### 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- 09 -0 00 28 -C V

______________________________

THE STATE OF TEXAS FO R THE B EST I NT ERE ST A

ND PRO TE CTI ON OF E. R.

On Appea l from the County Court at L aw No. 2 Hunt County , Texas Trial Court No. M-09447

B e f o r e M o r r i s s , C

. J. , C a

rt e r a n d M o s e l e y , JJ. Op ini on by Chi e f Jus tic e Mo rr issE.R. has bee n diag nosed with schizophrenia. 1 2 O P I N I O N No do ub t, E .R. is a wo man wh o s uf fe rs fr om m e nta l il lne ss and ha s n ot b e e n p a rt ic ula

rl y 1 cooper ative with ef

forts intended to he lp he r. But what comes bef ore this Court is E.R.'s appe al of the trial cour

t's or der c ommitt ing he r for temporar y mental health service s and direc ting that she be g iven psy choac tive medications. See T EX . H EA L TH & S AF ETY C ODE ANN . § 574.034 (Ve rnon 2003). To jus tif y su c h a n o rd e r, the State mus t mee t a ra the r ri g or ou s set of pr oo f r e qu ir e me nts . B e c a us e we f ind tha t t h e ev i d en ce is leg ally insufficient to show a r ece nt overt ac t by E.R. or a c ontinuing pattern of behavior that tends to confirm either (a) t he li kelihood of ser ious harm to E.R. or others or (b) her distre ss and the dete rioration of he r ability to function, we r ev er s e t h e o rder of the trial court and dire ct E.R.' s relea se fr om commitment. See T EX . H EA L TH & S AF ETY C ODE ANN . § 574.034(d). ( 1) W hat Must Be Prove n Orde rs for te mporary

mental hea lth services a

re g overne d by

Section 574.034 of the Te x as He a lthand

Sa fe ty Cod e , w hic h h a s v e ry

pa rt ic ula r p ro of re qu ir e me nts : (a) The judg e may

order a propose d patien t t o rec eive c ourt-orde red temporar y inpatient mental health service s only if the judge or jury finds, from cle ar and c on vin c inge vid e nc e , th a t: (1) the pr oposed patient is mentally ill; and (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:3 (A) is likely

to cause serious har

m to hims elf; (B ) is likely

to cause serious har

m to others; or (C ) i s: (i ) s uf

fe ri ngse ve re a nd

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) experi encing substantial mental or phy sical dete rioration of the proposed patient's a

bility to function independe ntly , which is exhibi ted by the proposed patient's ina

bility , e xc e p t f

or re asons of indig ence , to provide for the proposed patient's ba sic needs, including food, clothing, health, or safe ty ; and (iii) unable to make a rational and informed decision as to whe ther or not to submi t to treatment; . . . . 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 presc ribed 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 . § 5 74 .0 34 (c ). I n th is c a se , me nta l il lne ss is not disputed and there i s no claim t hat E.R

. is a threat to harm others. The two alternative g rounds for r elief at issue are subsections (2)( A) a nd (2)( C). Clear a nd convincing evidenc e is that measur e or de g ree of proof that will produce in the mind of the trier of

fac t a firm belief

or convic t i o n as t o t h e truth of the alleg ations sought to be established. T EX . C IV . P R AC . & R EM . C ODE ANN . § 41 .0 01 (2 ) (V e rn on 20 08 ); State v. Addington , 588 S.W

. 2 d 569, 570 (Tex. 1979). Section 574.034(a) specific ally require s that, to be clea

r and convincing , the ev i d ence must, unless waived, include expert testimony and evide nce of

a re cent overt a ct or a

continuing pattern of behavior that tends to confirm (a ) the likelihood of ser ious harmAn orde r of c ommitm ent may not b e u pheld on a f

actua l basis that was urg ed to, y et was 2 reje cted by , the trial cour

t. J oh ns ton e v . S

tat e , 961 S.W .2d 385, 388 (Tex. App.—Houston [1s t Dist.] 1997, no writ). 4 to the proposed patient or others or ( b) the propose d patient' s distress and t h e d eterioration of the proposed patient's a

bility to f unction. T EX . H EA L TH & S AF ETY C ODE ANN . § 574.034(d). The overt act or continuing pattern of be havior " must relate to the c riterion on which the judgme nt is based." See In re F.M

