RECORD IMPOUNDED
NOT FOR PUBLICATION WITHOUT THE APPROVAL OF THE APPELLATE DIVISION This opinion shall not "constitute precedent or be binding upon any court ." Although it is posted on the internet, this opinion is binding only on the parties in the case and its use in other cases is limited. R. 1:36-3.
SUPERIOR COURT OF NEW JERSEY APPELLATE DIVISION DOCKET NO. A-3230-19
IN THE MATTER OF THE CIVIL COMMITMENT OF R.H. ________________________
Argued October 18, 2021 – Decided November 15, 2021
Before Judges Vernoia and Firko.
On appeal from the Superior Court of New Jersey, Law Division, Camden County, Docket No. CACC-000468- 20.
Lorraine Gormley-Devine, Assistant Deputy Public Defender, argued the cause for appellant R.H. (Joseph E. Krakora, Public Defender, attorney; Lorraine Gormley-Devine, of counsel and on the briefs; Patrick J. Hurst, Assistant Deputy Public Defender, on the briefs).
Regina M. Philipps argued the cause for respondent Burlington County Office of the Adjuster (Madden & Madden, PA, attorneys; Regina M. Philipps and David E. Madden, on the brief).
PER CURIAM R.H.1 appeals from an April 17, 2020 order continuing her involuntary
civil commitment to the Hampton Behavioral Health Center (Hampton). Based
on our review of the record, we are convinced the court abused its discretion by
ordering the continuation of R.H.'s civil commitment. We therefore reverse.
I.
On April 8, 2020, R.H. was involuntarily committed to Hampton pursuant
to N.J.S.A. 30:4-27.10(b). Nine days later, on April 17, 2020, a municipal court
judge conducted a hearing on the Burlington County Office of the Adjuster's
(County) request for continuation of R.H.'s commitment. R.H. appeared at the
hearing with counsel. 2 The County presented the testimony of R.H.'s treating
physician, Dr. Atta-Ur Rehman, and R.H. testified on her own behalf.
Dr. Rehman explained R.H. has no history of treatment by a psychiatrist
in the community, or of prior psychiatric hospitalizations. R.H. has a family
history of schizophrenia; her father has schizophrenia.
R.H. was admitted to Hampton on April 8, 2020, because she was
"delusional, paranoid, [and] agitated," was receiving messages from her
1 We use initials to identify the appellant because records of civil commitment proceedings are excluded from public access under Rule 1:38-3(f)(2). 2 The hearing was conducted virtually. A-3230-19 2 deceased mother, and "was unable to care for herself or function." According
to Dr. Rehman, R.H. was upset with her husband because she believed he was
"trying to take the property" previously owned by her mother. Dr. Rehman
acknowledged he did not have actual knowledge whether R.H.'s claim
concerning her husband's attempt to take the property was true. Dr. Rehman
noted R.H.'s family members reported there was "a change in [R.H.'s] behavior
completely," R.H.'s father has schizophrenia, and "[t]hey all think . . . [R.H.] has
[had] a schizophrenic break."
Dr. Rehman diagnosed R.H. with "psychotic disorder not . . . specified,"
and a secondary diagnosis for cannabis abuse. 3 R.H. was prescribed Zyprexa
for the psychotic disorder. Dr. Rehman testified R.H. initially resisted taking
the medication, but started taking it a "couple of days," or perhaps "three days,"
before the April 17, 2020 hearing. Dr. Rehman further explained it was too early
to determine if the medication "reached an optimal level or dosage" because
R.H. "remain[ed] delusional and paranoid," R.H. "still believes that her husband
is manipulating everybody," and R.H. "has no place to go."
3 Dr. Rehman acknowledged R.H. used marijuana lawfully pursuant to a prescription for medical marijuana for pain management related to injuries she suffered in a disabling car accident. Dr. Rehman did not explain the nature or extent of the cannabis disorder or rely on it to support his recommendation for the continuation of R.H.'s involuntary commitment. A-3230-19 3 Dr. Rehman testified R.H. reported that "everybody is abusing her," she
is the victim of domestic violence by her husband, and she intended to "go back
to her oldest son" and live with him. Dr. Rehman further explained R.H. refused
to provide her oldest son's contact information. Dr. Rehman testified R.H. told
a nurse practitioner at Hampton "she [is] only taking medication because she
wants to be discharged." Dr. Rehman also opined R.H. could not be "treated in
a less restrictive setting."
