IN THE MATTER OF THE CIVIL COMMITMENT OF R.H. (CACC-000468-20, CAMDEN COUNTY AND STATEWIDE) (RECORD IMPOUNDED)

RECORD IMPOUNDED

NOT FOR PUBLICATION WITHOUT THE
APPROVAL OF THE APPELLATE DIVISION
This opinion shall not "constitute precedent or be binding upon any court ." Although it is posted on the
internet, this opinion is binding only on the parties in the case and its use in other cases is limited. R. 1:36-3.

SUPERIOR COURT OF NEW JERSEY
APPELLATE DIVISION
DOCKET NO. A-3230-19

IN THE MATTER OF THE
CIVIL COMMITMENT OF
R.H.
________________________

Argued October 18, 2021 – Decided November 15, 2021

Before Judges Vernoia and Firko.

On appeal from the Superior Court of New Jersey, Law
Division, Camden County, Docket No. CACC-000468-
20.

Lorraine Gormley-Devine, Assistant Deputy Public
Defender, argued the cause for appellant R.H. (Joseph
E. Krakora, Public Defender, attorney; Lorraine
Gormley-Devine, of counsel and on the briefs; Patrick
J. Hurst, Assistant Deputy Public Defender, on the
briefs).

Regina M. Philipps argued the cause for respondent
Burlington County Office of the Adjuster (Madden &
Madden, PA, attorneys; Regina M. Philipps and David
E. Madden, on the brief).

PER CURIAM
 R.H.1 appeals from an April 17, 2020 order continuing her involuntary

civil commitment to the Hampton Behavioral Health Center (Hampton). Based

on our review of the record, we are convinced the court abused its discretion by

ordering the continuation of R.H.'s civil commitment. We therefore reverse.

I.

On April 8, 2020, R.H. was involuntarily committed to Hampton pursuant

to N.J.S.A. 30:4-27.10(b). Nine days later, on April 17, 2020, a municipal court

judge conducted a hearing on the Burlington County Office of the Adjuster's

(County) request for continuation of R.H.'s commitment. R.H. appeared at the

hearing with counsel. 2 The County presented the testimony of R.H.'s treating

physician, Dr. Atta-Ur Rehman, and R.H. testified on her own behalf.

Dr. Rehman explained R.H. has no history of treatment by a psychiatrist

in the community, or of prior psychiatric hospitalizations. R.H. has a family

history of schizophrenia; her father has schizophrenia.

R.H. was admitted to Hampton on April 8, 2020, because she was

"delusional, paranoid, [and] agitated," was receiving messages from her

1
We use initials to identify the appellant because records of civil commitment
proceedings are excluded from public access under Rule 1:38-3(f)(2).
2
The hearing was conducted virtually.
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deceased mother, and "was unable to care for herself or function." According

to Dr. Rehman, R.H. was upset with her husband because she believed he was

"trying to take the property" previously owned by her mother. Dr. Rehman

acknowledged he did not have actual knowledge whether R.H.'s claim

concerning her husband's attempt to take the property was true. Dr. Rehman

noted R.H.'s family members reported there was "a change in [R.H.'s] behavior

completely," R.H.'s father has schizophrenia, and "[t]hey all think . . . [R.H.] has

[had] a schizophrenic break."

Dr. Rehman diagnosed R.H. with "psychotic disorder not . . . specified,"

and a secondary diagnosis for cannabis abuse. 3 R.H. was prescribed Zyprexa

for the psychotic disorder. Dr. Rehman testified R.H. initially resisted taking

the medication, but started taking it a "couple of days," or perhaps "three days,"

before the April 17, 2020 hearing. Dr. Rehman further explained it was too early

to determine if the medication "reached an optimal level or dosage" because

R.H. "remain[ed] delusional and paranoid," R.H. "still believes that her husband

is manipulating everybody," and R.H. "has no place to go."

