IN THE COURT OF APPEALS OF THE STATE OF WASHINGTON
In the matter of the Detention of E.G.-R., No. 81906-2-I
STATE OF WASHINGTON, DIVISION ONE
Respondent, v. UNPUBLISHED OPINION
E.G.-R.,
Appellant.
CHUN, J. — E.G.-R. displayed signs of decompensation. The State
petitioned for 14 days of involuntary treatment under the Involuntary Treatment
Act (ITA). The trial court found that E.G.-R. showed signs of “severe
deterioration in routine functioning, evidenced by repeated & escalating loss of
cognitive and volitional control over his actions such that, outside the hospital
setting, he would not receive care that is essential to his health and safety.” The
court concluded that E.G.-R. was gravely disabled and ordered commitment.
E.G.-R. appeals contending that insufficient evidence supports the court’s
finding. For the reasons discussed below, we affirm.
I. BACKGROUND
E.G.-R. lived with his mother (Adela Ramirez), father, and younger
brother. His family helped him with housing, food, medication, and transportation
to his mental health treatment provider.
Citations and pin cites are based on the Westlaw online version of the cited material. No. 81906-2-I/2
Erich Flaker, a mental health therapist at Consejo Counseling and Referral
Services, has been working with E.G.-R. since November 2019. On August 31,
2020, Flaker spoke with E.G.-R. on the phone and noted changes in his
presentation. E.G.-R. presented “complex paranoid symptoms,” spoke about
“unreal” situations, exhibited disorganized thinking, and expressed concern about
being sexually and physically abused. After the conversation, Flaker requested
that a Designated Crisis Responder (DCR) evaluate E.G.-R.
Casey Locke, a DCR, and two of his colleagues evaluated E.G.-R. on
September 7, 2020 at his parents’ home. Locke observed that E.G.-R. was
easily agitated, spoke in a disorganized manner, and was having paranoid
delusions about being followed by a dead person. When the DCRs encouraged
E.G.-R. to continue treatment services at Consejo he repeated, “‘No’” and “‘no
means no.’” Similarly, when the DCRs asked him about medication, and whether
he was currently taking any, he repeated, “‘[N]o’” and “‘no means no.’” The
DCRs paused the evaluation and went outside to discuss less restrictive
alternatives. When they returned, they suggested voluntary outpatient treatment
at Consejo. E.G.-R. became agitated. He “puff[ed] up his chest,” shouted at the
DCRs, and “gestur[ed] with his arms.” He threw a sock at one of the DCRs,
hitting him in the face. He stepped towards the DCRs and told them to leave.
The DCRs were concerned for their safety and left. Once outside, they called
911 to execute an emergency detention.
The same day, E.G.-R. was detained for 72 hours of psychiatric evaluation
and treatment. He was transferred to Navos Hospital on September 8. The
2 No. 81906-2-I/3
State then petitioned for 14-day involuntary treatment under the ITA, claiming
E.G.-R. posed a risk of harm to others and was gravely disabled.
On September 11, the trial court held a probable cause hearing.
Ramirez’s Testimony
E.G.-R.’s mother Ramirez testified that, during the three months leading to
hospitalization, she noticed behavioral changes including increased paranoia.
About a month before hospitalization, E.G.-R. had accused a stranger at the
grocery store of “fondling” his younger brother. Ramirez explained to E.G.-R.
that it did not happen but she struggled to calm him. She was finally able to get
E.G.-R. to leave the store but he remained upset.
Ramirez also described an incident, during the month before
hospitalization, when she saw him leave the apartment very upset and cursing to
himself. She watched him walk outside and throw a rock at a garbage can.
When he returned, he went to his room and did not come out for the rest of the
day. She did not ask him about it because she thought he would get upset. She
did not know why he seemed so angry that day.
Ramirez said she is concerned about her family’s and E.G.-R.’s safety
when he is “not doing well” because he does not listen and is often difficult to
calm down. She reported that he is happy, quiet, and relaxed when he is taking
his medication.
