Opinion
No. 12-04-00365-CV
Opinion delivered: December 21, 2005.
Appeal from the County Court at Law Cherokee County, Texas.
Panel consisted of WORTHEN, C.J., GRIFFITH, J., and DeVASTO, J.
MEMORANDUM OPINION
Appellant B.M. appeals from an order for temporary inpatient mental health services and an order to administer psychoactive medications. After a hearing without a jury, the trial court ordered B.M. committed to Rusk State Hospital (the "Hospital") for a period not to exceed ninety days and entered an order authorizing the Texas Department of Mental Health and Mental Retardation ("MHMR") to administer psychoactive medication to B.M. In two issues, B.M. asserts the evidence is legally and factually insufficient to support these orders. We reverse and render.
BACKGROUND
On November 8, 2004, an application for court ordered temporary mental health services was filed requesting the court to commit B.M. to the Hospital for a period not to exceed ninety days. At the time the application was filed, B.M. was a patient at the Hospital. The application was supported by two physician's certificates of medical examination for mental illness. The first certificate stated that the physician examined B.M. on November 5 and diagnosed him with schizophrenia, paranoid type. The physician found that B.M. is mentally ill and is likely to cause serious harm to others. According to the certificate, B.M. made death threats "to his mother" and was hallucinating and delusional. This physician also found that B.M. presents a substantial risk of serious harm to himself or others if not immediately restrained, demonstrated by his behavior and by evidence of severe emotional distress and deterioration in his mental condition to the extent that he cannot remain at liberty. The physician's opinion is based upon the specific behaviors described above and B.M.'s refusal to talk.
We were unable to decipher the handwritten printed name of this physician or his signature.
On November 11, Dr. Larry Hawkins evaluated and examined B.M. He diagnosed B.M. with schizophrenia, paranoid type. Hawkins found that B.M. is mentally ill; is likely to cause serious harm to others; and is suffering severe and abnormal mental, emotional, or physical distress, is experiencing substantial mental or physical deterioration of his ability to function independently, and is unable to make a rational and informed decision as to whether or not to submit to treatment. Hawkins based his opinion on B.M. "apparently" claiming that he hears voices telling him to hurt his mother. According to Hawkins, B.M. denies all symptoms, refuses treatment, is paranoid and evasive, and will not talk.
The hearing on the application was held on November 16. At trial, Hawkins testified that he examined B.M. on November 11 and concluded that B.M. is mentally ill and suffers from schizophrenia, paranoid type. He opined that B.M. is likely to cause serious harm to others and suffers severe and abnormal mental, emotional, or physical distress. Hawkins stated that B.M.'s distress makes him incapable of functioning outside a hospital setting and that he is unable to make a rational and informed decision about whether to submit to treatment. Hawkins also testified that B.M. is continually, in a pattern, very suspicious, evasive, and paranoid, which he exhibited when asked if he made death threats to his mother.
In Hawkins's opinion, B.M.'s suspicious, paranoid, and evasive behavior prevents him from obtaining his needs in the community because he cannot communicate his needs appropriately. Hawkins admitted that, since arriving at the Hospital, B.M. has not threatened anyone. Hawkins testified that his opinions are based on his personal interaction with B.M., a thorough review of B.M.'s medical history, and reasonable medical probabilities. Further, Hawkins stated that the Hospital is the least restrictive available option.
On cross examination, Hawkins admitted that he had not spoken to any independent source to confirm the alleged threat. In fact, he learned of the threat from MHMR and documents from Spindletop MHMR crisis screening. Hawkins admitted that B.M. had not required any emergency injections. According to Hawkins, B.M. becomes very agitated when someone attempts to talk to him about the issues that brought him to the Hospital and walks off. B.M. refuses to deal with his issues, does not want to talk about them, refuses treatment, and denies needing medication. B.M. denies hearing voices when, according to Hawkins, the application for emergency warrant documents allege that he does. B.M. appears to be hallucinating, which Hawkins believes is due to mental illness. Hawkins stated that B.M. must be prompted to cooperate and to take care of his personal hygiene. Further, B.M. often refuses to attend team meetings and must be coerced into attending. Hawkins also testified that, when B.M. came to his office to talk, he would not sit, would not cooperate, was "highly agitated," and did not want to talk. Hawkins did not believe that B.M. should be in a less restrictive environment because, in the emergency detention application, his mother claimed to be very afraid of him.
