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NON-PRECEDENTIAL DECISION - SEE SUPERIOR COURT I.O.P. 65.37
IN RE: R.B. : IN THE SUPERIOR COURT OF
: PENNSYLVANIA
:
APPEAL OF: R.B. :
:
:
:
:
: No. 484 MDA 2022
Appeal from the Order Entered March 3, 2022
In the Court of Common Pleas of Berks County Civil Division at No(s):
50-2022-MH
BEFORE: PANELLA, P.J., BENDER, P.J.E., and LAZARUS, J.
MEMORANDUM BY LAZARUS, J.: FILED: NOVEMBER 8, 2022
R.B. appeals from the order, entered in the Court of Common Pleas of
Berks County, affirming the certification for extended involuntary commitment
under section 7303 of the Mental Health Procedures Act (“MHPA”). 1 Upon
careful review, we affirm.
R.B. was admitted to Brooke Glen Behavioral Hospital (“Brooke Glen”)
on February 24, 2022, pursuant to Brooke Glen’s petition for involuntary
mental health treatment under 50 P.S. § 7302. On February 25, 2022, a
petition to extend R.B.’s court-ordered treatment by ten days was filed
pursuant to 50 P.S. § 7303 (“Section 303”). On March 2, 2022, a section 303
hearing was held telephonically2 before Mental Health Review Officer
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1 50 P.S. §§ 7101-7503.
2 An audio recording of the hearing has been made a part of the certified
record on appeal.
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(“MHRO”) Terry Weller, Esquire, at which R.B. was represented by court-
appointed counsel, Andrew Scott, Esquire, of the Berks County Public
Defender’s Office.
At the hearing, R.B.’s treating psychiatrist, Daniela Krausz, M.D.,
testified that R.B. originally came to the emergency room because he was
experiencing chest pains and felt as though he was unable to function. She
testified that R.B. had been under a significant amount of stress since his
house burned down and he was struggling to deal with his insurance company
and contractors. At the time he was admitted to Brooke Glen, R.B. was not
eating or sleeping enough, and was suffering from paranoid beliefs about
being followed and investigated by his insurance company. Doctor Krausz
diagnosed R.B. with psychosis NOS (not otherwise specified). She attempted
to treat him with medication to help with his sleeping and his mood, but he
refused. She stated that R.B. participated in group and other activities, but
that staff was having difficulty engaging him. Doctor Krausz testified that R.B.
was not aggressive or assaultive in his behavior, except “a little . . . at the
beginning.” MRHO Hearing, 3/2/22, at 7:47. Doctor Krausz testified that, at
the time of the hearing, R.B. was sleeping a little better and eating “some,”
although he did not like the food available to him. She testified that R.B. still
believed that he was being followed, had poor insight and limited judgment,
and was a danger to himself due to his lack of self-care. Doctor Krausz opined
that medicine would benefit R.B. by making him less paranoid, helping him
sleep better, and decreasing his anxiety. Doctor Krausz ultimately opined that
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Brooke Glen was the least restrictive facility for R.B. and recommended further
treatment there of up to ten days.
R.B. testified that he had gone to the emergency room because he felt
overwhelmed by his current situation—his house burned down in 2019 and,
since then, he has been unsuccessfully trying to work with contractors,
adjustors, and his insurance company to rebuild. He believed that, by going
to the hospital, he could obtain a doctor’s note and get time off from work to
focus on dealing with his situation. He stated that he has been unable to sleep
due to everything that is going on, as well as the fact that he and his family
are being evicted from their apartment. He attributed his weight loss to a
recent bout of COVID-19, which caused him to be out of work for two weeks.
Following the conclusion of the testimony, the MHRO stated that, while
he was not “hearing a great deal,” id. at 16:59, R.B.’s stressors remained,
which concerned him. Accordingly, in the hope that Dr. Krausz could “get
something set up for [R.B.],” id. at 17:05, the MHRO issued a certification
finding that R.B. was severely mentally disabled and was in need of continued
inpatient treatment for a period not to exceed five days.
