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NON-PRECEDENTIAL DECISION - SEE SUPERIOR COURT O.P. 65.37
IN RE: M.B. : IN THE SUPERIOR COURT OF
: PENNSYLVANIA
:
APPEAL OF: M.B. :
:
:
:
:
: No. 205 WDA 2023
Appeal from the Order Entered January 23, 2023
In the Court of Common Pleas of Allegheny County Orphans’ Court at
No(s): CC: 18 of 2023
BEFORE: BENDER, P.J.E., McCAFFERY, J., and STEVENS, P.J.E.*
MEMORANDUM BY STEVENS, P.J.E.: FILED: October 20, 2023
Appellant M.B. appeals from the January 23, 2023, order entered in the
Court of Common Pleas of Allegheny County Orphans’ Court, which
involuntarily committed her for inpatient psychiatric treatment with St. Clair
Memorial Hospital. M.B. challenges the sufficiency of the evidence for her civil
commitment pursuant to Section 7304 of the Mental Health Procedures Act
(“MHPA”).1 After a careful review, we affirm.
The relevant facts and procedural history are as follows: On January 4,
2023, the Allegheny County Department of Human Services Office of
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* Former Justice specially assigned to the Superior Court
1 50 P.S. §§ 7101-7503.
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Behavioral Health (“DHS”) presented a petition for commitment under Section
7303 of the MHPA requesting the emergency involuntary inpatient civil court
commitment of M.B at St. Clair Memorial Hospital. On that date, M.B.
stipulated to the recommendation of Bruce Wright, M.D. (“Dr. Wright”), that
she be committed for not more than twenty days, and Mental Health Review
Officer Jennifer Price (“MHRO Price”) issued a certification. Thus, M.B.’s
involuntary commitment was set to expire on January 23, 2023.
However, prior to the expiration of M.B.’s emergency involuntary
commitment, on January 13, 2023, DHS filed a petition under Section 7304
of the MHPA seeking additional involuntary inpatient commitment of M.B. for
a period not to exceed ninety days due to her continued dangerous behavior.
The petition contained a notation that M.B. was unable to sign an informed
consent form, and DHS attached to the petition a proper notice with intent to
file a petition for extended involuntary treatment.
On January 20, 2023, a tele-health hearing was conducted before MHRO
Price regarding the Section 7304 petition.2 At the hearing, Dr. Wright, who is
a board-certified psychiatrist, testified he was treating M.B., and he diagnosed
her with “a psychotic disorder not otherwise specified.” N.T., 1/20/23, at 4.
He testified M.B.’s psychotic disorder is “severe,” and she is “severely mentally
disabled.” Id. Dr. Wright indicated he was seeking additional inpatient
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2 M.B. was present and represented by counsel during the hearing.
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treatment for M.B. Id. at 5. Specifically, the following relevant exchange
occurred during the direct examination of Dr. Wright by DHS’s counsel:
Q. And, doctor, what is causing you to seek additional inpatient
treatment today?
A. She has persistent symptoms. She was admitted on an
involuntary commitment due to dilutional—paranoid thoughts
formal thought disorder specifically disjointed into logical thoughts
and aggression.
She was aggressive toward her daughter, who was the
petitioner. She has persistent symptoms. It’s my concern if she
were released at this time there would be a reoccurrence of
dangerous behavior.
Q. And, doctor, what persistent symptoms have you observed or
your staff?
A. She has not been aggressive in the hospital. She has been
intrusive with staff and with other patients. She has continued
paranoid thoughts and continued formal thought disorder. As I
mentioned, [she has] disorganized, illogical, disjointed thoughts.
***
Q. Doctor, how is the patient responding to treatment or
medication?
A. She has been compliant with medication, but I would say
there’s still disorder in that she’s very disjointed.
It’s very hard to follow her stream of thought. She seems
to be a little less suspicious; although, there’s still an element of
some suspiciousness and paranoia. So, she may be—to answer
your question slightly better but still very symptomatic.
Q. And, doctor, if additional treatment is authorized, what would
you need to see from [M.B.] to be able to discharge her safely?
A. Well, compliance. As I mentioned, she has been compliant but
only reluctantly so. So, I would like to see improved insight so
that I feel confident she will comply with medication outside of the
hospital, and I would like to see an improvement in the psychotic
symptoms.
