### In The C ou rt o f A p p ea ls Si x t h Appe l l at e Di st r i c t o f Te x as a t Te x ar ka na

______________________________ No . 0 6- 08 -0 00 28 -C V

______________________________ THE STATE OF TEXAS FO R THE B E ST I N T E RE ST A

N D PR O T E CT I O N O F C. R. W.
On Appea l from the County Court Fa nnin County , Texas Trial Court No. 2633

B e f o r e M o r r i s s , C
. J. , C a

rt e r an d M o s e l e y , JJ. Memorandum Opinion by J ustice Carte rI n companion ca se, ca use number 06- 08-00029-CV, C.R .W. appeals fr om the related orde r 1 authorizing a dminist ration of ps y ch o active medication. See T EX . H EA L TH & S AF ETY C ODE ANN . §§ 574.104, 574.106 (Ve rnon Supp. 2007). 2 MEMORANDUM OPI

NI ON C.R.W . appea ls the trial court' s order authorizing temporary mental hea lth services pur suant to T EX . H EA L TH & S AF ETY C ODE ANN . § 574.034 (Ve rnon 2003). On appeal, C .R.W . contends the 1 evid en ce i s l egally

and fa ctually

insufficient to support the finding s require d to support the trial court' s order . We ag ree and will reve rse the tr ial court' s order
. I. F ACTUAL AND P ROCEDURAL BACK GR OUND A. Dr . J ohn M ako wski, St aff P sy c hol og ist Dr. Makow ski prepar ed a c ertificate of medical examination for mental illness in which he diag nosed C.R.W . as having para noid sc hizophrenia afte r C.R.W
. had been in his c are for one wee k. F ur the r, he state d in

the re po rt

that C. R.W. is m e nta lly

ill and a s a re su lt of that illne ss, is l ike ly to
c a us e ha rm to h e rs e lf or oth e rs ; or wi ll, if no t tr e a te d, c on tin ue to su ff e r se ve re and

a bn or ma l me nta l, emotional, or phy sical distress and w ill continue to ex perie nce de terioration of her a bility to function ind e pe nd e ntl y and is un a

ble to make a ratio na l and inf or me d de c isi on

a s to wh e the r o r n ot t o s ub mit to treatment. The basis for these opinions is an alleg ed statement by C.R.W .' s brother c oncer

ning C.R.W .' s threat to over dose on her medication if she c annot g et bac k at least thirty of her cats that
wer e taken by law enforce ment. He also notes an allege d threat by C.R.W
. to shoot her husba nd, but do e s n ot r e ve a l th e so ur c e of thi s in fo rm a tio n. He fu

rt he r n ote d s ome inf

or ma tio n th a t C. R.W. is3

para noid an d f

e e ls h e r b r o th e r is w o r

k in g w it h th e ju d g e to g e t h e r h o u s e c o n d e mn e d s o th at the brother c an sell the land. The repor t contains no other f

actua l information. B. Dr. Erik Blois, E xam inin g P hysician Dr. B loi s co mp l et edt h e s ec o n d o f t h e r eq u i re d

ce rt i fi ca t es o f m ed i ca l ex am i n at i o nfo r m en t al illness in which he diag nosed C.R.W
. with depre ssion, not otherwise spec ified. He , too, stated that C.R.W
. is " mentally ill .
. . [and] likely to c ause serious harm to .
. . herse lf
. . . or . . . others . . . or wi ll, if not tr eat e d, c on tin

ue to s uf fe r s e ve re and

a bn or ma l me nta l, e mot ion a l, o r p hy sic a l di str e ss
and wi ll c on tin

ue to expe ri e nc e de te ri or a tio n o f [h e r] a bil ity to f un c tio n in de pe nd e ntl y

and is una ble to make a rational and informed decision as to w hether or not to submit to treatment." He we nt on to conclude that C.R
. W
. "presents a substantial risk of serious har m to self or others if not immediately

restra ined, which is demonstrated by . . . the per son' s behavior; or by evidenc e of se vere emotional distress and dete rioration i n [ h er ] mental condition to the extent that the person ca nnot
rema in at liberty ." H e ar rived at these conc lusions based, in part, on C.R.W.'s brother ' s alleg ed statement that s h e wa s going to g o into the country and over dose on her

medication, and on information that a police r eport indicated that C.R.W . had thre atene d to shoot her husband. Our
rec ord does not conta in either the br other' s statement or the pol ice report. Dr . Blois also noted that C.R.W
. was under a restra ining order based on a lleg ed thre ats ag ainst her husba nd and commente d on the number of

cats a nd C.R.W .' s poor hyg iene. Th e re cord a lso does not contain a c opy of the restra ining or der to whic h Dr. B lois refe rre d.4