3
Dr. Rehman acknowledged R.H. used marijuana lawfully pursuant to a
prescription for medical marijuana for pain management related to injuries she
suffered in a disabling car accident. Dr. Rehman did not explain the nature or
extent of the cannabis disorder or rely on it to support his recommendation for
the continuation of R.H.'s involuntary commitment.
A-3230-19
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 Dr. Rehman testified R.H. reported that "everybody is abusing her," she

is the victim of domestic violence by her husband, and she intended to "go back

to her oldest son" and live with him. Dr. Rehman further explained R.H. refused

to provide her oldest son's contact information. Dr. Rehman testified R.H. told

a nurse practitioner at Hampton "she [is] only taking medication because she

wants to be discharged." Dr. Rehman also opined R.H. could not be "treated in

a less restrictive setting."

Dr. Rehman testified R.H. would be "a danger to herself, others or

property" if she was released to a less restrictive setting. The doctor opined

R.H. "was destructive with property" at home, explaining R.H. had thrown her

husband's phone at their home. In support of this opinion, Dr. Rehman referred

to a "record indicat[ing] that [R.H.] had broken her husband's cell phone because

she was mad." Dr. Rehman agreed, however, that the reported incident

concerning the phone involved a fight between R.H. and her husband during

which R.H. threw her husband's phone but did not assault her husband in any

manner.

When asked if R.H. currently posed a danger to herself, Dr. Rehman

stated:

Because of her current delusion and paranoia[,] I think
she could be because if we will discharge her[,] we

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 don't know what [she would] do because [she] ha[s] no
place to go, we don't know where she would go from
here, and because of her psychosis.

[(Emphasis added).]

Dr. Rehman acknowledged, however, he had no information that R.H. had ever

taken any action to harm herself, or that, prior to her admission, she neglected

her need for food or shelter.

Dr. Rehman testified that when R.H. is discharged from Hampton, she will

be referred to a psychiatrist in the community who will be charged with

monitoring and prescribing R.H.'s medications. Dr. Rehman recommended the

continuation of R.H.'s involuntary commitment with a "two-week review" based

on his hope she would show improvement and a placement for her could be

located.

As noted, R.H. also testified. She admitted having difficulties in her

marriage. She denied throwing her husband's phone. She testified that during

an argument with her husband, she "tried to grab the phone." She also testified

"the phone is not broken" and her husband "still uses it."

R.H. explained she had been a nurse, but was receiving disability benefits

for lower back, shoulder, and neck injuries she suffered "through" work. She

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saw a pain management specialist for the injuries, and "recently had ablations

done on [her] back."

R.H. testified that prior to her involuntary commitment she bought food

and prepared meals for her and her husband. R.H. said she had trouble sleeping,

but she got "enough" sleep. She often tried sleeping on the couch at home and

was fearful of her husband unless her son was at home. R.H. testified she would

follow up with a psychiatrist in the community if released and would take any

medications prescribed by a psychiatrist in the community.

R.H. also testified she did not like the way the medication prescribed by

Dr. Rehman made her feel. R.H. was, however, amenable to a conditional

release requiring that she "follow up with a psychiatrist" and "take the

medication that is prescribed."

R.H. did not agree with Dr. Rehman's diagnosis that she suffered from

psychosis. She disagreed with her diagnosis of mental illness, claiming instead

she was "emotionally and physically abused by [her] husband." R.H. further

stated her husband has a history of domestic abuse and she had sought a

restraining order against her husband approximately two weeks before her

commitment. R.H.'s description of how she sought the restraining order against

her husband is vague. She testified "[she] tried going to [her] local police

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department but with [her husband] being a [local public official, she] didn't get

much help there with the police department."

R.H. also testified she filed a complaint with the "[g]rievance

[d]epartment" at Hampton alleging other patients were receiving improper

treatment. Specifically, R.H. claimed doctors at the facility did not respond to

patients' complaints regarding their prescribed medications.

R.H. testified that, if released from commitment, she would like to either

return to her marital home — if her husband was removed from the home — or

move in with her adult son. R.H. testified her adult son indicated there was a

place for her in his home.

