Opinion
22A-MH-1108
12-06-2022
In the Matter of the Commitment of T.P.; v. Adult & Child Health, Appellee-Petitioner. T.P., Appellant-Respondent,
Attorney for Appellant Heather L. George Myers Greenwood, Indiana Attorneys for Appellee Suzannah W. Overholt David E. Jose Amundsen Davis, LLC Indianapolis, Indiana
Pursuant to Ind. Appellate Rule 65(D), this Memorandum Decision shall not be regarded as precedent or cited before any court except for the purpose of establishing the defense of res judicata, collateral estoppel, or the law of the case.
Appeal from the Johnson Superior Court Trial Court Cause No. 41D01-2112-MH-66 The Honorable Kevin M. Barton, Judge
Attorney for Appellant Heather L. George Myers Greenwood, Indiana
Attorneys for Appellee Suzannah W. Overholt David E. Jose Amundsen Davis, LLC Indianapolis, Indiana
MEMORANDUM DECISION
TAVITAS, JUDGE 1
Case Summary
[¶1] T.P. appeals the trial court's order granting the request of Adult and Child Health ("ACH") for a regular outpatient commitment of T.P. T.P. argues that ACH presented insufficient evidence to support a finding that she was gravely disabled. We are cognizant that commitment proceedings are laden with medical judgments, which courts are often ill-equipped to make. We are also cognizant that trial courts, who witness such proceedings in-person, stand in a far better position than appellate courts to assess the demeanor and credibility of a person whose commitment is sought. Nonetheless, we must faithfully apply our standard of review. Here, that standard asks whether ACH proved by clear and convincing evidence that T.P. was gravely disabled. We find that ACH failed to meet its burden of proof. Accordingly, we reverse.
A regular commitment is a commitment for a period that exceeds ninety days, Ind. Code § 12-26-7-1, and a temporary commitment is a commitment for a period not to exceed ninety days. Ind. Code § 12-26-6-1.
Issue
[¶2] T.P. raises one issue on appeal, which we restate as whether ACH presented sufficient evidence to support a finding that T.P. was gravely disabled. 2
Facts
[¶3] T.P. was diagnosed with schizoaffective disorder, and on March 12, 2020, she began participating in voluntary services with ACH. On December 27, 2021, ACH filed a petition for an involuntary temporary commitment of T.P.
[¶4] The trial court held a hearing on the temporary commitment request on January 12, 2022. At the time of the hearing, T.P. was living with her father. Dr. Christine Negendank, a psychiatrist and the Chief Medical Officer of ACH, testified that T.P. displayed mania and psychosis. Dr. Negendank explained:
With her mania, what I've seen in my evaluations of her, she has displayed grandiosity, very pressured speech, irritability, and impulsivity. As far as her psychosis, she has voiced both hearing things that are not there, so auditory hallucinations, as well as visual hallucinations. So seeing things that are not there[,] and she has also voiced paranoia. Feeling that the devil, as well as other people are out to harm her in some way.Tr. Vol. II p. 8-9. Dr. Negendank further testified that T.P. lacked insight into her illness; struggled to feed herself, maintain her finances, and keep her home clean; and was hospitalized when she could not care for her wounds after an unrelated surgery. 3
Dr. Negendank testified that ACH did not immediately seek commitment of T.P. after her most recent hospitalization because T.P. was under a guardianship at the time. T.P. claims that the guardianship ended on October 14, 2021.
[¶5] T.P.'s treatment at the time consisted of oral medications, an injectable anti-psychotic medication, and services, which included therapy and skills support. Dr. Negendank testified that T.P. was "fairly compliant" with services, but that T.P. had "a pattern with non-adherence" with her oral medications and injections and that, "quickly after she stopped her injectable medications[,] she decompensated rapidly." Id. at 13, 16. On January 13, 2022, the trial court issued an order for temporary outpatient commitment and an order for ACH to treat and medicate T.P.