3 No. 81906-2-I/4
Locke’s Testimony
Locke testified at the hearing. He discussed the DCR evaluation and the
circumstances prompting the decision to conduct an emergency detention. He
said that during the evaluation, E.G.-R. “refused all mental health treatment.”
Flaker’s Testimony
Flaker testified that at his baseline, E.G.-R. is talkative, cooperative, and
willing to engage in therapeutic services. But by August 31, E.G.-R. was
displaying “complex paranoid symptoms” and delusional and disorganized
thinking. Flaker concluded that E.G.-R. was gravely disabled because he could
not provide for his own health and safety needs.
Dr. Julia Singer’s Testimony
Finally, Dr. Julia Singer, a licensed clinical psychologist and court
evaluator for Navos, testified as to the following. Singer had interviewed E.G.-R.
on September 10. E.G.-R. was basically cooperative but “very ambivalent about
treatment.” He did not know why he was in the hospital and said he did not need
treatment. He also said the last time he had taken some medication was three or
four days before hospitalization.
Singer said her working diagnosis of E.G.-R. was Schizoaffective
Disorder. She based this diagnosis off of E.G.-R.’s history of six involuntary
hospitalizations and his current symptoms, including disorganized thinking,
aggression, paranoia, delusions, impaired judgment and impulse control, and
lack of insight. She was unsure about E.G.-R.’s capacity to live on his own and
4 No. 81906-2-I/5
meet his needs, and she was concerned he might try to live alone because he
had expressed paranoia about his father.
Singer based her opinion in part on several records and she read them
into the record. First, she read Flaker’s declaration in support of the petition for
detention dated August 31. Flaker noted that E.G.-R. was in a manic and
irritable mood, and displayed delusional thinking and paranoia. E.G.-R. reported
feeling threatened by “a terrorist” and “the cartel.” He also said he pressed
charges against his father with “‘America’s Most Wanted.’” Flaker noted that
E.G.-R. “reported he would like to discontinue mental health services with
Consejo reporting, ‘I know what they’re trying to do and I’m not going to do it.’”
Second, Singer read Dr. Brian Coleman’s intake evaluation dated
September 9. Coleman noted that E.G.-R. was suspicious but cooperative with
treatment recommendations. E.G.-R.’s thought process was disorganized and
he had paranoid delusions.
Third, Singer read a social services assessment by Susan Wagner dated
September 10. E.G.-R. told Wagner he wanted to stop taking medication and
leave the hospital. He said he did not need outpatient services and had no plan
to seek treatment at Consejo or anywhere else after release. When Wagner
asked about whether E.G.-R. would return home, he did not respond definitively.
Instead, he made vague statements about not being a “kid anymore” and that his
father was “unwell.”
Finally, Singer read progress notes by advanced registered nurse
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IN THE COURT OF APPEALS OF THE STATE OF WASHINGTON
In the matter of the Detention of E.G.-R., No. 81906-2-I
STATE OF WASHINGTON, DIVISION ONE
Respondent, v. UNPUBLISHED OPINION
E.G.-R.,
Appellant.
CHUN, J. — E.G.-R. displayed signs of decompensation. The State
petitioned for 14 days of involuntary treatment under the Involuntary Treatment
Act (ITA). The trial court found that E.G.-R. showed signs of “severe
deterioration in routine functioning, evidenced by repeated & escalating loss of
cognitive and volitional control over his actions such that, outside the hospital
setting, he would not receive care that is essential to his health and safety.” The
court concluded that E.G.-R. was gravely disabled and ordered commitment.
E.G.-R. appeals contending that insufficient evidence supports the court’s
finding. For the reasons discussed below, we affirm.
I. BACKGROUND
E.G.-R. lived with his mother (Adela Ramirez), father, and younger
brother. His family helped him with housing, food, medication, and transportation
to his mental health treatment provider.