Based on that record, the municipal court judge issued a terse oral opinion,

concluding R.H.'s involuntary commitment should be continued "with a two-

week review." The judge's findings supporting his determination consist of the

following:

[R.H.] was admitted to the facility with -- with
delusions. This is her first hospitalization we're
advised and there's indication of a family history in
regard[] to the mental illness. Upon cross-examination
it appears that at least for eight years the – [R.H.] has
had some interaction with psychiatric healthcare
providers. There appears to be chronic pain issues.
And from her own testimony, in the course of the
Worker's Comp[ensation] injury that gave rise to her
disability, in her own words there has been consultation

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 with those with psychiatric treatment credentials. It
does appear there are in fact chronic pain issues. I can
appreciate the fact that her profession was that of a
nurse, it appears though that she does -- she's related
what has transpired over approximately eight years, it
does appear to the [c]ourt that she does not recognize
that she does in fact have a mental illness. I'm further
satisfied that with this non-recognition that she is a
danger to self. There does appear to be, at least in her
mind, indications of domestic violence. I find it most
telling that she indicates that she could go live with the
son and yet she has denied the medical staff access to
that individual to see if there is a place for her to stay.
I'm satisfied at this time until the medications reach
their proper level that she cannot be freed in a less
restrictive setting, accordingly [her commitment is
continued] with a two[-]week review.

[(Emphasis added).]

The judge entered an April 17, 2020 order continuing R.H.'s involuntary

commitment. R.H. appealed from the order. R.H. was released from Hampton

on April 28, 2020. The County moved to dismiss the appeal as moot, and this

court denied the motion.

II.

We first summarize the well-established legal principles that guide our

review of an order continuing an involuntary commitment following a temporary

commitment. "[T]he involuntary commitment of an individual 'is a profound

and dramatic curtailment of a person's liberty and as such requires meticulous

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adherence to statutory and constitutional criteria.'" In re Commitment of D.M.,

285 N.J. Super. 481, 486 (App. Div. 1995) (quoting Fair Oaks Hosp. v. Pocrass,

266 N.J. Super. 140, 149 (Law Div. 1993)). To continue an individual's

involuntary commitment after a temporary commitment order, a court must find

"by clear and convincing evidence presented at [a] hearing that the patient is in

need of continued involuntary commitment to treatment." R. 4:74-7(f)(1).

To establish a patient's need for continued involuntary commitment, the

State must present clear and convincing evidence that

(1) the patient is mentally ill[;] (2) mental illness causes
the patient to be dangerous to self or dangerous to
others or property as defined in N.J.S.A. 30:4-27.2(h)
and -.2(i)[;] (3) the patient is unwilling to be admitted
to a facility for voluntary care or accept appropriate
treatment voluntarily[;] and (4) the patient needs
outpatient treatment as defined by N.J.S.A. 30:4-
27.2(h) or inpatient care at a short-term care or
psychiatric facility or special psychiatric hospital
because other less restrictive alternative services are
not appropriate or available to meet the patient's mental
health care needs.

[R. 4:74-7(f)(1); see also N.J.S.A. 30:4-27.2(m).]

A "mental illness" under Rule 4:74-7(f)(1) is defined as "a current,

substantial disturbance of thought, mood, perception or orientation which

significantly impairs judgment, capacity to control behavior or capacity to

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9
recognize reality." N.J.S.A. 30:4-27.2(r). A person is deemed "[d]angerous to

self" if

by reason of mental illness the person has threatened or
attempted suicide or serious bodily harm, or has
behaved in such a manner as to indicate that the person
is unable to satisfy his need for nourishment, essential
medical care or shelter, so that it is probable that
substantial bodily injury, serious physical harm or
death will result within the reasonably foreseeable
future.

[N.J.S.A. 30:4-27.2(h).]

Whether an individual is dangerous to self within the meaning of N.J.S.A.

30:4-27.2(h) is a legal issue requiring that the "judge . . . make specific findings

and correlate them to the legal standards" while guided by medical expert

testimony. In re Commitment of M.M., 384 N.J. Super. 313, 337-38 (App. Div.

2006) (citing In re D.M., 313 N.J. Super. 449, 454, 456 (App. Div. 1998)).

Medical labels are not determinative of the existence of a qualifying mental

illness or an individual's dangerousness; a functional analysis of the patient's

condition under "the standards plainly articulated in the relevant statutes" is

required. D.M., 313 N.J. Super. at 456. The statutory definitions require a legal

judgment guided by medical expert testimony. In re D.C., 146 N.J. 31, 59

(1996); D.M., 313 N.J. Super. at 456.