B.M. testified that he does not need to stay at the Hospital. He denied making any threat to his mother. If he were released, B.M. stated, he could make plans if he knew when that would occur. Further, he testified that his counsel could call his mother. B.M. stated that, as yet, he had no source of income and that his mother had been supporting him. In fact, B.M. stated that he was "making it okay" and "had no complaints." He denied that he was violent and stated that he has had no altercations at the Hospital. In fact, he went out of his way to stay out of trouble. B.M. stated that when he visited "him" (possibly indicating Hawkins), "he was confrontational," rude, and told B.M. to "sit down." B.M. responded by stating his constitutional rights. B.M. noted that in his "Rights Handbook," his actions and "words [could] be used against [him] through observation." Thus, he was attempting to "give out" as few words as he could, but was not trying to be uncooperative. B.M. claimed that all he wanted was legal aid because it was against his constitutional rights to be admitted. He testified that he stated these opinions continually to a physician, the treatment team, and the admitting physician. According to B.M., his strategy to get out of the hospital included refusing some activities and stating his rights with each refusal. Moreover, B.M. stated that he did not want medication.
B.M. testified that his mother let him stay with her for eight months. B.M. stated that when he returned from San Antonio, he believed "they" were going to pick him up and he would have a trial, but it never occurred. He claimed that his mother was being harassed and that he stayed on her property. B.M. also talked about an unidentified "order" that was signed by a sister. On cross examination, B.M. testified that his mother sent him money to return to Orange. All he wanted was his trial. B.M. admitted that he was jailed twice, once for criminal trespass, but denied causing trouble. He admitted going on a hunger strike for his constitutional rights at that time. B.M. speculated that his mother might have told the judge he threatened her because she was tired of him or of what had occurred or because she believed he needed help.
B.M.'s speculation was in response to a question by the State asking if he knew why his mother would tell the judge that he threatened her. The record does not show that his mother made any such statement to the judge.
On November 16, the trial court found that B.M. is mentally ill and is suffering severe and abnormal mental, emotional or physical distress; is experiencing substantial mental or physical deterioration of his ability to function independently, that is exhibited by his inability, except for reasons of indigence, to provide for his basic needs, including food, clothing, health or safety; and is unable to make a rational and informed decision as to whether or not to submit to treatment. The trial court entered an order for temporary inpatient mental health services, committing B.M. to the Hospital for a period not to exceed ninety days. In a separate order signed the same day, the trial court authorized the Hospital officials to treat B.M. with psychoactive medication. This appeal followed.
SUFFICIENCY OF THE EVIDENCE
In his first issue, B.M. argues that the evidence is neither legally nor factually sufficient to support the order of commitment. While the State's evidence reflects that B.M. may be mentally ill and in need of hospitalization, he contends that the testimony fails to show that there is a substantial threat of future harm if he is released and that he is unable to care for himself outside the Hospital.
Standard of Review
In a legal sufficiency review where the burden of proof is clear and convincing evidence, we must look at all the evidence in the light most favorable to the finding to determine whether a reasonable trier of fact could have formed a firm belief or conviction that its findings were true. In re J.F.C. , 96 S.W.3d 256, 266 (Tex. 2002). We must assume that the fact finder settled disputed facts in favor of its finding if a reasonable fact finder could do so and disregard all evidence that a reasonable fact finder could have disbelieved or found incredible. Id. This does not mean that we are required to ignore all evidence not supporting the finding because that might bias a clear and convincing analysis. Id.