Citations and pin cites are based on the Westlaw online version of the cited material. No. 81906-2-I/2
Erich Flaker, a mental health therapist at Consejo Counseling and Referral
Services, has been working with E.G.-R. since November 2019. On August 31,
2020, Flaker spoke with E.G.-R. on the phone and noted changes in his
presentation. E.G.-R. presented “complex paranoid symptoms,” spoke about
“unreal” situations, exhibited disorganized thinking, and expressed concern about
being sexually and physically abused. After the conversation, Flaker requested
that a Designated Crisis Responder (DCR) evaluate E.G.-R.
Casey Locke, a DCR, and two of his colleagues evaluated E.G.-R. on
September 7, 2020 at his parents’ home. Locke observed that E.G.-R. was
easily agitated, spoke in a disorganized manner, and was having paranoid
delusions about being followed by a dead person. When the DCRs encouraged
E.G.-R. to continue treatment services at Consejo he repeated, “‘No’” and “‘no
means no.’” Similarly, when the DCRs asked him about medication, and whether
he was currently taking any, he repeated, “‘[N]o’” and “‘no means no.’” The
DCRs paused the evaluation and went outside to discuss less restrictive
alternatives. When they returned, they suggested voluntary outpatient treatment
at Consejo. E.G.-R. became agitated. He “puff[ed] up his chest,” shouted at the
DCRs, and “gestur[ed] with his arms.” He threw a sock at one of the DCRs,
hitting him in the face. He stepped towards the DCRs and told them to leave.
The DCRs were concerned for their safety and left. Once outside, they called
911 to execute an emergency detention.
The same day, E.G.-R. was detained for 72 hours of psychiatric evaluation
and treatment. He was transferred to Navos Hospital on September 8. The
2 No. 81906-2-I/3
State then petitioned for 14-day involuntary treatment under the ITA, claiming
E.G.-R. posed a risk of harm to others and was gravely disabled.
On September 11, the trial court held a probable cause hearing.
Ramirez’s Testimony
E.G.-R.’s mother Ramirez testified that, during the three months leading to
hospitalization, she noticed behavioral changes including increased paranoia.
About a month before hospitalization, E.G.-R. had accused a stranger at the
grocery store of “fondling” his younger brother. Ramirez explained to E.G.-R.
that it did not happen but she struggled to calm him. She was finally able to get
E.G.-R. to leave the store but he remained upset.
Ramirez also described an incident, during the month before
hospitalization, when she saw him leave the apartment very upset and cursing to
himself. She watched him walk outside and throw a rock at a garbage can.
When he returned, he went to his room and did not come out for the rest of the
day. She did not ask him about it because she thought he would get upset. She
did not know why he seemed so angry that day.
Ramirez said she is concerned about her family’s and E.G.-R.’s safety
when he is “not doing well” because he does not listen and is often difficult to
calm down. She reported that he is happy, quiet, and relaxed when he is taking
his medication.
3 No. 81906-2-I/4
Locke’s Testimony
Locke testified at the hearing. He discussed the DCR evaluation and the
circumstances prompting the decision to conduct an emergency detention. He
said that during the evaluation, E.G.-R. “refused all mental health treatment.”
Flaker’s Testimony
Flaker testified that at his baseline, E.G.-R. is talkative, cooperative, and
willing to engage in therapeutic services. But by August 31, E.G.-R. was
displaying “complex paranoid symptoms” and delusional and disorganized
thinking. Flaker concluded that E.G.-R. was gravely disabled because he could
not provide for his own health and safety needs.
Dr. Julia Singer’s Testimony
Finally, Dr. Julia Singer, a licensed clinical psychologist and court
evaluator for Navos, testified as to the following. Singer had interviewed E.G.-R.
on September 10. E.G.-R. was basically cooperative but “very ambivalent about
treatment.” He did not know why he was in the hospital and said he did not need
treatment. He also said the last time he had taken some medication was three or
four days before hospitalization.