C. C. R. W. , P r opo se d P at ie nt I n the only testimony rec eived at trial, C.R.W
. explained some of the medic al problems fr om which she suf

fer s, one beingmultipl e scle rosis. She also detailed how ma ny of the medic ations she has take n for he r illnesses that have m ad e h er i l l an d how ce rtain drugreg imes for one ailment interfe re w ith the treatment for the other. She doe s take one pain medication. She testified that she regularly visits her g y

necolog ist and her a cupunctur ist. S he testified that the ac upuncture has helpe d her significa

ntly
. She has converted to Buddhism. She also pref ers a holisti c approac h to medicine, but doe s still g o to he r neurolog ist, g y necolog ist, a

nd another doctor who p ra ct i ce s m ore
c on ve nti on a l me dic ine
. Th e re c or d s ug g e sts that sh e be g an me dic a l tr e a tme nt f or so me of he r h e a lth conditions beg inning in 1983. She emphasized that she is " terrif ied" of the medic ine that the state hospital wants t o g ive her and desc ribed the hospital as " a ver y harsh a nd frig htening place ." She de nied threatening to harm her husba nd, but admits that she has threatened to have him arre sted for instanc es of a lleg ed domestic violence . She also explained that her husba nd suffe rs from b i p o l ar disorder a nd intermittent rag e disorder ; he has stopped takingthe medic at ion prescr ibed to him for the mental conditions beca

use he lost his insurance when he lost his j ob. She acknow ledg ed that she a nd her husba

nd had an a

rg ument, but de n ied threatening him and further stated that she does not have a g un. She also testified that she wa s not suicidal, that she was bu sy tr y ingto t a ke c are of he r a ili ng fathe r, and that sh e wo uld ne ve r hurt any bo dy
. She is g re a tly5

conce rned a

bout keepingher pr omise to her father to take car e of him. She also expressed c oncer n for he r husband' s well-beingif she we re to be committed to the state hospital. She suspe cts that her b ro t her ha s had some involvement in g etting he r to this point i n the involuntary commitment proce eding s in an attempt to maintain control over their father' s aff

airs. The State c ross-ex am i ned C.R.W. about the unusually high numbe r of c ats she and he r husband had at the ir home; the State estimated the number at 200, including many who wer e living in t he c ou ple ' s atti c . C. R.W. e xpla ine d th a t th e y fe e d th e c a ts a

nd are tr y ingto f ind ho me s f or the m. C.R.W . admitted that the house was a mess, due to the cats. She e x presse d her dissatisfa ction for the condition of the house, but attempted to expl ain that t h e t as k of kee ping e very thing c lean wa s too gr eat f

or her to do without her husband' s help. She complained that he was unwilling to help. She was saddened when l aw enforc ement took s ome of the c ats. She also has thre e dog s. Raccoons live in the attic as we ll, after g aining entry throug h a broke n window in the attic. C.R.W . descr ibed the deve lopm en t o f h er health proble ms, the treatment she has re ceive d over the y ear s, and how, at times, the couple wa s uninsured, pre venting her f rom seekingadditional medical tre at m en t
. T h e S tate also que stioned C.R.W . on her spiritual re lationship with her acupunc turist. C.R .W. responded that her ac u p u n cturist serve d as her spiritual advisor. She explained that she has alwa y s maintained a love for animals and people a nd that she does not wa

nt to harm any

thing. S h e aga in denied eve r threa tening to harm her

husband or he rself a

nd assumes6

th a t h e r b r o t h e r t o l d t h e d o c t o r s t h a t s h e h a d d o n e s o . S h e f u rt h e r d e s c r i b e d h e r r e l a t i o n s h i p w ith her b rot her, who se m ot iv es s he q ues ti on s, bu t agai ns t w ho m s he h ol ds "no i ll wi ll ." D. Trial Court's F ind ings The trial c ourt found that C.R.W. di d pose a r isk of harm to her self and that, if untreate d, she
wo uld c on tin u e t o s u f f e r an d d e t e r i o r a t e . I t e xp r e s s l y d e c l i n e d t o f i n d t h a t C
. R
. W
. w a s l i k e l y to
cause harm to others. With that, we need not examine what li ttle rec ord t here is here f or evide nce relating to C.R.W.'s alleg ed thre ats ag ainst her husba nd. II. AP P LICABLE LAW Orde rs for te mporary

mental hea lth services a

re g overne d by

the following provision: (a) The judge may order a proposed patient to r ece ive co u rt -orde red temporar y inpatient mental health services only if the judg e or jury

finds, from cle ar and c on vin c inge vid e nc e , th a t:

