FILED MAY 9, 2023 In the Office of the Clerk of Court WA State Court of Appeals, Division III
IN THE COURT OF APPEALS OF THE STATE OF WASHINGTON DIVISION THREE
In the Matter of the Detention of: ) No. 38815-8-III ) M.S. ) UNPUBLISHED OPINION )
PENNELL, J. — M.S. appeals a 180-day involuntary treatment order. We affirm.
FACTS
M.S. has suffered from schizoaffective disorder, bipolar type, and alcohol use
disorder for several years. M.S. traveled from western Washington to Spokane for alcohol
treatment at American Behavioral Health Systems (ABHS) in 2021. He left ABHS and
began a homeless lifestyle in Spokane on October 14, 2021.
On November 3, 2021, passersby discovered M.S. slumped over, unconscious, at
a grocery store. He was brought by ambulance to Sacred Heart Medical Center, where
his blood alcohol concentration was measured as 0.302 percent. At Sacred Heart, M.S.
presented as disorganized: he did “not know how he came to be at the hospital,” and he
exhibited “incoherent mumbling,” “brief eye contact,” and he was hyperverbal with
“sexually inappropriate language.” Clerk’s Papers (CP) at 2. He appeared tense and
was placed in seclusion after becoming agitated and yelling. No. 38815-8-III In re Det. of M.S.
M.S.’s mother was contacted, and she estimated that M.S. had spent only six to
nine total months in the community in the previous three years, with the remaining time
spent in hospitals and jails. The mother was unable to be involved in caring for M.S.
because she had a protection order against him. Before being discovered passed out at the
grocery store, M.S. had apparently visited the emergency room 10 times in the previous
two weeks for alcohol intoxication and delirium. He had made 56 total emergency room
visits in the previous year. M.S. later reported he was drinking a fifth of vodka daily prior
to the November 3 admission. When asked where he would go or how he would feed
himself if he was discharged from Sacred Heart, M.S. was unable to give meaningful
answers.
Treatment professionals petitioned for 14 days of involuntary treatment on the
basis of grave disability. A behavioral health evaluator testified that, although M.S.
remained “pretty disorganized,” he “may be approaching his baseline,” so his treating
psychiatrist had begun planning for discharge. Rep. of Proc. (RP) (Nov. 10, 2021) at 15,
21. M.S. had spent most of his time at Sacred Heart in seclusion due to yelling and
agitation that necessitated security assistance. After a hearing, the superior court granted
the petition for 14 days of involuntary commitment, concluding by a preponderance of the
2 No. 38815-8-III In re Det. of M.S.
evidence that M.S. had schizoaffective disorder and alcohol use disorder, and that due to
those disorders, M.S. was gravely disabled.
In a subsequent petition, treatment professionals sought to involuntarily commit
M.S. for 90 more days. At the court’s hearing, a psychologist testified M.S. had “made
very little to no progress,” his psychotic symptoms persisted, and “he [was] not taking
medications as prescribed or appropriately.” RP (Dec. 1, 2021) at 54. Specifically,
M.S. was refusing to take anything other than Tylenol, Benadryl, or Ativan—which the
psychologist testified would not effectively address his psychiatric conditions—and that
he had been discovered to have been crushing and snorting his Benadryl to get high.
After the hearing, the superior court granted the petition to involuntarily commit M.S.
for up to 90 days, concluding that the State had met its elevated burden of proving grave
disability by clear, cogent, and convincing evidence. On December 7, 2021, M.S. was
transferred from Sacred Heart to Eastern State Hospital.
The following February, M.S.’s attending psychiatrist at Eastern, Dr. Daniel
Psoinos, petitioned for 180 additional days of involuntary treatment, alleging M.S.
remained gravely disabled. A supporting affidavit from psychologist Dr. Gretchen
Meader related troubling incidents. On several occasions in December and January,
M.S. stole hand sanitizer and other cleaning fluids containing alcohol and drank them to
3 No. 38815-8-III In re Det. of M.S.
become intoxicated. Some of these thefts were surreptitious, but on at least two occasions
he pushed past staff into the nursing station, desperate to obtain alcohol-based products.
Dr. Meader and social worker Mackenzie Bayless met with M.S. less than two
weeks prior to the hearing on the 180-day petition. Before that meeting, Dr. Meader and
Ms. Bayless hid hand sanitizer that was apparently usually in the room. During the
meeting, M.S. showed improvement: he was “calm, expressed himself well with a linear
thought process, and had adequate grooming and hygiene.” CP at 48. “He was adamant in
requesting immediate discharge, promising not to drink,” but “[h]is body posture and
mannerisms were noteworthy during this brief exchange in that he was actively scanning
the room, straining his neck, leaning to one side, and then the other, even arching his back
as if he was looking for something specific in the room.” Id. Dr. Meader opined that
M.S.’s compulsion to seek alcohol continued to require active management due to its
exacerbating effects on his psychosis. She added, however, that M.S. “expressed
willingness to discharge to inpatient substance use disorder treatment.” Id. She noted that
M.S.’s treatment team was “willing to pursue this” if M.S. continued to stabilize, but that
the process of readying him would likely take several weeks. Id.