Singer said her working diagnosis of E.G.-R. was Schizoaffective
Disorder. She based this diagnosis off of E.G.-R.’s history of six involuntary
hospitalizations and his current symptoms, including disorganized thinking,
aggression, paranoia, delusions, impaired judgment and impulse control, and
lack of insight. She was unsure about E.G.-R.’s capacity to live on his own and
4 No. 81906-2-I/5
meet his needs, and she was concerned he might try to live alone because he
had expressed paranoia about his father.
Singer based her opinion in part on several records and she read them
into the record. First, she read Flaker’s declaration in support of the petition for
detention dated August 31. Flaker noted that E.G.-R. was in a manic and
irritable mood, and displayed delusional thinking and paranoia. E.G.-R. reported
feeling threatened by “a terrorist” and “the cartel.” He also said he pressed
charges against his father with “‘America’s Most Wanted.’” Flaker noted that
E.G.-R. “reported he would like to discontinue mental health services with
Consejo reporting, ‘I know what they’re trying to do and I’m not going to do it.’”
Second, Singer read Dr. Brian Coleman’s intake evaluation dated
September 9. Coleman noted that E.G.-R. was suspicious but cooperative with
treatment recommendations. E.G.-R.’s thought process was disorganized and
he had paranoid delusions.
Third, Singer read a social services assessment by Susan Wagner dated
September 10. E.G.-R. told Wagner he wanted to stop taking medication and
leave the hospital. He said he did not need outpatient services and had no plan
to seek treatment at Consejo or anywhere else after release. When Wagner
asked about whether E.G.-R. would return home, he did not respond definitively.
Instead, he made vague statements about not being a “kid anymore” and that his
father was “unwell.”
Finally, Singer read progress notes by advanced registered nurse
practitioner Rebecca Skelly dated September 10 and 11. When Skelly checked
5 No. 81906-2-I/6
in with E.G.-R., he appeared to have minimum hygiene and grooming. He
denied his symptoms and was unable to give a coherent answer as to the events
preceding his hospitalization. On one day, he agreed he would probably benefit
from psychiatric treatment but on the next, he denied the need for treatment. He
was “[u]nable to identify a concrete plan to meet his basic needs in less
restrictive setting.”
Trial Court Decision
Following the hearing, the trial court found by a preponderance of the
evidence that E.G.-R. suffered from a mental disorder. The court found that his
mental disorder had a “substantial adverse effect on [his] cognitive and volitional
functions.” The court concluded that E.G.-R. was gravely disabled based on a
finding that he showed “severe deterioration in routine functioning, evidenced by
repeated & escalating loss of cognitive and volitional control over his actions
such that, outside the hospital setting, he would not receive care that is essential
to his health and safety.” The court noted that E.G.-R.’s “staunch refusal for
mental health frankly places him in a place where treatment for his mental
disorder is absolutely essential to his own health and safety.” The court
emphasized that no evidence showed he would seek treatment or medication on
his own, he had no specific discharge plan, and without treatment his symptoms
would go unmanaged putting his health and safety at risk. The court did not find
that E.G.-R. posed a risk of harm to others. The court ordered involuntary
commitment of up to 14 days. E.G.-R. appeals.
6 No. 81906-2-I/7
II. ANALYSIS
At a probable cause hearing for a 14-day commitment, the State must
establish grave disability by a preponderance of the evidence. In re Det. of V.B.,
104 Wn. App. 953, 963, 19 P.3d 1062 (2001) (citing RCW 71.05.240). “‘[W]here
the trial court has weighed the evidence, appellate review is limited to
determining whether substantial evidence supports the findings and, if so,
whether the findings in turn support the trial court’s conclusions of law and
judgment.’” In re Det. of H.N., 188 Wn. App. 744, 762, 355 P.3d 294 (2015)
(alteration in original) (quoting In re Det. of LaBelle, 107 Wn.2d 196, 209, 728
P.2d 138 (1986)) “Substantial evidence is the quantum of evidence sufficient to
persuade a fair-minded person of the truth of the declared premise.” Id. “The
party challenging a finding of fact bears the burden of demonstrating the finding
is not supported by substantial evidence.” In re Det. of A.S., 91 Wn. App. 146,
162, 955 P.2d 836 (1998), aff’d sub nom. In re Det. of A.S., 138 Wn.2d 898, 982
P.2d 1156 (1999). Whether an individual is gravely disabled is a legal conclusion
and we treat it as such. In re Det. of M.K., 168 Wn. App. 621, 624 n.4, 279 P.3d
897 (2012).
