                                NUMBER 13-13-00631-CV

                                   COURT OF APPEALS

                       THIRTEENTH DISTRICT OF TEXAS

                          CORPUS CHRISTI - EDINBURG


               THE STATE OF TEXAS FOR THE BEST INTEREST
                        AND PROTECTION OF C.B.


                            On appeal from the Probate Court
                               of Hidalgo County, Texas.


                                MEMORANDUM OPINION

               Before Justices Rodriguez, Benavides, and Perkes
                  Memorandum Opinion by Justice Rodriguez
        This is an appeal from an involuntary commitment proceeding under the Texas

Mental Health Code.          TEX. HEALTH & SAFETY CODE ANN. § 571.001 (West, Westlaw

through 2013 3d C.S.).           Appellant C.B. 1 challenges the trial court's judgment that


         1 Although not required by rule or statute, we will use appellant's and her family members’ initials

to protect appellant’s privacy in this mental health proceeding. See, e.g., State ex rel. T.M., 362 S.W.3d
850, 851 (Tex. App.—Dallas 2012, no pet.) (using initials to describe psychotic bipolar adult challenging
her temporary involuntary commitment); L.S. v. State, 867 S.W.2d 838, 840 (Tex. App.—Austin 1993, no
writ) (using initials to refer to mentally disabled adult appealing an order extending an involuntary
commitment to a state hospital).
ordered extended inpatient mental health services for her at the Rio Grande State Center

(the Center), a mental health facility. By one issue, appellant argues that the evidence

adduced at the commitment hearing was legally insufficient to support jury findings under

section 574.035(a). See id. § 574.035(a) (West, Westlaw through 2013 3d C.S.). We

affirm.

                                       I. BACKGROUND

A. Procedural History

          On August 22, 2013, Susan Fuller, a court liaison, filed an application for

appellant’s emergency apprehension and detention and an application for extended

commitment for mental illness. Fuller alleged that appellant was mentally ill and was

likely to cause harm to herself and, if not treated, would continue to suffer emotional and

mental distress, would continue to experience deterioration of her ability to function

independently, and would be unable to make a rational and informed decision as to

whether to submit to treatment. In her application for emergency apprehension and

detention, Fuller further indicated that appellant had been diagnosed with and had been

suffering from schizophrenia “for decades,” had started fasting at God’s request, had

stopped taking her medications, and had threatened to bomb the San Juan Shrine.

          On the same date, the State filed a motion for protective custody together with the

requisite medical examination certificate from a physician substantiating the need for

appellant’s custody. The trial court then issued an order to detain appellant pending a

final hearing.




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B. The Commitment Hearing

       On October 15, 2013, a jury heard the application.           The following witnesses

testified for the State: (1) psychiatrist Daniel Villarreal, M.D.; (2) appellant’s daughter

C.O.; and (3) social work manager Mike Torres. Appellant testified in her case-in-chief.

       1. Psychiatrist Daniel Villarreal, M.D.

       Dr. Villarreal, a psychiatrist at the Center where appellant was a patient, testified

that he had treated appellant since the beginning of 2013. He confirmed that appellant

was diagnosed with schizophrenia. According to Dr. Villarreal, appellant’s schizophrenia

manifested itself through delusions, specifically delusions where she communicates

directly with Jesus Christ.    Dr. Villarreal explained that while under his supervision,

appellant had threatened to stop eating and had refused to take her medication. Dr.

Villarreal believed that because of appellant’s lack of insight into her condition, her refusal

to take medication or to eat, and her conviction that she has divine protection, appellant

would endanger herself or others. Although Dr. Villarreal heard about appellant being

aggressive and putting herself in dangerous situations, he had not witnessed such

conduct or behavior. In closing, Dr. Villarreal responded to the following questions asked

by the State:

       Q. Okay. Now, at this time do you believe [C.B.] can make a rational and
          informed decision whether to submit to treatment?

       A. No.

       Q. Why do you believe she cannot?

       A. Because I think her judgment and her insight are impaired by her
          delusions, and that that's above anything else, and not enough
          explaining, trying to rationalize in regards of her treatment and how it

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             might improve some of her conditions would be—she would be able to
             even consider.

        Q. Okay. And so at this time can you tell this jury what is your expert
           opinion as to the type of treatment that [C.B.] needs?

        A. [C.B.] suffers with schizophrenia, and the primary treatment for
           schizophrenia has to do with medications for her hallucinations and
           delusions.    These are called antipsychotics.          She has taken
           medicines like this in the past with some improvement, so I think that
           we would most likely ask of the Court to allow us to use the medications
           again, hopefully that we can see that improvement that we've had
           before.