[¶6] ACH filed a report requesting an extension of T.P.'s temporary commitment to a regular commitment on March 21, 2022. ACH alleged that T.P. continued to suffer from a psychiatric disorder and was "gravely disabled and in need of continuing custody, care or treatment in an appropriate facility." Appellant's App. Vol. II p. 27. Dr. Negendank submitted a physician's statement, which states, in part,
When unmedicated[, T.P.] becomes focused on delusional content to the extent she neglects her physical health needs. She becomes agitated without provocation. . . . When unmedicated, [T.P.] suffers from delusions, sees and hears spirits, and presents with disorganized thinking that interferes with her ability to care for herself. . . . After being placed on a temporary commitment . . . she has responded well to medications and has received two injections. . . . Despite receiving medications, [T.P.] continues to experience psychotic symptoms of delusions and hallucinations, but her response to these symptoms has less of an impact on her functioning as compared to when she was not receiving injectable medication. . . .4 Appellant's App. Vol. II p. 29-30.
[¶7] The trial court held a hearing on the regular commitment request on April 12, 2022. ACH did not offer evidence that T.P. failed to take any of her medications or receive any injections during the temporary commitment period. Dr. Negendank, however, testified that ACH was concerned that T.P. would stop taking her medication without a court order and that T.P. would then revert back to her previous condition. Dr. Negendank further testified that T.P. had missed at least five therapy appointments since the temporary commitment.
[¶8] Regarding T.P.'s symptoms, Dr. Negendank testified that T.P. was "having less paranoia," was less irritable, and was "more organized in her thought process." Id. at. 86. Dr. Negendank also testified that T.P. was "better able to manage day to day living [and] taking care of herself," but was "still struggling." Id. at 77. When asked whether T.P. "continues to be unable to provide for her food, clothing, shelter, or other essential human needs or has a substantial impairment of obvious deterioration in her judgment, reasoning, or behavior, that results in [T.P.'s] inability to function independently," Dr. Negendank testified that T.P. "still has that disability in that area. [T.P.'s] been improving, but still requires a lot of assistance, for her health in particular." Id. at 79-80. Dr. Negendank further testified that T.P. continued to lack insight into her illness and that T.P. repeatedly denied having a mental illness and needing medication. Id. at 77. Dr. Negendank testified that she believed a regular commitment was necessary because it would take longer than another ninety- 5 day temporary commitment period for T.P. to develop insight into her illness "and be able to accept medication without a Court order." Id. at 95.
[¶9] T.P. testified at the hearing that she believed her treatment and services were helping her and that she planned to continue to follow her treatment plan without a commitment order. T.P. further testified that she drives herself to ACH to receive injections and attend appointments. T.P. denied missing appointments; however, she explained that, if she had missed appointments, it would have been because she was hospitalized at the time. Id. at 100.
T.P. attributed her improved condition and consistency with her medications and injections to switching her injectable anti-psychotic medication from Risperdol Consta to Invega Sustena.
T.P. also testified that ACH had "cancelled" several appointments. Tr. Vol. II p. 100.
[¶10] T.P. also testified that she had a good relationship with her father and had his support. ACH did not present evidence that T.P. was no longer living with her father at the time of the regular commitment hearing; however, when asked if T.P. had sufficient support from family members, Dr. Negendank testified that T.P.'s "father assists, but he can't offer enough help to help her without the medications." Id. at 81. In addition, T.P. testified that she provided for her son "full time."
ACH did not call T.P.'s father to testify.
[¶11] The trial court found that T.P. was mentally ill and gravely disabled, though not dangerous, and granted ACH's request for a regular commitment on an outpatient basis. The trial court stated during the hearing, "I'm seeing progress, 6 and I don't want to risk losing that progress." Tr. Vol. II p. 111. The trial court further found that "[p]lacement with [ACH] is . . . the least restrictive environment suitable for treatment and stabilization as well as protecting [T.P.] while restricting [T.P.'s] liberty to the least degree possible." Appellant's App. Vol. II p. 8. T.P. now appeals.
Discussion and Decision
[¶12] T.P. argues that ACH failed to prove by clear and convincing evidence that T.P. was gravely disabled. We agree.
