In the Matter of C.B., Alleged to Be Seriously Mentally Impaired

IN THE COURT OF APPEALS OF IOWA

No. 22-2089
Filed April 26, 2023

IN THE MATTER OF C.B.,
Alleged to Be Seriously Mentally Impaired,

C.B.,
Respondent-Appellant.
________________________________________________________________

Appeal from the Iowa District Court for Woodbury County, Robert D.

Tiefenthaler, Judge.

C.B. appeals the district court finding he is seriously mentally impaired.

AFFIRMED.

Debra S. De Jong of De Jong Law Firm, P.C., Orange City, for appellant.

Brenna Bird, Attorney General, and Sarah A. Jennings, Assistant Attorney

General, for appellee State.

Considered by Bower, C.J., and Badding and Buller, JJ.
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BOWER, Chief Judge.

C.B. appeals an order of noncompliance finding him seriously mentally

impaired, challenging the sufficiency of the evidence. We affirm.

“We review challenges to the sufficiency of the evidence in involuntary

commitment proceedings for errors at law.” In re B.B., 826 N.W.2d 425, 428 (Iowa

2013). “The allegations made [in support of] involuntary commitment must be

proven by clear and convincing evidence.” Id. In other words, “there must be no

serious or substantial doubt about the correctness of a particular conclusion drawn

from the evidence.” Id. (citation omitted).

To find a person seriously mentally impaired, “that person must first be

found to be ‘afflicted with a mental illness,’ and consequently ‘to lack sufficient

judgment to make responsible decisions with respect to his or her hospitalization

or treatment.’” Id. at 432 (citation omitted); see Iowa Code § 229.1(21) (Supp.

2022). And, because of their illness, the person must also be found to meet any

of the following criteria:

a. Is likely to physically injure the person’s self or others if
allowed to remain at liberty without treatment.
b. Is likely to inflict serious emotional injury on members of the
person’s family or others who lack reasonable opportunity to avoid
contact with the person with mental illness if the person with mental
illness is allowed to remain at liberty without treatment.
c. Is unable to satisfy the person’s needs for nourishment,
clothing, essential medical care, or shelter so that it is likely that the
person will suffer physical injury, physical debilitation, or death.
d. Has a history of lack of compliance with treatment and any
of the following apply:
(1) Lack of compliance has been a significant factor in
the need for emergency hospitalization.
(2) Lack of compliance has resulted in one or more acts
causing serious physical injury to the person’s self or others
or an attempt to physically injure the person’s self or others.
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Iowa Code § 229.1(21).

On August 26, 2022, C.B.’s mother filed an application alleging serious

mental impairment and requesting his hospitalization. The application stated C.B.

had auditory hallucinations, outbursts with swearing and sometimes violence, self-

isolation behaviors, paranoia, and an inability to maintain his home or pay his bills.

She also asserted C.B. had been involuntarily released from school. C.B.’s father

provided a supporting affidavit corroborating concerns about C.B.’s paranoia,

auditory hallucinations, and the possibility he might hurt himself or others.

Based on the application and supporting affidavit, the court ordered C.B.

into medical custody and appointed a physician to examine C.B. The physician

diagnosed C.B. with a schizophrenia spectrum disorder and stated C.B. lacked

sufficient judgment to make responsible treatment decisions during periods of

impairment. The physician determined C.B. was likely to physically injure himself

or others and was unable to satisfy his personal needs due to the mental illness.

The doctor cited self-harm elements of C.B.’s auditory hallucinations, fluctuating

stability, and reliance on family support for housing and finances. The physician

found C.B. to be seriously mentally impaired and recommended therapy and a

neurological review.

Following a hearing on September 1, the court found C.B. to be seriously

mentally impaired and ordered C.B. to participate in outpatient placement for

evaluation and treatment. C.B. was ordered “to follow all treatment

recommendations . . . including taking any medication recommended by the

provider.” At his intake evaluation, the treating advanced registered nurse

practitioner (ARNP) found C.B. not capable of making responsible treatment
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decisions and opined his mental health would continue to decline without proper

treatment, including outpatient medication management. The evaluating ARNP

suggested injectable medication might be necessary due to C.B.’s lack of insight

into treatment.

A periodic report filed November 17 noted C.B. had not started the

recommended medications, he was paranoid of others, and his “mental health

seems to be deteriorating.” C.B. had not held down a job the prior two months and

was unable to obtain food or manage his medical needs. The reviewing ARNP

considered C.B. seriously mentally impaired and in need of inpatient treatment and

injectable medication to improve his prognosis. The report included an observation

C.B. had been evaluated by professionals in other fields of medicine who

confirmed his diagnosis. The district court ordered C.B. back into custody for

treatment. C.B. was picked up, and a noncompliance hearing was scheduled for

December 12.