. , 1 83 S.W. 3d

48 9, 49 2 (T e x. Ap p. —H ou sto n [14thDi st. ] 200 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.). Be cause the S tate' s burden of proof is clear a nd convincing evidenc e, we apply heig htened standards of revie w. See In re C.H. , 8 9 S. W.3 d 1 7, 25 (T e x. 20 02 ); In re M .M. , 184 S.W .3d 416, 417–18 (Tex. App.—Dallas 2006, no pe t.). I n revie wing the leg al suffic iency of the e vidence wher e the burde n of proof

is clear and convinc ing e vidence , we c o n s i der a ll of the evidenc e in the lig ht most favora

ble to the findi ng to determine w hether a re asonable trier of

fac t could have f

ormed a 2 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 disp ute d fa c ts i n f a vo 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 contrar y 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 ng fact ual s uf

fi c ie nc y c ha lle ng e s, we re vie w a ll t he e vid e nc e in t

he re c or d, bo th supporting a

nd opposing the trial court' s findings. C.H. , 8 9 S

. W

. 3 d at 27–29. We must give due

co n s i d er at i o n t o ev i d en ce t h e tr i er o f fa ct co u l d re as o n ab l y h av e fo u n d t o b e cl ea r an d co n v i n ci n g.We do not have a c opy of the orde r authorizing psychoac tive medication in the re cord be fore 3 us, althoug h it was originally and mi stakenly attache d as an e x hibit to t he cour t reporte r' s rec ord, a mistake which wa s promptly corr ecte d. Although E.R. challeng es the suff iciency of the e vidence to support the trial court' s findings in that orde r, her notice of a

ppeal did not indicate that she wa s appea ling that or der spe cifica lly

. Nonethele ss, the order authorizing administration of psy choac tive medication must be supported b y a v al i d order for tempor ary

mental hea lth services. See T EX . H EA L TH & S AF ETY C ODE ANN . § 574.106(a) (1) ( Ver non 2008). That sa id, if the order for tempor ary mental hea lth services is found to be unsupported, the or der a uthorizi ng administration of psy choac tive medication will, likewise, fail. See T EX . H EA L TH & S AF ETY C ODE ANN . § 574.104(a) (3) ( Ver

non Supp. 2008), § 574.106(a) (1). 5 Id. at 25. Under

the clea r-a nd-convinc ing sta

ndard, w e dete rmine whe ther the e vidence is such that the trier of

fac t could rea sonably form " a firm be lief or c onviction" a s to the truth of the alleg ations soug ht to be established by the State. Id. We must consider whethe r disputed evidenc e is such that

a r e a s o n a b l e t ri er

o f f ac tco u l d n o th av e r ec o n ci l edth at d i s p u t edev i d en ce i n fa v o r o f i t s fi n d i n g. J .F .C. , 96 S.W .3d at 266. ( 2) The Trial

Court' s Findings The trial c ourt order ed tempora ry mental hea lth services fo r a time per iod not to ex cee d ninety day s and authorized the a dminist ration of psy choac tive medication. I n its o rd er, the court 3 found t hat E.R . is likely

to cause serious har

m to herself. I t made fur

ther finding s: she will, if not tr e a te d, c on tinue to suff e r s e ve re a

bn or ma l me nta l, e mot ion a l, o r p hy sic a l di str e ss; sh e is experienci n g s u

b s t an t i al m en t al o r p h y s i ca l d et er i o ra t i o n o f h er ab i l i t y t o fu n ct i o n , wh i ch i s exhibi ted b y h er 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 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, he a lth , o r s a fe ty ; and

sh e is una

ble to m a ke a

ratio na l a nd inf

or me d de c isi on a s to wh e the r t o s ub mit to treatment.6

( 3) The Evidenc e Prese nted The State pre sented the te stimony of Dr. A

. Olufemi L ay eni, M.D., a psy chiatrist at the Terr ell State Hospital. L ay eni was the only witness to te stify at the hear ing on the State' s application. The r e c o r d

o f th e h e a r in g o n th e St a te ' s a p p li c a ti o n c o n ta in s a

p p r o xim a te ly

n in e te e n p a g e s of te sti mony , a

lit tle ov e r fi ve of wh ic h ar e de dic a te d to tes tim on y c on c e rn ingthe a va ila

bil ity , p os sib le

s i d e e f f e c t s , a n d o v e r a l l e f

f e c t i v e n e s s o f p s y c h o a c t i v e m e d i c a t i o n t o t r e a tE