Dr. Rehman testified R.H. would be "a danger to herself, others or
property" if she was released to a less restrictive setting. The doctor opined
R.H. "was destructive with property" at home, explaining R.H. had thrown her
husband's phone at their home. In support of this opinion, Dr. Rehman referred
to a "record indicat[ing] that [R.H.] had broken her husband's cell phone because
she was mad." Dr. Rehman agreed, however, that the reported incident
concerning the phone involved a fight between R.H. and her husband during
which R.H. threw her husband's phone but did not assault her husband in any
manner.
When asked if R.H. currently posed a danger to herself, Dr. Rehman
stated:
Because of her current delusion and paranoia[,] I think she could be because if we will discharge her[,] we
A-3230-19 4 don't know what [she would] do because [she] ha[s] no place to go, we don't know where she would go from here, and because of her psychosis.
[(Emphasis added).]
Dr. Rehman acknowledged, however, he had no information that R.H. had ever
taken any action to harm herself, or that, prior to her admission, she neglected
her need for food or shelter.
Dr. Rehman testified that when R.H. is discharged from Hampton, she will
be referred to a psychiatrist in the community who will be charged with
monitoring and prescribing R.H.'s medications. Dr. Rehman recommended the
continuation of R.H.'s involuntary commitment with a "two-week review" based
on his hope she would show improvement and a placement for her could be
located.
As noted, R.H. also testified. She admitted having difficulties in her
marriage. She denied throwing her husband's phone. She testified that during
an argument with her husband, she "tried to grab the phone." She also testified
"the phone is not broken" and her husband "still uses it."
R.H. explained she had been a nurse, but was receiving disability benefits
for lower back, shoulder, and neck injuries she suffered "through" work. She
A-3230-19 5 saw a pain management specialist for the injuries, and "recently had ablations
done on [her] back."
R.H. testified that prior to her involuntary commitment she bought food
and prepared meals for her and her husband. R.H. said she had trouble sleeping,
but she got "enough" sleep. She often tried sleeping on the couch at home and
was fearful of her husband unless her son was at home. R.H. testified she would
follow up with a psychiatrist in the community if released and would take any
medications prescribed by a psychiatrist in the community.
R.H. also testified she did not like the way the medication prescribed by
Dr. Rehman made her feel. R.H. was, however, amenable to a conditional
release requiring that she "follow up with a psychiatrist" and "take the
medication that is prescribed."
R.H. did not agree with Dr. Rehman's diagnosis that she suffered from
psychosis. She disagreed with her diagnosis of mental illness, claiming instead
she was "emotionally and physically abused by [her] husband." R.H. further
stated her husband has a history of domestic abuse and she had sought a
restraining order against her husband approximately two weeks before her
commitment. R.H.'s description of how she sought the restraining order against
her husband is vague. She testified "[she] tried going to [her] local police
A-3230-19 6 department but with [her husband] being a [local public official, she] didn't get
much help there with the police department."
R.H. also testified she filed a complaint with the "[g]rievance
[d]epartment" at Hampton alleging other patients were receiving improper
treatment. Specifically, R.H. claimed doctors at the facility did not respond to
patients' complaints regarding their prescribed medications.
R.H. testified that, if released from commitment, she would like to either
return to her marital home — if her husband was removed from the home — or
move in with her adult son. R.H. testified her adult son indicated there was a
place for her in his home.