(1 ) the pr op os e d p a tie nt i s me nta lly ill ; (2 ) a s a

re su lt o f t

hat me nta l il lne ss t

he pr op os e d p a tie nt: (A) is likely

to cause serious har

m to hims elf; (B ) is likely

to cause serious har

m to others; or (C ) is: (i ) su ff

e ri ng se ve re and

a bn or ma l me nta l, e mot ion a l, o r p hy sic a l di str e ss; (ii) experiencingsubstantial mental or phy sical deter ioration of the pr opos ed p atient' s ability to function i n d ep en d en t l y , wh i ch i s ex h i b i t edb y t h e p ro p o s edp at i en t 'sWe note that the waiver of the rig ht to confront the State' s witnesses does not touch on a ny 2 iss ue c on c e rn ing C.R .W. ' s wa ive r of the re qu ir e me nt t

hat th e State pr e se nt anyexpert testimony as to a re ce nt overt ac t or a c ontinuing patter n of beha vior that would confir

m either of the rele vant finding s under Sec tion 574.034(a)( 2). 7 inability , except for r easons of indige nce, to pr ovide for the p ro p o s edp at i en t 's b as i c n ee d s , i n cl u d i n g fo o d , cl o t h i n g, health, or sa fety ; and (iii) unable to ma k e a r ational and infor med de c isi on a s to wh e the r o r n ot t o s ub mit to t re a tme nt. T EX . H EA L TH & S AF ETY C ODE ANN . § 574.034. I f the judge or jury finds that the proposed patient meets the pre scribed commitment c riteria, the judge or jury must specify

which cr iterion forms the basis of the de cision. T EX . H EA L TH & S AF ETY C ODE ANN . § 574.034(c)
. Clear a nd convincingevidenc e is that measur e or deg ree of proof that will produce in the mind of the trier of

fac t a fi rm b el i ef o r conviction as to t he truth of the a lleg ations sought to be established. T EX . C IV . P R AC . & R EM . C ODE ANN . § 41 .0 01 (2 ) ( Ve rn on Sup p. 20 07 ); State v. Addington , 588 S.W .2d 569, 570 (Tex. 1979). To be c lear and convincing under Sec tion 574.034(a), the evidenc e must, unless waived, include expert testimony and evidenc e of a rec ent overt a ct or a 2 cont i n u i n g pattern of

behavior that tends to confirm (1) the likelihood of serious har m to the proposed patient or others or ( 2) the propose d patient' s distress and the deterioration of t he propose d patien t 's ab i lity

to function. T EX . H EA L TH & S AF ETY C ODE ANN . § 574.034(d). The overt a ct or
con ti nu in g patt ern o f beh avi or "m us t r ela te to th e cri ter io n on whi ch th e ju dgmen t i s b ased ." See In8

re F.M. , 1 83 S.W. 3d

48 9, 49 2 ( Te x. Ap p. —H ou sto n [14t h Di st. ] 2 00 5, no pe t.) ; J

.M . v . S tat e , 178 S.W .3d 185, 193 (Tex. App.—Houston [1s t Dist.] 2005, no pet.). We pause to poi nt out that there was no testimony taken from either of the above -re fer ence d phy sicians. C.R.W . waived he r rig ht to cross-e x amine the doc tors, and the pa rties ag ree d that expert testimony would be take n in the form of r eports and w ritten statements. Consequently , the only form of e x p ert testimony

the trial cour

t had bef ore it wa s the two doctors' completed c ertificates of medical e x amination for menta l illness. The only testimony

at the hear ing on the State' s application was C.R.W.'s own testimony . I f t he propose d patient waive s her r ight of cross-e x amination, the trial court may

admit as evidenc e the c ertificates of medica l examination for mental i l l n es s , and the
cer tificates a dmitted under t his subsection constitute competent medica l or psy chiatric testimony on which a court' s finding s may be base d alone. T EX . H EA L TH & S AF ETY C ODE ANN . § 57 4. 03 4( f) ; In

re E. T. , 137 S.W. 3d

69 8, 70 0 ( Te x. Ap p. —Sa n A nto nio 20 04 , n o p e t.) . In o the r w or ds , th e do c tor s'
cer tificates a lone c ou ld

constitute sufficient e vidence to support the trial court 's fi n d i ng s. Here , ho we ve r, the y

do no t. III . LEG AL SUF F IC IEN CY O F T HE EV ID EN CE TO SU P P OR T OR DE R F OR TEM P OR

AR Y M EN TA L HEA LTH SE RV IC ES C.R.W . challeng es the leg al sufficie ncy of the evidenc e that supports the trial c ourt' s order authorizing tempora

ry mental hea lth se rvice s. The order for tempor ary mental hea lth services state s the trial cour

t found, by

clea r and c onvincing evidenc e, C.R.W. is mentally ill and, as a re sult of that
me nta l il lne ss, is l ike ly

