AFFIRM; and Opinion Filed December 19, 2014.




                                          S   In The
                                Court of Appeals
                         Fifth District of Texas at Dallas
                                       No. 05-14-01242-CV
                                       No. 05-14-01314-CV


                             THE STATE OF TEXAS
                 FOR THE BEST INTEREST AND PROTECTION OF T.T.


                          On Appeal from the Probate Court No. 3
                                   Dallas County, Texas
                  Trial Court Cause Nos. M.I.-14-70647 and MED-14-80400

                              MEMORANDUM OPINION
                         Before Justices Bridges, Lang-Miers, and Myers
                                 Opinion by Justice Lang-Miers
       T.T. appeals from a judgment of commitment for temporary inpatient mental health

services (No. 05-14-01242-CV) and an order to administer psychoactive medications (No. 05-

14-01314-CV). In the involuntary commitment case, T.T. asserts that the evidence is legally

insufficient to support the trial court’s findings that as a result of mental illness: (1) T.T. was

likely to cause serious harm to himself; (2) T.T. was likely to cause serious harm to others; and

(3) T.T. is deteriorating in his ability to function independently. In the medication case, T.T.

contends that the evidence is legally insufficient to show that the criteria were established for the

administration of psychoactive medications. For the following reasons, we resolve T.T.’s issues

against him and affirm the trial court’s judgment of involuntary commitment and order to

administer psychoactive medications.
                                          BACKGROUND

         On August 31, 2014, a Dallas police officer responded to a disturbance at the Greyhound

bus station where it was reported that T.T. had threatened to have the security officer at

Greyhound killed. The police officer reported that T.T. claimed to work with the Defense

Department and the Central Intelligence Agency, has “top clearance,” and was a “chief

magistrate.”    The police officer stated that based on what he was told or observed, T.T.

evidenced “a substantial risk of serious harm to himself . . . or others[.]” The police transported

T.T. to Green Oaks Hospital for admission for inpatient mental health services on an emergency

basis.

         The State of Texas filed an application for temporary court-ordered mental health

services on the grounds that T.T. is mentally ill and as a result of the mental illness is likely to

cause serious harm to himself or others, or is deteriorating in his ability to function

independently. On September 1, 2014, the court ordered T.T. into the protective custody of the

Department of Veterans Affairs Medical Center pending a hearing on the State’s application, and

T.T. was transferred from Green Oaks to the VA Medical Center.

         At the hearing on the State’s application for involuntary commitment, the court heard the

expert medical testimony of Dr. Monte L. Goen of the VA Medical Center and considered the

Physician’s Certificates of Medical Examination for Mental Illness of Dr. Goen and Dr. Roger

Butler, a psychiatrist at Green Oaks Hospital. T.T. also testified. At the conclusion of the

hearing, the court granted the state’s application and ordered T.T. involuntarily committed. The

court signed a judgment in which it found that T.T. is mentally ill and that as a result of the

mental illness was likely to cause serious harm to himself or others, was deteriorating in his

ability to function independently, and was unable to make a rational and informed decision about




                                                –2–
whether to submit to treatment. The court also ordered the administration of psychoactive

medications.

        In issues one, two, and three, T.T. argues, respectively, that the evidence is legally

insufficient to support the court’s findings that T.T. is a danger to himself, to others, and is

deteriorating in his ability to function independently. In issue four, T.T. argues that the evidence

is legally insufficient to support the court’s finding that the criteria were established for the

administration of psychoactive medications.

                                       STANDARD OF REVIEW

        The standard of review is the same for both a commitment judgment and an order to

administer psychoactive medications. State ex rel. D.W., 359 S.W.3d 383, 385 (Tex. App.—

Dallas 2012, no pet.). We apply a heightened standard of review in determining whether the

State satisfied its burden. Id. The trial court must find that the statutory criteria were established

by clear and convincing evidence. Id. Clear and convincing evidence is “that measure or 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). In our review, we examine all the evidence in the light most favorable to the

finding to determine whether a reasonable factfinder could have formed a firm belief or

conviction that the finding was true. D.W., 359 S.W.3d at 385.

                             ORDER OF INVOLUNTARY COMMITMENT

        A court may order a proposed patient to receive temporary inpatient mental health

services if the court finds by clear and convincing evidence that the proposed patient is mentally

ill and that as a result of the mental illness, the proposed patient:

                (A) is likely to cause serious harm to himself;

                (B) is likely to cause serious harm to others; or


                                                  –3–
               (C) is:

                         (i) suffering severe and abnormal mental, emotional, or physical
       distress;

                     (ii) experiencing substantial mental or physical deterioration of the
       proposed patient’s ability to function independently, which is exhibited by the
       proposed patient’s inability, except for reasons of indigence, to provide for the
       proposed patient’s basic needs, including food, clothing, health, or safety; and

                      (iii) unable to make a rational and informed decision as to whether
       or not to submit to treatment.