[¶13] In Civil Commitment of T.K. v. Department of Veterans Affairs, the Indiana Supreme Court recently stated:
[T]he purpose of civil commitment proceedings is dual: to protect the public and to ensure the rights of the person whose liberty is at stake." In re Commitment of Roberts, 723 N.E.2d 474, 476 (Ind.Ct.App. 2000), trans. not sought. The liberty interest at stake in a civil commitment proceeding goes beyond a loss of one's physical freedom, and given the serious stigma and adverse social consequences that accompany such physical confinement, a proceeding for an involuntary civil commitment is subject to due process requirements. See Addington v. Texas, 441 U.S. 418, 425-26, 99 S.Ct. 1804, 60 L.Ed.2d 323 (1979).27 N.E.3d 271, 273 (Ind. 2015).
[¶14] Indiana Code Section 12-26-2-5(e) provides that, to have a person committed, "[t]he petitioner must prove by clear and convincing evidence that: 7
(1) the individual is mentally ill and either dangerous or gravely disabled; and
(2) detention or commitment of that individual is appropriate.(Emphasis added). The clear and convincing standard "is defined as an intermediate standard of proof greater than a preponderance of the evidence and less than proof beyond a reasonable doubt." In re B.J., 67 N.E.3d 1034, 1038 (Ind.Ct.App. 2016) (citing T.D. v. Ezkenazi Midtown Cmty. Mental Health Ctr., 40 N.E.3d 507, 510 (Ind.Ct.App. 2015)). "In order to be clear and convincing, the existence of a fact must be highly probable." Id. (citing T.D., 40 N.E.3d at 510). "When we review a determination made under that clear and convincing standard, we affirm 'if, considering only the probative evidence and the reasonable inferences supporting it, without weighing evidence or assessing witness credibility, a reasonable trier of fact could find [the necessary elements] proven by clear and convincing evidence.'" A.S. v. Ind. Univ. Health Bloomington Hosp., 148 N.E.3d 1135, 1139 (Ind.Ct.App. 2020) (citing T.K., 27 N.E.3d at 273) (internal quotation marks omitted).
[¶15] In T.K., our Supreme Court clarified that our clear and convincing standard for civil commitment cases must be applied faithfully. See 27 N.E.3d at 274. In that case, the Court disapproved of several Court of Appeals decisions that "recit[ed] the phrase 'clear and convincing'" but did not "appl[y] this standard of proof in their analys[e]s." Id. Instead, those decisions affirmed civil commitment orders merely when such orders "'represent[ed] a conclusion that 8 a reasonable person could have drawn, even if other reasonable conclusions [were] possible.'" Id.
[¶16] Here, the trial court found that: (1) T.P. is mentally ill; (2) T.P. is gravely disabled; and (3) commitment is appropriate. T.P. only challenges the finding that she is gravely disabled.
[¶17] Indiana Code Section 12-7-2-96 defines "gravely disabled" as "a condition in which an individual, as a result of mental illness, is in danger of coming to harm because the individual:"
(1) is unable to provide for that individual's food, clothing, shelter, or other essential human needs; or
(2) has a substantial impairment or an obvious deterioration of that individual's judgment, reasoning, or behavior that results in the individual's inability to function independently.
"Because the definition of grave disability is written in the disjunctive, the evidence needs to support only one of those two prongs for a person to be found gravely disabled." A.S., 148 N.E.3d at 1140 (citing A.L. v. Wishard Health Servs., 934 N.E.2d 755, 760 (Ind.Ct.App. 2010), trans. denied). The trial court's order does not specify which prong it relied upon to find T.P. gravely disabled. Accordingly, we will address both prongs.
1. Ability to Function Independently
[¶18] We begin by addressing whether ACH presented sufficient evidence to demonstrate that T.P. has a substantial impairment or an obvious deterioration 9 of her judgment, reasoning, or behavior that results in her inability to function independently. T.P. argues that the trial court's decision is based solely upon her lack of insight into her illness and the possibility that she will stop taking her medications if not under a commitment.