to c a us e se ri ou s ha

rm to h e rs e lf

, a nd is s uf fe ri ngse ve re and

a bn or ma l me nta l,9

emotional, or phy sical distress; experiencingsubsta n t i al mental or phy sical dete rioration of the p ro p o s ed patient's a

bility to function independe ntly which is exhibi ted by

the proposed patien t 's inability , except for r easons of indige nce, to pr ovide for the proposed patient's ba sic nee ds, including food, clothing , health, or safe ty ; a nd is una ble to make a rational and informed de cision as to whether
or no t to su bmi t to tr e a tme nt. A. Stand ards of Review Be cause the State' s burden of proof is clea

r and convincing evidenc e, we apply a heig htened standard of

revie w. See In re C.H. , 8 9 S. W.3 d 1 7, 25 (T e x. 20 02 ); I n re M.M

. , 1 8 4 S
. W .3d 416, 417–18 (Tex. App.—Dallas 2006, no pet.). In revie wing the leg al suffic iency of the e vidence wher e t h e burden of

proof is cle ar a

nd convincingevidenc e, we consider a ll of the evidenc e in the lig ht most favora

ble to the finding to determine w hether a re asonable trier of

fac t could have f

ormed a firm belief

or convic tion that its finding s were true. In re J .F .C. , 96 S.W .3d 256, 266 (Tex. 2002). We m us t a ssume that th e tr ie r o f f a c t r e so lve d d isp ute d f

a c ts in favo r o f i ts f

ind ingif a re a so na ble trier of fac t could do so, and we must disreg ard all contra ry evidenc e that a r easona ble trier of

fac t could have disbelieved or f ound to be incre dible. Id. I n r e vie wi ngfa c tua l su ff

ic ie nc y c ha lle ng e s, we re vie w a ll the e viden ce in t he re c or d, bo th support i n g an d o p p o s ing the trial court' s findings. C.H. , 89 S.W .3d at 27–29. We must give due
co n s i d er at i o nt o ev i d en ce t h e t ri er o f f ac tco u l d re as o n ab l y

h av e f o u n d t o b e c l ea r a n d

co n v i n ci n g. Id. at 25. Under the clear-a nd-convinc ing standard, we deter mine whether

the evidenc e is such that10

the trier of fac t could re asonably form " a firm be lief or c onviction" a s to the truth of the alleg ations soug ht to be established by the S tate. Id. We must consider whethe r disputed evidenc e is such that
a r ea s o n ab l e t ri er

o f f ac tco u l d n o th av e r ec o n ci l edt h at d i s p u t ed e v i d e n c e i nfa v o r o f i t s fi n d i n g. J .F .C. , 96 S.W .3d at 266. B. Evi de nc e of M e nt al I llne ss First, C.R.W. contends that the evidenc e is insufficient to support the trial court' s finding that she is mentally

ill. "Mental illness" is de fi n ed as "a n illness, disease, or c ondition, other than ep i l ep s y , s en i l i t y , al co h o l i s m , o r m en t al d ef i ci en cy , t h a t : (A ) s u

b s t an t i al l y

i mp ai rs a p er s o n 's thought, pe rce ption of rea lity , emotional proce ss, or judg m en t ; o r (B ) g rossly impairs behavior

as dem on st rat ed b y r ecent di st urb ed b ehav io r." T EX . H EA L TH & S AF ETY C ODE ANN . § 571.003(14) (Ve rnon Supp. 2007). Her e, we have only the doctor's certifica tes of ex amination as a source of expert testimony
on me nta l il lne ss. Whil e Dr . M a ko ws ki d ia g no se d C.R .W. wi th pa ra no id sc hizo ph re nia , Dr . B loi s dia g no se d h e r wit

h de pr e ssi on no t othe rw ise sp e c if ie d. Ne ith e r ce rt if

ic a te c le arl y

e xpla ins the ba sis fo r t he re sp e c tiv e dia g no sis . N e ith e r c e rt if ic a te de sc ri bes h owthi s c on dit ion ha s su bs tanti a lly impaired C.R.W.'s thoug ht, perc eption, emotional proce ss, or judg ment or has g rossly impaired he r behavior
. Reading the ce rtificate s g ener ously , we c an find indirec t links between some de scription of the be havio rs on

wh ic h th e do c tor s arr ive d at hi s d ia g no sis . Dr . M a ko ws ki' s c e rt if ic a te ro ug hly links the diag nosis of para noid schizophrenia to some repor t, of unknown orig in, he was g iven that11