On March 3, 2022, R.B. filed a petition for review of certification for
extended involuntary commitment in the Court of Common Pleas pursuant to
section 7109 of the MHPA. R.B. requested that the audio recording of the
section 303 hearing be used in lieu of a formal de novo hearing. Upon review
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of the recording, the trial court affirmed the extended involuntary certification
on March 3, 2022.3
R.B. filed a timely notice of appeal, followed by a court-ordered
Pa.R.A.P. 1925(b) concise statement of errors complained of on appeal. He
raises the following claim for our review:4
Whether [Brooke Glen] failed to present sufficient evidence to
support the involuntary commitment of R.B. where R.B.’s treating
psychiatrist could not articulate any clear or present danger [that]
R.B. posed to himself or others and could not say that R.B. posed
a substantial risk of serious bodily injury or death within thirty
days in a less restrictive environment.
Brief of Appellant, at 4.
The standard of review for an involuntary commitment order under the
MHPA is to “determine whether there is evidence in the record to justify the
court’s findings.” In re S.M., 176 A.3d 927, 935 (Pa. Super. 2017).
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3R.B. was ultimately discharged from treatment at Brooke Glen on March 4,
2022.
4 Although R.B.’s commitment order has expired, his appeal is not moot.
We recognize that an important liberty interest is at stake in all
involuntary commitments and by their nature, most commitment
orders expire prior to appellate review. Since a finding of
mootness would allow such claims to go unchallenged in most, if
not all, cases, we continue to hear these matters and, where the
facts allow, we have authority to vacate a commitment order and
direct that the record be expunged.
In re R.D., 739 A.2d 548, 553 (Pa. Super. 1999) (citations omitted); see
also In re J.M., 726 A.2d 1041, 1045 n.6 (Pa. 1999) (holding appeals from
expired involuntary commitment orders not moot as issues raised on appeal
capable of repetition and may evade review). Accordingly, the appeal is
properly before us.
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“Although we must accept the trial court’s findings of fact that have support
in the record, we are not bound by its legal conclusions from those facts.” Id.
We have explained the involuntary commitment process under the
MHPA as follows.
The MHPA provides for involuntary emergency examination and
treatment of persons who are “severally mentally disabled and in
need of immediate treatment.” 50 P.S. § 7301(a). It then
authorizes increasingly long periods of commitment for such
persons, balanced by increasing due process protections in
recognition of the significant deprivations of liberty at stake. See
In re A.J.N., 144 A.3d 130, 137 (Pa. Super. 2016) (highlighting
MHPA’s purpose as “an enlightened legislative endeavor to strike
a balance between the state’s valid interest in imposing and
providing mental health treatment and the individual patient’s
rights”). Accordingly, “[i]n applying the [MHPA,] we must take a
balanced approach and remain mindful of the patient’s due
process and liberty interests, while at the same time permitting
the mental health system to provide proper treatment to those
involuntarily committed to its care.” In re S.L.W., 698 A.2d 90,
94 (Pa. Super. 1997).
In re S.M., 176 A.3d at 930–31.
Under subsection 301(a) of the MHPA:
Whenever a person is severely mentally disabled and in need of
immediate treatment, he may be made subject to involuntary
emergency examination and treatment. A person is severely
mentally disabled when, as a result of mental illness, his capacity
to exercise self-control, judgment and discretion in the conduct of
his affairs and social relations or to care for his own personal needs
is so lessened that he poses a clear and present danger of harm
to others or to himself, as defined in subsection (b)[.]
50 P.S. § 7301(a). Subsection 301(b)(2) defines “clear and present danger”
to oneself, in relevant part, as follows:
Clear and present danger to himself shall be shown by establishing
that within the past 30 days:
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(i) the person has acted in such manner as to evidence that
he would be unable, without care, supervision[,] and the
continued assistance of others, to satisfy his need for
nourishment, personal or medical care, shelter, or self-
protection and safety, and that there is a reasonable
probability that death, serious bodily injury or serious
physical debilitation would ensue within 30 days unless
adequate treatment were afforded under this act[.]