TEX. HEALTH & SAFETY CODE ANN. § 574.034(a) (West Supp. 2014). To constitute clear and

convincing evidence, expert testimony is required and there must be evidence of a recent overt

act or a continuing pattern of behavior that tends to confirm:

               (1) the likelihood of serious harm to the proposed patient or others; or

               (2) the proposed patient’s distress and the deterioration of the proposed
       patient’s ability to function.

Id. § 574.034(d).

       Evidence of a recent overt act or continuing pattern of behavior must relate to the criteria

on which the judgment was based. State ex rel. N.H., No. 05-14-00660-CV, 2014 WL 4724708,

at *2 (Tex. App.—Dallas Sept. 24, 2014, no pet.) (mem. op.). And the expert’s opinions and

recommendations must be supported by a showing of the factual bases on which they are

grounded. State ex rel. T.M., 362 S.W.3d 850, 852 (Tex. App.—Dallas 2012, no pet.).

       Here, the court found that the commitment was justified under all three criteria listed in

section 574.034(a). T.T. contends that the evidence is legally insufficient to support those

findings.

       At the commitment hearing, the court considered Dr. Goen’s and Dr. Butler’s written

evaluations of T.T. Dr. Butler diagnosed T.T. with “psychosis NOS” and Dr. Goen diagnosed

T.T. with paranoid schizophrenia and hypertension. Both agreed that due to T.T.’s delusions and

psychosis, he is unable to provide for his basic needs, care for his medical conditions, or make
                                                –4–
decisions about whether to submit to treatment. Dr. Goen also reported that T.T. “threatens to

harm people even with threats of death,” claims to have authority “to order the executions of

anyone in my way[,]” and claims to be the adopted son of President and Nancy Reagan. Dr.

Goen also reported that T.T. does not sleep and takes “showers, paces & disrupts unit every

day[.]” Dr. Goen asked the court for an order to administer psychoactive medications, stating

that T.T. has a long history of untreated mental illness, has “zero insight,” and that “supportive

therapy” has not worked.

       Dr. Butler reported that while T.T. was in Green Oaks, he was “talking to his

armband/watch and saying ‘take them out now.’” He also stated that T.T. claimed to be “the

45th president of the United States, T– R– T– Reagan,” was “about to get flying privileges and

. . . am going to Washington D.C. to meet with the Pentagon,” and claimed to be “the one who

will bring peace to the Palestinian-Israeli conflict.”

       In addition to his written evaluation, Dr. Goen testified at the commitment hearing. He

gave a history of T.T.’s hospitalizations and stated that T.T. claimed to have sustained a spinal

cord injury, claimed to be a quadriplegic, couldn’t talk, and was blind. But he said T.T. refused

all medical scans and “showed zero evidence of being paralyzed of all four limbs, [and] zero

evidence of being blind.” Dr. Goen said all efforts to treat T.T. as an outpatient have been

unsuccessful, and he has had “zero follow-up” at the VA Medical Center because T.T. refuses

treatment. He also said T.T. has no family to care for him because of his refusal to get treatment

for his mental illness. Dr. Goen testified that treatment in a structured psychiatric hospital is the

least restrictive approach that will benefit T.T. at this point. But when Dr. Goen has talked to

T.T. about that, T.T. has “threaten[ed] to have [Dr. Goen] handcuffed, . . . threaten[ed] [him]

with a Supreme Court injunction, . . . [and] possible execution.”




                                                 –5–
       Dr. Goen testified that T.T. believes he is a CIA agent, a secret service agent, and the

45th president of the United States. He said T.T. “has a need to go to Washington to speak with

President Obama about anti-terrorism issues. And if he doesn’t get his way, he believes he has

the authority not just to go meet with him but to execute him.” Dr. Goen said T.T. “is seen as

very, very dangerous to others.” He said T.T. “has also come to the attention of the United

States treasury department secret service and is viewed as a significant threat to the President of

the United States.” Dr. Goen said reports from the Pentagon indicated that T.T. was planning to

purchase weapons and take a bus to Washington D.C. Dr. Goen said T.T. “confirm[ed] that he

ordered [the Greyhound agent] to be executed.” He said T.T. is “viewed as a serious threat to

national security and possibly the President.” He also said the “Secret Service reported last year

[T.T.] got in the White House in a wheelchair, claiming to be a federal police officer to try to see

President Obama [and] is viewed as a serious threat among our nation’s highest security levels.”