C.R.W . believed he r brother and the trial judg e we re c onspiring to g et her house conde mned so that the land c ou ld b e so ld. Th e c e rt if ic a te do e s n ot, ho we ve r, g o b ey on d th at to e xpla in h owthi s behavior fits within the definition of me ntal illness. Dr. Blois' cer tificate also fails to provide any dir e c t li nk

be tw e e n f

a c tua l ob se rv a tio ns and

his dia g no sis of

de pr e ssi on . I t c ou ld be re a d fr om h is
c e rt if ic a te tha t hi s d ia g no sis wa s b a se d o n C. R.W. ' s r e a c tio n to the se izur e of so me of the se ve ra l c a ts at her house. I n In re J .S .C. , the testifying doc tor explained the basis for his diag nosis of "sc hizophrenia,
un di fferen ti ate d t y

pe, chro ni c, an d acu te e x acerb ati on ": When [ J .S.C.] was at the MHMR Clinic, they found he was also catatonic. He w as ha llu c inatin g . He wa s de lus ion a l and wi thd ra wn . He wa s h e lpl e ss. He wa s n ot a ble to car e for

himself, and he c an not re member. H e wa s admitted to SASH here; a nd when I saw him on the first visit, he was c onfused. His spee ch wa s fifty perc ent ir re le va nt. He wa s d iso ri e nte d. He wa s to ta lly ou t of it. 81 2 S. W.2 d 9 2, 94 (T e x. Ap p. —Sa n A nto nio 19 91 , no wr it) . T he San A nto nio c ourt he ld t his
e v id e n c e s u f

f ic ie n t to s u

p p o rt th e f

in d in g th a t J. S. C. w a s me n ta ll y il l. Id. On the other ha nd,
cer tificates ba sed on mere conclusions, such a s that the proposed pa t i en t h as ' ' schizo affe ctive disorder,' ' without the factual observations that form the basis for that opinion, ar e insuffic ient. See In re Sta te for

Ma y be rry , 685 S.W .2d 121, 123 (Tex. App.—Amarillo 1985, no writ) (c oncluding
cer tificates whic h constituted the only evidenc e supporting tr e a

tm e nt d id " n o t c o nta in

a ny descr iptive fac tual observations of the doctors that would for m a detailed basis for the c onclusions and opinions of t he doctors")
. An expert diag nosis of mental illness alone is not sufficient to conf ine a patient for12

compulsory

treatment. See Me

zic k v . S tat e , 920 S.W .2d 427, 430 (Tex. App.—Houston [1s t Dist.] 1996, no writ). Ex pert opinions a nd rec ommendations must be supported by a showing of the fa ctual bases on whic h they

are g rounded. Id. ; T.G . v . S tate , 7 S.W .3d 248, 252 (Tex. App.—Dallas 1999,
no pe t.) ; Lod

ge v . S tat e , 597 S.W .2d 773, 779 (Tex. Civ. App.—San Antonio), a ff 'd , 608 S.W .2d 910 (Tex. 1980). Her e, th e r e c o r d

p r o v id e s n o in f

o r mati o no f p e r s o n a l f

a c tu a l o b s e r

v a ti o n s o f

th e d octors which lea d them to di agnose C.R.W. as mentally ill. W e ca

nnot conclude the evidenc e pre sented here was suff

iciently clea r and c onvincing to form a f irm conviction o r belief that C.R.W . was
me nta lly ill . T he c los e st l ink

we have to a

fa c tua l ob se rv a tio n to su pp or t a dia g no sis is Dr . M a ko ws ki' s d e sc ri pti on of a re po rt of C.R .W. ' s su sp ic ion s of her bro the r. We t hin k th is insufficient to mee t the heig htened e videntiary standard he re. N onetheless, ev en i f t here wer e
su ff ic ie nt e vid e nc e of

me nta l illne ss, the State ' s e vid e nc e of the oth e r r e qu ir e d e le me nts fa ils on thi s
re c or d. C.R .W. c or

re c tly dir e c ts u s to a

uth or ity tha t, e ve n if the e viden ce o f m e nta l il lne ss i s sufficie nt, such evidenc e alone is insuff icient to satisfy the statutory elements of Sec tion 574.034. See In re L.H. , 1 83 S.W. 3d 90 5, 91 1 ( Te x. Ap p. —T e xar ka na 20 06 , n o p e t.) ; K.T. v . S

tat e , 68 S.W .3d 88 7, 89 3 ( Te x. Ap p. —H ou sto n [1s t D ist .] 20 02 , n o p e t.) . Si nc e e vid e nc e of me nta l ill ne ss a lon e is insufficient to justify

invol u n t ar y

commitment, we look to evidence that supports the other challeng ed ele ments of Section 574.034. Specifica lly , C.R.W . contends the e vidence is insufficient to s h o w ano v e rt a c t o r

c o n ti n u in g p a tt e r

no f b e h a v io r th a t w o uld support a

f in d in g th a t C
. R. W.13

poses a r isk of harm to he rself under Section 574.034(a) (2)( A) a nd the multi-face ted finding under Section 574.034(a) (2)( C). We will address those finding s in turn. C. Evid ence of a Rec ent Over t Ac t or C ontinu ing Patt ern of Posing a Risk of Harm to Se lf Ag ain, to be cle ar a

