In the Matter of A.H.

• Court: Massachusetts Appeals Court
• Decided: July 13, 2026
• Docket: AC 25-P-103
• Status: Published

Opinion

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25-P-103 Appeals Court

IN THE MATTER OF A.H.

No. 25-P-103.

Worcester. May 4, 2026. – July 13, 2026.

Present: Walsh, Hershfang, & D'Angelo, JJ.

Practice, Civil, Civil commitment, Commitment of mentally ill person. Witness, Expert, Physician. Regulation.

Petition for civil commitment filed in the Worcester Division of the District Court Department on January 13, 2021.

The case was heard by Robert J. Pellegrini, J.

Susan F. Ennis for the respondent. Alexander Weiss, Assistant Attorney General, for the petitioner.

D'ANGELO, J. This case turns on whether the record

sufficiently established that A.H.'s diagnosis of intermittent

explosive disorder (IED) qualified as a "mental illness" for

purposes of 104 Code Mass. Regs. § 27.05(1) (2019), the

Department of Mental Health (department) regulation applicable

to involuntary civil commitments under G. L. c. 123, §§ 7 and 8. 2

A.H. appeals from a decision and order of the Appellate Division

of the District Court (Appellate Division) affirming a District

Court judge's order granting the petition for involuntary civil

commitment filed by Worcester Recovery Center and Hospital

(petitioner). We conclude that there was sufficient evidence

for the judge to find that A.H.'s IED diagnosis constituted a

mental illness as defined by 104 Code Mass. Regs. § 27.05(1), in

accordance with G. L. c. 123, § 2. We further conclude that the

judge did not err in finding that there was no less restrictive

alternative to A.H.'s commitment. We therefore affirm the

decision and order of the Appellate Division.

1. Background. We recite the facts in the light most

favorable to the petitioner. See Fazio v. Fazio, 375 Mass. 394,

402 (1978). On January 13, 2021, the petitioner filed a

petition pursuant to G. L. c. 123, §§ 7 and 8, to civilly commit

A.H. Testimony at the hearing established that A.H. had a

significant history of struggling to independently conduct the

activities of daily life, of aggressive and assaultive behavior

toward others, and of accosting others with inflammatory and

threatening racial slurs. In the year prior to the hearing,

A.H. punched a nurse with such force that it caused a fracture

to the nurse's orbital bone. The petitioner's expert, who was

A.H.'s treating psychiatrist, also testified that A.H. required

observation while eating due to a risk of choking. 3

The petitioner's expert further testified that A.H.

suffered from IED, which is a "substantial disorder" included in

both the department's regulations and the American Psychiatric

Association, Diagnostic and Statistical Manual of Mental

Disorders (5th ed. 2013) (DSM-V). The petitioner's expert

opined that IED manifested itself in A.H. as a substantial

disorder of mood. The petitioner's expert explained that

although IED is not characterized as a mood disorder by the DSM-

V, "in [A.H.'s] case, it can be a mood disorder because it

affect[ed] his mood."

The petitioner's expert further opined that IED caused a

gross impairment of A.H.'s behavior and that he could become

extremely agitated and angry, and without warning. She also

testified that the disorder manifested in unpredictable angry

outbursts arising from minor provocations (such as someone's

changing the television channel or A.H.'s being frustrated by a

peer sitting nearby) or without any apparent provocation. She

stated that the disorder grossly impaired A.H.'s judgment, as

"he continue[d] to lash out and strike out at staff" members

despite desiring to be discharged.

The petitioner's expert also opined that because of his

mental illness, A.H. posed a substantial risk of harm to himself

and to others. A.H. had committed at least twenty-five 4

attempted assaults, including six assaults after which

mechanical restraints had to be applied.

The petitioner's expert stated that IED caused A.H. to be

unable to live independently and to meet the ordinary demands of

life, such that he would not change his clothes without

prompting, would not take care of his health or appearance, and

had difficulty swallowing, creating a risk of choking and

necessitating supervision while eating. She also opined that

there was no less restrictive alternative available for A.H.