        2. Daughter C.O.

        C.O. testified that her mother had been delusional and had demonstrated periods

of erratic behavior and aggressiveness. C.O. indicated that, in her experience, appellant

refused to take prescribed medication. C.O. expressed concern that if released from the

mental health center, appellant would stop taking her medications and would hurt herself

or others.      C.O. related the following instances of appellant’s mental instability:

threatening to bomb the Pentagon in Washington, D.C.; asking C.O. to “help her get

bombs to bomb some places for some great escape”; walking in front of a tractor-trailer

rig, which the driver jackknifed to avoid hitting appellant; sitting Indian-style next to a busy

road across from C.O.’s step-family’s home; threatening to send bombs to their home;

wandering the streets at night looking for C.O.; calling C.O. a demon that had to be

purified; and telling C.O. that she “was going to ask God to send a necromancer2 to rape

[C.O.] to humble [her].” When the State asked C.O. if there was anything that was



         2 Merriam–Webster defines “necromancy” as “conjuration of the spirits of the dead for purposes of

magically revealing the future or influencing the course of events.” Merriam–Webster Dictionary,
http://www.merriam-webster.com/dictionary/necromancy (last visited Oct. 15, 2014).

                                                    4
important for the jury to know regarding appellant’s condition, C.O. answered, in relevant

part, “[I]f you let her out, either she's never going to come back because she's going to

get hurt or she's going to hurt somebody else. Unknowingly.”

       3. Social Work Manager Mike Torres

       Torres, the manager of social work at the Center, testified that he worked at the

hospital and had known appellant personally for more than eight years. He explained

that appellant was a special needs patient; that she had been at the Center since March

2, 2011, without being discharged or furloughed; and that she would fast on a regular

basis. He also testified that, in his opinion, appellant was not ready to be discharged

from the Center because she posed a danger to herself and “eventually” to others. When

asked if he had seen any signs of psychosis over the last few months, Torres responded

that until a few weeks before the hearing, appellant was “thinking very calmly, very

rationally, able to make some pretty good decisions about her future,” but then, as he

testified below, the following occurred:

       You know, quite honestly, last week she left me a message that told me—
       a phone message that told me that she was decompensating pretty—she
       was definitely going back, backsliding. It was a message where she was—
       there was some things that she wanted, she wanted her resume typed up,
       which I told her I would try to help her with, and she wanted to apply for
       some jobs online, but the message was that, you know, basically I needed
       to help her or she was going to tell Jesus to punish me.

Torres explained that appellant was “talking about fasting again and . . . that always leads

to her putting her health at risk. . . . She starves herself.” He also testified that appellant

had tried to buy bombs and had threatened to bomb a shrine and to kill the Pope. After

this testimony, the following exchange occurred between the State and Torres:

       Q. Do you believe that she is ready to be discharged?
                                              5
       A. No.

       Q. Do you believe that she poses a danger to herself if she is discharged?

       A. Yes.

       4. Appellant

       Through her own testimony, appellant confirmed that at times she would refuse

her medication because of the side effects it produced—facial hair, weight gain, and acne.

Appellant testified that she would take her medication, provided it was not the generic

brand because she was “allergic to the fillers inside generics.” And she explained that

although she would take “her” medication, she would not take “the doctor’s medication,”

or “the hospital’s medication.” Appellant reasoned “it's been my experience that when

[the doctors and hospital] choose a medication for me, it's really something that they

believe will work, but they don't have any experience being in my body and knowing my

side effects and then my allergies.” Appellant testified that she would fast as a cleansing

ritual because Jesus told her to do so. She indicated that she takes care of herself, her

health, and her appearance.

       Appellant also testified that her roommate physically attacked her and that she

feared for her safety. On cross-examination, appellant referenced an instance of an

alleged rape at the Center and her miscarriage. She talked about the spirit of that child

and explained that the spirit of her own mother who died in 2008 haunted her. Appellant

explained that Dr. Igoa, a psychiatrist at the Center, was making a building where she

could work because he had caused her to gain weight through the medication he had

administered. Appellant confirmed that Jesus had appeared to her and directed her to

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bomb the shrine because it was blasphemous. She further testified that she has sought

to obtain bombs. Nonetheless, appellant reiterated, without hesitation, that she would

not hurt herself.

C. Findings, Judgment, and Appeal

       At the conclusion of the trial, the jury found for the State on all of the elements

required for extended inpatient mental health services contained in section 574.035(a).

Consistent with the jury’s verdict, the trial court entered a judgment ordering extended

inpatient mental health services for appellant. This appeal followed.

                                    II. APPLICABLE LAW

       Extended inpatient mental health services may be ordered if it is found by clear

and convincing evidence that the proposed patient is mentally ill and that the patient's

behavior satisfies at least one of three criteria as a result of that mental illness. See id.

