                                   NO. 12-19-00230-CV

                            IN THE COURT OF APPEALS

                 TWELFTH COURT OF APPEALS DISTRICT

                                      TYLER, TEXAS

 THE STATE OF TEXAS                                 §       APPEAL FROM THE

 FOR THE BEST INTEREST                              §       COUNTY COURT AT LAW

 AND PROTECTION OF S.P.                             §       CHEROKEE COUNTY, TEXAS

                                   MEMORANDUM OPINION
       S.P. appeals from an order authorizing the Texas Department of State Health Services to
administer psychoactive medication. In one issue, S.P. contends the evidence is legally and
factually insufficient to support the trial court’s finding that administering the medication is in his
best interest. We affirm.


                                           BACKGROUND
       A criminal court rendered an order subjecting S.P. to in-patient mental health services
pursuant to Chapter 46B of the Texas Code of Criminal Procedure, the statute relating to
incompetency to stand trial. The State petitioned the court for an order to administer psychoactive
medications to S.P. At the hearing, the application filed by Dr. Satyajeet Lahiri was entered into
evidence. Additionally, Dr. Lahiri and S.P. testified at the hearing. After hearing the evidence,
the court found that S.P. lacks the capacity to make a decision regarding administering medication
and that treatment with the proposed medication is in his best interest. Accordingly, the court
rendered an order authorizing the administration of psychoactive medication. S.P. appeals the trial
court’s order.


                                 BEST INTERESTS OF THE PATIENT
       In his sole issue, S.P. asserts that the evidence is legally and factually insufficient to support
the trial court’s finding that the administration of psychoactive medication is in the best interest of
the patient. He complains that the testifying physician’s testimony is largely conclusory. He also
asserts that there was no testimony that the patient received adequate information about side effects
and no testimony explaining how, or if, the symptoms to be treated would actually restore
competency.
Standard of Review
       Texas law requires that orders authorizing administration of psychoactive medication be
supported by clear and convincing evidence.            See TEX. HEALTH & SAFETY CODE ANN.
§ 574.106(a-1) (West 2017). “Clear and convincing evidence” means the measure or degree of
proof that 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). While proof must weigh heavier than merely the greater weight of the credible
evidence, there is no requirement that the evidence be unequivocal or undisputed. Id.
       In a legal sufficiency review where the burden of proof is clear and convincing evidence,
we must 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 findings were true.
In re J.F.C., 96 S.W.3d 256, 266 (Tex. 2002). When reviewing factual sufficiency, we must give
due consideration to evidence that the factfinder could reasonably have found to be clear and
convincing and then determine whether, based on the entire record, a factfinder could reasonably
form a firm conviction or belief that the allegations in the application were proven. Id. We must
consider whether disputed evidence is such that a reasonable factfinder could not have resolved
that disputed evidence in favor of its finding. Id. If, in light of the entire record, the disputed
evidence that a reasonable factfinder could not have credited in favor of the finding is so significant
that a factfinder could not reasonably have formed a firm belief or conviction, then the evidence
is factually insufficient. Id. The factfinder is the sole arbiter when assessing the credibility and
demeanor of witnesses. In re H.R.M., 209 S.W.3d 105, 109 (Tex. 2006) (per curiam).
Applicable Law
       A trial court may issue an order authorizing 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). The court may issue an order if it
finds by clear and convincing evidence after the hearing that (1) the patient lacks the capacity to
make a decision regarding the administration of the proposed medication, and (2) treatment with



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the proposed medication is in the best interest of the patient. Id. § 574.106(a-1). “Capacity” means
a patient’s ability to (1) understand the nature and consequences of a proposed treatment, including
the benefits, risks, and alternatives to the proposed treatment, and (2) make a decision whether to
undergo the proposed treatment. Id. § 574.101(1).
       In making its finding that treatment with the proposed medication is in the best interest of
the patient, the trial court shall 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).
Analysis
       Dr. Lahiri, S.P.’s treating physician, prepared an application for court ordered authorization
for the administration of psychoactive medication. He diagnosed S.P. with schizoaffective
disorder, bipolar type. S.P. refused to take the prescribed medication voluntarily. The doctor
indicated that S.P. lacks the capacity to make a decision regarding administration of psychoactive
medication because he is psychotic with an impaired sense of reality and has poor insight and poor
judgment. Dr. Lahiri stated that the medication is the proper course of treatment and, if S.P. is
treated with the psychoactive medication, his prognosis is fair, with clinical improvement and a
decrease in aggressive risk, and restoration of competency is likely. If the medication is not
administered, the consequences will be poor, with clinical deterioration and an increase in
aggressive risk, and restoration of competency would be unlikely. Dr. Lahiri determined that
medical alternatives will not be as effective as administration of psychoactive medication. He
believed that the benefits of the psychoactive medication outweigh the risks of such medication in
relation to present medical treatment and S.P.’s best interest.
       Dr. Lahiri also testified at the hearing. He affirmed the statements he made in the
application, and the application was entered into evidence. He stated that S.P. suffers from
schizoaffective disorder, bipolar type, S.P. refused medication, and he lacks the capacity to make
a decision regarding medication. S.P. is irrational in his thinking, has poor insight into his



