Opinion
24A-MH-725
12-06-2024
In re: the Civil Commitment of: R.R., Appellant-Respondent v. Richard L. Roudebush Veterans Affairs Medical Center, Appellee-Petitioner
ATTORNEY FOR APPELLANT MATTHEW D. ANGLEMEYER MARION COUNTY PUBLIC DEFENDER APPELLATE DIVISION INDIANAPOLIS, INDIANA ATTORNEY FOR APPELLEE PREANDRA LANDRUM VETERANS ADMINISTRATION INDIANAPOLIS, INDIANA
Pursuant to Ind. Appellate Rule 65(D), this Memorandum Decision is not binding precedent for any court and may be cited only for persuasive value or to establish res judicata, collateral estoppel, or law of the case.
Appeal from the Marion Superior Court The Honorable David Certo, Judge Trial Court Cause No. 49D08-2402-MH-6584
ATTORNEY FOR APPELLANT MATTHEW D. ANGLEMEYER MARION COUNTY PUBLIC DEFENDER APPELLATE DIVISION INDIANAPOLIS, INDIANA
ATTORNEY FOR APPELLEE PREANDRA LANDRUM VETERANS ADMINISTRATION INDIANAPOLIS, INDIANA
MEMORANDUM DECISION
May, Judge
[¶1] The trial court ordered R.R. committed to the Richard L. Roudebush Veterans Affairs Medical Center (hereinafter "the VA") in Indianapolis. R.R. raises two issues on appeal, which we restate as:
1. Whether the VA demonstrated R.R. is gravely disabled; and
2. Whether the VA demonstrated that commitment was appropriate.
We affirm.
We remind counsel for both R.R. and the VA that the Statement of Facts required in an Appellate Brief "shall be in narrative form and shall not be a witness by witness summary of the testimony." Ind. Rule of Appellate Procedure 46(A)(6)(c) (emphasis added). Counsels' failure to abide by this rule impeded our review of this matter and we thus admonish each of them to provide an appropriate Statement of Facts in any future appellate briefs.
[¶2] R.R. is a fifty-seven-year-old army veteran who has been diagnosed with "schizo-affective disorder bipolar type." (Tr. Vol. 2 at 15.) On January 26, 2024, R.R. was admitted to the psychiatric unit of the VA after being brought to the hospital by police. At that time, "her thought process was very difficult to follow[.]" (Id. at 13.) R.R. displayed three symptoms of psychosis: (1) "disorganized behavior" exemplified by following a doctor into a public area of the hospital while she was naked, (id. at 15); (2) "disorganized thought processes" presented as being unable to sleep and having concern that her medications were being altered, (id.); and (3) "hallucinations" that she acknowledged to staff. (Id.) R.R. also exhibited at least three symptoms of mania: rapid speech that jumps from one topic to another, decreased need for sleep, and racing thoughts. The combination of psychosis and mania is what led to R.R.'s diagnosis. R.R. left the VA on February 8, 2024.
The record suggests police brought R.R. to the VA from a nursing home where she was not a resident, but the record does not provide additional details about the circumstances that brought R.R. into contact with police at that location.
[¶3] After R.R. left the VA, she went to her aunt's house, but her aunt would not let her in the house, so R.R. sat outside to see if her cousin would arrive to let her into the house. R.R. then went to her own apartment, but she could not find her keys, so she contacted maintenance to open her apartment for her. At that time, R.R. had no access to her money because the bank had placed a lock on her bank card.
[¶4] While in the VA in early February, R.R. had failed to pay her February rent. When R.R. went to the landlord's office after her release from the VA, staff asked when she would pay her rent. R.R. argued with staff and, as she left the office, told them to evict her. R.R.'s cousin helped R.R. remove the lock from her bank card so that R.R. could access money. R.R. went shopping and gave money to some homeless people, but she evidently did not pay her rent because, on February 13, 2024, R.R.'s landlord filed an eviction action against R.R.
[¶5] On February 14, 2024, R.R. went to Eskenazi Hospital because she wanted to visit a surgeon's office to reschedule a knee surgery that had been cancelled. She visited the surgeon's office and then went outside to smoke. R.R. "had made the appointment, but they took me out of the computer because I went outside to smoke. So, I was going back there to go to the second floor to make sure the doctors know I'm back trying to get this surgery, I do have Medicare." (Id. at 45.) Transportation home from Eskenazi was unavailable so R.R. "took a cab from Eskenazi to VA" and paid "ten dollars cash to go across the street." (Id. at 43.) R.R. arrived at the VA to obtain transportation but, for reasons undisclosed in the record before us, ended up in the psychiatric unit.