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 "The evidence must permit the judge 'to come to a clear conviction [that

person is mentally ill and dangerous], without hesitancy.'" M.M., 384 N.J.

Super. at 334 (alteration in original) (quoting In re G.G.N., 372 N.J. Super. 42,

59 (App. Div. 2004)). The evidence must be "so clear, direct and weighty and

convincing as to enable [the factfinder] to come to a clear conviction, without

hesitancy, of the truth of the precise facts in issue." In re Commitment of Robert

S., 263 N.J. Super. 307, 312 (App. Div. 1992) (alteration in original) (quoting

In re Jobes, 108 N.J. 394, 407-08 (1987)).

To support an order continuing a civil commitment, a court must make

specific findings and correlate them to the legal standards. D.M., 313 N.J.

Super. at 454. The court "shall, by an opinion or memorandum decision, either

written or oral, find the facts and state its conclusions of law thereon in all

actions tried without a jury[.]" R. 1:7-4(a). The court must state the facts

forming the basis of its decision, and then weigh and evaluate those facts under

the governing law "to reach whatever conclusion may logically flow from" those

facts, Slutsky v. Slutsky, 451 N.J. Super. 332, 357 (App. Div. 2017), because

justice requires that "[a]ll conclusions must be supported." Ibid.

We review a decision continuing an individual's civil commitment for an

abuse of discretion. See D.C., 146 N.J. at 58-59. "[W]e afford deference to the

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trial court's supportable findings," In re Commitment of T.J., 401 N.J. Super.

111, 119 (App. Div. 2008), and "reverse[ ] only when there is clear error or

mistake." M.M., 384 N.J. Super. at 334. However, we "must consider the

adequacy of the evidence." Ibid.

On appeal, R.H. argues the court erred by ordering the continuation of her

involuntary commitment because the County did not present clear and

convincing evidence she posed an imminent danger to self under N.J.S.A. 30:4-

27.2(h), or a danger to others or property under N.J.S.A. 30:4-27.2(i). She also

argues the court erred by relying on her lack of insight concerning her mental

illness and need for further stabilization as a basis for its continuation order.

R.H. also claims the court erred because any issues related to R.H.'s need for

shelter could have been satisfied through release with services available in the

community. See N.J.S.A. 30:27.15(a) (requiring consideration of "the least

restrictive environment for the patient to receive clinically appropriate

treatment" in determining whether to continue an involuntary civil

commitment).

We first observe the court failed to make the requisite findings of fact

supporting its determination that continuing R.H.'s involuntary civil

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commitment was required because she was a danger to self.4 See R. 1:7-4. Other

than vaguely referring to R.H.'s history of chronic back pain, and her "family

history of mental illness," the court's findings are comprised of nothing more

than its observations that R.H. does not recognize she has a mental illness, she

appears "in her mind" to have "indications" of domestic violence, and she said

she would live with her son if released but would not give Hampton staff contact

information for her son. It was on those sparse findings alone that the court

determined R.H. was a danger to self and that she could not be released under

any set of less restrictive circumstances.

We find the court's findings inadequate. The court did not make any

credibility determinations even though R.H. denied Dr. Rehman's assertions,

based on what he was told by others, that R.H. threw her husband's phone and

R.H. conjured up the story about her husband's effort to take property that had

belonged to her mother. The court also did not make any factual findings related

to the elements necessary to support the continuation of an involuntary

commitment under N.J.S.A. 30:4-27.2(m) and R. 4:74-7(f)(1). See Curtis v.

4
The court did not find continuation of R.H.'s civil commitment was required
because R.H. presented a danger to others or property under N.J.S.A. 30:4-
27.2(i). The County does not argue the court erred by not finding R.H. was a
danger to others or property. It is therefore unnecessary to address R.H.'s claim
the court erred by continuing her involuntary commitment on that basis.
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Finneran, 83 N.J. 563, 570 (1980) (explaining a trial court must "state clearly its

factual findings and correlate them with the relevant legal conclusions").