. R

. ' s m e n t a l i l l n e s s . In the re ma ini ngte sti mony

sp a nn inga lmo st f

ourt e en pages , mo st o f t

he de ta ils te nd

to c on fi rm

on ly the fac t that, indeed, E.R. suffe rs from a mental illness, a fa ct not in dispute. W here the testimony ad dre s s es n ec es s ary

el em en t s o f p ro o f o n t h e i s s u es i n qu es t i o n , t h e S t at e's qu es t i o n s an d L ay en i 's te sti mony , in

many pla c e s, tr a c ks the lang ua g e of the statut e . T hu s, muc h o f t he te sti mony

is

c on c lus or y , e sp e c ia lly

a s to the li kel ih oo d th a t E .R. wi ll c on tin ue to d e te ri or a te . Wh ile tho se char acte ristics of the re cord do not make it impossibl e for the State to meet its burden of proof, we offe r them to show the re latively brief, la rg ely conclusory

rec ord. None theless, the question bef ore us is whether the State proved e ach e lement of the c ase by clea r and c onvincing evidenc e. L ay e n i e xp la in e d th a t E

. R. f ir s t c a me to th e h o s p it a l F e b r u a r y 2 5 , 2 0 0 9 , h aving been transfe rre d from the Me dical Center of McKinney based on cer tain specific behavior s: (1) not taking

c are of he rs e lf , ( 2) no t ta

kin g me dic a tio ns , (3 ) no t ha vin g fo od in the ho us e , (4 ) ba rr ic a din g he rs e lf in the house, and ( 5) not al l o wi ng any contac t with those people trying to se e to her welfa re. H e7

testified that E.R. was supposed to be attending a mental hea lth clinic on an outpatient basis but that she had stopped g oing in De cembe r 2008. L ay e ni t e sti fi e d th a t E .R. has bee n d ia g no se d w ithsc hizo ph re nia . Wh e n a sk e d if sh e sti ll suffe red f rom that condition, he re plied, "I believe so." He we nt on to testify that, in this i nstance , he has diag nosed E.R. w ith sc hizophrenia. His diag nosis wa s based on her histor y an d the information from r efe rra l sources. H e explained that it has " been r eally difficult to g et a history

from [E. R]. b e c a

us e sh e re fu se s to c oo pe rate wi th t he tr e atme nt t e a m" and

wi ll n ot tal k to any on e . A ll eff orts to "disc uss and gain any meaning ful information" from E.R. has be en pre vented by her r efusa l to cooper ate. L ay eni desc ribed the sy

m p t o m s of E.R.' s mental illness. He conc eded that there is no evidenc e that E.R. suffe rs from hallucinations associate d with schizophrenia, later clar ifying that her

re fu sa l to c oo pe rate ha s pr e ve nte d him fr om de te rm ini ng wh e the r sh e is e xpe ri e nc ingha llu c inatio ns . L ay eni conc luded that E.R. is likely to cause herse lf serious ha rm i f s h e is not treate d proper ly for he r mental illness. He ba sed this conclusion on the re ports made be fore she ar rived at Terr ell State Hospital, her f ailure to e at, her failure to take care of herself, and reports of the instance in w hich she barr icade d herse lf in he r home without f ood. Acc ording to L ay eni , s u ch b eh aviors sug g est that E.R.' s illness is i nterfe ring with her a bility to fend for

herse lf. L ay e ni a dd ed th a t E .R. wi ll c on tin ue to d e te ri or a te wi tho ut t re a tme nt. He r c on dit ion is deter iorating , and it beg an to do so afte r she stopped taking her medication. The sy mptoms of her8

mental illness will return when me dication is stopped, he say s. Acc ording to L ay eni, a patient who g oes untreated deter iorates a nd become s withdrawn a

n d p a r a n o id , not talking to anyone, re fusing any help, and not eating. He explained that the worst ca se scena rio will be starvation. He did not opine

w h e t h e r t h a ts c e n a r i o w a s l i k e l y. Medica l rec ords from McKinney Medica l Center, at whic h E.R. was first admitted, show that she made comments to medical staf f that family

members or

someone e lse had be en stabbing her with needles. L ay eni testified that such delusions are consistent with the delusions that acc ompany schizophrenia. The rec ords also demonstrate that, at least at some point, E.R. believed that

me dic a tio n w a s b e ingpu t in he r m ou th w hil e sh e sle pt. L a y e ni re lie d on the se me dic a l r e c or ds in developing his opinion about E.R. Th e State a sk e d L a y e ni t o ela bo ra te on wh a t he tho ug ht wo uld c on fi rm that E.R. is l ike ly to

cause serious har

m to herse lf. He explained that he r social withdrawa l, refusa l to talk to any one, and poor hyg iene c onfirmed that she is likely to cause serious har

m to herself. The doctor re iterate d that he believe s E.R. wi l l d et eriorate fur ther without treatment. He say s he ca nnot determine w hether E.R. is able to provide food f or her self or w hether

she just does not car e to eat. He c onfirmed that she has be en ea

ting at the hospital. The State a lso presente d the two re quired phy sician' s cer tificates of

medical e x amination for mental illness, one fr o m L ay eni and the othe r fr om Dr. Doyle Carson of the Medica l Center of McKinney