Id. at § 7301(b)(2)(i). Section 302 provides for emergency examination and
treatment of persons, which
may be undertaken at a treatment facility upon the certification of
a physician stating the need for such examination; or upon a
warrant issued by the county administrator authorizing such
examination; or without a warrant upon application by a physician
or other authorized person who has personally observed conduct
showing the need for such examination.
Id. § 7302(a). Under subsection 302(b), a physician must examine the
person “within two hours of arrival in order to determine if the person is
severely mentally disabled within the meaning of [sub]section 301(b) and in
need of immediate treatment.” Id. at § 7302(b) (internal footnote omitted).
If the physician so finds, then “treatment shall be begun immediately.” Id.
If not, then “the person shall be discharged and returned to such place as he
may reasonably direct.” Id. Section 302 allows a person to be committed up
to 120 hours. Id. § 7302(d).
When a treatment “facility determines that the need for emergency
treatment is likely to extend beyond 120 hours,” or five days, section 303
provides that the facility may apply to extend the involuntary commitment for
up to 20 days. Id. at § 7303(a), (h). The facility files an application for
extended commitment with the court of common pleas, which then appoints
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an attorney for the person unless it appears “that the person can afford, and
desires to have, private representation.” Id. at § 7303(b). “Within 24 hours
after the application is filed, an informal hearing shall be conducted by a judge
or [MHRO].” Id.
If the judge or MHRO certifies that an extended section 303 commitment
is appropriate, the committed person may petition the court of common pleas
for review of the certification. Id. at § 7303(g). The trial court must hold a
hearing “within 72 hours after the petition is filed unless a continuance is
requested by the person’s counsel.” Id. “The hearing shall include a review
of the certification and such evidence as the court may receive or require.”
Id. “If the court determines that further involuntary treatment is necessary
and that the procedures prescribed by the [MHPA] have been followed, it shall
deny the petition. Otherwise, the person shall be discharged.” Id.
The MHPA is to be strictly construed. Commonwealth v. Moyer, 595
A.2d 1177, 1179 (Pa. Super. 1991) (citation omitted).
Recognizing the substantial curtailment of liberty inherent to an
involuntary commitment, our Supreme Court has cautioned that
the courts must strictly interpret and adhere to the statutory
requirements for commitment. In interpreting section
301(b)(2)(i), this Court has held that a mere finding of senility is
insufficient to establish that a person is a “clear and present
danger” to himself. See In re Remley, [] 471 A.2d 514 ([Pa.
Super.] 1984). Without evidence that the individual would die or
suffer serious bodily injury or serious physical debilitation in the
immediate future unless he was committed, the statutory
requirement had not been met. Similarly, . . . it is not sufficient
to find only that the person is in need of mental health services.
The court must also establish that there is a reasonable probability
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of death, serious injury[,] or serious physical debilitation to order
commitment.
In re T.T., 875 A.2d 1123, 1126–27 (Pa. Super. 2005).
The issue in this case is whether there was sufficient evidence to warrant
R.B.’s continued involuntary treatment under section 303. “The burden is on
the petitioner to prove the requisite statutory grounds by clear and convincing
evidence.” In re S.M., 176 A.3d at 937 (citation and quotation marks
omitted). “Our Supreme Court has defined clear and convincing evidence as
testimony that is so clear, direct, weighty, and convincing as to enable the
trier of fact to come to a clear conviction, without hesitation, of the truth of
the precise facts in issue.” Id. (citations and internal quotation marks
omitted).
