In the Matter of B.H., Alleged to be Seriously Mentally Impaired

IN THE COURT OF APPEALS OF IOWA _______________ No. 25-1569 Filed August 19, 2026 _______________ In the Matter of B.H., Alleged to be Seriously Mentally Impaired B.H., Respondent-Appellant. _______________ Appeal from the Iowa District Court for Johnson County, The Honorable Elizabeth Dupuich, Judge. _______________ AFFIRMED _______________ Michelle M. Jay of Bray & Klockau, P.L.C., Iowa City, attorney for appellant. Brenna Bird, Attorney General, and Tamara Knight, Assistant Attorney General, attorneys for appellee State. _______________ Considered without oral argument by Schumacher, P.J., Ahlers, J., and Bower, S.J. Opinion by Schumacher, P.J. 1 SCHUMACHER, Presiding Judge. B.H. appeals the district court’s denial of his appeal pursuant to Iowa Code section 229.21(3)(a) (2025) that resulted in an involuntary commitment based on serious mental impairment. Upon our review, we affirm. I. Background Facts & Proceedings B.H. was sentenced to ten years of incarceration on an unrelated willful-injury conviction in January 2024. While incarcerated at the Iowa Medical Classification Center (IMCC), B.H. refused to take his prescribed medications to treat his diagnosis of schizophrenia. B.H. also mailed a letter to his father and stepmother’s home that detailed accusations of sexual abuse by his father, that his father was trying to kill B.H., that his father was instructing B.H. to harm others, and that B.H. was being controlled by his father through a “neural network” implanted in B.H.’s brain, among other assertions. B.H. is tentatively scheduled to be released from incarceration in 2027. The Iowa Department of Corrections (DOC) applied for an involuntary commitment of B.H., seeking to force him to take his medications. Dr. Gary Keller, a staff psychiatrist at IMCC, provided an affidavit supporting the application and testified at both hearings. The Johnson County Hospitalization Referee found that B.H. was seriously mentally impaired, in that he lacked insight into his mental illness, was treatable, and was a danger to others. The hospitalization referee granted the application. B.H. appealed the decision, and the district court denied the appeal. B.H. was involuntarily committed, placed in outpatient care, and the DOC began forcibly administering B.H.’s medications. B.H. now appeals. II. Analysis B.H. contends that the district court erred in upholding his involuntary hospitalization. He asserts the State offered insufficient evidence to “prove a recent overt act justif[ying] a finding of dangerousness” under chapter 229. 2  “We review challenges to the sufficiency of the evidence in involuntary commitment proceedings for errors at law.” In re V.H., 996 N.W.2d 530, 536 (Iowa 2023) (citation omitted). The required elements for involuntary commitments “must be established by clear and convincing evidence.” Id. If the evidence in a chapter 229 proceeding is substantial, then the district court’s findings are binding on our court. “Evidence is substantial if a reasonable trier of fact could conclude the findings were established by clear and convincing evidence. We will not set aside the trial court’s findings unless, as a matter of law, the findings are not supported by clear and convincing evidence.” Id. (citation omitted). To involuntarily commit an individual under chapter 229, the State must prove the individual possesses a serious mental impairment. Iowa Code §§ 229.11(1), 229.12(3)(c). To find that a person is seriously mentally impaired, the district court must determine the person, (1) possesses a mental illness; (2) due to the illness, “lacks sufficient judgment to make responsible decisions with respect to the person’s hospitalization or treatment”; and (3) “because of that illness meets 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 applies: (1) Lack of compliance has been a significant factor in the need for emergency hospitalization. 3  (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. Id. § 229.1(22). The third element is referred to by our courts as the “endangerment element.” V.H., 996 N.W.2d at 543. This element “requires the threat the patient poses to himself or another be evidenced by a recent overt act, attempt, or threat.” Id. (cleaned up). “In the context of civil commitment . . . an ʻovert act’ connotes past aggressive behavior or threats by the respondent manifesting the probable commission of a dangerous act upon himself or others that is likely to result in physical injury.” In re Foster, 426 N.W.2d 374, 378 (Iowa 1988). The element also “requires a predictive judgment, based on prior manifestations but nevertheless ultimately grounded on future rather than past danger.” V.H., 996 N.W.2d at 543 (citation omitted). In this appeal, B.H. only contests this element, that the district court found a recent overt act to justify his involuntary commitment. B.H.’s serious mental impairment can be proven if it is shown he “[i]s likely to physically injure [himself ] or others if allowed to remain at liberty without treatment.” Iowa Code § 229.1(22)(a). The term “likely” means “probable or reasonably to be expected.” In re A.J.M, 847 N.W.2d 601, 606 (Iowa 2014) (citing Foster, 426 N.W.2d at 377). But, “[w]e do not confine people simply because their conduct is unusual or bizarre.” Foster, 426 N.W.2d at 377. Here, B.H. asserts the State failed to prove by clear and convincing evidence there was a recent overt act to satisfy the “endangerment element.” We reject B.H.’s assertion. 4  The evidence shows that B.H., in the letter sent to his stepmother and father’s residence, stated that his father “wants me to kill him and I told everyone else I’m not doing it.” B.H. testified that his father communicates to B.H. through a “neural network” and can control his actions and force him to perform violent acts. The letter also references the “neural network” controlling his actions when he cut a victim’s throat in 2017, hit another victim with a hammer, and beat and burned a third victim. This letter was dated July 6, 2025. The initial hearing on the application alleging mental impairment was held on July 22, 2025. B.H. asserts that because he stated in the letter that he will not let his father control B.H. to kill his father, the statement is not a recent overt threat. But B.H. has indicated several times that his prior acts of violence were uncontrollable due to others dictating actions through his brain. B.H. also seems obsessed with others, mostly his father, controlling his thoughts and actions resulting in unwanted sexual encounters. Further, the initial hearing was held in the same month as receipt of the letter, so it was a recent act. We determine that this letter is sufficient clear and convincing evidence of a recent overt act that can “manifest the probable commission of a dangerous act . . . likely to result in physical injury.” See V.H., 996 N.W.2d at 544 (cleaned up). Dr. Keller testified that B.H. has historically refused his medications and becomes assaultive when not medicated. Dr. Keller stated that in 2023, B.H. assaulted him when attempting to administer medication, and that B.H. claimed that the “network” told him that Dr. Keller wanted to be assaulted. And, importantly, B.H. is currently incarcerated because of assaulting members of the public. We agree with the district court that “[B.H.]’s actions and lack of insight into his condition demonstrate that he continues to pose a 5 threat to himself or others if he is not subject to committal.” See In re Mohr, 383 N.W.2d 539, 542 (Iowa 1986) (relying on “threatening nature” of sexual and assaultive fantasies when finding respondent “poses a threat to himself and others”). Further, under the “endangerment element,” we find that B.H. 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” absent appropriate treatment. Iowa Code § 229.1(22)(b). The letter that B.H. sent to his stepmother and father caused such anxiety and fear that they contacted the DOC, communicating their concerns about his eventual release from custody. Although B.H. argues that his father and stepmother “can avoid him due to his incarceration,” and could “simply throw [future letters] in the trash” to avoid contact, B.H.’s release date will tentatively be in 2027. It is probable that without involuntary commitment resulting in forceful medication administration, B.H. will likely cause emotional injury to his family. III. Conclusion We find the district court’s determination that clear and convincing evidence supports B.H.’s involuntary commitment was not in error and accordingly affirm. AFFIRMED. 6