Id. at 5-6.
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Dr. Wright opined that additional inpatient treatment was the least
restrictive treatment option. Id. at 7. He testified M.B. does not have “insight
into her psychiatric illness,” and, thus, she does not “understand that she has
a problem[.]” Id. He opined that, absent inpatient treatment, M.B. would
have a “persistence of her symptoms and a risk of reoccurring dangerous
behaviors.” Id. He noted he was committed to discharging M.B. as soon as
it was safe to do so. Id.
On cross-examination, Dr. Wright explained that M.B. is so intrusive that
it is “very difficult to disengage from her.” Id. at 8. She demands immediate
attention, and when she is given attention, it is very hard for staff and other
patients to “disengage from that interaction.” Id. Dr. Wright admitted that
M.B. had not been aggressive in the hospital towards staff or patients;
however, she did “barricade her daughter in the room” on an occasion. Id.
Dr. Wright explained that M.B.’s thoughts are neither logical nor goal
directed. Id. She can’t get “from Point A to Point B” in any logical manner.
Id. Dr. Wright reaffirmed that inpatient treatment in the hospital was the
least restrictive option for M.B. to have her mental health needs met. Id. at
9. He opined she does not presently have the insight needed to comply with
her medication, and although she was not aggressive while in the “controlled
and protected environment” of the hospital, she was aggressive when she was
not committed to the hospital. Id. at 9-10. Dr. Wright specifically opined
that, within a reasonable degree of medical certainty, in “[his] professional
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opinion there would be a reoccurrence of the dangerous behavior” if M.B. were
released from inpatient treatment at that time. Id. at 10.
On redirect examination, Dr. Wright testified that, on one occasion
during the initial emergency twenty-day involuntary commitment, M.B.
barricaded her daughter in a hospital room and would not allow her to leave.
Id. at 11-12. It took “coercion” by the staff to convince M.B. to unlock the
door. Id. at 12.
M.B. testified she would like to be discharged from involuntary
commitment. Id. at 14. She testified (verbatim):
I do not have any passive aggressiveness. I did not hold
my daughter in the room. I’m a Christian, and I was telling her
that her holy spirit man is when you put on your armor of God.
She gets a little anxious, and she gets very upset.
I did not have any past things at my house. I just had no
electric, and I had to make sure that everything was okay. If you
have no electric, you’re not sure what will happen. So, I had to
keep—make sure that my house was secure, and I spoke with my
group therapist, and we both agreed about no procrastination—do
not procrastinate, you know, that I was ready to go home.
I know how to set my goals straight in the right path. I’m
assured that I will be fine. I’ve made my way all my life in the
right direction. I’ve never had any mental disorders. It was just
due to a lot of COVID-19 and a lot of people that were changing
their direction because of flooding and disasters that went through
the town from 2018 to 2021, and I had a lot that I had to, you
know, set forth and take care of.
It's always depending upon the situation of where, you
know, things go on. And I believe a lot of things with the hospital
here—when I came a lot did not know of my situation. I came on
very strongly, and a lot of that was due to that. I know that I will
be fine, and I love my daughter very much and would never hold
her down or hurt her. I raised her right.
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I took care of a three-bedroom house on my own, took care
of my parents since 1995….I know how to make my way and take
care of myself. As I was quoting to you, I love my daughter very
much and would never harm her, and I don’t persist on my own
way. I just take care of myself, and you do good onto others. But
you stay out of other’s business, and I just do what I have to do
for myself. And I wish no bad on no one.
But I have the wisdom, insight, and good discernment how
to take care of myself, and the right directive path and how to put
things---set forth a schedule for myself.
And the medication I, you know, believe that it was fine
when it was the lower—we had lowered the medicine, and it was
absolutely fine with me before I was not on any medicine. I have
no suspicion of nobody. I’m not paranoid.
There is a lot of things in my family line that a lot of—just
the aggressiveness, just a lot of things that—the old school way
that I, you know, grew up with. But I do not plug in—I plug into
taking care of myself in the right directive path, and I truly believe
that I would be fine going home.
***
I’m a Christian. I’m a Christian. I believe in the mighty
kingdom of God, and I raised my daughter---
Id. at 14-16.
At the conclusion of the hearing, MHRO Price dismissed the petition, and
on January 20, 2023, DHS filed a petition for review with the orphans’ court.