R.B. argues that Dr. Krausz could not testify that he posed a “clear and
present danger to himself,” Brief of Appellant, at 11, where she “could not say
one way or the other if the rate at which R.B. was eating and sleeping would
cause death or serious bodily injury within thirty days.” Id. at 16. He notes
that “Dr. Krausz did not testify that the amount R.B. was eating was not
enough to sustain life.” Id. at 17. R.B. argues that “Dr. Krausz’s assertion
that she did not have enough information to determine if [R.B.] would pose a
risk to himself or others is clearly deficient, as it does not even qualify as
speculation, let alone reasonable speculation.” Id. at 17. R.B. asserts that,
while he “could probably have benefitted from some sort of treatment and
assistance[,] . . . this is not the purpose of the MHPA,” which requires a finding
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that he is a clear and present danger to himself before depriving him of his
liberty. Id. at 18.
In support of his claim, R.B. relies on this Court’s decision in In re S.M.,
supra. There, S.M., who suffered from schizoaffective bipolar disorder, was
committed primarily on the basis that she was not taking her medication in
therapeutic doses, as she believed that her illness “was better treated through
homeopathic remedies[.]” Id. at 938. Following her recommittal by an
MHRO, S.M. filed an appeal de novo to the court of common pleas. The
evidence showed that S.M. believed that “various hospital and state officials
were conspiring and colluding with her mother to keep her involuntarily
committed.” Id. Testimony also revealed that S.M. had gone several days
without eating, went several nights without sleep, and made racial slurs to
other residents. Id. at 939. Although her treating psychiatrist testified that
S.M.’s illness and unwillingness to properly take her medication affected her
judgment, he did not testify that S.M. posed a danger to herself or that there
was “a reasonable probability that death, serious bodily injury[,] or serious
physical debilitation would ensue within 30 days unless adequate treatment
were afforded.” Id. Instead, “the essence of his testimony was that S.M.
would be better off taking her medications in therapeutic doses, and that the
best way to ensure that she did so was through continued involuntary
commitment.” Id. The court of common pleas affirmed the MHRO’s
certification.
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This Court reversed the order of the trial court, finding that the evidence
did not show by clear and convincing evidence that S.M. posed a clear and
present danger to herself, and noting that “the serious deprivations of liberty
authorized by the MHPA demand that such deprivations be justified through
strict compliance with statutes substantive and procedural requirements.” Id.
R.B. argues that the evidence adduced at his MHRO hearing and
reviewed by the trial court on de novo appeal was similar to that presented to
the court in In re S.M. Specifically, like S.M., R.B. refused medication—
although unlike S.M., he had never before been on medication—and both
experienced disruptions in eating and sleeping habits. Likewise, both R.B. and
S.M. had paranoid beliefs. However, R.B. argues that “[p]aranoia alone is not
sufficient to involuntarily commit an individual under the MHPA without some
sort of evidence that the person might act in such a way . . . that would place
himself or others in danger, and that is not established here.” Brief of
Appellant, at 16. Moreover, Dr. Krausz acknowledged that R.B.’s sleep habits
had improved—without medication—during the short time he had been
hospitalized, and he argues that “his refusal to take medication[,] by itself[,]
is not enough to establish that he poses a clear and present danger to
himself.” Id. at 15.
After our review of the record in this matter, we are constrained to
conclude that the evidence was sufficient to support the trial court’s affirmance
of the MHRO’s order extending R.B.’s involuntary commitment by five days.
This case is, admittedly, a close call. The MHRO himself admitted that he had
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“not hear[d] a great deal,” but extended the commitment for 5 days in the
hopes that Dr. Krausz could “get him set up with something as an outpatient
or something with medication.” MRHO Hearing, 3/2/22, at 16:59, 17:05.
However, viewed in its totality, the evidence clearly and convincingly
demonstrates that there is a reasonable probability that R.B. would suffer
serious bodily injury or death within thirty days if untreated. We note that:
in establishing the “clear and convincing” standard of proof for
involuntary treatment:
Whether the individual is mentally ill and dangerous to
[either himself or] others . . . turns on the meaning of the
facts which must be interpreted by expert psychiatrists and
psychologists. . . .