For example, the court did not make a finding R.H. suffered from a mental

illness or identify the mental illness it determined warranted her continued civil

commitment, even though those findings are essential to a determination the

commitment should be continued. See N.J.S.A. 30:4-27.2(m) and R. 4:74-

7(f)(1). Similarly, the court did not make a finding as to causation; that is, the

court did not make findings as to whether R.H.'s mental illness caused her to be

dangerous to self. Again, such a finding is a prerequisite to the continuation of

an involuntary civil commitment under N.J.S.A. 30:4-27.2(m) and R. 4:74-

7(1)(2), because the County is required to prove such causation by clear and

convincing evidence to justify the continued involuntary commitment of a

patient. R. 4:74-7(f)(1).

The lack of requisite findings did not end there. The court did not make

any findings supporting its determination R.H. posed a danger to self, other than

its oblique, conclusory determination that her "non-recognition of her mental

illness" satisfied the court "she is a danger to self." The court added that there

"appears" to be "at least in [R.H.'s] mind, indications of domestic violence" but

the court does not make any findings as to whether there was domestic violence

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as R.H. testified there was, or there was no domestic violence based on Dr.

Rehman's vague testimony about what he heard from others. Last, the court

noted R.H.'s reported statements and testimony she would live with her son if

released, and Dr. Rehman's testimony R.H. would not provide contact

information for her son, as an apparent basis for its finding R.H. was a danger

to self. But the court does not explain how her failure to provide the contact

information rendered her a danger to self under the N.J.S.A. 30:4-27.2(h)

standard.

What is also missing from the court's analysis are findings addressing the

legal standard for dangerous to self under N.J.S.A. 30:4-27.2(h). See D.M., 313

N.J. Super. at 456 (reversing an order continuing an involuntary civil

commitment because the testifying treating physician did not "focus upon a

functional analysis of [the patient's] condition within the context of the[]

statutory definitions" in N.J.S.A. 30:4-27.2).

To satisfy its burden of proving R.H. was a danger to self, the County was

required to clearly and convincingly establish that "by reason of" R.H.'s mental

illness she threatened or attempted suicide or behaved in a manner that indicates

she is unable to satisfy her need for nourishment, medical care or shelter, "and

it is resultantly probable that substantial bodily injury, serious physical harm or

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death will result within the reasonably foreseeable future." N.J.S.A. 30:4-

27.2(h). The court, however, made no findings addressed to this essential

element of the County's proofs. In its failure to make such findings, the court

did not honor its obligation to cull through the evidence presented, make factual

determinations based on the evidence it deemed credible, and correlate those

determinations to the applicable legal standards in support of an order grounded

in competent evidence and the law. See Curtis, 83 N.J. at 570; D.M., 313 N.J.

Super. at 454. As we have explained,

[t]he importance of the individual and public interests
implicated by civil commitment "demonstrate the
particular necessity . . . for the trial judge to comply
assiduously with the mandate of . . . [the] myriad [of]
cases pointing out the importance of findings." In re
Commitment of S.D., 212 N.J. Super. 211, 218-19
(App. Div. 1986). A judge presiding over a
commitment hearing is vested with extraordinary
responsibility; when the judge does not apply the legal
standards and find the relevant facts, our subsequent
correction of the abuse of discretion is a poor remedy
for the ill.

[M.M., 384 N.J. Super. at 332-33 (alterations in
original).]

Here, the dearth of proper and complete findings would otherwise require

a remand for further findings by the court, see, e.g., D.M., 313 N.J. Super. at

454, but a remand is unnecessary because R.H. has been released and we are

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otherwise convinced the County failed to present clear and convincing evidence

R.H. was a danger to self under the statutory standard in N.J.S.A. 30:4-27.2(h).

Most simply stated, the County failed to present evidence that by reason

of a mental illness R.H. threatened or attempted suicide or otherwise behaved in

a manner indicating an inability to satisfy her need for shelter "so that it is

probable that substantial bodily injury, serious physical harm, or death will

result in the reasonably foreseeable future." N.J.S.A. 30:4-27.2(h). The best

the County could muster in support of its claim R.H. was a danger to self is Dr.

Rehman's testimony that R.H. "could" be a danger to self if released.