Based on that record, the municipal court judge issued a terse oral opinion,
concluding R.H.'s involuntary commitment should be continued "with a two-
week review." The judge's findings supporting his determination consist of the
following:
[R.H.] was admitted to the facility with -- with delusions. This is her first hospitalization we're advised and there's indication of a family history in regard[] to the mental illness. Upon cross-examination it appears that at least for eight years the – [R.H.] has had some interaction with psychiatric healthcare providers. There appears to be chronic pain issues. And from her own testimony, in the course of the Worker's Comp[ensation] injury that gave rise to her disability, in her own words there has been consultation
A-3230-19 7 with those with psychiatric treatment credentials. It does appear there are in fact chronic pain issues. I can appreciate the fact that her profession was that of a nurse, it appears though that she does -- she's related what has transpired over approximately eight years, it does appear to the [c]ourt that she does not recognize that she does in fact have a mental illness. I'm further satisfied that with this non-recognition that she is a danger to self. There does appear to be, at least in her mind, indications of domestic violence. I find it most telling that she indicates that she could go live with the son and yet she has denied the medical staff access to that individual to see if there is a place for her to stay. I'm satisfied at this time until the medications reach their proper level that she cannot be freed in a less restrictive setting, accordingly [her commitment is continued] with a two[-]week review.
The judge entered an April 17, 2020 order continuing R.H.'s involuntary
commitment. R.H. appealed from the order. R.H. was released from Hampton
on April 28, 2020. The County moved to dismiss the appeal as moot, and this
court denied the motion.
II.
We first summarize the well-established legal principles that guide our
review of an order continuing an involuntary commitment following a temporary
commitment. "[T]he involuntary commitment of an individual 'is a profound
and dramatic curtailment of a person's liberty and as such requires meticulous
A-3230-19 8 adherence to statutory and constitutional criteria.'" In re Commitment of D.M.,
285 N.J. Super. 481, 486 (App. Div. 1995) (quoting Fair Oaks Hosp. v. Pocrass,
266 N.J. Super. 140, 149 (Law Div. 1993)). To continue an individual's
involuntary commitment after a temporary commitment order, a court must find
"by clear and convincing evidence presented at [a] hearing that the patient is in
need of continued involuntary commitment to treatment." R. 4:74-7(f)(1).
To establish a patient's need for continued involuntary commitment, the
State must present clear and convincing evidence that
(1) the patient is mentally ill[;] (2) mental illness causes the patient to be dangerous to self or dangerous to others or property as defined in N.J.S.A. 30:4-27.2(h) and -.2(i)[;] (3) the patient is unwilling to be admitted to a facility for voluntary care or accept appropriate treatment voluntarily[;] and (4) the patient needs outpatient treatment as defined by N.J.S.A. 30:4- 27.2(h) or inpatient care at a short-term care or psychiatric facility or special psychiatric hospital because other less restrictive alternative services are not appropriate or available to meet the patient's mental health care needs.
[R. 4:74-7(f)(1); see also N.J.S.A. 30:4-27.2(m).]
A "mental illness" under Rule 4:74-7(f)(1) is defined as "a current,
substantial disturbance of thought, mood, perception or orientation which
significantly impairs judgment, capacity to control behavior or capacity to
A-3230-19 9 recognize reality." N.J.S.A. 30:4-27.2(r). A person is deemed "[d]angerous to
self" if
by reason of mental illness the person has threatened or attempted suicide or serious bodily harm, or has behaved in such a manner as to indicate that the person is unable to satisfy his need for nourishment, essential medical care or shelter, so that it is probable that substantial bodily injury, serious physical harm or death will result within the reasonably foreseeable future.
[N.J.S.A. 30:4-27.2(h).]
Whether an individual is dangerous to self within the meaning of N.J.S.A.
30:4-27.2(h) is a legal issue requiring that the "judge . . . make specific findings
and correlate them to the legal standards" while guided by medical expert
testimony. In re Commitment of M.M., 384 N.J. Super. 313, 337-38 (App. Div.
2006) (citing In re D.M., 313 N.J. Super. 449, 454, 456 (App. Div. 1998)).
Medical labels are not determinative of the existence of a qualifying mental
illness or an individual's dangerousness; a functional analysis of the patient's
condition under "the standards plainly articulated in the relevant statutes" is
required. D.M., 313 N.J. Super. at 456. The statutory definitions require a legal
judgment guided by medical expert testimony. In re D.C., 146 N.J. 31, 59
(1996); D.M., 313 N.J. Super. at 456.
