NO. 12-06-00142-CV
IN THE COURT OF APPEALS
TWELFTH COURT OF APPEALS DISTRICT
TYLER, TEXAS
THE STATE OF TEXAS § APPEAL FROM THE
FOR THE BEST INTEREST § COUNTY COURT AT LAW
AND PROTECTION OF C.S. § CHEROKEE COUNTY, TEXAS
MEMORANDUM OPINION
C.S. appeals from an order of commitment for temporary inpatient mental health services and an order to administer psychoactive medication. After a hearing without a jury, the trial court ordered C.S. committed to Rusk State Hospital for a period not to exceed ninety days and entered an order authorizing the Texas Department of Mental Health and Mental Retardation to administer psychoactive medication to C.S. In two issues, C.S. asserts the evidence is legally and factually insufficient to support the order of commitment and the trial court erred in granting the State’s application to administer psychoactive medication. We affirm.
Background
On April 17, 2006, an application for court ordered temporary mental health services was filed requesting the court commit C.S. to Rusk State Hospital for a period not to exceed ninety days. The application was supported by a certificate of medical examination for mental illness, prepared by a physician, Dr. C. Cuellar, who had examined C.S. on April 13. Dr. Cuellar diagnosed C.S. as suffering from schizoaffective disorder. He found that C.S. is mentally ill and likely to cause serious harm to himself and others.
Dr. Cuellar reached these conclusions because, on April 12, C.S. had threatened to kill family members. Dr. Cuellar found that C.S. presents a substantial risk of serious harm to himself or others if not immediately restrained, an opinion he based on C.S.’s behavior and on evidence of severe emotional distress and deterioration in C.S.’s mental condition to the extent he cannot remain at liberty. Dr. Cuellar formed this opinion because C.S. threatened to kill family members.
On April 14, 2006, C.S. was examined by Dr. Larry Hawkins who then also prepared a certificate of medical examination for mental illness. Dr. Hawkins diagnosed C.S. with psychosis NOS and indicated that C.S. is mentally ill and likely to cause serious harm to himself and others. He further determined that C.S. is suffering severe and abnormal mental, emotional, or physical distress, is experiencing substantial mental or physical deterioration of his ability to function independently, which is exhibited by his inability to provide for his basic needs, and he is unable to make a rational and informed decision as to whether or not to submit to treatment. He came to these conclusions because C.S. was guarded, suspicious, and denied all symptoms. C.S. believed others lie about him.
On April 17, 2006, C.S. was examined by Dr. Jon A. Guidry who also prepared a certificate of medical examination for mental illness. Dr. Guidry diagnosed C.S. with psychosis NOS, with a history of methamphetamine abuse. He noted that C.S. refuses treatment. Dr. Guidry indicated that C.S. is mentally ill and is likely to cause serious harm to others. The basis for this opinion is C.S.’s denial of the allegation that he threatened to kill his brother in law and his statement that “I wouldn’t eat dinner, they must have thought I was in a hunger strike.” Dr. Guidry also indicated that C.S. presents a substantial risk of serious harm to himself or others if not immediately restrained, which is demonstrated by C.S.’s behavior. The basis for this opinion was C.S.’s statement that “I don’t want him to know the court date.” Also, his opinion was based on C.S.’s behavior. C.S. self conversed and appeared to be responding to auditory hallucinations, yet denied their presence.
Dr. Guidry testified at the hearing, explaining that he diagnosed C.S. with psychosis not otherwise specified, with a history of methamphetamine abuse. He testified that C.S. is likely to cause serious harm to others. The doctor reached this conclusion based on a review of the information on the application for emergency detention, from examination of and discussions with the patient, and by observing the patient. He explained that C.S. remains psychotic, self converses, and sits in the doctor’s office talking to unseen persons. C.S. would not allow the doctor to contact the people he allegedly threatened to harm. The doctor’s diagnosis was based on his examination of C.S., review of the medical history, and reasonable medical probability. He estimated that, once C.S. is on medications, he would need to remain in the hospital for three or four weeks. The doctor stated that Rusk State Hospital is the least restrictive available option for C.S. at this time and treatment at the hospital is in his best interest.