A physician from a different facility evaluated C.B. before the hearing. The

doctor found C.B. had a mental illness, would benefit from additional time in the

hospital for stabilization and medication, and was not capable of making

responsible treatment decisions as shown by his refusing medication. The doctor

also stated C.B. had no insight into his illness and posed a danger to himself and

others as demonstrated by threats made against his former school. The doctor

found C.B. had a history of noncompliance with treatment and noted he refused

medications and mental health treatment.

At the noncompliance hearing, the parties accepted the physician’s report

in lieu of live testimony. C.B., his mother, his father, and a mental health advocate
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testified. C.B.’s mother testified about seeing C.B.’s symptoms worsen over the

past year and her understanding of a recent incident where police were notified of

C.B. making threats against his former school on social media the day before the

hearing.1 She discussed purchasing all his groceries, needing to manage his bills,

and C.B.’s recent accrual of multiple driving violations. C.B.’s father mentioned his

fear that C.B. does not remember some of his actions after the fact.

When C.B. testified, he opined he had been wrongly diagnosed. He claimed

a religious belief that rejected the recommended medications and mental illness in

general. He testified using ear plugs muffled the voices he hears, so they must be

external. As to caring for himself, C.B. testified he could do his shopping and pay

the bills, but his mother later clarified he did not do so. He misses medical

appointments despite written reminders from his mother, and only goes to therapy

to avoid being committed. C.B. first testified he did not remember posting anything

threatening but later admitted “ranting” about his former school and including a

photo from a rally following “murders that happened at a[nother] school.” He

testified he felt the curricular concepts of his former school were attempting to kill

him and he wanted to go “say my piece at the school.”

The court ruled C.B. remains seriously mentally impaired and ordered he

be hospitalized, explaining C.B. would not follow through with any outpatient

treatment because he does not believe in mental illness. The court ordered C.B.

follow all recommended treatment including medication and authorized the use of

injectable medication if medical personnel deemed it necessary.

1His mother was also told of an ominous message posted by C.B. attached to a
school shooting article.
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C.B. appeals the court’s December ruling, specifically challenging the

determination he meets the statutory definition of a seriously mentally impaired

person. On appeal, C.B. does not contest his mental illness diagnosis, but he

asserts he is able to make rational decisions about his treatment and does not

pose a danger to himself or others.

As already noted, part of the criteria for serious mental impairment is that

because of mental illness a person “lacks sufficient judgment with respect to the

person’s hospitalization or treatment.” Iowa Code § 229.1(21). C.B. asserts his

decision not to medicate was rationally reached—even if medically inadvisable—

so the court cannot second guess it. See In re J.P., 574 N.W.2d 340, 343 (Iowa

1998) (finding a decision to not take medication because of concerns about its side

effects was reasonable under the circumstances). Claiming an ill-defined religious

belief that mental illness does not exist in order to refuse all treatment weighs

against a finding C.B. exhibits reasonable and rational judgment in making

treatment decisions.2 This criterion has been met.

Finally, C.B. asserts the evidence is insufficient to establish a recent overt

act, attempt, or threat needed to support a finding of dangerousness. See In re

Foster, 426 N.W.2d 374, 378 (Iowa 1988). The legislature has expanded the

definition of dangerousness to self to include the inability to satisfy one’s own need

for food, clothing, essential medical care or shelter and a history of lack of

compliance resulting in hospitalization or causation or attempt at physical injury.

2 When asked what about his religious belief conflicted with medication treatment,
C.B. vaguely cited “a spiritual tradition” to support his belief there is no mental
illness; rather, he believes he is being attacked by an external force.
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C.B. admitted he would not comply with any ordered medication. Also, while C.B.

asserted he could take care of his needs, the testimony from C.B.’s mother

established C.B. relies on his mother to get him food, clean his home, pay his bills,

and to comply with recommended medical tests and treatments.

In ruling on C.B.’s serious mental impairment, the district court referenced

the social media post described in testimony and expressed concern that if C.B.

felt threatened by an educational institution, he “may try to inflict harm on

somebody else to prevent that from happening.” The doctor’s report provided in

support of the noncompliance hearing also noted C.B. making threats against his

school and implying a school shooting, though it is not clear if the doctor was

reporting a new threat or was referring to the threat on social media discussed

above.

In light of the evidence supporting multiple potential harm criteria, we

conclude the district court did not err in finding C.B. likely to hurt himself or others.

The district court’s finding C.B. was seriously mentally impaired is supported by

substantial evidence. We affirm.

AFFIRMED.