nd convincingunder Sec tion 574.03 4 ( a ) , th e e v id e n c e must include expert testimony and evide nce of a rece nt overt act or a continuing pattern of behavior that tends to confirm (1 ) t h e l i k el i h o o d

o f s er i o u s h ar m t o t h e p ro p o s edp at i en t o r o t h er s o r ( 2 ) t h e p ro p o s edp at i en t 's distress and the de terioration of the proposed patient's ability to function. T EX . H EA L TH & S AF E TY C ODE ANN . § 574.034(d). The overt a ct or c ontinuing patter n of beha vior " mus t relate to the cri ter io n on whi ch the ju dgmen t is bas ed. " See F.M. , 183 S.W. 3d a t 49 2; J.M. , 178 S.W .3d at 193. The Houston–First Court review ed the e vidence to support a finding that a propose d patient
was likely

to harm her self in J.M. 178 S.W .3d at 193. Evidenc e that J.M. t hreatened to har m herse lf, standing alone, was insufficient to support a finding under Section 574.034(a) (2)( A). Id. The c ourt pointed out that no specific details wer e provided about the purported threats of suicide made by J .M. befor e her

commitment. Id. F or

ins tanc e , th e re c or d d id n ot r e ve a l e xac tly wh e n J.M. alleg edly made th e th

r e ats, specif

ically to whom she made those thr eats, or unde r what circumstanc es she may have ma de the thre ats. Id. I mportantly , no evidenc e wa s prese nted that J .M. eng ag ed in any
rec ent over

t act to ac tually

harm herself at the time she made the threats or during her hospitalization. Id. at 193–94. We see in J.M. that a thre at of ha rm to the patient must be s ubstantial and base d onWe examined a doctor' s notation of a patient' s statements about death: 3 I n Dr. F ag an' s cer

tificate, he ref

err ed to the family ' s repor

t that R.G. had been " stating he wa nts to d i e. " T his phrase is the only ref ere nce to suc h statements. Dr. Chadalava da did not testify to any such statements by

R.G. From this short, g ener al ref ere nce in Dr
. Fa g an' s cer

tificate, we cannot deter

mine the context in which R.G. may have ma de stateme nts to thi s eff ect. And, cer

tainly , there is no evidenc e R.G. attempted suicide or

purposely

harme d himself. So, we ca nnot conclude that Dr. Fa g an' s five-w ord notation in his certificate constitutes evidenc e of a re cent ove rt ac t or continuing pattern of

behavior that tends to confirm the likelihood of ser ious harm t o R
. G
. o r a s u b s t an t i a l d e t e r i o r a t i o no f

R
. G
. ' s a b i l i t y t o f u n c t i o ni n d e p e n d e n t l y. In re R.G

. , No. 06-05-00147- CV, 2006 Tex App. L EXIS 851, at *9–10 (Te x . App.—Texarkana Fe b. 2, 2006, no pet.) (me m. op.). 14 a c tua l da ng e ro us be havio r m anif

e ste d b y so me ov e rt

a c t or thr e a ts i n th e re c e nt p a st. See id. ; In re 3 K.D .C. , 78 S.W .3d 543, 547 (Tex. App.—Amarillo 2002, no pet.). We now turn to the doctors' cer tificates in t he instant ca se to look for e vidence of a r ece nt
o v e rt a c t o r

a c o n ti n u in g p a tt e r

n o f b e h a v io r th a t c o n f

ir ms th a t C
. R. W. is li k e ly

to h ar m h e r s e lf
. We find none. Dr
. Makowski' s cer tificate state s "she told her brother that if she could not g et bac k at least 30 of he r 200+ c ats that she would g o into the country and ove rd o s e on medication." The do c tor did no t pu rp or t to have pe rs on a l kn ow le dg e of thi s st a te me nt, it doe s not ap pe ar a ny wh e re in the re cord, a

nd her br other did not testify at t ri al
. At t ri al, the only evidenc e conc erningsuch a
s t at em en twa s C
. R
. W
. 's d en i al o f i t
. W h i l e t h e d o ct o r m i gh tre l y o nt h e r ep o rt o f t h e b ro t h er 's statement in forming an opinion, if the statement proves to be inacc urate , the basis for the opinion is oblit erated. One pur

pose of the hear ing befor e an impartial judge or jury is to establish the factua l ba sis fo r t