[¶6] After arriving at the VA's psychiatric unit on February 14, 2024, R.R. had rapid speech and met the "criteria for a manic episode." (Id. at 17.) Based on R.R.'s report of what had been happening after she left the VA on February 8, 2024, the VA filed paperwork requesting emergency detention because R.R. was gravely disabled due to her mental illness. That paperwork explained:
On assessment patient was unable to describe how she planned to care for her basic needs. She was able to provide superficial plans to contact people to find lodging, however, in the event she was unable to contact them she planned to sleep outside because [she] believed she would not die, even in the event of extreme weather. Was unable to provide plans to feed herself. She also reports using the bathroom outside. For those reasons I believe the patient's unable to provide for her essential needs + has impaired Judgment due to psychiatric disorder. Additionally patient reports sleeping outside recently + she also reported in the event of a life threatening injury she would do nothing[.](Appellant's App. Vol. 2 at 14) (errors in original). The trial court granted the petition for emergency detention on February 15, 2024.
[¶7] On February 21, 2024, the VA filed a Petition for Involuntary Commitment that requested the court order a regular commitment for R.R. because she was gravely disabled and unable to "provide for her food, clothing, shelter, or other essential human needs." (Id. at 19.) The Petition noted specifically: "Veteran lost her apartment keys and debit card and then demanded her landlord to evict her. She also does not attend to her hygiene and is noted to have her hospital gown unbuttoned." (Id.) The physician's statement attached to the petition indicated R.R. "exhibits disorganization of her thought processes to the point that she cannot maintain shelter or her basic personal hygiene. She is also unable to participate in meaningful discussions about her mental health and is refusing psychiatric medications." (Id. at 21.)
[¶8] On February 27, 2024, the court held a hearing on the Petition for Involuntary Commitment at which R.R. appeared with counsel. The VA presented testimony from Dr. Caleb Nissen, who was a resident psychiatrist at the VA and treated R.R. during her two stays at the VA in 2024. Dr. Nissen explained that VA records indicated R.R. was diagnosed with schizo-affective disorder in 2008 and she also was hospitalized on a temporary commitment in July 2023. During the nearly two weeks that R.R. had been at the VA before the hearing, she had taken only "about half" of her oral anti-psychotic medications, but she had accepted two doses of a "long-acting anti-psychotic injection." (Tr. Vol. 2 at 21.) Dr. Nissen noted R.R.'s symptoms of mania and psychosis had improved "mildly" (id.) - "her speech is um, a little less rapid, she's a little more re-directable like I mentioned, and you know her features of psychosis have also been improving." (Id.) Nevertheless, R.R. continued to experience disorganized thoughts and paranoia.
[¶9] Dr. Nissen was concerned that, while R.R. could engage in discharge planning, "her current state of mania has not improved enough to the point where we would have a different result than occurred upon her last discharge." (Id. at 22.) Dr. Nissen did not believe R.R. would be compliant with her medication if released from the VA, because she had not been compliant in the past. Nor did he believe R.R. would be able to manage her finances, maintain shelter, or participate in follow-up care - due specifically to the "disorganized thought process that she's been experiencing[,]" (id. at 24), and the "limited insight" that she has about her diagnosis. (Id. at 26.) Dr. Nissen believed R.R. was gravely disabled and unable to function independently because "she has this disorganization of her thought process which makes it difficult for her to problem solve, to maintain shelter and to manage her finances." (Id.) Dr. Nissen also testified he believed a temporary commitment would be insufficient because of R.R.'s "intermittent adherence with medication while being hospitalized as well has her prior need for a temporary commitment during which she was stabilized and then subsequently um decompensated after that commitment fell off." (Id. at 28.)