. See T EX . H EA L TH & S AF ETY C ODE ANN . § 5 7 4

. 0 0 9 (a ) ( Ve rn o n 2 0 0 3 ). L ay en i 's9

cer tificate pr esents similar opinions and bases, c it i ng that E.R. was not taking adequate ca re of herse lf, was not keeping a sanitary home, did not have f ood in the home, was not bathing, wa s not cooper ating with her tre atment, and wa s selectively mute. I n an adde ndum, L ay eni noted that, on or about Mar ch 3 , 2 0 0 9, E.R. barric aded he rself in he r house, a dding that she was stay ing in he r ho us e wi tho ut f

oo d a nd tha t sh e wa s re fu sin g to a llo w vis its fr om h e r c a re g ive rs . Ca rs on ' s c e rt if

ic a te opines that E.R. poses a risk of se rious harm to herse lf based on her failure to eat, failure to bathe, ref usal of medication, unsanitary state, and de lusions that people wer e poisoning her a nd stabbing her w ith needles. In an adde ndum to his report, Carson notes the following acts by E.R.: refusing all medication, not eating , not bathing, a nd not allowing c are g ivers into her house . The a ddendum do e s n ot d e ta il the sig nif

ic a nc e of the se a c ts. The medic al re co rds admit ted into evidence g ener ally indicate that E.R. may have experience d some hallucinations or, at least, some par anoia a nd confusion. Fu rt her, the rec ords show that E.R. w as reluc tant to c ooperate with the hospital staff to some de g ree : she allowed the m to chec k her vital sig n s b u t refused medication they offe red. E.R. wa s withdrawn, a social, and poorly g roomed but wa s "e ating well" and posed no be havior mana g ement proble ms. ( 4) Legally Insufficient Evidenc e Supports Trial Court' s Findings E.R. does not challeng e the tria l c ourt' s finding that she suffe rs from a mental illness. See T EX . H EA L TH & S AF ETY C ODE ANN . § 571.003(14) ( Ver non Supp. 2008) (def

ining menta l illness). But a n expert diag nosis of mental illness, standing a lone, is not sufficient to conf i n e a patient for10

treatment. See M. S. v . S

tat e , 137 S.W .3d 131, 136 (Tex. A pp.—Houston [1s t Dist.] 2004, no pet.); Br ou ssa rd

v . S tate , 827 S.W .2d 619, 622 (Tex. App.—Corpus Christi 1992, no writ). L ikewise,

e vid e nc e that me re ly re fl e c ts a patie nt' s me nta l il lne ss a

nd ne e d f or ho sp ita lizatio n is ins uf

fi c ie nt t o meet the State' s burden. See M.S. , 137 S.W .3d at 136. The ex pert' s opinions and rec ommendations must be supported by

a showing of the fac tual bases on whic h they are g rounded. Sta te e

xre l. C .C. , 25 3 S.W .3 d 88 8, 893 ( Te x. Ap p. —D a lla s 2 00 8, no pe t.) ; State ex re l. E.E. , 224 S.W .3d 791, 794 (T e x. Ap p. —T e xar

ka na 20 07 , n o p e t.) ; T.G . v. Sta te , 7 S.W .3d 248, 252 (Tex. App.—Dallas 1999,

no pe t.) . Pu t ano the r w a y , th e State mus t sh owmor e tha n d e lus ion s or ot her fact s th a t me re ly confirm a

p roposed patient's me ntal illness to meet the evidentiar y standard f

or a te mporary commitment. See In re C.O. , 65 S.W .3d 175, 182 (Tex. App.—Ty ler 2001, no pe t.). We now turn to the rec ord to deter

mine whether

the State did so. ( a) The Likelihood of Serious Harm to E.R. The tria l c o u rt f

o u n d th a t E

. R. " is li k e ly to c a u s e s e r io u s h a r

m to s e lf

. " T o b e c le ar a nd convincing under Sec tion 574.034(a), the e vidence to support this finding must include expert testimony and evidence 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 e d p a t i en to 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 a bility 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 " must relate to the cri ter io n on whi ch th e ju dgmen t i s b ased ." See F.M. , 1 83 S.W. 3d a t 49 2; J.M. , 178 S.W .3d at 193.11