he c omm itm e nt. He re , th e re c or d is tot a lly vo id o f a

ny e vid e nc e fr om a

wi tne ss w ith15

persona l knowledg e that C.R.W. m ade s u ch a stateme nt. Even take n as true, w e do not know the context in which it was said and note that this was simply a stateme nt and that there is nothing in the
rec ord that would sug g est it was any thing other than an isolated statement, not a c ontinuing patter n of beha vior. The rec ord shows no evidenc e that C.R.W
. made any rec ent overt act to a ctually harm he rs e lf e ve n if sh e did make the state me nt. Th is ev ide nc e , whi le the c los e st w e fi nd to b e su ff ic ie nt, fails to rea ch the he ighte ned standa rd of r eview he re. Simi larly , Dr. B lois noted this allege d threat to ove rdose on he r medication. Aga in, though, with no evidence that C.R.W . took any action in furthe ra n ce o f t his threat, no evide nce a s to the context or tone of the stateme nt, and no evidenc e that she e ng age d i n a continuing patter n of behavior that would confirm that C.R.W . is, indeed, at risk of ha rming herse lf, we c annot say that thi s e vid e nc e is c le ar a

nd c on vi nci ng. W e c on c lud e that th e e vid e nc e is l e g a lly ins uf fi c ie nt t o support the trial cour

t's f inding that C.R.W. is likely , as a r esult of her mental illness, to harm herse lf. D. Evi de nc e of a R e c e nt Ove r t A c t o r a C ontinu ing P at te r n of D ist r e ss a nd Det erior ation Next, we ex am i n e the re cord f or evide nce of

a re cent ove rt ac t or a c ontinuing patter n of behavior that con fi rm s t h e multiface ted finding under Sec tion 574.034(a)( 2)(C). We must find sufficie nt evidence of the followingthree elements: 1) the patient is sufferingsever e and a bnormal mental, emotional, or phy sical distress, 2) the patient is ex perie ncing substantial mental or phy sical deter ioration of the pr oposed patient' s ability to function independe ntly , which is exhibi ted by the p ro p o s edp at i en t 's i n ab i l i t y , ex ce p tfo r r ea s o n s o f i n d i gen ce , t o p ro v i d e f o r t h e p ro p o s edp at i en t 's16

basic ne eds, including food, clothi ng , health, or safe ty ; and 3) the pa tient is unable to make a

rational and informe d decision as to whe ther or not to submit to treatment. T EX . H EA L TH & S AF ETY C ODE ANN . § 574.034(a) (2)( C). The doc tors' cer

tificates, ag ain the only expert testimony for our re view, provide no evidenc e
conce rning a re cent ove rt ac t or continuing pattern of b eh av i o r t h at would serve to confirm that C.R.W . was, at the time she was c ommitt ed to the state hospital, suf fe ring sever e and a

bnormal mental, emotional, or phy sical distress. We lea rn from C .R.W . herse lf that she does suf fer from some phy sical ailments and doe s seek reg ular treatment, when she is cover ed by health insuranc e, fo r t ho se a ilm e nts . T he re c or d s ug g e sts sh e ha s d on e so fo r y e ars . F or the e vid e nc e to b e le g a lly su ff ic ie nt t o s up po rt

the tr ia l c ourt ' s f

ind ing s, the re c or d w ou ld also have to show that, when C.R.W. was committed, she was experienc in g s u b s t anti al mental or p h ys i c a l d e t e r i o r at i o no f

h e r a b i l i t y t o f u n c t i o ni n d e p e n d e n t l y, w h i c h w a s e x h i b i t e d b y h e r i n a b i l i t y, except for rea sons of indige nce, to pr ovide for he r basic ne eds, including food, clothing , health, or safe ty
. See T EX . H EA L TH & S AF ETY C ODE ANN . § 5 7 4
. 0 3 4 ( a ) ( 2 ) ( C)
. D r . B lo is ' c e rti f ic a te does tou c h o n C. R.W. ' s p oo r hy g ie ne and the fa c t th a t sh e wa s li vin g in a ho us e wi th o ve r 2 00 c a ts. Th is mig ht s e rv e a s so me e vid e nc e of a c on tin uin g patte rn of be havio r— c oll e c tin g c a ts— that c on fi rm s deter ioration of her ability to f unction independe ntly
. C.R.W
. admitted that she could not ke ep the house cle an under those circ umstances without help from her husband. The inability to maintain a17

somewhat s an it ar

y h o me c o u ld , ar g u a

b ly , c a ll in to is s u e C. R. W. ' s a b il it y to p r o v id e f

o r h er ow n health and sa fety
. We share the Houston–First Court' s relucta nce to c onclude that suc h evidenc e, without more, demonstrates a

continuing pattern of be havior that would c onfirm m ental or phy sical dete rioration: [E] vidence of the e ffe cts of mental illness does not nece ssarily establish evidenc e of substantial

me nta l or ph y sic a l de te ri or a tio n unle ss t h e e f f e c t s i m p a i r a pe rs on ' s a bil ity to function independe ntly to pr ovide for ba sic nee ds. For e x ample, poor g rooming is in su ffi cie nt "to ju st if