[¶10] R.R. also took the stand and testified. At the end of the hearing, the trial court explained:
Today, [R.R.] has done her best and I believe has tried to testify honestly and as a result the court has received from her testimony that is disorganized, irrelevant, tangential. Today [R.R.] has blurted out a variety of things that are clearly not in her interest if she's trying to demonstrate she is not disorganized or mentally ill or incapable of putting a plan into effect. Including her volunteering mental health services at a variety of different facilities without a coherent plan. Her testimony concerning her past suicide attempt and today trying to negotiate what good mental health treatment might look like including insisting she wants Eskenazi Health to assume her mental health treatment and with dosage that worked for her in 2008 which our record should reflect is approximately fifteen years ago even though she and her attorney have just discussed how people change over time and have to respond to it by adjusting treatments sometimes. Today, [defense counsel] worked so hard to assist [R.R.] in testifying but asking three times what the court might take as evidence that [R.R.] is willing to take her medications as prescribed has been unavailing in receiving any assurances from [R.R.] that she will comply with mental health treatment. Instead, again [R.R.] has demonstrated that she either doesn't have the insight or is unwilling to put into practice a plan that might keep her safe. Her disorganized thought is reflected in her inability to remain housed, to have her car impounded, to lose access to her finances, and during the time between the two most recent mental health incidents where she was hospitalized, she was unable to pay her rent. Her accounts today are bizarre and difficult to follow, and it gives me no pleasure to say these things, but our record reflects them and it's my responsibility to summarize what appears in our record. It is clear and convincing that [R.R.] continues to suffer from a chronic mental illness, schizo-affective disorder bipolar, and it gives me no pleasure to note that for our record .... But ma'am it doesn't [get] easier if you fail to follow through with what the mental health treatment professionals lay out for you as a treatment plan for your care and safety. There is no evil in having a mental health illness, the
disservice ma'am, is if you fail to take the treatment that you've earned especially through the VA.
Because ma'am it is clear and convincing based on the evidence today that you are currently gravely disabled and unable to care for yourself, lacking in judgement and insight to keep yourself safe, I'll order a regular commitment. That means ma'am, not that you have to stay at the hospital for a year but that the court will be a partner in your treatment.(Id. at 63-5.) R.R. interrupted the court twice during the court's pronouncement.
[¶11] The trial court entered a written order that found:
1. [R.R.] is suffering from a Psychiatric Disorder which is a mental illness as defined in IC 12-7-2-130.
2. [R.R.] is . . . gravely disabled as defined in IC 12-7-2-96.
3. [R.R.] is gravely disabled and in need of continuing custody, care and treatment at [the VA] for a period of time expected to exceed ninety (90) days."
4. Placement is determined to be the least restrictive environment suitable for treatment and stabilization as well as protecting [R.R.] while restricting [R.R.'s] liberty to the least degree possible.
5. That the treatment plan for [R.R.] has been fully evaluated, including alternate forms, and is believed to result in benefiting [R.R.] while outweighing any risk of harm.(Appellant's App. Vol. 2 at 10.) Based thereon, the court ordered a regular commitment. Below the signature line, the court added the following additional explanation:
[R.R.] remains gravely disabled in her judgment and reasoning and incapable of housing herself, accessing her money, and executing a plan for mental health treatment, as demonstrated between her two most recent hospitalizations for mental health crisis in the last 30 days. Today she is profoundly disorganized and unable to answer questions clearly about her treatment, even with assistance of Counsel.(Id. at 11.)
Discussion and Decision
[¶12] Civil commitment proceedings have two purposes - to protect the public and the rights of the person for whom involuntary commitment is sought. In re Civil Commitment of T.K., 27 N.E.3d 271, 273 (Ind. 2015). "The liberty interest at stake in a civil commitment proceeding goes beyond a loss of one's physical freedom," id., because commitment is accompanied by "serious stigma and adverse social consequences[.]" Id. Accordingly, proceedings for civil commitment are subject to the requirements of the Due Process Clause. Id. (citing Addington v. Texas, 441 U.S. 418, 425-26 (1979)).
[¶13] To comport with due process requirements, a person may not be committed without clear and convincing evidence in support thereof. Id. When we review a determination made under that clear and convincing standard, we affirm "if, 'considering only the probative evidence and the reasonable inferences supporting it, without weighing evidence or assessing witness credibility, a reasonable trier of fact could find [the necessary elements] proven by clear and convincing evidence.'" Id. (quoting Bud Wolf Chevrolet, Inc. v. Robertson, 519 N.E.2d 135, 137 (Ind. 1988)). "Clear and convincing evidence requires proof that the existence of a fact is highly probable." Matter of Commitment of C.N., 116 N.E.3d 544, 547 (Ind.Ct.App. 2019) (citation and internal quotation marks omitted).
[¶14] To have a person committed, a petitioner - here, the VA - must prove by clear and convincing evidence that:
(1) the individual is mentally ill and either dangerous or gravely disabled; and
(2) detention or commitment of that individual is appropriate.Ind. Code § 12-26-2-5(e) (emphasis added). R.R. challenges whether the VA provided sufficient evidence to prove either of these prongs.