On cross examination, Dr. Guidry testified that he has not observed C.S. perform any overt act of intent to harm himself at the hospital. Further, there have been no reports of any overt act that would indicate his likelihood to cause serious harm to others. The doctor testified that C.S. has the ability to take care of his basic needs outside the hospital.
On redirect, the doctor explained that C.S. told him he had not engaged in a hunger strike or been missing meals. However, C.S. is very underweight, a sign he has not been caring for himself. The records indicate he had engaged in a hunger strike at home. Also, C.S. has bradycardia, a low heart rate. Dr. Guidry testified that if not treated for mental illness, C.S. will either end up in jail or return to the hospital. The doctor explained that the allegations were that C.S. had religious delusions. He believed he was God and when people did not endorse that belief, he either stopped eating or threatened to harm them. Further, if not treated for his psychiatric illness, his physical health will deteriorate. The doctor testified that Rusk State Hospital is the least restrictive available medical treatment option for C.S., and he would need to remain at the hospital three to four weeks after medications are initiated.
Upon questioning by the court, Dr. Guidry explained that, most likely, the physical symptoms are caused by a combination of poor nutrition and methamphetamine abuse. The doctor stated that this places C.S. at risk for his personal health. He does not know what is causing the bradycardia.
On further cross examination, Dr. Guidry stated that C.S.’s weight loss “is a result of either delusions forcing him not to eat or methamphetamine abuse, and those are both mental illnesses.” He repeated that, in the hospital, he has seen no evidence of the likelihood that C.S. would cause harm to himself or serious harm to others. Again, he stated C.S. is able to provide for his basic needs outside the hospital.
On further redirect, the doctor was asked what is the cause of C.S.’s refusal to allow him to contact anyone regarding his health. Dr. Guidry explained that he thinks C.S. is trying to hide something. C.S. told him he did not want “them” to know the court date. The doctor testified that the fact that C.S. did not want him to investigate his physical symptoms and their causes suggests that he is paranoid and does not want others knowing about him. On recross, the doctor conceded that it could be that C.S. does not like his family or is a private person who does not want his family to be at the hearing.
Upon questioning by the court, Dr. Guidry said discovery of C.S.’s prior medical records would be extremely helpful in the diagnosis and treatment of the cardiac problems. The records would tell the doctor if the condition is benign or something that is newly developed and in need of further investigation.
C.S. testified in his own behalf. He said he is a professional bull rider. He denied going on a hunger strike or wanting to harm himself or anyone else. C.S. said he had never threatened to harm anyone else. If released, he would live in his mobile home. To make money, in addition to bull riding, he does odd jobs and drives a truck. The money he makes is sufficient to pay room and board, utilities, and clothing. He does his own shopping and gets fast food. He does his own household chores and yard work. He does not believe he needs to be in the hospital for any reason. If he had a broken arm, he would go to the emergency room. If his mobile home were on fire, he would call the fire department and the police. He denied being on any type of medication and said he tries to eat three times a day. He is 5' 8" tall and weighs 128 pounds. That is his normal weight. He has friends he sometimes socializes with.
On cross examination, C.S. said he refuses to allow the doctor or staff to contact his family because he is a grown man and it is none of their business. He does not want to give the doctor his medical history concerning his bradycardia because it is none of the doctor’s business. He explained that if he wanted to go to a doctor and have it checked, he would have gone himself. C.S. said he can run a mile and has no concern about his heart rate. He refused the medication ordered by Dr. Cuellar because he feels he does not need it. When asked if he feels his medical opinion is superior to the doctors’ opinions he said no, but he was not taking the medication. He explained that, while in the hospital, one of the other patients jumped out of bed and tried to bite him. C.S. ran down the hall to get away. He did not tell anyone the reason he ran down the hall until the day of the hearing because no one asked. While in the hospital, he received a letter from his mother, which angered him. When asked why, he said “because they want medication.”