y dep ri vi ng an i nd iv id ual o f her li bert y ." J.M. , 178 S.W .3d a t 19 5. Poo r hyg ie ne and " op po sit ion a l beh a vio r" a lso de mon str a te me nta l il lne ss, bu t a lon e do no t rise to t

he le ve l of

an o ve rt a c t or patte rn of be havio r t

hat c on fi rm s a substantial deterioration of a person' s ability to function independe ntly to provide for he r basic ne eds. Id. Evidence of poor insight and judgme nt, lack of trust towa rds others, insomnia, and diminished we ight a re likew ise serious hea lth problems, but they must be coupled with e vidence that Armstrong is suf fe ri n g s ubstantial dete ri o ra t i on of her

ability to provide for

her ba sic nee ds. See id. Although the evidenc e shows that Armstrong is mentally ill, has phy sical hea lth problems, and has been previously hospitaliz ed for the mental illness, the State offe red no t es t i m o ny tha t, a s a r e s u lt o f h e r me n ta l c o n d it io n , s h e is u n a b le to f u n c ti o n in d e p e n d e n tl y

as e xhibi te d b y

he r i na bil ity to p ro vid e fo r h e r b a sic ne e ds
. Ar ms tro ng v . S tat e , 190 S.W .3d 246, 252 (Tex. App.—Houston [1s t Dist.] 2006, no pet.). He re , Dr
. Bl o i s d o es n o tp ro v i d e d et ai l s i n t o t h e c o n d i t i o no f t h e h o u s e o r ab o u tC
. R
. W
. 's hyg ie ne . We do la te r le arn a lit tle bit mor e fr om C.R. W. h e rs e lf . Sh e e xpla ine d th a t sh e wa s una ble to pr operly car e for herse lf at the time, that she was " a mess and stinky rig ht now" be cause she wa s
ru sh e d in to s ta te c us tod

y and wa s not a

ble to t a ke any

of he r " stu ff ," pr e su ma

bly g ro omi ngpr od

uc ts. She a lso e xpre sse d dis satis fa c tio n fo r the c on dit ion of the ho us e ; sh e tol d h e r h

us ba nd that sh e did not want to live in such conditions. A lthough not expert testimony , as re quired, C.R.W.'s testimony18

g ives us a bit mo r e in s ig h t in to th e s it u a ti o n . F u rth e r , w e n o te th a t, b y th e ti me th e h e ar in g took pla c e , th e re c or d de mon str a te s that law e nf or c e me nt s e ize d ma

ny of the c a ts f ro m th e ho me . Wh ile ther e is s o me e v id e n c e o f th is s e c o n d e le me n t u n d e r Se c ti o n 5 7 4
. 0 3 4 ( a ) ( 2 ) ( C) , it f a ll s short of sufficie ntly

clea r and c onvincing . A re asonable trier of fac t could not ha

ve formed a firm conviction or belief as to the truth of these finding s based on this evidenc e. Finally , we f

ind no evidence that C.R.W . is unable t o make a rational and informed de cision as to whethe r or not to submit to t reatment. To the contra ry , the re cord shows that C.R.W . has
so ug ht r e g ula

r t re a tme nt f

or he r s e ve ra l he a lthpr ob le ms and ha s le arn e d th a t sh e is s e ns iti ve to
sev eral me dic a tio ns . Sh e e xpla ins that sh e is a ble to t a ke on e c e rt a in p a in m e dic a tio n, bu t mo st others make her ill. She has explored holistic medicine and a cupunctur e. She pursue s these ave nues in conjunction with her "re g ular" doctors for her phy sical and mental health. Evidence of a de cision to p ur su e tr e a tme nt o the r t han or in c on jun c tio n w ith

c on ve nti on a l me dic ine do e s n ot s a tis fy thi s element. The rec ord is voi d of evide nce that C.R.W . is unable to make a rational a

nd informed decision as to whe ther to submit to treatment. IV . CO NC LU SION We reve rse the tr ial court' s order an d re n d er judgme nt denying the State' s application for
me nta l he a lthse rv ic e s. Ha vin g re nd e re d s uc h jud g me nt, we a c c or din g ly or de r C .R. W.' s im me diate rele ase f rom the i nstitut ion to which she has been committed. See T EX . H EA L TH & S AF ETY C ODE19

ANN . § 574. 03 3( b) (V e rn on 20 03 ); se e als o T EX . R. A PP . P. 43.2(c). Our mandate w ill is sue immediately

upon motion, shoul d appropr iate ac tion not be taken in ac corda nce w ith this opinion.

J ack Ca rter J ustice Date Submitted: April 24, 2008 Date D ecide d: April 25, 2008