       Dr. Goen testified that T.T.’s blood pressure, uncontrolled, is “above 200 over 110.” He

said the only time T.T.’s blood pressure is normal is after T.T. has had an “emergency injection

with psychotropic medications.” Dr. Goen testified that T.T. is “at risk for all the complications

of hypertension[.]” And he testified that T.T. is unable to make rational and informed decisions

about his treatment and is deteriorating in his ability to function independently. He testified that

if T.T. is released, “[h]e is going to have the secret service following him, possibly indefinitely

. . . [and] right now he is broke – he’s been on the streets for a while already . . . possibly try to

buy some undisclosed weapons, and he will probably get arrested or worse [t]oday, tomorrow, or

shortly in the near future, because he is viewed as a serious threat to national security and

possibly the President.”

       T.T. also testified at the commitment hearing. He said he grew up in Fort Worth and

served in the Army for almost four years. He said he was injured while serving in Beirut, “such

                                                 –6–
as a spinal cord injury as well as being legally blind.” He said he received an honorable

discharge with a “medical pending.” He said he currently receives a 100% medical disability

from the VA.

        T.T. testified that he does not have a mental illness, that he has been a model patient at

the VA Medical Center and is not disruptive, and “it’s just a big misunderstanding at this point.”

T.T. stated that he receives disability income due to post-traumatic stress disorder, but that the

medical condition does not affect him. When the State asked T.T. whether he had threatened any

of the medical staff at the VA Medical Center, T.T. said, “What you deem as a threat is not really

a threat.” He said he told the staff they did not have a right to medicate him. T.T. took issue

with much of Dr. Goen’s testimony, stating, “I don’t know where he got his facts from, but

Judge, it shouldn’t be a problem for you to contact the Fort Worth bus terminal and they can

prove that I did purchase a roundtrip bus ticket, sir.”

        When T.T. was asked why he was at a hospital earlier in the year, he replied “because

there was a brief moment that maybe somebody thought that they were – I was out in the

community and they felt that they needed to contact those particular people that they know.

Next thing I know I had to go to John Peter Smith for three days. I finally got out, and when I

got out I went back towards my normal life. . . .” He said he was not homeless and had just

rented an apartment a few months earlier. He said he was “here just enjoying this particular area

as well as planning on getting my particular personal space age flight. Judge, I was going to

catch a space age flight and go to D.C. area that’s what I thought I would do, because I do have

that particular privilege.”

        T.T. denied threatening the President of the United States. When the court asked T.T.

how he would threaten the President if he was going to, T.T. replied, “Well, sir, due to all




                                                 –7–
common sense, you do not threaten the President of the United States.” When pressed for an

answer, T.T. said “if I would disagree with him I would contact my senator or my congressman.”

       T.T. explained that the weapons referred to in earlier testimony “was to keep here. I was

going to visit Washington, but just to visit the historical sites; the museum as well as all the other

historical buildings and sites in the D.C. area.” He said he had a ticket for the Greyhound bus

from Fort Worth to Dallas and back. He said he had a “run-in with security” at the bus station,

but explained that “security made a serious error.” When asked whether he told anyone he was

the 45th president of the United States, T.T. said, “Well in the fake terms it was kind of like, it’s

was [sic] a misunderstanding. Since they say they know me and I know they was kind of afraid

of me, I was actually playing with him.”

       T.T. said if the trial court released him, he might go back to his apartment and referred to

it as a “navy gateway.” He said the security there apologized to him and said they made a

mistake because “they were not aware that [his] security status was still valid.”

       Based on the entire record, we conclude that a reasonable factfinder could form a firm

belief or conviction that T.T. is mentally ill and that as a result of the mental illness, as

confirmed by his recent threats and continuing pattern of behavior, there is likelihood of serious

harm to himself or others and T.T. is deteriorating in his ability to function independently.

Accordingly, we conclude that the evidence is legally sufficient to support the trial court’s

judgment of involuntary commitment and resolve issues one, two, and three against T.T.

                     ORDER TO ADMINISTER PSYCHOACTIVE MEDICATIONS

       A court may order the administration of one or more classes of psychoactive medications

to a patient who is under a court order to receive inpatient mental health services. TEX. HEALTH

& SAFETY CODE ANN. § 574.106(a)(1) (West 2010). The court may issue an order if it finds by

clear and convincing evidence that the patient lacks the capacity to make a decision regarding the

                                                 –8–
administration of the proposed medications, and treatment with the proposed medications is in

the best interest of the patient. Id. In making its determination that treatment with the proposed

medications is in the best interest of the patient, the trial court must consider

       (1) the patient’s expressed preferences regarding treatment with psychoactive
       medication;

       (2) the patient’s religious beliefs;

       (3) the risks and benefits, from the perspective of the patient, of taking
       psychoactive medication;

       (4) the consequences to the patient if the psychoactive medication is not
       administered;

       (5) the prognosis for the patient if the patient is treated with psychoactive
       medication;

       (6) alternative, less intrusive treatments that are likely to produce the same results
       as treatment with psychoactive medication; and

       (7) less intrusive treatments likely to secure the patient’s agreement to take the
       psychoactive medication.