1. Gravely Disabled
[¶15] The first prong of Indiana Code section 12-26-2-5(e) required the VA to demonstrate by clear and convincing evidence that R.R. "is mentally ill and either dangerous or gravely disabled[.]" R.R. acknowledges that she is mentally ill. (Appellant's Br. at 13) ("R.R. is mentally ill."). The VA did not allege that R.R. was a danger to herself or others, and the trial court accordingly made no finding thereof. Rather, the VA alleged R.R. is "gravely disabled." (Appellant's App. Vol. 2 at 19.) The trial court found R.R. is gravely disabled, and R.R. argues the VA did not prove that fact by clear and convincing evidence.
In this context, "mentally ill" has been defined as: "a psychiatric disorder that: (A) substantially disturbs an individual's thinking, feeling, or behavior; and (B) impairs the individual's ability to function." Ind. Code § 12-7-2-130. Dr. Nissen diagnosed R.R. as having "schizo-affective disorder bipolar type." (Tr. Vol. 2 at 15.)
Because Section 12-26-2-5(e) is written in the disjunctive, a petitioner needs to prove the respondent is "either dangerous or gravely disabled." Ind. Code § 12-26-2-5(e) (emphasis added); see also In re: the Civil Commitment of C.M., 191 N.E.3d 278, 280 (Ind.Ct.App. 2022) (Hospital "need only prove that C.M. was either dangerous or gravely disabled.").
[¶16] Our legislature defined "gravely disabled" as
a condition in which an individual, as a result of mental illness, is in danger of coming to harm because the individual:
(1) is unable to provide for that individual's food, clothing, shelter, or other essential human needs; or
(2) has a substantial impairment or an obvious deterioration of that individual's judgment, reasoning, or behavior that results in the individual's inability to function independently.Ind. Code § 12-7-2-96 (emphasis added). Because the definition of gravely disabled is written in the disjunctive, the evidence needs to support only one of those two prongs for a person to be found gravely disabled. See A.L. v Wishard Health Servs., 934 N.E.2d 755, 760 (Ind.Ct.App. 2010) ("When Indiana Code section 12-7-2-96(2) is at issue, the trial court need not find that the person in question is incapable of providing himself or herself with food or clothing[.]"), trans. denied.
[¶17] The trial court did not enter a finding exclusively implicating either of those prongs in its written order. Instead, the court indicated:
[R.R.] remains gravely disabled in her judgment and reasoning and incapable of housing herself, accessing her money, and executing a plan for mental health treatment, as demonstrated between her two most recent hospitalizations for mental health crisis in the last 30 days. Today she is profoundly disorganized and unable to answer questions clearly about her treatment, even with assistance of Counsel.(Appellant's App. Vol. 2 at 11.)
1.1 Unable to provide for essential needs
[¶18] R.R. argues the evidence does not support this prong because Dr. Nissen testified that R.R. could shop for groceries, plan her meals, and engage in daily living activities, which "takes care of most of her human needs." (Appellant's Br. at 17.) While Dr. Nissen did testify that he believed R.R. could take care of those items, he also testified that he did not believe she would be able "to maintain shelter[.]" (Tr. Vol. 2 at 26.)
[¶19] R.R. argues "it was her earlier commitment that caused her apartment issues" rather than her mental illness. (Appellant's Br. at 17.) However, her assertion ignores the fact that, after R.R. was discharged from the VA on February 8 and her cousin helped her unlock her debit card, R.R. took cash out of her bank account, shared money with homeless people, and went shopping, but she evidently did not pay her rent because her landlord filed an eviction action on February 13. That R.R. had gone to the landlord's office on February 9, when her bank card was still locked and, according to her own testimony, argued with the staff about when she would pay the rent and taunted them to evict her only further supports a reasonable inference that R.R.'s mental illness impacts her ability to maintain shelter and, thereby, have a safe place to perform the daily living skills that she does have.
1.2 Impairment resulting in inability to function independently
[¶20] R.R. challenges the trial court's determination that her thought process at the hearing was "profoundly disorganized." (Appellant's App. Vol. 2 at 11.) R.R. claims the "majority of [her] testimony was directly responsive to the questions put to her." (Appellant's Br. at 20.) Having read the full transcript, we disagree.