[¶19] In T.K., our Supreme Court addressed a similar situation. In that case, T.K. was diagnosed with schizophrenia and paranoid personality disorder. Id. The petitioner sought a regular commitment of T.K. and argued that T.K. was gravely disabled based on T.K.'s refusal of treatment, denial that he had any mental illness, and "reports that T.K. had been aggressive in several areas of his life." Id. at 276. The trial court granted the commitment order, and our Supreme Court reversed, holding that "denial of illness and refusal to medicate, standing alone, are insufficient to establish grave disability because they do not establish, by clear and convincing evidence, that such behavior 'results in the individual's inability to function independently.'" Id. at 276 (quoting Ind. Code § 12-7-2-96(2)).
[¶20] Following T.K., we reversed an order for a regular commitment in B.J., 67 N.E.3d 1034. In that case, the petitioner sought extension of B.J.'s second temporary commitment to a regular commitment. Id. at 1036. The petitioner did not allege that B.J. stopped taking his medications or receiving his injections during his second temporary commitment; B.J. agreed to continue taking his medications and to participate in treatment without a commitment. Id. at 1036-37. The petitioner presented evidence that B.J. made threats during the temporary commitment period. Id. at 1036. B.J. also had an "outburst" 10 that interrupted the regular commitment hearing, and the trial court got the "impression" that B.J. denied that he had any mental illness. Id. at 1037. The trial court found that B.J. was gravely disabled based, in part, on a finding that B.J. had "absolutely no insight into [his] illness" and needed continued treatment. Id. at 1037-38. In reversing the trial court's commitment order, we offered this analysis:
Here, Dr. Salama was the only witness who testified that B.J. had a grave disability. When asked whether B.J. could provide himself with food, clothing, shelter, or other essential human needs, Dr. Salama replied, "Well, there is going to be a[n] escalation in the symptoms which at the one point he's not going to be able to reach that. He's always supported now by his parents. He lives with them and they-they help him out. Before that he was in a restrictive environment." When asked whether she believed there was a risk that B.J. would harm himself or others, Dr. Salama responded, "If he does not-if he does not stick with the treatment and treatment plan, he will eventually deteriorate to-to where (indiscernible)." In both of these instances, Dr. Salama evaluated B.J.'s hypothetical state based on future contingencies. We do not find this testimony persuasive as the statute clearly requires the trier of fact to assess the individual's state at the time of the hearing prior to ordering a commitment. See I.C. § 12-7-2-96 (stating-in present tense-that a person is gravely disabled if that person "(1) is unable to provide for ... food, clothing, shelter, or other essential human needs; or (2) has a substantial impairment or an obvious deterioration of ... judgment, reasoning, or behavior that results in the individual's inability to function independently").11 Id. at. 1039 (citations omitted) (bold emphasis added; italics original; brackets original).
[¶21] We find that ACH failed to prove by clear and convincing evidence that T.P. was unable to function independently. As in B.J., ACH did not offer evidence that T.P. stopped taking her medications or resisted receiving her injections during the temporary commitment period. Id. at 1036. Rather, T.P. testified that her new medications and treatment were helping her. Further, as in B.J., T.P. testified that she planned to adhere to her treatment plan without a commitment order and that she had the support of her family. Id. at 1037. T.P. further testified that she could drive herself to appointments and treatments and that she provided for her child. The trial court, moreover, observed that T.P. was "very well spoken today" and "look[ed] as good as I've ever seen[.]" Tr. Vol. II pp. 106, 111.
[¶22] The gravamen of ACH's argument that T.P was gravely disabled is that, without a commitment order, T.P. would cease taking her medications and her condition would deteriorate. Indeed, the trial court rested its commitment order on a finding that denying the request for a regular commitment would "risk losing [T.P.'s] progress." Tr. Vol. II p. 111. B.J., however, held that we must consider the patient's state at the time of the commitment hearing. 67 N.E.3d at 1040. Here, ACH failed to prove that T.P. failed to take her medications or receive injections during the temporary commitment, and T.P. testified that she would follow her treatment protocol without a commitment order. ACH's argument is essentially the same "hypothetical" argument that 12 we rejected in B.J. See id. Under these facts and circumstances, we find that ACH failed to meet its burden to prove by clear and convincing evidence that T.P. was unable to function independently.