The subtleties and nuances of psychiatric diagnosis render
certainties beyond reach in most situations. . . . Within the
medical discipline, the traditional standard . . . is a
“reasonable medical certainty[.]” [The] “beyond a
reasonable doubt” standard would forc[e] reject[ion] [of]
commitment for many patients desperately in need of
institutionalized psychiatric care.
Commonwealth v. Helms, 506 A.2d 1384, 1389 (Pa. Super. 1986), quoting
Addington v. Texas, 441 U.S. 418, 429–30 (1979) (citations omitted)
(emphasis added). The legislature did not require indisputable proof that an
individual’s behavior would be repeated, but rather proof of the “probability”
of such an event, which denotes “a chance stronger than possibility but falling
short of certainty.” Helms, 506 A.2d at 1389, quoting Webster’s New World
Dictionary, Coll. Ed. (1966). Thus, a petitioner must present evidence
demonstrating a substantial likelihood that the behavior will recur if the
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individual is not involuntarily committed. Id. We believe that standard has
been met here.
Although Dr. Krausz could not say with absolute certainty that death or
serious bodily injury would result within thirty days, the trial court deemed
her testimony sufficient to find that R.B. posed a clear and present danger to
himself in the absence of further treatment, as contemplated by the statute:
Dr. Krausz testified that [R.B.] presented to the emergency
department with “chest pains,” which she believed were caused
by “severe anxiety,” as well as “allegations of some paranoid
delusions” and that he was not sleeping or eating. Though Dr.
Krausz testified that [R.B.] was participating in his unit’s
treatment schedule, including group therapy, she raised concerns
regarding medication compliance upon release due to R.B.
refusing any medication during his treatment. Further, in
response to a question from the [MRHO], the doctor described []
R.B.’s insight and judgment as “poor,” stating that these factors
contributed to her concerns that he would pose a risk of harm or
danger to himself due to lack of self-care. [Doctor] Krausz
testified that Brooke Glen is the least restrictive facility for R.B.
“because he has failed to fully engage in treatment,” continues to
hold paranoid beliefs about being followed, and refused all
medication, which she believes is vital to helping [R.B.] feel “less
paranoid, sleep better[,] and reduce the anxiety he has.”
Together these factors led Dr. Krausz to believe that, to the best
of her knowledge, without continued inpatient care, R.B. would
pose a substantial risk of serious bodily injury to himself in a less
restrictive environment. She was unable to conclusively state
whether this injury would happen within the thirty days prescribed
by statute, but it was her belief that it would happen.
Trial Court Opinion, 4/26/22, at 2.
We find R.B.’s reliance on In re S.M. to be misplaced. While the facts
there are similar to those in the matter sub judice, the Court in In re S.M.
found the evidence supporting the commitment insufficient primarily because
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the doctor “did not testify that S.M. posed a danger to herself or that there
was ‘a reasonable probability that death, serious bodily injury or serious
physical debilitation would ensue within 30 days unless adequate treatment
were afforded.’” In re S.M., 176 A.3d at 939. Conversely, here, Dr. Krausz
testified that R.B.’s behavior would continue without further treatment and
that he was a danger to himself because of his lack of self-care.
In sum, the record supports the trial court’s factual findings, and we can
discern no error of law. In re S.M., supra. Doctor Krausz’s testimony
demonstrated that, without further treatment—including medication—R.B.
would continue to pose a clear and present danger to himself through his lack
of self-care, poor insight, and limited judgment, particularly where the
stressors that caused the behavior continue to exist. See MRHO Hearing,
3/2/22, at 5:59 (Dr. Krausz testifying “what happened before is going to
continue without addressing it—not sleeping, not eating”). Accordingly, we
affirm the order of the trial court.
Order affirmed.
Judgment Entered.
Joseph D. Seletyn, Esq.
Prothonotary
Date: 11/8/2022
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