A thre at o f h ar m to the patient must be substantial and base d on actua l dang erous be havior manifested by

some overt act or t hreats in the rec ent past. J.M. , 1 78 S.W. 3d a t 19 3; In re K.D .C. , 78 S.W .3d 543, 547 (Tex. App.—Amarillo 2002, no pet.). L ay eni testified that E.R. is likely to cause serious harm to herself , basing his opinion on prior

re po rt s, he r f

a ilure to e a t, h e r f

a ilure to t a ke c a re of he rs e lf , an d th e re po rt

of the ba rr ic a din g inc ide nt. He la te r ad de d tha t E.R. ' s soc ia l with dr a wa l, r e fu sa l to c omm un ic a te , a nd po or hyg ie ne de mon str a te a thre at of ha

rm to herse lf. We reiter ate that L ay eni' s cer tificate of medical e x amination provided the following bases f

or his opinion that E.R. poses a risk of ser ious harm to herse l f: s h e wa s not taking adequate ca

re of herse lf, she was not keeping a sanitary home, she did not have food in the ho me , sh e wa s no t bathi ng , sh e wa s no t c oo pe ra tin g wi th he r tr e a tme nt, and sh e was sele c tiv e ly mute. He a lso noted that E.R. barric aded he rself in he r home a nd added that she was stay ing in he r home without food and that she was r efusing to allow visits from her ca reg ivers althoug h he did not provide a specific connec tion between those acts a nd a spec ific opinion

. C ar s on' s cer tificate of

me dic a l e xami natio n c ite d the fo llo wi ng de ta ils a s su pp or t f or his op ini on

tha t E .R. is l ike ly

to c a us e

se r io u s h ar

m t o h e r s e lf

: r e f u s a l t o e a t, f

a il u r e to b a th e , r e f

u s a l o f me d ic a ti o n , u n s a n it a r

y li v ing conditions, and delusions that people wer e stabbing her with ne edles and/or poisoning her. He a dded notations to his certificate that conce rned he r re fusal of me dication, her poor eatin g and bathing prac tices, and he r ref

usal to a llow c are g ivers into he r home. Ag ain, though, these notations do not

re ve a l th e sig nif

ic a nc e of the no te d a c tio ns .12

Th e Sta te pr e se nte d e vid e nc e of a n inc ide nt in w hic h E .R. wa s sa id t o h a ve ba rr ic a de d h e rs e lf i nh er h o m e. L ay en i re fe rr edt o t h i s i n ci d en ti n h i s ce rt i fi ca t e o f m ed i ca l ex am i n at i o n , aga i n , t h o u gh without e x planation of the incident' s signific ance . He a lso testified very briefly about the bar

rica de incident. We know nothing of the details of the ba

rrica de incident suc h as durat ion or manner of barr icading , but we do lea rn that, appa

rently , E.R. barric aded he rse lf in her home out of fea r that

so me on e wa s tr

y ingto h a rm

he r. Th is e vid e nc e is a re c e nt ove rt a c t, but the re c or d le a ve s unc e rt a in as to what the a ct may

confirm. The rec ord does not g ive us enoug h information to conclude that the evidenc e satisfies the he ighte ned burde n place d on the S tate. W hat little the rec ord does show us about the incident sug g ests that the incident was broug ht a bout by E.R.'s pa ranoia , a sy

mptom of he r m e nta l il lne ss. F ur

the r, the re c or d wo uld a lso su g g e st that E. R. ba rr ic a de d he rs e lf in he r h ome

as a me asure of protec tion, albeit an ef fort most likely

made in re sponse to para

noia. Without more,

e vid e nc e of

the inc ide nt l e nd s n o s up po rt to a fi nd ingthat E .R. po se d a ri sk of se ri ou s h a rm

to he rs e lf

. As we have no te d, that e vid e nc e c on fi rm ingon ly that a pr op os e d p a tie nt i s me nta lly ill is insufficient to mee t the evidentiar y standard for cour

t-order ed mental he alth service s. See C.O. , 65 S.W .3d at 182. L ay eni spec ifically cited E.R.' s ref usal to communicate a s evidenc e that she pose s a risk of

se ri ou s h arm

to h e rs e lf

. Hi s ce rt if

ic a te of me dic a l e xami natio n li ke wi se re fe rs to t he fa c t th a t E .R.

rema ins "sele ctively

mute." Apatient' s ref

usal to communicate w ith the hospital staff is insufficient to support the finding require d to authorize court-or dere d mental hea lth services. J.M. , 178 S.W .3dTo the extent that the evidenc e that E.R. was selec tively mute is rele vant t o the distress and 4 deter ioration finding , we a lso conclude that such evidenc e is insuff icient. When fac ed with evidenc e of poor hyg iene, mania , and oppositional behavior, the Ty ler c ourt conc luded that such e vidence mere ly demonstrate d t h e p roposed patient's me ntal illness and failed to c onstitut e evide nce of a re c e nt o ve rt

a c t or co nti nu ing patte rn of be havio r that dem on str a te d distre ss or te nd e d to con fi rm a substantial deteriora

tion of the proposed patient' s ability to provide for his own basic needs. See I n re B.S. , No. 12-02-00217-CV, 2003 Tex. App. L EXI S 4640, at *13–14 (Te x . App.—Tyler May 30, 20 0 3 , n o p e t
. ) ( m e m . o p . )