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condition, and is psychotic. Due to illogical thinking, S.P. acted violently and has been charged
with aggravated assault with a deadly weapon and family violence assault, repeat offender. Dr.
Lahiri testified that, if S.P. is treated with the requested medication, his prognosis will be “good
and encouraging,” there will be a “resolution of his psychosis,” and it will lead to a “restoration of
competency.” He also stated that the medications will decrease the aggressive risk. Conversely,
if he is not treated with the requested medication, he will not show any improvement, and his
competency is not likely to be restored. He asserted that the requested medications are in the
proper course of treatment and in S.P.’s best interest. He explained that psychotherapy can be
considered an alternative to medication, but it is “impractical and has no defined or proven benefit
as far as restoration of competency is concerned.” Dr. Lahiri stated that the benefits of the
medication outweigh the risks, competency will be restored faster, and medication will facilitate
S.P’s communication with his attorney.
       S.P. testified, stating that he objects to taking the medication. He explained that he has
bullets in his body and is concerned that the medications might “counteract something that’s going
on” with him. He also said his religion, the “New American Standard,” forbids him from taking
“mind alternating drugs” like “hallucinogenics or psycho hallucinogenics or any type of uppers,
downers, or even alcohol.” He does not want to be “dosed up” so that he leaves the hospital in
worse condition than he is already in. He believes he is in the hospital because he is misunderstood,
and he feels like he is being railroaded. He also feels that he is being discriminated against because
he has an RFID chip implanted in his wrist. He explained that it is a radio frequency identification
device placed in his wrist in the early 1980’s by a government agency. The chip “holds equity”
and shows his social security number, bank account numbers, and “information about [his] religion
and everything.” S.P. said that the reason it is there is “self-explanatory.” He said the chip was
made by Queen Elizabeth, and Prince Harry and Prince William have the same type of chip in their
wrist. S.P. denied having a history of mental health diagnosis or treatment. He acknowledged the
charges against him but said the victim lied. He did not agree that without medications he had an
increased risk of aggression. He denied wanting to hurt himself or anyone else, and he denied
hearing voices in his head. He invited the court to x-ray his wrist to prove the chip is there.
       In his sufficiency challenge, S.P. relies on State ex rel E.G., 249 S.W.3d 728 (Tex.
App.−Tyler 2008, no pet), in which we held the evidence was insufficient to support a finding that
the proposed medications were in the patient’s best interest. There, the only evidence regarding



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the patient’s best interest was in the application. This court determined that a conclusory statement
in the application, without any testimony from a physician at the hearing, could not support the
order for administration of psychoactive medication. Id. at 731-32.
       S.P. argues that the testimony provided at the hearing regarding the patient’s best interest
is no less conclusory than the assertion in the application, and therefore is insufficient. In support
of this argument, S.P. cites to State ex rel B.D., No. 12-17-00174-CV, 2017 WL 4161297 (Tex.
App.−Tyler Sept. 20, 2017, no pet.) (mem. op.). In B.D., this court held the evidence insufficient
to support a finding that administration of psychoactive medication was in the patient’s best
interest. In that case, we determined that the testifying physician’s testimony regarding best
interests “was merely a perfunctory recitation of the conclusory statements made in his
application.” Id. at *3. Additionally, the testifying physician offered no testimony as to the
consequences to the patient of not administering the medications, his prognosis if the medication
is administered, or the alternatives to treatment with psychoactive medication. Id.; see also State
ex rel. G.L., No. 12-18-00201-CV, 2018 WL 6191110, at *3 (Tex. App.−Tyler Nov. 28, 2018, no
pet.) (mem. op.).
       We determine that each of these cited cases is distinguishable from the case before us. In
State ex rel E.G., there was no testimony presented at the hearing on the question of whether
treatment with the proposed medication is in the patient’s best interest. Here, Dr. Lahiri testified
in open court regarding this factor. In State ex rel B.D. and State ex rel G.L., this court held that
the testifying physician provided a perfunctory recitation of conclusory statements in the
application regarding the patient’s best interest. But we further explained that the doctor failed to
address three of the statutory items the trial judge must consider: the consequences to the patient
of not administering the medication, his prognosis if the medication is administered, and
alternatives to treatment with psychoactive medication. These topics were addressed by Dr. Lahiri
at S.P.’s hearing.
       While Dr. Lahiri did reiterate much of what was in the application, his testimony addressed
the majority of the required items listed in Section 574.106(b). He stated that, on two occasions,
S.P. said he does not need medications. Although he asked S.P. if he had any religious objections
to taking the medications, S.P. did not respond to the question. He explained that the benefits of
the medication include a decreased risk of aggressiveness, resolution of S.P.’s psychosis,
restoration of competency at a faster rate than without medication, and facilitation of