§ 574.035(a). The three criteria are: (1) the patient is likely to cause serious harm to

herself; (2) the patient is likely to cause serious harm to others; or (3) the patient is

suffering severe and abnormal mental, emotional, or physical distress, is deteriorating in

her ability to function independently, and is unable to make a rational and informed

decision as to whether or not to submit to treatment. Id. § 574.035(a)(2)(A)–(C). As the

statute is written in the disjunctive, finding any one of the three grounds makes the

commitment order valid. See T.G. v. State, 7 S.W.3d 248, 251 (Tex. App.—Dallas 1999)

(no pet.).

       Case law and the legislature have set out that

       [t]he trial court[, or in this case, the jury,] must find by clear and convincing
       evidence the statutory criteria for a commitment order. See A.S. v. State,
       286 S.W.3d 69, 71 (Tex. App.—Dallas 2009, no pet); see also TEX. HEALTH
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       & SAFETY CODE ANN. § 574.03[5](a). Clear and convincing evidence is that
       “degree of proof which will produce in the mind of the trier of fact a firm belief
       or conviction as to the truth of the allegations sought to be established.”
       State v. Addington, 588 S.W.2d 569, 570 (Tex. 1979) (per curiam).

State ex rel. T.M., 362 S.W.3d 850, 851–52 (Tex. App.—Dallas 2012, no pet.); see also

In re A.C., No. 13–13–00278–CV, 2014 WL 1369116, at *2 (Tex. App.—Corpus Christi

April 3, 2014, no pet.) (mem. op.).       In addition, section 574.035 sets forth specific

requirements for clear and convincing evidence under subsection (a). See TEX. HEALTH

& SAFETY CODE ANN. § 574.035(e). The evidence must include expert testimony and,

unless waived, evidence of a recent overt act or a continuing pattern of behavior that

tends to confirm: (1) the likelihood of serious harm to the patient or others; or (2) the

patient's distress and the deterioration of the patient's ability to function.        Id.   The

expert's opinions and recommendations must be supported by a showing of the factual

bases on which they are grounded and not simply on the statutory criteria. T.M., 362

S.W.3d at 852; see also In re A.C., 2014 WL 1369116, at *2. The recent overt act or

continuing pattern of behavior proven by the State must relate to the criterion on which

the court bases its judgment. In re C.O., 65 S.W.3d 175, 181 (Tex. App.—Tyler 2001,

no pet.).

                                 III. STANDARD OF REVIEW

       Because the State's burden of proof is clear and convincing evidence, we
       apply a heightened standard of review. In re C.H., 89 S.W.3d 17, 25 (Tex.
       2002). In reviewing a legal sufficiency claim, we look at all the evidence in
       the light most favorable to the finding to determine whether a reasonable
       trier of fact could have formed a firm belief or conviction that its finding was
       true. In re J.F.C., 96 S.W.3d 256, 266 (Tex. 2002).

T.M., 362 S.W.3d at 852; see also In re A.C., 2014 WL 1369116, at *2.



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                                             IV. DISCUSSION

        By one issue, appellant argues that the evidence is legally insufficient to support

certain findings under subsection 574.035(a). See TEX. HEALTH & SAFETY CODE ANN. §

574.035(a).

A. Unchallenged Findings

        The jury found that appellant is a person with a mental illness that is expected to

continue for more than ninety days and for which she has received court-ordered inpatient

mental health services for at least sixty consecutive days during the preceding twelve

months.      See id. § 574.035(a)(1), (3), (4).             Appellant does not contest these jury

findings.    However, she does challenge the jury’s remaining findings regarding the

grounds for commitment.

B. Challenged Findings

        Appellant complains that there is not clear and convincing evidence that as a result

of her mental illness she is likely to cause serious harm to herself, the first ground for

commitment. See id. § 574.035(2)(A). And she argues that the evidence does not

support the jury’s findings related to the third ground—that as a result of her mental illness

she suffers severe and abnormal mental, emotional, or physical distress, experiences

substantial mental or physical deterioration of her ability to function independently, and is

unable to make a rational and informed decision as to whether or not to submit to

treatment.3 See id. § 574.035(2)(C).



        3 C.B. also challenges the jury’s finding that she is likely to cause serious harm to others.

However, the trial court’s October 7, 2014 order clarifying its previous judgment did not identify this ground
as a basis for its judgment. So we need not address C.B.’s challenge to the jury’s harm-to-others finding.
See TEX. R. APP. P. 47.1.
                                                      9
       1. Harm to Self

       At the hearing, Dr. Villarreal provided expert testimony that appellant had a history

of schizophrenia. He testified that appellant’s schizophrenia manifests itself through

delusions, specifically delusions that she communicates directly with Jesus Christ and

that she has divine protection.      He explained that appellant lacks insight into her

condition. She has threatened to stop eating and has refused to take her medication.