ACH dedicates a single sentence to B.J. and dismisses it as a case in which no evidence was presented that B.J. was unable to provide for his essential needs. ACH does not address B.J.'s analysis regarding the other prong of the grave disability standard, which is whether the person can function independently.
[¶23] ACH also cites three cases for the proposition that lack of insight and the need for continued treatment support a regular commitment order. See Appellee's Br. p. 14 (citing In re M.M., 826 N.E.2d 90, 96 (Ind.Ct.App. 2005), trans. denied; In re W.S., 23 N.E.3d 29, 34 (Ind.Ct.App. 2014), trans. denied; G.Q. v. Branam, 917 N.E.2d 703, 706 (Ind.Ct.App. 2009)). These cases were all decided before the Indiana Supreme Court refined our application of the clear and convincing evidence standard to commitment cases in T.K. See T.K., 27 N.E.3d at 274. Accordingly, we do not find that the cases, on which ACH relies, are persuasive.
[¶24] Finally, ACH points out that, unlike in B.J., here, T.P. was not employed. See 67 N.E.3d 1034, 1040. ACH also argues that T.P. missed several therapy appointments during the temporary commitment period. T.P., however, denied missing any appointments. T.P. and ACH, further, offered conflicting reasons for any missed appointments. Finally, in B.J., we reversed despite evidence that B.J. missed several appointments. Id. at 1036. In light of the 13 other evidence presented, we do not find that these facts amount to clear and convincing evidence that T.P. was unable to function independently.
2. Ability to Provide Essential Human Needs
[¶25] We turn next to whether ACH proved by clear and convincing evidence that T.P. was gravely disabled because she was unable to provide for her "food, clothing, shelter, or other essential human needs." Ind. Code § 12-7-2-96. We find that ACH did not.
[¶26] In her physician's statement, Dr. Negendank only alleged that T.P. was unable to function independently; Dr. Negendank did not allege that T.P. was unable to provide for her basic needs. See In re M.E., 64 N.E.3d 855, 863 (Ind.Ct.App. 2016) (finding that physician's failure to check the box in physician's statement, which indicated that the patient was gravely disabled, was evidence that petitioner had failed to prove that patient was gravely disabled), disapproved of on other grounds, A.A. v. Eskanazi Health/Midtown CMHC, 97 N.E.3d 606, 612 (Ind. 2018). Dr. Negendank did state in her physician's statement that T.P. "neglects her physical health needs" and lacks the ability to care for herself "when unmedicated." Appellant's App. Vol. II p. 29-30 (emphasis added). ACH, however, did not present any evidence that T.P. had failed to take her medications or receive injections during the temporary commitment period.
[¶27] At the regular commitment hearing, Dr. Negendank testified that T.P. was improving but "still requires a lot of assistance, for her health in particular." Tr. Vol. II p. 80. Dr. Negendank, however, did not elaborate on the type of 14 assistance T.P. requires, and accordingly we are unable to discern the state of T.P.'s ability to meet her essential needs at the time of the regular commitment hearing. The evidence submitted indicated that T.P. was living with and had the support of her father. We find ACH failed to prove by clear and convincing evidence that T.P. was unable to meet her essential needs.
[¶28] In light of T.K., we are constrained to reverse under the evidence presented. Put simply, ACH failed to prove by clear and convincing evidence that: (1) T.P. has a substantial impairment or an obvious deterioration of her judgment, reasoning, or behavior that results in her inability to function independently; or (2) T.P. is unable to provide for her food, clothing, shelter, or other essential human needs. Accordingly, ACH failed to prove that T.P. was gravely disabled.
Conclusion
[¶29] ACH failed to present sufficient evidence that T.P. was gravely disabled, and thus, the trial court erred by granting ACH's petition for a regular commitment of T.P. Accordingly, we reverse.
[¶30] Reversed.
Brown, J., and Altice, J., concur. 15