At the court’s hearing, Dr. Psoinos testified, opining that M.S. remained fixated on
obtaining alcohol, in part based on his recent successful efforts to steal and get drunk on
4 No. 38815-8-III In re Det. of M.S.
hand sanitizer. Dr. Psoinos also testified as to M.S.’s improvement, explaining that while
“there are symptoms of lingering psychosis,” M.S. was now “able to communicate overall
coherently” and was “relatively stable.” RP (Feb. 24, 2022) at 91-92, 95-96. Nevertheless,
M.S.’s impulse control remained poor; the very morning of the hearing, he ran down the
hall with a container of coffee and “drank as much of it as he possibly could, to the point
where he vomited.” Id. at 93. Dr. Psoinos testified that while M.S. was still reluctant to
take his needed medications, M.S. had finally made an “agreement” with staff at Eastern
to take them for now, and he had been medication compliant for six weeks, greatly
alleviating his delusions. Id. at 92.
Eastern was not treating M.S.’s alcohol use disorder at the time of the hearing.
Despite the overall improvement in his psychiatric symptoms, Dr. Psoinos noted that
M.S. was “not really engaging with us” about “[h]is substance use disorder.” Id. at 94.
Dr. Psoinos explained that there were many treatment options Eastern could provide for
substance use disorders, but that accessing those resources was necessarily contingent on
an individual’s willingness to engage. Such treatment would not typically be successful
for a patient who had not meaningfully appreciated the need to remain sober. Treatment
for alcohol use disorder could entail therapeutic intervention and medication that could
curb cravings, but Dr. Psoinos opined that such treatment was not yet appropriate for
5 No. 38815-8-III In re Det. of M.S.
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FILED MAY 9, 2023 In the Office of the Clerk of Court WA State Court of Appeals, Division III
IN THE COURT OF APPEALS OF THE STATE OF WASHINGTON DIVISION THREE
In the Matter of the Detention of: ) No. 38815-8-III ) M.S. ) UNPUBLISHED OPINION )
PENNELL, J. — M.S. appeals a 180-day involuntary treatment order. We affirm.
FACTS
M.S. has suffered from schizoaffective disorder, bipolar type, and alcohol use
disorder for several years. M.S. traveled from western Washington to Spokane for alcohol
treatment at American Behavioral Health Systems (ABHS) in 2021. He left ABHS and
began a homeless lifestyle in Spokane on October 14, 2021.
On November 3, 2021, passersby discovered M.S. slumped over, unconscious, at
a grocery store. He was brought by ambulance to Sacred Heart Medical Center, where
his blood alcohol concentration was measured as 0.302 percent. At Sacred Heart, M.S.
presented as disorganized: he did “not know how he came to be at the hospital,” and he
exhibited “incoherent mumbling,” “brief eye contact,” and he was hyperverbal with
“sexually inappropriate language.” Clerk’s Papers (CP) at 2. He appeared tense and
was placed in seclusion after becoming agitated and yelling. No. 38815-8-III In re Det. of M.S.
M.S.’s mother was contacted, and she estimated that M.S. had spent only six to
nine total months in the community in the previous three years, with the remaining time
spent in hospitals and jails. The mother was unable to be involved in caring for M.S.
because she had a protection order against him. Before being discovered passed out at the
grocery store, M.S. had apparently visited the emergency room 10 times in the previous
two weeks for alcohol intoxication and delirium. He had made 56 total emergency room
visits in the previous year. M.S. later reported he was drinking a fifth of vodka daily prior
to the November 3 admission. When asked where he would go or how he would feed
himself if he was discharged from Sacred Heart, M.S. was unable to give meaningful
answers.
Treatment professionals petitioned for 14 days of involuntary treatment on the
basis of grave disability. A behavioral health evaluator testified that, although M.S.
remained “pretty disorganized,” he “may be approaching his baseline,” so his treating
psychiatrist had begun planning for discharge. Rep. of Proc. (RP) (Nov. 10, 2021) at 15,
21. M.S. had spent most of his time at Sacred Heart in seclusion due to yelling and
agitation that necessitated security assistance. After a hearing, the superior court granted
the petition for 14 days of involuntary commitment, concluding by a preponderance of the
2 No. 38815-8-III In re Det. of M.S.
evidence that M.S. had schizoaffective disorder and alcohol use disorder, and that due to
those disorders, M.S. was gravely disabled.