Dr. Villarreal believes that, based on the foregoing, if not committed, appellant would

endanger herself. See TEX. HEALTH & SAFETY CODE ANN. § 574.035(a)(2)(A); T.M., 362

S.W.3d at 852.

       C.O. expressed concern that if released from the mental health center appellant

would stop taking her medications. C.O. testified that appellant has threatened to bomb

the Pentagon, C.O.’s family home, and other places, some at the request of Jesus; has

sought C.O.’s help in getting bombs; has walked in front of a tractor-trailer rig, fortunately

without any physical injuries; has sat on the side of a busy road and wandered the streets

at night; and has told C.O. that she would “ask God to send a necromancer to rape [C.O.]

to humble [her].”    C.O. testified that if released, appellant would never come back

because she would either get hurt, herself, or would hurt somebody else, albeit

unknowingly.

       Torres testified that appellant was not ready to be discharged from the Center

because she posed a danger to herself. According to Torres, although appellant had

been making “some pretty good decisions about her future,” recently “she was definitely

going back, backsliding.” Torres based this opinion, in part, on a message that appellant

left him regarding his offer to help with her resume and her job search. Appellant’s
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message stated “[Torres] needed to help her or she was going to tell Jesus to punish

[him].” He also explained that appellant talked about fasting again, which “always leads

to her putting her health at risk,” to the point of starvation. He, too, testified that appellant

had threatened to bomb a shrine and kill the Pope and had tried to buy bombs.

       Finally, while appellant testified that she would not hurt herself, she also testified

that at times she would refuse to take her medication because of allergies or side effects

not understood by the doctors who prescribed them. Appellant testified that she would

fast as a cleansing ritual because Jesus told her to do so. She spoke of the spirit of a

child and the spirit of her mother who haunted her. And appellant confirmed that Jesus

directed her to bomb a shrine.

       Based on the above, we conclude that the State produced clear and convincing

evidence to support its request for temporary commitment. The evidence was such that

it could produce in the mind of the trier of fact a firm belief or conviction that appellant was

mentally ill and, as a result of her illness, was likely to cause serious harm to herself.

See In re C.H., 89 S.W.3d at 25; Addington, 588 S.W.2d at 570; see also TEX. HEALTH &

SAFETY CODE ANN. § 574.035(a)(1), (2)(A). The evidence includes expert testimony and

evidence of recent overt acts through Torres’s testimony and of a continuing pattern of

behavior through the testimony of all witnesses that tends to confirm the likelihood of

serious harm to herself. See TEX. HEALTH & SAFETY CODE ANN. § 574.035(e); see G.H.

v. State, 94 S.W.3d 115, 117 (Tex. App.—Houston [14th Dist.] 2002, no pet.) (“Texas law

does not require relatives or physicians of the mentally ill (or the courts) to stand idly by

until serious harm occurs. . . . The purpose of temporary commitment is to avoid just

such harm.”). In this case, we conclude there is sufficient evidence, from both expert
                                               11
and lay testimony, that appellant is likely to cause serious harm to herself.

       2.   Suffering Distress and Deterioration

       Although the evidence need only establish one of the three grounds for

commitment, see T.G., 7 S.W.3d at 251, we nonetheless further conclude that the clear

and convincing evidence was such that it could produce in the mind of the trier of fact a

firm belief or conviction that appellant was mentally ill and, as a result of her illness, was

suffering mental, emotional, or physical distress and the deterioration of the her ability to

function. See In re C.H., 89 S.W.3d at 25; Addington, 588 S.W.2d at 570; see also TEX.

HEALTH & SAFETY CODE ANN. § 574.035(a)(1), (2)(C). The testimony discussed above,

which included pattern-of-behavior testimony—for example, appellant’s refusal to take

prescribed medications, her refusal to eat to the point of starvation, and placing herself in

dangerous situations because of her conviction that she had divine protection—tends to

confirm the likelihood that she is suffering distress and deterioration of her ability to

function. See TEX. HEALTH & SAFETY CODE ANN. § 574.035(e); In re C.O., 65 S.W.3d at

181.

C. Summary

       Because the evidence was legally sufficient to support the findings and the trial

court's judgment ordering appellant’s commitment, we overrule appellant's sole issue.

                                      V. CONCLUSION

       We affirm the judgment of the trial court.

                                                                 NELDA V. RODRIGUEZ
                                                                 Justice

Delivered and filed the 30th
day of October, 2014.
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