                                                  5
communication. He explained that the consequences of not taking the medication include the
absence of improvement and unlikeliness of restored competency. Conversely, S.P.’s prognosis
if treated with the medications “will be good and encouraging,” and Dr. Lahiri believes “there will
be a resolution of his psychosis and it’ll also lead to a restoration of competency.” The doctor
explained that psychotherapy is an available alternate treatment, but it is impractical and has no
proven benefit regarding restoration of competency. While mindful that unsupported conclusions
are legally insufficient to support the existence of the fact asserted, there may be a fine line between
conclusory and succinct. However, the trial court may well be able to connect the dots, based on
its knowledge of the law and brief testimony. A sufficiency finding does not necessarily require
lengthy descriptions of a patient’s symptoms or an in-depth explanation of how medications
resolve the medical problems they were designed to resolve.
        S.P. complains that there was no testimony that he received adequate information about
the side effects of the medication. The statute does not require such testimony. He also complains
there was no testimony explaining how, or if, the symptoms to be treated would actually restore
competency. Competency to stand trial requires that the individual have the present ability to
consult with his lawyer with a reasonable degree of rational understanding, and a rational and
factual understanding of the proceedings against him. See TEX. CODE CRIM. PROC. ANN. art.
46B.003(a) (West 2018). Dr. Lahiri testified that the medication would facilitate communication
between S.P. and his attorney. The judge could infer that an improved ability to communicate
could lead to competency as that term is used in the statute.
        Considering the evidence in the light most favorable to the finding, the record shows that
S.P. committed violent acts brought on by psychosis, and the psychosis would be resolved, and
competency restored, if the requested medications were administered. Further, in conducting a
legal sufficiency review, we are to assume that the trial court resolved disputed facts in favor of
its finding if a reasonable factfinder could do so and disregarded all evidence that a reasonable
factfinder could have disbelieved or found to have been incredible. In re J.F.C., 96 S.W.3d at
266. Accordingly, the trial court could have disregarded S.P.’s assertions that he did not have an
increased risk of aggression without the medications and that the medications might counteract
something in his body. Considering all the evidence in the light most favorable to the findings,
we conclude the evidence is legally sufficient for a reasonable trier of fact to have formed a firm




                                                   6
belief or conviction that the proposed medications are in S.P.’s best interest. See TEX. HEALTH &
SAFETY CODE ANN. § 574.106(b).
         In a factual sufficiency review, we consider whether a reasonable factfinder could not have
resolved disputed evidence in favor of its finding and, if there is such evidence, whether that
evidence is so significant that a factfinder could not have reasonably formed a firm belief or
conviction that administering the medication is in the patient’s best interest. See In re J.F.C., 96
S.W.3d at 266. The court was entitled to disbelieve S.P.’s theories that he was in the hospital
because he was misunderstood and being railroaded. Although S.P. objected to the medications
based on his religious beliefs, the trial court is not required to defer to the patient’s preferences on
the subject of psychoactive medication. See In re M.H., No. 02-16-00160-CV, 2016 WL 4411114,
at *5 (Tex. App.−Fort Worth Aug. 19, 2016, no pet.) (mem. op.); State ex rel D.P., No. 12-03-
00005-CV, 2003 WL 21998759, at *7 (Tex. App.−Tyler Aug. 30, 2003, no pet.) (mem. op.). The
court could have reasonably determined that the medication’s value in decreasing risk of
aggression and restoring competency outweighed S.P’s concerns.              After all, the trial court
determined that S.P. does not have the capacity to make this decision, and S.P. has not challenged
that determination. In short, there was not any disputed evidence that the trial court could not
reasonably have resolved in favor of its ruling. Accordingly, the evidence is factually sufficient
to support the trial court’s determination that administration of psychoactive medications is in
S.P.’s best interest. See In re J.F.C., 96 S.W.3d at 266. We overrule S.P.’s sole issue.


                                                  DISPOSITION
         Having overruled S.P’s sole issue, we affirm the trial court’s order authorizing the
administration of psychoactive medication.

                                                                JAMES T. WORTHEN
                                                                   Chief Justice


Opinion delivered November 27, 2019.
Panel consisted of Worthen, C.J., Hoyle, J., and Neeley, J.



                                                   (PUBLISH)




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                                  COURT OF APPEALS

      TWELFTH COURT OF APPEALS DISTRICT OF TEXAS

                                          JUDGMENT

                                       NOVEMBER 27, 2019


                                        NO. 12-19-00230-CV


                          THE STATE OF TEXAS FOR THE BEST
                          INTEREST AND PROTECTION OF S.P.


                               Appeal from the County Court at Law
                          of Cherokee County, Texas (Tr.Ct.No. 42689)

                   THIS CAUSE came to be heard on the appellate record and briefs filed herein,
and the same being considered, it is the opinion of this court that there was no error in the order
authorizing administration of psychoactive medication.
                   It is therefore ORDERED, ADJUDGED and DECREED that the order of the
court below be in all things affirmed, and that this decision be certified to the court below for
observance.
                   James T. Worthen, Justice.
                   Panel consisted of Worthen, C.J., Hoyle, J., and Neeley, J.