On January 23, 2023, the orphans’ court held a hearing, during which the
recording from the January 20, 2023, hearing was played for the orphans’
court.
By order filed on January 23, 2023, the orphans’ court reversed the
dismissal issued by MHRO Price and ordered the involuntary commitment of
M.B. to the St. Clair Memorial Hospital for inpatient treatment pursuant to
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Section 7304 of the MHPA for a maximum of ninety days beginning on January
20, 2023. This timely, counseled appeal followed,3 and all Pa.R.A.P. 1925
requirements have been met.
On appeal, M.B. sets forth the following issue in her “Statement of
Questions Presented” (verbatim):
1. Did the orphans’ court err in reversing the decision of the
Mental Health Review Officer (MHRO), who did not find that
M.B. was a danger to herself or to others and denied the
request for additional commitment pursuant to Section 7304 of
the Mental Health Procedures Act?
M.B.’s Brief at 4 (suggested answer omitted).
On appeal, M.B. contends the orphans’ court erred in reversing the order
of MHRO Price and directing that she be involuntarily committed for inpatient
treatment pursuant to Section 7304 of the MHPA for an additional period not
to exceed ninety days. Specifically, M.B. contends the evidence was
insufficient to justify her continued involuntary commitment under Section
7304 since “there was no evidence presented at the review hearing that M.B.
is a clear and present danger to herself or to others.” M.B.’s Brief at 18 (italics
omitted). M.B.’s position is that, while some of her behavior “may be annoying
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3 Although M.B.’s ninety-day commitment order has expired, this matter is
not moot. See Commonwealth v. C.B., 452 A.2d 1372, 1373 (Pa.Super.
1982) (stating that because an “order of involuntary commitment affects an
important liberty interest, and because by their nature most involuntary
commitment orders expire before appellate review is possible, [an appeal
therefrom] is not moot.”).
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or irritating to the person conversing with [her],” it did not rise to the level of
a clear and present danger to herself or others, which the MHPA requires in
order to justify continued involuntary commitment. M.B.’s Brief at 25.
This Court reviews determinations pursuant to the MHPA to “determine
whether there is evidence in the record to justify the [orphans’] court’s
findings.” In re S.M., 176 A.3d 927, 935 (Pa.Super. 2017) (citation omitted).
“Although we must accept the [orphans’] court’s findings of fact that have
support in the record, we are not bound by its legal conclusions from those
facts.” Id.
We briefly summarize the MHPA:
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.
Accordingly, in 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.M., 176 A.3d at 930-31 (some citations omitted and formatting
altered).
Section 7301(a) describes the circumstances under which a mentally
disabled person may be subject to involuntary treatment:
Whenever a person is severely mentally disabled and in need of
immediate treatment, [she] may be made subject to involuntary
emergency examination and treatment. A person is severely
mentally disabled when, as a result of mental illness, [her]
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capacity to exercise self-control, judgment and discretion in the
conduct of [her] affairs and social relations or to care for [her]
own personal needs is so lessened that [she] poses a clear and
present danger of harm to others or to [herself], as defined in [50
P.S. § 7301(b)].
50 P.S. § 7301(a).
Relevantly, Section 7301(b)(1) defines clear and present danger of
harm to others, and Section 7301(b)(2) defines clear and present danger of
harm to herself, in relevant part, as follows:
(1) .... For the purpose of this section, a clear and present danger
of harm to others may be demonstrated by proof that the person
has made threats of harm and has committed acts in furtherance
of the threat to commit harm.
(2) Clear and present danger to [herself] shall be shown by
establishing that within the past 30 days:
(i) the person has acted in such manner as to evidence that
[she] would be unable, without care, supervision and the
continued assistance of others, to satisfy [her] 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;….
50 P.S. § 7301(b)(1), (2)(i).
Section 7304 permits court-ordered involuntary treatment for up to
ninety days. 50 P.S. § 7304(g). Section 7304(a)(2) states the criteria for
involuntary treatment of a person that is already subject to involuntary
treatment:
(2) Where a petition is filed for a person already subject to
involuntary treatment, it shall be sufficient to represent, and upon
hearing to reestablish, that the conduct originally required by
section [7301(b)] in fact occurred, and that [her] condition
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continues to evidence a clear and present danger to [herself] or
others….In such event, it shall not be necessary to show the
reoccurrence of dangerous conduct, either harmful or debilitating,
within the past 30 days.