Id. § 574.106(b).

       At the medication hearing, Dr. Goen asked for an order to administer four types of

psychoactive medications: antidepressants, antipsychotics, sedatives, and mood stabilizers. Dr.

Goen explained that he would “hold [antidepressants] in reserve” and administer only if T.T.

“continues to have severe insomnia . . . or possibly becomes depressed[.]” With regard to

antipsychotics, Dr. Goen testified that T.T. has never been diagnosed with PTSD, there is no

indication T.T. has ever been paralyzed, and T.T. “has a present record of disruptive and

assaultive behavior[.]” Dr. Goen said T.T. had received seven rounds of emergency injections of

antipsychotics and “there has been a significant improvement, improved sleep, improved reality

testing.” Dr. Goen also testified that T.T. needs a mood stabilizer because of his “grandiose

delusions” including that he is the Reagans’ adopted son, a naval criminal investigations security

agent, a secret service agent, a federal police officer with authority to order others with
                                                 –9–
disabilities executed, and the 45th president of the United States. The doctor said a mood

stabilizer would help control T.T.’s “explosive behaviors . . . some of his grandiose delusions

and . . . shorten his hospital stay.” Dr. Goen also testified that T.T. could benefit from sedatives

because T.T. “gets extremely agitated, disruptive, and threatens to put me in handcuffs or

worse.” Dr. Goen testified that sedatives will help calm T.T. down, improve his sleep, and

shorten his hospital stay.

       In addition to the benefits of each type of medication, Dr. Goen testified about the side

effects of each, but said the benefits of all the requested medications outweigh any risks to T.T.

He also said the medical staff would monitor T.T. very closely and adjust the medications as

necessary. Dr. Goen testified that T.T.’s prognosis without the medications is “[h]orrible.” But

with the medications, T.T. could have improved sleep and reality testing, hopefully improved

insight and improvement in his medical conditions, and his long-term outlook was “good.”

       Dr. Goen said there was no viable alternative to inpatient administration of the

medications because of T.T.’s refusal to submit to treatment on an outpatient basis. Dr. Goen

testified that T.T. is unable to make a decision about the administration of medications because

“he has zero insight about his mental illness and that severely impacts his ability to understand

treatment options.” He said T.T. “is very intelligent” and in his experience, “the more intelligent

a person is, especially with schizophrenia, the worse their insight is.”

       T.T. did not testify through question and answer at the medication hearing, but asked his

attorney to advise the trial court that he was opposed to taking medications because he is Jewish.

T.T. also made a statement to the court that his purchase of a bus ticket, spinal cord injury, and

blindness were all matters of record that the court could verify.

       Having reviewed the entire record and the factors the trial court must consider in making

its decision, we conclude that the court could have formed a firm belief or conviction that T.T.

                                                –10–
lacked the capacity to make a decision about the administration of the proposed medications, and

treatment with the proposed medications was in T.T.’s best interest. We conclude that the

evidence is legally sufficient to support the court’s findings and resolve issue four against T.T.

                                           CONCLUSION

       We affirm the trial court’s judgment of involuntary commitment and order to administer

psychoactive medications.




                                                    /Elizabeth Lang-Miers/
                                                    ELIZABETH LANG-MIERS
                                                    JUSTICE

141242F.P05




                                               –11–
                                         S
                               Court of Appeals
                        Fifth District of Texas at Dallas
                                       JUDGMENT

THE STATE OF TEXAS FOR THE BEST                      On Appeal from the Probate Court No. 3,
INTEREST AND PROTECTION OF T.T.                      Dallas County, Texas
                                                     Trial Court Cause No. M.I.-14-70647.
No. 05-14-01242-CV                                   Opinion delivered by Justice Lang-Miers,
                                                     Justices Bridges and Myers participating.


     In accordance with this Court’s opinion of this date, the judgment of the trial court is
AFFIRMED.


Judgment entered this 19th day of December, 2014.




                                              –12–
                                         S
                               Court of Appeals
                        Fifth District of Texas at Dallas
                                       JUDGMENT

THE STATE OF TEXAS FOR THE BEST                      On Appeal from the Probate Court No. 3,
INTEREST AND PROTECTION OF T.T.                      Dallas County, Texas
                                                     Trial Court Cause No. MED-14-80400.
No. 05-14-01314-CV                                   Opinion delivered by Justice Lang-Miers,
                                                     Justices Bridges and Myers participating.


     In accordance with this Court’s opinion of this date, the judgment of the trial court is
AFFIRMED.


Judgment entered this 19th day of December, 2014.




                                              –13–