C.S. admitted to previous use of methamphetamines. He denied threatening to kill his brother in law. He denied having walked in the street in traffic. He said he is a religious person and he knows he is not Jesus. He admitted quitting a carpentry job but when asked why, he declined to answer, saying it had nothing to do with being in the hospital for mental illness. In response to counsel’s statement that the records indicate he was fired because he would sit in his truck and talk to himself, C.S. said he might have been listening to the radio. He denied being fired. On redirect, C.S. said he sometimes sings with the radio and it could appear that he was talking to himself.
The trial court entered an order for temporary inpatient mental health services after determining that the evidence supports the allegations that C.S. is mentally ill and that he is likely to cause serious harm to himself and others. The court ordered C.S. committed to Rusk State Hospital for a period not to exceed ninety days.
A separate hearing was then held on the State’s application for court ordered administration of psychoactive medication. Dr. Guidry testified as to C.S.’s need for medication and C.S.’s refusal to take it. At the close of evidence, the court entered an order to administer psychoactive medication for the period of temporary commitment.
Commitment Order
In his first issue, C.S. asserts the evidence is neither legally nor factually sufficient to support the order of commitment. He contends that the evidence does not show that he is mentally ill. He also argues that the evidence does not show an overt act or continuing pattern of behavior tending to confirm that he is likely to cause serious harm to himself or others. Thus, he argues, the State failed to meet its evidentiary burden under the statute.
Standard of Review
In a legal sufficiency review where the burden of proof is clear and convincing evidence, the reviewing court must consider all of 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 finding was true. In re J.F.C., 96 S.W.3d 256, 266 (Tex. 2002). The reviewing court must assume that the factfinder resolved disputed facts in favor of its finding if a reasonable factfinder could do so. Id. A court should disregard all evidence that a reasonable factfinder could have disbelieved or found to have been incredible. Id.
In addressing a factual sufficiency of the evidence challenge, we must consider all the evidence in the record, both that in support of and contrary to the trial court’s findings. In re C.H., 89 S.W.3d 17, 27-29 (Tex. 2002). This court must give due consideration to evidence that the factfinder could reasonably have found to be clear and convincing. Id. at 25. We must determine whether the evidence is such that a factfinder could reasonably form a firm belief or conviction about the truth of the State’s allegations. Id. We must consider whether disputed evidence is such that a reasonable trier of fact could not have reconciled that disputed evidence in favor of its finding. In re J.F.C., 96 S.W.3d at 266. Appellate courts retain deference for the constitutional roles of the factfinder. In re C.H., 89 S.W.3d at 26. The trier of fact is the exclusive judge of the credibility of the witnesses and the weight to be given their testimony. See id. at 27; In re J.J.O., 131 S.W.3d 618, 632 (Tex. App.–Fort Worth 2004, no pet.).
Applicable Law
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). “Mental illness” means an illness, disease, or condition, other than epilepsy, senility, alcoholism, or mental deficiency, that substantially impairs a person’s thought, perception of reality, emotional process, or judgment, or grossly impairs behavior as demonstrated by recent disturbed behavior. Tex. Health & Safety Code Ann. § 571.003(14) (Vernon Supp. 2006). To be clear and convincing under the 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).
Discussion
The State provided expert testimony explaining that C.S. is mentally ill and describing his behavior. Dr. Cuellar stated in his certificate of medical examination that C.S. threatened to kill family members. Dr. Hawkins stated in his certificate that C.S. was guarded and suspicious, believing others lie about him, and that he denied all symptoms. Dr. Guidry stated in his certificate that C.S. refused treatment, denied threatening his brother in law, and said he would not eat dinner. Also, C.S. did not want family members to know the court date, he self conversed, and appeared to be responding to auditory hallucinations while denying their presence.