50 P.S. § 7304(a)(2).
In In re S.M., supra, this Court clarified Section 7304(a)(2) as follows:
[T]he petitioner need not relitigate the initial commitment
and….the [orphans’] court may consider a patient’s original
commitment as contained in that patient’s commitment history as
long as the patient’s commitment history shows that the requisite
behavior occurred in the past. If the patient challenges that
original commitment, the burden is on the patient to show that
the original commitment was improper.
In re S.M., 176 A.3d at 936 (citations omitted and formatting altered).
In sum, under Section 7304(a)(2), a petitioner must prove two factors.
First, the petitioner, at a hearing, must “reestablish” the patient’s prior
conduct, which qualified as a clear and present danger to herself or others,
“in fact occurred.” See 50 P.S. §§ 7301(b)(1)-(2), 7304(a)(2). Second, the
petitioner must establish the patient’s condition continues to evidence a clear
and present danger to herself or others. 50 P.S. § 7304(a)(2).
Regarding the first factor, in the case sub judice, M.B. specifically
concedes there is no dispute that DHS established the first factor, i.e., her
prior conduct, which resulted in her original commitment, qualified as a clear
and present danger to herself or others, and it in fact occurred. See In re
S.M., supra. That is, she concedes “there is no question that the initial
Section 7302 petition that committed M.B. to involuntary treatment was
properly filed and decided. Moreover, M.B. consented to the initial up-to-20
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days of confinement and treatment under Section 7303.”4 M.B.’s Brief at 13-
14. Accordingly, we proceed to examine whether DHS established the second
factor, i.e., M.B.’s condition continues to evidence a clear and present danger
to herself or others. See In re S.M., supra.
Here, in analyzing the second factor, the orphans’ court relevantly
indicated the following:
Per the tape of the January 20, 2023, hearing, which was
played in open court on January 23, 2023, Bruce Wright, M.D.,
who is [M.B.’s] treating psychiatrist, testified that [M.B.] has “a
psychotic disorder not otherwise specified” in the “severe” range.
N.T., 1/20/23, at 4. He stated that [M.B.] has persistent
symptoms and that if she were released there would be a
reoccurrence of dangerous behavior. [M.B.] has continued
paranoid thoughts and continued formal thought disorder. Her
thoughts are “disjointed” and “illogical” (i.e., she cannot get from
Point A to Point B, her thoughts “do not make sense”). [Id.] at
5, 8-9. While [M.B.] has been compliant with medication [during
the time she has been committed], she is reluctant to take the
medication, and Dr. Wright expressed his concern that she will not
comply with the medication requirements outside the hospital
setting. [Id.] at 6-7. In his professional opinion, within a
reasonable degree of medical certainty, Dr. Wright further stated
that additional inpatient treatment is the least restrictive
treatment option because he does not believe [M.B.] has the
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4 In any event, we note the record contains M.B.’s commitment history,
including her original commitment, which was based on her severe mental
disability. See In re S.M., supra. DHS sought the original Section 7303 civil
commitment based on an application completed by M.B.’s adult daughter.
Specifically, M.B.’s daughter indicated M.B. could not care for herself, could
not pay bills, could not take care of her basic needs, could not make decisions
for her own well-being, was violent, was paranoid, did not make sense when
having a conversation, threw temper tantrums, and threatened to kill her
daughter. She noted that M.B. often lived in a home with no utilities because
she could not remember to pay the bills, would not eat because she believed
her food had been poisoned, and believed people were following her.
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insight into her psychiatric illness to understand that she has a
problem [or] that she will comply with treatment by taking her
mediation [sic] outside the hospital setting. Dr. Wright stated that
he will discharge [M.B.] as soon as it can be done safely. [Id.] at
7.
[M.B.] made a statement to [MHRO Price] in a rather
rambling fashion. She stated that she loves her daughter, and
she would not harm her. She further stated that she has “no
suspicion of nobody,” she is not paranoid, and she “would be fine
going home.” [Id.] at 14-16.
Based upon [the orphans’] court’s further review of the
transcripts, it is abundantly clear that the reversal of the dismissal
was proper under the facts of the case….Dr. Wright testified
without hesitation that, in his professional opinion, [M.B.] was
likely to engage in dangerous conduct in the future due to her
continued lack of insight into her mental illness…[and] she would
not maintain her medication regime.