. I n d e e d , c o u rt s h a v e g e n e r a l l y t r e at e d p o o r g r o o m i n g a s i ns uf fi c ie nt t o justify depriving an indi vidual of hi s or her liberty and poor hy

g iene, while de monstrative of menta l illness, as falling short of an overt act or pattern of behavior that confirms a

substantial deterioration of a pe rson' s ability

to function independe ntly to provide for

his or her ba sic nee ds. See K.E.W . v. Sta te , 2 76 S.W. 3d

68 6 ( Te x. Ap p. —H ou sto n [1s t D ist .] 20 08 , n o p e t.) ; Ar ms tro ng v. S tate , 190 S.W .3d 246, 252 (Tex. App.—Houston [1s t Dist.] 2006, no pet.). 13 at 1 9 5

. T h e e v i d en ce t h at E

. R

. re m ai n s s el ec t i v el y m u t e p r o v i d e s n o s u p p o rt t o t h e t ri al co u rt 's finding that E.R. poses a risk of se rious harm to her self. 4 There is also evidence that E.R. had not been e ating proper ly

. A proposed patient's r efusa l to e a t ma y be su ff ic ie nt e vi den ce to sup po rt an o rd e r f

or te mpo ra ry c omm itm e nt w he n th e re is sp e c if ic e vid e nc e of

the patie nt' s r e fu sa l and the re su l t i n g h ar m that ref usal has ca

used to the proposed patient. Com

pa re K.T. v . S

tat e , 68 S.W .3d 887 (Tex. App.—Houston [1st Dist.] 2002, no pe t. ) ( e v i d e n c e i n s u f

f i c i e n tw h e n S t a t e p r e s e n t e d e v i d e n c e o f

p a t i e n t ' s r e f

u s a l t o e a tw h i le hospitaliz ed but fa iled to show that her r efusa l resulted in m alnutrition or other ha rm) with E.E. , 224 S.W .3d at 79 4 (evide nce suf ficient to show risk of ha rm to self whe n patient was f ound to be de hy dr a te d a ft e r a dmi tti ngsh e ha d b e e n f a sti ngfo r o ne we e k) ; se e als o S t a t e e x r e l

. Y. A

- Y. , No . 1 2- 03 -0 02 42 -C V, 20 04 Te x. Ap p. L EX I S 29 61 (T e x. Ap p. —T y le r Jan. 8, 20 04 , no p e t.) (m e m. op.) (evidence sufficie nt where patient re fused to eat and drink for day s at a time, re sulting in weig htL ay eni testified that he c ould not say whether E.R.' s eating decisions wer e base d on her 5 choice or her

inability t o p ro v ide food for

herse lf, at lea st sugg esting that indige nce ma y be the rea son for E.R.' s failure to e at proper ly

. Adding to the sug g estion, the rec ord shows that E.R. has be e n e a tin g in the ho sp ita l. Se c tio n 574 .0 34 sp e c if ic a lly e xce pts " re a so ns of ind ig e nc e " a s a

ba sis fo r a fi nd ing that a pr op os e d patie nt c a nn ot pr ov ide fo r his or he r bas ic nee ds

. T EX . H EA L TH & S AF ETY C ODE ANN . § 57 4. 03 4( a )( 2) (C )( ii) ; Sta te for theBe st I nte re st &Pr ot. of S

.C. , No. 05-08- 00 37 3- CV , 2 00 8 T e x. Ap p. L EX I S 60 95 , at *1 4 ( Te x. Ap p. —D a lla s A ug . 1 3, 20 08 , n o p e t.) (m e m. op.). So, the evidence that E.R. was not eating proper ly would also fail t o constitute a continuing pattern of behavior that would confirm E.R.' s distress and the de terioration of her a bility to function. See T EX . H EA L TH & S AF ETY C ODE ANN . § 574.034(d). 14 loss and risk of dehydration). The San Antonio c ourt conclude d that the evidenc e wa s insufficient wh e n it sh ow e d th a t a