The appropriate standard for reviewing a factual sufficiency challenge is whether the evidence is such that a fact finder could reasonably form a firm belief or conviction about the truth of the petitioner's allegations. In re C.H. , 89 S.W.3d 17, 25 (Tex. 2002). In determining whether the fact finder has met this standard, we consider all the evidence in the record, both that in support of and contrary to the trial court's findings. Id. at 27-29. Further, we must consider whether disputed evidence is such that a reasonable fact finder could not have reconciled that disputed evidence in favor of its finding. In re J.F.C. , 96 S.W.3d at 266. If the disputed evidence is so significant that a fact finder could not reasonably have formed a firm belief or conviction, then the evidence is factually insufficient. Id. Involuntary Commitment Order
The trial judge may order a proposed patient to receive court ordered temporary inpatient mental health services if the judge or jury finds, from clear and convincing evidence, that the proposed patient is mentally ill and, as a result of the mental illness, he is likely to cause serious harm to himself, is likely to cause serious harm to others, or is (i) suffering severe and abnormal mental, emotional, or physical distress, (ii) experiencing substantial mental or physical deterioration of his ability to function independently, which is exhibited by his inability, except for reasons of indigence, to provide for his basic needs, including food, clothing, health, or safety, and (iii) unable to make a rational and informed decision as to whether or not to submit to treatment. Tex. Health Safety Code Ann. § 574.034(a) (Vernon 2003).
To be clear and convincing under this statute, the evidence must include expert testimony and, unless waived, evidence of a recent overt act or a continuing pattern of behavior that tends to confirm either the likelihood of serious harm to the proposed patient or others or the proposed patient's distress and the deterioration of his ability to function. TEX. HEALTH SAFETY CODE ANN. § 574.034(d) (Vernon 2003). Clear and convincing evidence means the measure or degree of proof that will produce in the mind of the trier of fact a firm belief or conviction as to the truth of the allegations sought to be established. State v. Addington , 588 S.W.2d 569, 570 (Tex. 1979). The statutory requirements for an involuntary commitment are strict because it is a drastic measure. In re C.O. , 65 S.W.3d 175, 182 (Tex.App.-Tyler 2001, no pet.).
The State provided expert testimony from Hawkins who examined B.M. and diagnosed him with schizophrenia, paranoid type. However, expert testimony confirming mental illness, standing alone, will not support an involuntary commitment. T.G. v. State , 7 S.W.3d 248, 252 (Tex.App.-Dallas 1999, no pet.). Both doctors concluded that B.M. was mentally ill, and Hawkins testified that B.M. exhibited a pattern of being very suspicious, evasive, and paranoid. Further, Hawkins stated that B.M. appeared to be hallucinating. However, evidence of continuing delusional or paranoid behavior merely reflects that an individual is mentally ill and in need of hospitalization, but does not provide the continuing pattern of behavior necessary to support a commitment. See In re C.O. , 65 S.W.3d at 182; Broussard v. State , 827 S.W.2d 619, 622 (Tex.App.-Corpus Christi 1992, no writ). An expert opinion recommending commitment must be supported by the factual bases on which it is grounded and not simply recite the statutory criteria. See J.M. v. State , Nos. 01-05-00146-CV, 01-05-00147-CV, 2005 WL 1606931, at *7 (Tex.App.-Houston [1st Dist.] Jul. 7, 2005, no pet.). In fact, what is necessary is the expert's description of the patient's specific behaviors on which his or her opinion is based. See id. Thus, we turn to the evidence offered by the State as clear and convincing proof that B.M. should involuntarily receive temporary mental health services.
Regarding B.M.'s continuing pattern of behavior that tended to confirm his distress or inability to function, Hawkins stated that B.M.'s distress made him incapable of functioning outside a hospital setting. Additionally, Hawkins testified that B.M. would be unable to obtain necessities in the community because he could not communicate properly. These statements are conclusory and merely mirror the requirements of the statute. Hawkins's only factual bases for these opinions is that B.M. becomes agitated when anyone, including Hawkins, attempts to talk to him, and refuses to cooperate without prompting. Hawkins admitted that B.M. took care of his personal hygiene with prompting. B.M. testified that he lived with his mother, had no income, and was "doing okay." Neither that testimony nor B.M.'s reasoned approach to his commitment, i.e., refusing to participate in activities, talking as little as possible, and insisting on his constitutional rights, shows a deterioration of B.M.'s inability to function. The State lacks any evidence showing how B.M.'s agitation, refusal to cooperate, or paranoid behavior tends to confirm the deterioration of his ability to function independently as exhibited by his inability to provide for his own needs. Thus, the State failed to provide clear and convincing evidence to support Hawkins's opinion that B.M. demonstrated a continuing pattern of behavior that tended to confirm his distress and inability to function.