Orphans’ Court Opinion, filed 3/21/23, at 3-4 (some quotation marks
omitted).
We conclude the orphans’ court’s factual findings are supported by the
record, and we find no error in its legal conclusions. See In re S.M., supra.
Here, Dr. Wright testified M.B.’s severe mental disability, for which she was
originally committed, persists with M.B. having paranoid thoughts, disjointed
thoughts, illogical thoughts, and formal thought disorder. He noted that,
during the time she has been receiving inpatient treatment, her severe
mentally disabling symptoms have become “slightly better but [she is] still
very symptomatic.” N.T., 1/20/23, at 5.
Dr. Wright indicated that M.B. had been “reluctantly compliant” with
taking her medication while she was receiving inpatient treatment. Id. at 5.
He opined that, if M.B. were immediately released from inpatient mental
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treatment, she would not remain compliant with taking her medications
because she does not have insight into her own psychiatric illness. Id. at 7.
However, he noted that, given further improvement in her psychotic
symptoms, she may improve in the areas of awareness and compliance. Id.
Further, M.B.’s own statements to MHRO Price during the January 20,
2023, hearing confirmed Dr. Wright’s testimony that she would not remain
compliant with taking her medications if she were discharged from inpatient
treatment. M.B. informed MHRO Price that “it was absolutely fine with me
before I was not on any medicine.” Id. at 16.
Moreover, Dr. Wright opined, beyond a reasonable degree of medical
certainty, that M.B.’s persisting symptoms made it likely her dangerous
behaviors would reoccur if she were released from inpatient treatment. As
indicated supra, M.B. was originally involuntarily committed, in part, because
she evidenced a clear and present danger to herself, including being unable
to meet her own personal, medical, or safety needs to an extent that there
was a reasonable probability of death, serious bodily injury, or serious physical
debilitation. See 50 P.S. § 7301(b)(2)(i). In her testimony to MHRO Price
during the January 20, 2023, hearing, M.B. demonstrated her continued
inability to think logically so as to meet her own personal, medical, and safety
needs. For example, she demonstrated no recognition that the reason her
house did not have electricity arose from her failure to pay the utility bill.
Further, she blamed the COVID-19 pandemic, as well as “flood[s] and disaster
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that went through the town from 2018 to 2021,” for her mental state. N.T.,
1/20/23, at 14. Also, as indicated supra, she indicated she was “fine” without
taking her medication. Thus, the orphans’ court was justified in concluding
DHS demonstrated M.B.’s condition continues to evidence a clear and present
danger to herself. See 50 P.S. § 7301(b)(2)(i).
While our analysis could end at this point, we note the orphans’ court
was also justified in concluding DHS demonstrated M.B.’s condition continues
to evidence a clear and present danger to others. See 50 P.S. § 7301(b)(1).
M.B. was originally involuntarily committed, in part, because she evidenced a
clear and present danger to others, including her daughter, who she
threatened to kill.
During the time M.B. received inpatient medication and treatment under
the original Section 7303 civil commitment, M.B. did not demonstrate
aggressive behavior towards staff or other patients. However, M.B. barricaded
herself and her daughter in a hospital room and did not unlock the door until
being coerced by hospital staff. In her testimony to MHRO Price during the
January 20, 2023, hearing, M.B. explained that she kept her daughter in her
room because she wanted to tell “her that her holy spirit man is when you put
on your armor of God.” N.T., 1/20/23, at 14. The evidence demonstrates
that, while being medicated, M.B.’s aggressive behavior improved; however,
due to her severe mental disability, M.B. continued to be a clear and present
danger to at least her daughter. See 50 P.S. § 7301(b)(1). Moreover, as
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indicated above, Dr. Wright opined that if M.B. were released from inpatient
treatment, she would not take her medication, and her dangerous behavior,
including her behavior towards others, would reoccur.
Based on the record, we agree with the orphans’ court that there is
sufficient evidence to justify its findings that M.B’s condition continued to
evidence a clear and present danger to herself and others. See In re S.M.,
supra. Therefore, we affirm the order extending M.B.’s commitment pursuant
to Section 7304.
Affirmed.
Date: 10/20/2023
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