pr op os e d patie nt wa s no t e a tin g pr op e rl y bu t fa ile d to sh owthe e a tin g ha bit s resulted in we ight loss or malnutrition. See In re Bre eden , 4 S.W .3d 782, 788–89 (Tex. App.—San Antonio 1999, no pet.). Her e, we have ve ry littl e information reg arding E.R.'s eating habits. We do not know, for 5 instance, howlong she had been wit hout food or whether there is a reg ular and continuous state of bare cupboar ds. The re cord is silent as to w h ether E.R. has suffe red a

ny adver se hea lth effe cts as

a re su lt o f h e r f

a ilu re to m a int a in p ro pe r e a tin g ha bit s. F ur the r, the re c or d d oe s sh owthat E .R. ha s, in f a c t, b e e n e a tin g a t th e ho sp ita l. L ay eni testified that the "w orst case scena rio" would be that re fusal of tre atment could lea d to d e a th b y

sta rv a tio n. Whil e we re c og nize thi s sc e na ri o a s a c omp e lli ngpo ssi bil ity th at shou ld

c a us e c on c e rn , it re ma ins jus t that, a po ssi bil ity

. Th e re is n o e vid e nc e that w ou ld s ug g e st that E .R. has suffe red any of the eff ects of starvation and no evidenc e that starvation or other ill effe cts wer e lik e ly

. Ev ide nc e that the pr op os ed pat ie nt might c a us e se ri ou s h a rm

to h ims e lf

or he rs e lf isWe must find sufficient evidenc e of the following three elements: (1) patient is suffer ing 6 sever e and a

bnormal mental, e motional, or phy sical distress; (2) patient is ex perie ncing substantial mental or phy sical dete rioration of the proposed patient's a bility to function independe ntly , which is ex hibited by

the proposed pa

tient's ina bili t y , ex ce pt for re asons of indig ence , to provide for the pr op os e d p a tie nt' s b a sic ne e ds , in c lud ing fo od , c lot hin g , he a lth , or

sa fe ty ; and

(3 ) p a tie nt i s una

ble to make a r ational and infor med decision as t o whether or not to submit to treatment. T EX . H E AL TH & S AF ETY C ODE ANN . § 574.034(a) (2)( C). 15 insufficient to satis fy

the sec ond element. State ex re l. L.C .F. , 9 6 S. W. 3 d 6 5 1 , 6 5 7 ( T e x. App.—El Paso 2003, no pet.); C.O. , 6 5 S. W.3 d at 18 1– 82 ; Br ou ssa rd , 827 S.W .2d at 621–22. We c onclude that the evidenc e is le g ally insufficient to suppor t the trial court' s finding that E.R. is li kely , as a r esult of her mental illness, to harm herse lf. ( b) Distress and Deterioration Next, we examine the rec ord for evidenc e of a

recen t o v er t act or

a continuing pattern of behavior that confirms the multifac eted f inding unde r Section 574.034(a )(2) (C). For this evidence 6 to me et the clea

r and convincing standard, it must show a rec ent overt act or a continuing pattern of behavior that tends to c onfirm the proposed patient's distre ss and the dete rioration of the proposed patient' s abil i t y t o function. T EX . H EA L TH & S AF ETY C ODE ANN . § 5 7 4

. 0 3 4 (d )( 2 ). L ay en i 's testimony sug g ested that E.R. will deterior ate a s a re sult of the cessation of medica t i o n for he r

me nta l il lne ss. Th e re is a lso so me dis c us sio n re g a rd ing the de lus ion s E. R. may be havin g . We wi ll discuss eac h item of evidenc e in turn. F ir st, L a y e ni t e sti fi e d th a t he be lie ve s E .R. wi ll d e te ri or a te fu rt he r wi tho ut tr e a tme nt. Th is conclusion, without the requir ed evide nce of a re cent ove rt act or

a continuing pattern of

behavior16

of the risk of s er i ous harm to her self or e vidence confirming her distre ss and deter ioration of her ability to function, is insufficient to satisfy the State' s burden to pres en t clea r and c onvincing evidenc e. An expert opinion recommendingcommitment must be supported by the fa ctual base s on which it is g rounded a

nd not simpl y

rec ite the statutory

criter ia. See J

.M. , 178 S.W .3d at 193. Evidence of re fusal to take me dication, alone, is not an overt act or continuing pattern of behavior tending to confirm a pr oposed patient' s distress or a de terioration of the ab i lity to function. See Armstrong , 1 90 S.W. 3d

a t 25 2– 54 ; Johnstone , 961 S.W .2d at 389. We a dd that evidenc e that the proposed patient will ex perie nce substantial menta l or phy sical deterioration i n the future does not establish this e lement. See Armstrong , 190 S.W .3d at 252–53 (evide nce showed onl y that patient

wa s beginning

to de te ri or a te du e to he r re fu sa l to take me dic a tio ns fo r he r ch ro nic he a lthpr ob le ms,

no t th a t sh e wa s c u r r e ntl y ex p er i en ci n g substantial deter ioration of her

ability to function independe ntly). Althou gh L ay en i ad m i t t edt h at h e c o u l d n o td et er m i n e w h et h er