Dr. Rehman's testimony does not constitute clear and convincing evidence

R.H. was a danger to self under N.J.S.A. 30:4-27.2(h) for two reasons. First,

Dr. Rehman did not testify R.H. was a danger to self under the statutory

standard. Dr. Rehman's testimony R.H. could be a danger to self if released was

made without reference to the statutory standard, without correlating any facts

pertaining to R.H. under the standard, and without any functional analysis under

the statute. See D.M., 313 N.J. Super. at 456. For example, Dr. Rehman did not

testify that if released, it was probable R.H. would suffer the injuries or death in

the reasonably foreseeable future as required to establish dangerousness to self

under N.J.S.A. 30:4-27.2(h).

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 Second, Dr. Rehman's testimony is insufficient to satisfy the dangerous-

to-self standard because she opined only that R.H. "could" be a danger to self if

released. That is not enough. The County was required to present clear and

convincing evidence it was "probable" R.H. would suffer the defined injuries or

death within a reasonably foreseeable time after her release. See N.J.S.A. 30:4-

27.2(h); R. 4:74-7(f)(1). Evidence R.H. "could" be a danger to herself allows

nothing more than a conclusion it is possible R.H. was danger to self. See Could,

Merriam-Webster, https://www.merriam-webster.com/dictionary/could (last

visited Oct. 29, 2021) (defining "could" as "past tense of can"); see Can,

Merriam-Webster, https://www.merriam-webster.com/dictionary/can (last

visited Oct. 29, 2021) (defining "can" as "used to indicate possibility" and

"sometimes used interchangeably with may"); see May, Merriam-Webster,

https://www.merriamwester.com/dictionary/may (last visited Oct. 29, 2021)

(defining "may" as "used to indicate possibility"). N.J.S.A. 30:4-27.2(h)

requires evidence establishing a probability of the injuries supporting a finding

of dangerous to self, and the County offered no evidence, and certainly not clear

and convincing evidence, permitting such a finding as to R.H.

We are not persuaded by the County's claim the evidence established R.H.

was dangerous to self under N.J.S.A. 30:4-27.2(h) because she suffered from a

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mental illness and did not have a place to stay if released. The County's

argument finds no support in the evidence, and, in fact, is undermined by the

evidence.

Dr. Rehman was fully aware of the circumstances surrounding R.H.'s

mental illness, including her alleged psychosis, delusions, and paranoia; R.H.'s

refusal to provide contact information for the son with whom she said she would

live if released; and all the other circumstances pertaining to R.H.'s civil

commitment. Dr. Rehman, however, opined only that R.H.'s release "could"

result in a danger to self for R.H. if the involuntary commitment was not

continued. Again, the record lacked any evidence that, given all the

circumstances the County now argues supported R.H.'s continued commitment,

it was probable R.H. would suffer the consequences required to render her

dangerous to self under the statute N.J.S.A. 30:4-27.2(h). The County's only

witness, Dr. Rehman, did not offer testimony permitting a finding R.H. was

dangerous to self under the statute. See T.J., 401 N.J. Super. at 119 (explaining

an order continuing a civil commitment must clearly and convincingly establish

that the danger the patient poses constitutes "a substantial risk of dangerous

conduct within the reasonably foreseeable future") (quoting In re S.L., 94 N.J.

128, 138 (1983)).

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 Because the County failed to present sufficient competent evidence

establishing R.H. was dangerous to self, see N.J.S.A. 30:4-27.2(h), the court

abused its discretion by finding the County satisfied its burden of demonstrating

an entitlement to the continuation of R.H.'s involuntary commitment under

N.J.S.A. 30:4-27.2(m). See U.S. Bank Nat. Ass'n v. Guillaume, 209 N.J. 449,

467-68 (2012) (explaining a court abuses its discretion "when a decision is 'made

without a rational explanation, inexplicably departed from established policies,

or rested on an impermissible basis'" (quoting Iliadis v. Wal-Mart Stores, Inc.,

191 N.J. 88, 123 (2007))). "[W]e have not hesitated to reverse involuntary

commitments when the record failed to contain clear and convincing evidence

of 'a substantial risk of dangerous conduct within the reasonably foreseeable

future,'" T.J., 401 N.J. Super. at 119 (quoting S.L., 94 N.J. at 139), and are

compelled to do so again here based on the record presented. That conclusion

renders it unnecessary to address R.H.'s remaining arguments.

Reversed.

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