead of focusing on the individual's symptoms and condition.

Based on these problems, Mr. J. requested that the court modify the Helen E.F. framework for defining “rehabilitation,” in part, as “if treatment will go to improving his or her disorder, then the subject individual has rehabilitative potential and is a subject for proper treatment” (J.W.J., p 789). Under his suggested language, Mr. J. would not be a subject for treatment.

The court declined to differentiate between “behaviors” and “symptoms” and maintained that the proper categories are “activities” and “symptoms.” The court relied on C.J. v. State, 354 N.W.2d 219 (Wis. Ct. App. 1984), which stated that “habilitation” addresses control of activities, and “rehabilitation” addresses control of symptoms. In the current case, “behavior” “comfortably resides in the ‘symptom’ side of our analytical dichotomy,” in that behaviors are the direct result of symptoms (J.W.J., p 791). The court related activities to functional capabilities such as eating and dressing. It distinguished whether the focus of treatment is “endogenous to the patient (symptoms) or exogenous (activities),” with symptom defined as “an expression of the disorder at work within the patient” (J.W.J., p 792). The court concluded that habilitation refers to “interventions that help a patient put exogenous things to his benefit (that is, activities)” and rehabilitation refers to “improving the patient's condition through ameliorating endogenous factors such as symptoms and behaviors” (J.W.J., p 792). A subject has rehabilitative potential, and thus is a proper subject for treatment, if treatment will control more than activities and will control the disorder and its symptoms.

The court determined that there was no need to identify which symptoms or the number of symptoms the treatment targets before concluding that an individual has rehabilitative potential. It noted that Mr. J.'s treatment reduced his symptoms such that he did not act on them and allowed him to live in society while undergoing outpatient treatment. As the state has an obligation to provide treatment in the least restrictive setting, “if a treatment controls symptoms to such a degree that withdrawing it would subject the patient to a more restrictive treatment alternative, then the treatment controls enough symptoms to establish the patient has rehabilitative potential” (J.W.J., p 793). If treatment was withdrawn, the court reported that Mr. J.'s clinical condition would likely deteriorate to the point that he would require a more restrictive level of care. “It is enough that treatment can accomplish this to demonstrate that the patient has rehabilitative potential” (J.W.J., p 793).

The court rejected Mr. J.'s assertion that providers' word choices to describe a patient's condition, rather than the patient's actual condition, could determine eligibility for treatment. Expert witness testimony would still be needed to differentiate treatments that improve a patient's disorder from those that do not. “So if we are currently at risk of deciding wrongly because of vagaries of an expert's choice of words, Mr. J.'s proposed change will do nothing to protect us. It would just give us an opportunity to err in making a different distinction” (J.W.J., p 793).

The court stated that its previous rulings explicitly required an inquiry into each individual's condition and potential for rehabilitation and not an inquiry based on determination of a group of disorders. Here, the county proved all elements for continued commitment by clear and convincing evidence.