She testified that A.H. required assistance with his daily

tasks, and although the petitioner had looked for an alternative

group living environment for A.H. through the Department of

Developmental Services (DDS), A.H. was not eligible for those

services because he needed to be restraint free for three months

(a requirement that he had been unable to meet).

A.H. called an expert psychiatrist to testify. A.H.'s

expert agreed with the petitioner's expert that A.H. suffered

from IED, that A.H. was dangerous and posed a risk of harm if

released into the community, and that there was no less

restrictive placement presently available to A.H. However,

A.H.'s expert opined that A.H. did not meet the criteria for

commitment because IED is not a "disorder of mood" for purposes

of 104 Code Mass. Regs. § 27.05(1), nor is it characterized as

such in the DSM-V. 5

The judge committed A.H. for a period not to exceed one

year. A.H. appealed to the Appellate Division, which affirmed

the commitment order. A.H. thereafter appealed to this court.

2. Discussion. a. Legal framework. "General Laws

c. 123, §§ 7 and 8, address the long-term commitment of persons

with mental illness." Matter of J.D., 97 Mass. App. Ct. 15, 18

(2020). To support a civil commitment under G. L. c. 123, §§ 7

and 8, a petitioner must prove beyond a reasonable doubt that

(1) a person is suffering from a mental illness, (2) discharge

from a facility would create a likelihood of serious harm, and

(3) no less restrictive alternative to hospitalization is

available. See Matter of J.P., 486 Mass. 117, 118-119 (2020).

Although commitments are not criminal, the "proof beyond a

reasonable doubt" standard, universally applicable to criminal

cases, applies. Id. at 118.

We "scrutinize without deference the propriety of the legal

criteria employed by the [hearing] judge and the manner in which

those criteria were applied to the facts." Matter of A.M., 94

Mass. App. Ct. 399, 401 (2018), quoting Iamele v. Asselin, 444

Mass. 734, 741 (2005). We review the hearing judge's findings

of fact for clear error. See Matter of a Minor, 484 Mass. 295,

302 (2020) ("The hearing judge is in the best position to weigh

the evidence, assess the credibility of witnesses, and make

findings of fact"). Clear error exists when a reviewing court, 6

after considering the entire record, is left "with the definite

and firm conviction that a mistake has been committed" (citation

omitted). Marlow v. New Bedford, 369 Mass. 501, 508 (1976).

b. Mental illness. A.H. contends that IED does not

constitute a mental illness permitting involuntary commitment

under G. L. c. 123, §§ 7 and 8. We disagree.

The definition for mental illness is not set forth in the

statute, see G. L. c. 123, § 2, but rather is set forth in

regulations promulgated pursuant to c. 123. See 104 Code Mass.

Regs. § 27.05(1). Per the department's regulation,

"For the purpose of involuntary commitment, mental illness is defined as a substantial disorder of thought, mood, perception, orientation, or memory which grossly impairs judgment, behavior, capacity to recognize reality or ability to meet the ordinary demands of life, but shall not include intellectual or developmental disabilities, autism spectrum disorder, traumatic brain injury or psychiatric or behavioral disorders or symptoms due to another medical condition as provided in the [DSM-V] . . . ."

104 Code Mass. Regs. § 27.05(1).

Both experts diagnosed A.H. with IED. Sufficient evidence

existed for the judge to conclude that IED was a mental illness

pursuant to G. L. c. 123 and 104 Code Mass. Regs. § 27.05(1).

The petitioner's expert opined that IED is a substantial

disorder of mood and that the disorder grossly impaired A.H.'s

judgment and behavior and prevented him from meeting the

ordinary demands of life. She also opined that IED is a mental

illness that meets the criteria for commitment under 104 Code 7

Mass. Regs. § 27.05(1). A.H.'s expert opined that IED is not

categorized as a mood disorder in the DSM-V and is not a

"disorder of mood" qualifying as a mental illness for purposes

of 104 Code Mass. Regs. § 27.05(1). The judge properly

considered the testimony of the experts and the information in

the DSM-V presented to him in concluding that IED was a mental

illness.