In a subsequent petition, treatment professionals sought to involuntarily commit
M.S. for 90 more days. At the court’s hearing, a psychologist testified M.S. had “made
very little to no progress,” his psychotic symptoms persisted, and “he [was] not taking
medications as prescribed or appropriately.” RP (Dec. 1, 2021) at 54. Specifically,
M.S. was refusing to take anything other than Tylenol, Benadryl, or Ativan—which the
psychologist testified would not effectively address his psychiatric conditions—and that
he had been discovered to have been crushing and snorting his Benadryl to get high.
After the hearing, the superior court granted the petition to involuntarily commit M.S.
for up to 90 days, concluding that the State had met its elevated burden of proving grave
disability by clear, cogent, and convincing evidence. On December 7, 2021, M.S. was
transferred from Sacred Heart to Eastern State Hospital.
The following February, M.S.’s attending psychiatrist at Eastern, Dr. Daniel
Psoinos, petitioned for 180 additional days of involuntary treatment, alleging M.S.
remained gravely disabled. A supporting affidavit from psychologist Dr. Gretchen
Meader related troubling incidents. On several occasions in December and January,
M.S. stole hand sanitizer and other cleaning fluids containing alcohol and drank them to
3 No. 38815-8-III In re Det. of M.S.
become intoxicated. Some of these thefts were surreptitious, but on at least two occasions
he pushed past staff into the nursing station, desperate to obtain alcohol-based products.
Dr. Meader and social worker Mackenzie Bayless met with M.S. less than two
weeks prior to the hearing on the 180-day petition. Before that meeting, Dr. Meader and
Ms. Bayless hid hand sanitizer that was apparently usually in the room. During the
meeting, M.S. showed improvement: he was “calm, expressed himself well with a linear
thought process, and had adequate grooming and hygiene.” CP at 48. “He was adamant in
requesting immediate discharge, promising not to drink,” but “[h]is body posture and
mannerisms were noteworthy during this brief exchange in that he was actively scanning
the room, straining his neck, leaning to one side, and then the other, even arching his back
as if he was looking for something specific in the room.” Id. Dr. Meader opined that
M.S.’s compulsion to seek alcohol continued to require active management due to its
exacerbating effects on his psychosis. She added, however, that M.S. “expressed
willingness to discharge to inpatient substance use disorder treatment.” Id. She noted that
M.S.’s treatment team was “willing to pursue this” if M.S. continued to stabilize, but that
the process of readying him would likely take several weeks. Id.
At the court’s hearing, Dr. Psoinos testified, opining that M.S. remained fixated on
obtaining alcohol, in part based on his recent successful efforts to steal and get drunk on
4 No. 38815-8-III In re Det. of M.S.
hand sanitizer. Dr. Psoinos also testified as to M.S.’s improvement, explaining that while
“there are symptoms of lingering psychosis,” M.S. was now “able to communicate overall
coherently” and was “relatively stable.” RP (Feb. 24, 2022) at 91-92, 95-96. Nevertheless,
M.S.’s impulse control remained poor; the very morning of the hearing, he ran down the
hall with a container of coffee and “drank as much of it as he possibly could, to the point
where he vomited.” Id. at 93. Dr. Psoinos testified that while M.S. was still reluctant to
take his needed medications, M.S. had finally made an “agreement” with staff at Eastern
to take them for now, and he had been medication compliant for six weeks, greatly
alleviating his delusions. Id. at 92.
Eastern was not treating M.S.’s alcohol use disorder at the time of the hearing.
Despite the overall improvement in his psychiatric symptoms, Dr. Psoinos noted that
M.S. was “not really engaging with us” about “[h]is substance use disorder.” Id. at 94.
Dr. Psoinos explained that there were many treatment options Eastern could provide for
substance use disorders, but that accessing those resources was necessarily contingent on
an individual’s willingness to engage. Such treatment would not typically be successful
for a patient who had not meaningfully appreciated the need to remain sober. Treatment
for alcohol use disorder could entail therapeutic intervention and medication that could
curb cravings, but Dr. Psoinos opined that such treatment was not yet appropriate for
5 No. 38815-8-III In re Det. of M.S.
M.S., saying, “I definitely do not think [M.S.] meets the criteria” to begin such a course
of treatment. Id. at 106. M.S. had made conclusory promises that he would not drink
in the community, apparently motivated by a desire for discharge. But he had not, in
Dr. Psoinos’s view, expressed a genuine willingness to quit, which Dr. Psoinos reiterated
was a prerequisite for substance abuse treatment to be successful.
Dr. Psoinos opined that M.S. had insight into his mental illness and his need for
treatment, and that there was a “fairly decent discharge plan” for M.S. Id. at 97-98. But
based on his observations of M.S., Dr. Psoinos also testified that he did not believe M.S.
would voluntarily take needed medications if he was discharged or that he would abstain
from substance use, which would be necessary for M.S.’s health and welfare. Dr. Psoinos
explained the connection between M.S.’s mental illness and his alcohol use:
I have no intention of discharging him until we start seeing something happen about his really desperate craving for drugs and alcohol. . . . I think he would use alcohol promptly on discharge. . . . [H]is psychotic symptoms become much worse [when intoxicated]. . . . I think if he drinks excessive alcohol, which I’m quite confident he will, he won’t remain in a stable place and he’ll be on the streets, in and out of hospitals and jail.
Id. at 99-101, 104.
On cross-examination, Dr. Psoinos agreed that if M.S. did not crave alcohol, he
would be ready for discharge immediately. But on redirect, the State’s attorney asked
Dr. Psoinos if he would be seeking to extend M.S.’s commitment if his only concerns
6 No. 38815-8-III In re Det. of M.S.
were alcohol related. Dr. Psoinos answered: “No, I probably would have discharged him
after four days in the hospital.” Id. at 112.
Ms. Bayless, M.S.’s social worker, also testified and explained she had observed
“ongoing seeking of alcohol, . . . [as] well as just a lack of awareness about . . . his need
for additional support at the time of discharge.” Id. at 114. Ms. Bayless stated that, in
her opinion, M.S. understands he has a mental health diagnosis but has told her he does
not see a need for treatment for either a schizoaffective disorder or alcohol use.
Ms. Bayless testified that she believed M.S. would begin drinking if discharged, and
explained that alcohol exacerbates his psychotic symptoms such as disorganized
cognition.
The superior court granted the petition to involuntarily commit M.S. for up to
180 additional days. The court concluded the State had shown, by clear, cogent, and
convincing evidence, that M.S. had behavioral health disorders and that he was gravely
disabled as a result. In its oral comments, the superior court explained that “I can’t ignore
the alcohol piece” because M.S.’s schizoaffective disorder and his alcohol abuse are
“intertwined” and “go hand-in-hand.” Id. at 123-26. The court memorialized this
conclusion in its written order, crediting the experts’ opinions that “[i]f discharged,
[M.S.] would rapidly decline and be at substantial risk of harm.” CP at 52.
7 No. 38815-8-III In re Det. of M.S.
M.S. appeals the 180-day commitment order.
ANALYSIS
The superior court ordered M.S.’s 180-day commitment on the basis of grave
disability. See RCW 71.05.020(24); RCW 71.05.320(4)(d), (6)(a). M.S. does not
challenge the court’s finding that he is gravely disabled. Instead, he argues the order of
commitment violates his due process rights because he has not been provided alcohol
treatment, despite the fact that his alcohol cravings are preventing his release from
detention. See State v. Kidder, 197 Wn. App. 292, 311, 389 P.2d 664 (2016) (recognizing
that due process requires that the nature of an involuntary commitment bear a reasonable
relation to the purpose for commitment).
M.S.’s due process argument rests on a mistaken assumption about the basis of
his confinement. M.S. carries dual diagnoses of alcohol use disorder and schizoaffective
disorder. As recognized by the trial court, these two conditions are intertwined such that
each exacerbates the harms posed by the other. At the 180-day commitment hearing,
professionals from Eastern State Hospital expressed concern that if M.S. were released,
he would immediately resume drinking and then become mentally unstable due to
his schizoaffective disorder. Thus, the trial court ordered M.S. detained based on the
8 No. 38815-8-III In re Det. of M.S.
combination of his alcohol use disorder and his schizoaffective disorder. M.S. was
not detained solely because of his alcohol use.
The record indicates M.S. was receiving treatment for his schizoaffective disorder
and that he would receive treatment specific to alcohol use once he made sufficient
progress and demonstrated a genuine willingness to remain sober. At the hearing, the
professionals from Eastern testified that while M.S. had made some progress in
addressing his schizoaffective disorder, he had not yet gained insight into his condition
sufficient to remain compliant with treatment outside a controlled hospital setting.
Furthermore, M.S.’s alcohol-seeking behavior made clear that M.S. was not yet ready
to benefit from alcohol treatment.
M.S. suggests that the superior court improperly sought a guarantee against relapse
in order to allow release from involuntary treatment. We disagree with this assessment.
The trial court did not order M.S.’s continued detention because of the mere possibility of
relapse. Instead, M.S. was detained because he had not made any appreciable progress in
preparing himself for successful discharge. This was an appropriate exercise of the trial
court’s authority.
9 No. 38815-8-III In re Det. of M.S.
CONCLUSION
The order of commitment is affirmed.
A majority of the panel has determined this opinion will not be printed in
the Washington Appellate Reports, but it will be filed for public record pursuant to
RCW 2.06.040.
Pennell, J.
WE CONCUR:
____________________________ Siddoway, J.
Staab, J.