E

. R

. i s cu rr en t l y

ex p er i encing ha llu c inatio ns or

de lus ion s, the me dic a l r e c or ds su g g e st sh e may be e xpe ri e nc ingha llu c inatio ns to some degree , re p o rt i n g t h at p eo p l e h adb ee n s t ab b i n g h er wi t h n ee d l es , p o i s o n i n g h er , an d at t em p t i ng to medicate he r while she sle pt. Assuming that these scena rios are , in fac t, hallucinations and that

no o n e is tr

y in g to me d ic a te h e r w h il e s h e s le e p s o r g iv e h e r in je c ti o n s , w e n o te th at evidenc e of hallucinations or delusions alone is insufficient to justify involuntary

commitment on the gr oundsThe Da llas court provide d a compr ehensive list of case s conce rning evidenc e of de lusions 7 as i t relates to the findi ng require d for court-orde red me ntal health ser vices. See C.C

. , 253 S.W .3d at 894–95. A re ading of those and othe r ca ses would sug g est that proposed patients would have ha d to have done some ac t or made some omission base d on these ha llucinations or delusions and that su c h a c t or

omi ssi on

de mon str a te s th e de te ri orat ion of the a bil ity to f un c tio n. Suc h a

ste p is consistent with the statutory require ment that the re cord de monstrat e an o v ert act or a c ontinuing pattern of behavior

. 17 of mental distress a

nd the deter ioration of the a bil i t y to function independe ntly

. See C.C

. , 253 S.W .3d at 895; F.M. , 183 S.W .3d at 499–500. 7 [E] vidence of t he ef

fec ts of mental illness does not nece ssarily establish evidenc e of su bs tanti a l me nta l or

ph y s i c a l de te ri or a tio n unle ss t he e ff e c ts i mpa ir

a pe rs on ' s a bil ity to function i ndepende ntly to provide for basic needs. For example, poor g rooming is insuffici en t "t o justify

depriving an individual of her liberty ." Poor hy

g iene a nd "oppositional behavior" also demonstrate mental illness, but alone do not rise to the level of a n overt a ct or pattern of behavior that confirms a substantial deterioration of a pe rs on ' s a

bil ity to f un c tio n in de pe nd e ntl y

to p ro vide fo r h e r b a sic ne e ds

. Evidence of poor insight and judg ment, lack of trust towards other s, insomnia, and diminis hed w ei gh t are likewise ser ious health problems, but they must be coupled wi th e vid e nc e tha

t A rm str on g is s uf

fe ri ng su bs tanti a l de te ri or a tio n of he r a bil ity to pr ov ide fo r h e r b a sic needs . A lth ou g h th e e vid e nc e sh ow s th a t A rm str on g is mentally ill, has phy sical health problems, and has be en pre viously hospitaliz ed for the mental illness, the State offe red no te stimony that, as a r esult of her

mental c on dit ion , s he is una

ble to f un c tio n in de pe nd e ntl y as ex hi bit e d b y he r i na bil ity to pr ov ide fo r h e r b a sic ne e ds

. Armstrong , 190 S.W .3d at 252 (c itations omi tted). The evidenc e is leg ally

insufficient to show a r ece nt overt ac t or continuing pattern of behavior that tends to confirm E.R.' s distress and dete rioration of he r ability to function.18

( 5) Conclusion The e vidence is insuff

icient to show a rec ent overt act or a continuing pattern of behavior that tends to confirm the likelihood of se rious harm to E.R . L ikewise, on the r ecor d befor e us, we cannot say t h at the evide nce w ould lead a r easona ble trier of

fac t to form a firm be lief or c onviction that E.R. had eng ag ed in a r ecent overt a ct or a continuing pattern of be havior tendingto confirm her distress and the de terioration of her a bility to function. See T EX . H EA L TH & S A FE TY C ODE ANN . § 574.034(d). We reve rse the tr ial court' s order and re n d er j u dg ment 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 ju dg me nt, we a c c ord ing ly or de r E .R. ' s im me diate rele ase f rom the i nstitut ion to which she ha s been c ommitt ed. See T EX . H EA L TH & S AF ETY C ODE ANN . § 57 4. 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 o s h R

. M o r

r i s s , III Chief J ustice Date Submitted: April 9, 2009 Date D ecide d: April 29, 2009