RCW 71.05.240(4)(a) provides: [A]t the conclusion of the probable cause hearing, if the court finds by a preponderance of the evidence that such person, as the result of a behavioral health disorder, . . . is gravely disabled, and, after considering less restrictive alternatives to involuntary detention and treatment, finds that no such alternatives are in the best interests of such person or others, the court shall order that such person be detained for involuntary treatment not to exceed fourteen days.
7 No. 81906-2-I/8
(Emphasis added.) RCW 71.05.020(24)(b) defines “gravely disabled” as when a
person “manifests severe deterioration in routine functioning evidenced by
repeated and escalating loss of cognitive or volitional control over his or her
actions and is not receiving such care as is essential for his or her health or
safety.”1 This “prong B” definition sets forth two requirements, (1) severe
deterioration in routine functioning, and (2) not receiving essential care. See
LaBelle, 107 Wn.2d at 205.
E.G.-R. concedes that sufficient evidence supports a finding that he
manifested “severe deterioration in routine functioning.” He says insufficient
evidence supports the finding that he “is not receiving such care as is essential
for his [] health or safety.” And he contends insufficient evidence supports a
causal nexus between the two. To show that he “is not receiving such care as is
essential for his [] health or safety,” it is not enough to show that care and
treatment “would be preferred or beneficial or even in his best interests,” it must
be essential. LaBelle, 107 Wn.2d at 208. And “the mere fact that an individual is
mentally ill does not also mean that the person so affected is incapable of making
a rational choice with respect to [their] need for treatment.” Id. “‘Implicit in the
definition of gravely disabled . . . is a requirement that the individual is unable,
because of severe deterioration of mental functioning, to make a rational decision
with respect to [their] need for treatment.’” In re Det. of A.M., 17 Wn. App. 2d
1 RCW 71.05.020 contains two prongs under which a person can be considered “gravely disabled.” “Prong A,” which provides that a person is gravely disabled if they are “in danger of serious physical harm resulting from a failure to provide for his or her essential human needs of health or safety,” is not at issue here.
8 No. 81906-2-I/9
321, 335, 487 P.3d 531 (2021) (alteration in original) (quoting LaBelle, 107
Wn.2d at 208). Satisfaction of this requirement “ensure[s] that a causal nexus
exists between proof of ‘severe deterioration in routine functioning’ and proof that
the person so affected ‘is not receiving such care as is essential for [their] health
or safety.’” LaBelle, 107 Wn.2d at 208.
Substantial evidence supports the trial court’s finding that E.G.-R. was
“showing severe deterioration in routine functioning, evidenced by repeated &
escalating loss of cognitive and volitional control over his actions such that,
outside the hospital setting, he would not receive care that is essential to his
health and safety.”2 Evidence shows that he repeatedly stated that he would not
continue his treatment or medication upon discharge and lacked insight about his
mental state. He told Flaker he did not want to continue treatment with Consejo.