[¶21] R.R.'s counsel and the VA's counsel each asked R.R. twice if she would follow the VA treatment plan if she were discharged, and R.R. never agreed that she would follow the treatment plan. R.R. provided confusing testimony, even in response to simple questions about how and why she went from Eskenazi Hospital to the VA on February 14. It is not fully clear from R.R.'s testimony whether she was able to reschedule the knee surgery, which was her initial reason for going to Eskenazi that day. Interspersed with her confusing answers, R.R. testified about topics that had no bearing on the issues before the court and clearly demonstrated the extent to which R.R.'s psychosis and mania impact her ability to function independently.
The first time she was asked how the trial court judge could be confident that she would take her medications if he denied the commitment, R.R. responded:
Um, I want my medications issued from Eskenazi where I talked to those doctors about my surgery. I feel more comfortable at Eskenazi, I've been at VA thirty something years sir and this is not the first time I've been committed, and I felt like I told the truth as best I understood it and they still want to give me this new medicine. I have a rapid heartbeat from some medication they gave me, nobody told me how important potassium was, I had to find out the hard way. I went to Eskenazi for potassium, and they mistreated me sir, in between Eskenazi and VA my paper, my things got lost, very important things, my phone, my keys, my jacket. VA is saying Eskenazi did it, not Eskenazi, Community East did it. Community East said VA did it and the reason why I went to Community East is because I had a severe episode in 2013 where I got nude and ran around a gas station. When I got there, there was nobody there, when I came out it was classic weekend so I'm stressing because my moms been dead five years, everything just went haywire. I was on my meds at the time, my medical records may say different ....(Tr. Vol. 2 at 52-53) (errors in original).
[¶22] R.R.'s schizo-affective disorder "makes it difficult for her to think clearly, [to] have goal directed activity, to plan through um and problem solve[.]" (Tr. Vol. 2 at 24.) Dr. Nissen did not believe R.R. would be able to manage her finances independently because of her "disorganized thought process" and her historical difficulty doing so. (Id. at 24.) Nor did Dr. Nissen believe R.R. could participate in follow-up care for her mental illness if she were released from the VA.
[¶23] The evidence in the record supports the trial court's determination that R.R.'s thinking was profoundly disorganized to an extent that she was gravely disabled because she was unable to function independently. See, e.g., In re Civil Commitment of W.S., 23 N.E.3d 29, 34 (Ind.Ct.App. 2014) (evidence clearly and convincingly demonstrates impaired judgment that results in an inability to function independently when patient recently began antipsychotic injections, has little insight into illness, is noncompliant with medications, becomes destabilized without medications, and has been committed many times), trans. denied.
2. Appropriateness of commitment
[¶24] R.R. challenges the trial court's determination that a regular commitment was appropriate for her. Specifically, the trial court indicated placement in the VA for a period to exceed ninety days was "the least restrictive environment suitable for treatment and stabilization as well as protecting [R.R.] while restricting [R.R.'s] liberty to the least degree possible." (Appellant's App. Vol. 2 at 10.)
[¶25] Although R.R. had accepted two injections of long-acting antipsychotics during her two week stay in the VA, her manic and psychotic symptoms had improved only "mildly[.]" (Tr. Vol. 2 at 21.) Dr. Nissen did not believe R.R. would be able to engage in follow-up care if she were released from commitment because of her disorganized thinking and her "intermittent poor adherence [to prescribed medications] and intermittent poor engagement with mental health care in the past." (Id. at 25.) R.R. had only "limited insight into her diagnosis[,]" (id. at 26), which renders her unable to "engage in meaningful conversations" about the risks and benefits of various treatment options. (Id.) Dr. Nissen believed R.R. needed continuing care in a facility and that such an environment was the least restrictive that was suitable for R.R. Dr. Nissen testified that temporary commitment would be insufficient for R.R. "due to her intermittent adherence with medication while being hospitalized as well as her prior need for a temporary commitment during which she was stabilized and then subsequently um decompensated after that commitment fell off." (Id. at 28.) This evidence in the record supports finding the regular commitment was appropriate for R.R. See, e.g., B.A. v. State, 219 N.E.3d 134, 142 (Ind.Ct.App. 2023) (holding reasonable fact-finder could determine from doctor's testimony that B.A. would not do well in a less-restrictive setting because, at time of hearing, B.A. had had only "some improvement" from psychotropic medication).
Conclusion
[¶26] Clear and convincing evidence in the record supports the trial court's determination that R.R. was in need of regular commitment because she is gravely disabled by her mental illness and a regular commitment is appropriate. We accordingly affirm the trial court's judgment.
[¶27] Affirmed.
Tavitas, J., and DeBoer, J., concur.