Regarding the death threat, the first physician's certificate merely recited that B.M. "made death threats to his mother." Hawkins's certificate stated that "apparently [B.M.] claimed the voices he hears tells [sic] him to hurt his mother," and that he "reportedly made death threats to his mother." No details of the threats were given. At the hearing, Hawkins admitted that he had not independently verified that there was a threat. The State did not provide documentation of the threats from MHMR.
Moreover, Hawkins admitted that B.M. had not committed a recent overt act. A threat of harm to others must be substantial and based on actual dangerous behavior manifested by some overt act or threats in the recent past. See J.M. , 2005 WL 1606931 at *7. Here, no specific details were provided about the purported death threat made by B.M. before his admission to the Hospital. The record does not reveal exactly when the threat was made, specifically to whom it was made, under what circumstances the threat was made, or its severity. No evidence was presented that B.M. engaged in any recent overt act to actually harm anyone else at the time he made the threat or during his hospitalization. See Broussard , 827 S.W.2d at 622; In re P.W. , 801 S.W.2d 1, 2 (Tex.App.-Fort Worth 1990, writ denied).
Finally, the recent overt act or continuing pattern of behavior proven by the State must relate to the criterion on which the judgment is based. See In re C.O. , 65 S.W.3d at 181. Here, the trial court did not find that B.M. is likely to cause harm to others. Evidence of a death threat by B.M. does not tend to confirm B.M.'s distress and the deterioration of his ability to care for himself. See J.M. , 2005 WL 1606931, at *7.
In summary, the State failed to introduce clear and convincing evidence of an overt act or continuing pattern of behavior that tended to confirm B.M.'s distress and a deterioration of his ability to function. Therefore, viewing the evidence in the light most favorable to the finding, we conclude that a reasonable trier of fact could not have formed a firm belief or conviction that this finding was true. See In re J.F.C. , 96 S.W.3d at 266. Consequently, the evidence is legally insufficient to support the trial court's finding based upon section 574.034(d) of the Texas Health and Safety Code. Having determined that the evidence is legally insufficient, it is unnecessary for us to address B.M.'s argument that the evidence is factually insufficient to support the trial court's finding. See TEX. R. APP. P. 47.1.
Psychoactive Medication Order
In his second issue, B.M. argues the evidence is legally and factually insufficient to support the order authorizing administration of psychoactive medication. A trial court may issue an order authorizing the administration of one or more classes of psychoactive medications only if the trial court finds by clear and convincing evidence after the hearing that (1) the patient is under an order for temporary or extended mental health services, (2) the patient lacks the capacity to make a decision regarding the administration of the proposed medication, and (3) treatment with the proposed medication is in the best interest of the patient. TEX. HEALTH SAFETY CODE ANN. § 574.106(a) (Vernon 2003). Having found the evidence legally insufficient to support the trial court's order of commitment, we have held that the trial court's order for temporary inpatient mental health services is invalid. Therefore, the order authorizing administration of psychoactive medication is also invalid. See id. We sustain B.M.'s second issue.
CONCLUSION
Based upon our review of the record, we conclude that the evidence is legally insufficient to support the trial court's order of commitment for temporary inpatient mental health services. Therefore, the order for administration of psychoactive medication is invalid.
We reverse the trial court's orders of commitment for temporary inpatient health services and for administration of psychoactive medication. We render judgment denying the State's applications for court ordered temporary mental health services and for an order to administer psychoactive medication.