He repeatedly told the DCRs “‘no means no’” when they asked about treatment
and medication. He became agitated and aggressive when they suggested
outpatient treatment. Singer noted that E.G.-R. was confused about why he was
in the hospital and said he did not need treatment. He told Singer he had not
taken his medication for three or four days before hospitalization. He told
Wagner he wanted to stop taking medication and leave the hospital. He also told
her that he had no plan to seek treatment at Consejo or anywhere else and that
he did not need such treatment. When Skelly evaluated him, he denied his
2 E.G.-R. contends his appeal is not moot despite the detention at issue having lapsed. The State responds that it is not pursuing any mootness argument. We do not address mootness. See M.K., 168 Wn. App. at 625 (holding that because involuntary commitment orders may have consequences for future commitment decisions, an appeal of such an order is not moot even if the detention at issue has ended).
9 No. 81906-2-I/10
symptoms and could not explain why he was in the hospital. Though he agreed
treatment might be beneficial on one day, the next day he denied his need for it.
E.G.-R. made these comments while he displayed undisputed signs of
severe deterioration in routine functioning; this shows that he was unable,
because of such deterioration, to make a rational choice about his need for
treatment. See A.M., 17 Wn. App. 2d at 335 (noting that the definition of gravely
disabled requires that an “‘individual is unable, because of severe deterioration of
mental functioning, to make a rational decision with respect to his need for
treatment.’” (quoting LaBelle, 107 Wn.2d at 208)). And the evidence shows that
without treatment, E.G.-R. continued to decompensate. Thus, a causal nexus
exists between his severe deterioration in routine functioning and not receiving
care essential to his health and safety. See LaBelle, 107 Wn.2d at 208 (noting
that when an individual is unable to make a rational choice about treatment, a
causal nexus exists between severe deterioration in routine functioning and not
receiving essential care).
E.G.-R. mostly focuses on why his lack of a discharge plan does not
suffice to sustain a conclusion of grave disability. He concedes that the evidence
shows that he lacked such a plan but he claims that this is irrelevant because
evidence shows he would return home upon discharge and there his needs
would be met. But the record lacks evidence showing that he would return
home. And even if he did return home, his refusal to engage in treatment or take
medication would still lead to further decompensation. See LaBelle, 107 Wn.2d
at 213 (finding grave disability under prong B where “even if appellant were able
10 No. 81906-2-I/11
to provide for his essential food and shelter needs, [by staying with his sister], the
evidence indicates that without treatment for his mental disorder he would rapidly
exhibit those symptoms which resulted in his initial confinement.”).
In A.M., the court determined that substantial evidence supported a finding
that the appellant was “not receiving such care as is essential for his or her
health or safety.” 17 Wn. App. 2d at 330. A.M. involved a hearing for a 180-day
involuntary commitment.3 In determining that substantial evidence supported a
finding under prong B, the court noted that the evidence showed that the
appellant had “no insight into his mental illness, did not believe that he was
mentally ill,” “did not believe that he needed any medication,” had a “history of
noncompliance with medication,” and had “three prior admissions for mental
health treatment.” Id. at 336. Here, the evidence is similar. The only difference
is that the State offered no evidence of a history of noncompliance with
medication, but E.G.-R. has had six prior hospitalizations.
The evidence the State presented at the hearing sufficed to persuade a
fair-minded person that E.G.-R. showed “severe deterioration in routine
functioning, evidenced by repeated & escalating loss of cognitive and volitional
control over his actions such that, outside the hospital setting, he would not
receive care that is essential to his health and safety.” And this finding supports
3 A 180-day commitment hearing involves a higher burden of proof. See A.M., 17 Wn. App. 2d at 330 (“The Petitioners’ burden of proof in a 180-day involuntary commitment proceeding is by clear, cogent, and convincing evidence.”). E.G.-R. contends that “the standard of proof is irrelevant to the underlying rule that there must be some evidence that release is incompatible with the respondent’s essential health and safety needs.” But the standard of proof pertains to our review of the issue. That the evidence in A.M. satisfied the clear, cogent, and convincing evidence standard suggests that similar evidence here satisfies the lower preponderance of the evidence standard.
11 No. 81906-2-I/12
the court’s conclusion that E.G.-R. was gravely disabled. See RCW
71.05.020(b).
We affirm.
WE CONCUR: