Nexus between Mental Illness and Dangerousness in Civil Commitment

Facts of the Case

On January 30, 2020, C.G. presented to Duke University Medical Center (DUMC) with psychotic symptoms that his Assertive Community Treatment (ACT) team had difficulty treating in the community. Following North Carolina’s statutorily defined process for involuntary commitment, a physician petitioned for C.G.’s involuntary commitment “for safety and stabilization” given that his psychotic symptoms were interfering with his ability to communicate and take medication as prescribed. The magistrate then ordered C.G. to be involuntarily committed and, the following day, a different physician conducted a second examination. This physician also documented several psychotic symptoms and concluded that C.G. was a danger to himself and others. Over the next week, treatment providers noted that C.G. exhibited hallucinations, grandiose delusions, disorganized speech, and unstable mood; he was diagnosed with schizoaffective disorder.

On February 7, 2020, the trial court held a hearing to determine whether C.G. should be released or remain hospitalized for further treatment. No counsel appeared on behalf of the state or DUMC. A physician who had not conducted either commitment examination yet was involved in C.G.’s current treatment testified that C.G. had been the victim of several assaults while at DUMC but had no history of self-harm other than placing himself in dangerous situations. He opined that C.G.’s belief that he did not have a mental illness and did not need treatment, coupled with the continued severity of his symptoms, would lead to “immediate decompensation” on discharge from DUMC. C.G. also testified; he expressed little insight into the reason for his hospitalization and made a number of disorganized and illogical statements. During his testimony, he stated that he did not have thoughts of harming himself or others and indicated that he would continue taking his psychiatric medication if released.

The trial court ordered C.G. to remain involuntarily committed for another 30 days based on the finding that his psychotic symptoms caused him to be a danger to himself and others and interfered with his ability to care for himself, specifically citing dental and nourishment needs. To support its decision, the court noted C.G.’s living arrangement with a person who has “anger issues,” his history of being the victim of assaultive behavior, and having “disturbing thoughts” that had led to deterioration and had rendered him unable to perceive dangers to himself. C.G. appealed this decision, arguing that the trial court’s written findings were insufficient to support its conclusion that C.G. posed a danger to himself and others and that the trial court had violated C.G.’s due process rights by eliciting evidence when counsel for the state did not appear. The court of appeals affirmed the trial court’s holding on both matters.

C.G. appealed to the Supreme Court of North Carolina on the grounds that his due process rights had been violated, that the court of appeals based its decision on current self-care conditions without any evidence of future debilitation, and that mental illness and related symptoms are insufficient by themselves to support a finding of dangerousness.

Ruling and Reasoning

The Supreme Court of North Carolina affirmed the decision of the court of appeals that C.G.’s due process rights were not violated, referencing the holding in a companion case, In re J.R., 2022 WL 177726219 (N.C. 2022).

Regarding the sufficiency of the trial court’s written findings supporting commitment, the court reversed. The court found that the trial court’s finding regarding C.G.’s mental health lacked a nexus to risk of dangerousness. The court referenced North Carolina’s civil commitment criteria under N.C. Gen. Stat. §122C-261(a) (2021), which allows for commitment based on danger to self, danger to others, or a need for treatment to prevent deterioration likely to result in dangerousness. The court determined that C.G.’s danger to self was in question, specifically the component of the definition regarding whether the individual has “acted in a manner that presents a reasonable probability that he or she will suffer serious physical debilitation in the near future” (N.C. Gen. Stat. § 122C-3(11)(a) (2008)). This determination requires evidence that the individual cannot care for self and a reasonable probability that the individual will experience serious physical debilitation in the absence of continued inpatient treatment. The court also noted that, in determining whether there was sufficient evidence for C.G.’s commitment, it could only review the trial court’s written findings rather than the entire record.

The court found that the trial court’s findings about C.G.’s diagnosis, symptoms, and circumstances prompting the initial commitment examinations were insufficient to support a reasonable probability of serious physical debilitation in the near future. The court reviewed a series of prior cases, which held that findings related to mental illness, symptoms of mental illness, and an inability to care for one’s needs are insufficient to prove that an individual will experience “serious physical debilitation” without further inpatient treatment. Thus, the court indicated that the trial court did not adequately explain how C.G.’s symptoms might lead to future decompensation outside of the hospital. The court also noted that the risk of someone else engaging in unlawful conduct against C.G. could not be used to justify C.G.’s commitment following In re Hogan, 232 S.E.2d 492 (N.C. Ct. App. 1977).

Dissent

The dissent said that the trial court did make findings about the potential for future dangerousness. Specifically, the dissent emphasized the trial court’s findings about the ongoing nature of C.G.’s symptoms and the likelihood of dangerousness if those symptoms went untreated. The dissent cited expert testimony that included a prediction of “immediate decompensation” if C.G. were discharged, evidence of C.G.’s recent noncompliance with medication as an outpatient, and evidence of insufficient nourishment and dental care before involuntary commitment, as opposed to the majority’s strict review of the trial court’s written findings. According to the dissenting opinion, based on the entire record, there was sufficient evidence of the likelihood of future harm to justify C.G.’s continued commitment.

Discussion

The holding in this case emphasizes the importance of strict adherence to the specific criteria in civil commitment statutes given the significant liberty interests and rights at stake for individuals with a history of mental illness. In particular, the holding underscores the need to delineate clearly the nexus between psychiatric symptoms and future dangerousness. In this case, the majority held that, to support the civil commitment of an individual, the trial court must make findings about the individual’s past and current symptoms of mental illness and link those symptoms to the individual’s risk of dangerousness to self or others in the absence of continued inpatient treatment.

Overall, clinicians must be aware of their jurisdiction’s specific legal framework for civil commitment, often in state statute, so that they address the appropriate criteria and assist legal decision makers in understanding to what extent an individual’s psychiatric symptoms have implications for future dangerousness as defined by statute. An individual may display symptoms of mental illness but still not be considered a danger to self or others. Although the holding in this case was a critique of the trial court’s written findings rather than the physicians’ reports or expert testimony, clear communication by clinicians about the nexus between psychiatric symptoms and future dangerousness can aid courts in arriving at sound judgments and writing clear opinions. More broadly, the seriousness of involuntary treatment in relation to patient rights and freedoms underscores the need for clinicians to provide clear reasoning that aligns with the legal framework for involuntary commitment. When clinicians match their practice, reports, and testimony with statutory language, they will not only improve the ethics of their practice but also be of greater assistance when communicating with legal actors in civil commitment hearings.