The categorizations detailed in the DSM-V may inform but do

not bind a hearing judge or this court in concluding whether a

particular mental illness is contemplated by 104 Code Mass.

Regs. § 27.05(1). See Commonwealth v. DelVerde, 401 Mass. 447,

450 & n.5 (1988). We see no requirement that the judge be

constrained by the DSM-V's categorization of disorders. There

is no such limitation on the definition of mental illness in

G. L. c. 123, § 2, or 104 Code Mass. Regs. § 27.05(1), and we

will not read such a limitation into the definition. See

Retirement Bd. of Somerville v. Buonomo, 467 Mass. 662, 672

(2014).

A "substantial disorder of . . . mood" that "grossly

impairs" a person's judgment can be a mental illness pursuant to

104 Code Mass. Regs. § 27.05(1). See DelVerde, 401 Mass. at

450. The judge was permitted to credit the petitioner's

expert's testimony that A.H. could not care for himself and had

angry outbursts -- sometimes unprovoked -- that caused him on 8

occasion to assault staff. This evidence demonstrated A.H.'s

grossly impaired judgment and sufficiently supported the judge's

conclusion that IED severely affected A.H.'s behavior and mood

and that, as a result, A.H.'s mental condition fell within the

regulatory definition of mental illness.

The judge permissibly credited the petitioner's expert's

opinion, and other evidence, demonstrating that IED as

manifested in A.H. constituted a substantial disorder of mood.

That the experts did not agree is "irrelevant," as "[t]he law

does not give the opinion of experts . . . the benefit of

conclusiveness, even if there are no contrary opinions

introduced at the trial" (quotation and citation omitted).

DelVerde, 401 Mass. at 450. It was the judge's role to assess

the weight and credibility of the evidence, including the

experts' testimony. He did so, and we discern no clear error in

his findings.1

c. Less restrictive alternative. Ordering hospitalization

under G. L. c. 123, §§ 7 and 8, requires the absence of "any

viable, plausibly available options that bring the risk of harm

below . . . [a] 'very substantial risk.'" Matter of a Minor,

1 In light of our conclusion, we are unpersuaded by A.H.'s contention that the petitioner, by purportedly failing to make the threshold showing of a mental illness under 104 Code Mass. Regs. § 27.05(1), also failed to meet its burden of demonstrating a likelihood of serious harm caused by such a mental illness. 9

484 Mass. at 310, quoting Matter of G.P., 473 Mass. 112, 128-129

(2015). This is commonly referred to as the "least restrictive

alternative" doctrine. Commonwealth v. Nassar, 380 Mass. 908,

917-918 (1980) (in context of civil commitment proceedings, all

parties should aim "to find the least burdensome or oppressive

controls over the individual that are compatible with the

fulfilment of the dual purposes of our statute, namely,

protection of the person and others from physical harm and

rehabilitation of the person").

The burden was on the petitioner to prove, beyond a

reasonable doubt, that there was no less restrictive alternative

to hospitalization. See Matter of J.P., 494 Mass. 654, 661

(2024). The absence of such an alternative may be shown through

expert opinion testimony or other types of evidence, including a

respondent's conduct within the facility and the absence of

plausible alternatives. See id. at 667, quoting Commonwealth v

A.Z., 493 Mass. 427, 432-433 (2024).

There was ample evidence to support the judge's conclusion

that there was no less restrictive alternative. A.H. required

assistance with his daily tasks, including basic grooming,

caring for his health, and eating. The petitioner had looked

for alternative group living housing for A.H. through DDS and

found that A.H. was not eligible for those services because he

had not been restraint free for three months. There was, 10

therefore, sufficient proof beyond a reasonable doubt that there

was no less restrictive alternative.

Decision and order of the Appellate Division affirmed.