Dr. Guidry testified that C.S. is psychotic, self converses, and hallucinates. He sits in the doctor’s office talking to unseen persons. He explained that C.S. is very underweight, a sign he has not been caring for himself. The records show he had engaged in a hunger strike at home. Also, C.S. had used methamphetamines. Dr. Guidry explained that C.S. has religious delusions that lead to either his refusal to eat or his threatening others. The combination of methamphetamine use and poor nutrition put his personal health at risk. The evidence supports a finding that C.S. is mentally ill as it shows that his perception of reality is substantially impaired. See Tex. Health & Safety Code Ann. § 571.003(14); In re J.S.C., 812 S.W.2d 92, 94 (Tex. App.–San Antonio 1991, no writ). Additionally, this is expert testimony of a continuing pattern of behavior, hallucinations and delusions that lead to his refusal to eat, showing that C.S. is likely to cause serious harm to himself. The trial court could have disbelieved C.S.’s testimony to the contrary. See In re J.F.C., 96 S.W.3d at 266.
Considering all the evidence in the light most favorable to the findings, we conclude a reasonable trier of fact could have formed a firm belief or conviction that the finding that C.S. is likely to cause serious harm to himself is true. Id. The evidence presented satisfies the statutory requirement for clear and convincing evidence in support of the order for temporary inpatient mental health services. See Tex. Health & Safety Code Ann. § 574.034(d). The evidence is legally sufficient to support the trial court’s order. See In re J.F.C., 96 S.W.3d at 266.
In addressing C.S.’s factual sufficiency complaint, we consider the evidence the factfinder could reasonably have found to be clear and convincing. In re C.H., 89 S.W.3d at 25. C.S. testified that he considered himself an athlete because he rides bulls. He denied participating in a hunger strike and said his weight was normal for him. He said he does not need to be in the hospital and does not need medication. He also testified that he does not think he is Jesus. The trial court was entitled to disbelieve C.S.’s testimony and disregard evidence contrary to the State’s position. See id. at 27. In light of the entire record, the evidence that the trial court could not have credited in favor of its findings is not so significant that it could not reasonably form a firm belief or conviction that C.S. is mentally ill and is likely to cause serious harm to himself. See id. Thus, the evidence is factually sufficient to support these trial court findings. Because we hold the evidence is both legally and factually sufficient to support the trial court’s order, we overrule C.S.’s first issue.
Psychoactive Medication
In his second issue, C.S. asserts the trial court erred in entering an order authorizing administration of psychoactive medication. He argues that such an order must be based on a valid order for inpatient mental health care and, due to the reasons asserted in his first issue, the trial court’s order for inpatient mental health care is not valid.
The court may enter an order authorizing the administration of psychoactive medication if it finds by clear and convincing evidence that the patient is under an order for inpatient mental health services, the patient lacks the capacity to make a decision regarding the administration of the proposed medication, and treatment with the proposed medication is in the best interest of the patient. Tex. Health & Safety Code Ann. § 574.106(a) (Vernon Supp. 2006).
Having found the evidence sufficient to support the trial court’s order of commitment, we have determined that the trial court’s order for temporary mental commitment is valid. Therefore, we reject C.S.’s argument that the order authorizing administration of psychoactive medication is invalid on that basis. See id. We overrule C.S.’s second issue.
Conclusion
The evidence is legally and factually sufficient to support the trial court’s order of commitment for temporary inpatient mental health services. Further, the trial court did not err in ordering administration of psychoactive medication.
We affirm the trial court’s orders of commitment for temporary inpatient mental health services and for administration of psychoactive medication.
SAM GRIFFITH
Justice
Opinion delivered September 29, 2006.
Panel consisted of Worthen, C.J., Griffith, J., and Hoyle, J.
(PUBLISH)