A-3230-19 10 "The evidence must permit the judge 'to come to a clear conviction [that
person is mentally ill and dangerous], without hesitancy.'" M.M., 384 N.J.
Super. at 334 (alteration in original) (quoting In re G.G.N., 372 N.J. Super. 42,
59 (App. Div. 2004)). The evidence must be "so clear, direct and weighty and
convincing as to enable [the factfinder] to come to a clear conviction, without
hesitancy, of the truth of the precise facts in issue." In re Commitment of Robert
S., 263 N.J. Super. 307, 312 (App. Div. 1992) (alteration in original) (quoting
In re Jobes, 108 N.J. 394, 407-08 (1987)).
To support an order continuing a civil commitment, a court must make
specific findings and correlate them to the legal standards. D.M., 313 N.J.
Super. at 454. The court "shall, by an opinion or memorandum decision, either
written or oral, find the facts and state its conclusions of law thereon in all
actions tried without a jury[.]" R. 1:7-4(a). The court must state the facts
forming the basis of its decision, and then weigh and evaluate those facts under
the governing law "to reach whatever conclusion may logically flow from" those
facts, Slutsky v. Slutsky, 451 N.J. Super. 332, 357 (App. Div. 2017), because
justice requires that "[a]ll conclusions must be supported." Ibid.
We review a decision continuing an individual's civil commitment for an
abuse of discretion. See D.C., 146 N.J. at 58-59. "[W]e afford deference to the
A-3230-19 11 trial court's supportable findings," In re Commitment of T.J., 401 N.J. Super.
111, 119 (App. Div. 2008), and "reverse[ ] only when there is clear error or
mistake." M.M., 384 N.J. Super. at 334. However, we "must consider the
adequacy of the evidence." Ibid.
On appeal, R.H. argues the court erred by ordering the continuation of her
involuntary commitment because the County did not present clear and
convincing evidence she posed an imminent danger to self under N.J.S.A. 30:4-
27.2(h), or a danger to others or property under N.J.S.A. 30:4-27.2(i). She also
argues the court erred by relying on her lack of insight concerning her mental
illness and need for further stabilization as a basis for its continuation order.
R.H. also claims the court erred because any issues related to R.H.'s need for
shelter could have been satisfied through release with services available in the
community. See N.J.S.A. 30:27.15(a) (requiring consideration of "the least
restrictive environment for the patient to receive clinically appropriate
treatment" in determining whether to continue an involuntary civil
commitment).
We first observe the court failed to make the requisite findings of fact
supporting its determination that continuing R.H.'s involuntary civil
A-3230-19 12 commitment was required because she was a danger to self.4 See R. 1:7-4. Other
than vaguely referring to R.H.'s history of chronic back pain, and her "family
history of mental illness," the court's findings are comprised of nothing more
than its observations that R.H. does not recognize she has a mental illness, she
appears "in her mind" to have "indications" of domestic violence, and she said
she would live with her son if released but would not give Hampton staff contact
information for her son. It was on those sparse findings alone that the court
determined R.H. was a danger to self and that she could not be released under
any set of less restrictive circumstances.
We find the court's findings inadequate. The court did not make any
credibility determinations even though R.H. denied Dr. Rehman's assertions,
based on what he was told by others, that R.H. threw her husband's phone and
R.H. conjured up the story about her husband's effort to take property that had
belonged to her mother. The court also did not make any factual findings related
to the elements necessary to support the continuation of an involuntary
commitment under N.J.S.A. 30:4-27.2(m) and R. 4:74-7(f)(1). See Curtis v.
4 The court did not find continuation of R.H.'s civil commitment was required because R.H. presented a danger to others or property under N.J.S.A. 30:4- 27.2(i). The County does not argue the court erred by not finding R.H. was a danger to others or property. It is therefore unnecessary to address R.H.'s claim the court erred by continuing her involuntary commitment on that basis. A-3230-19 13 Finneran, 83 N.J. 563, 570 (1980) (explaining a trial court must "state clearly its
factual findings and correlate them with the relevant legal conclusions").
For example, the court did not make a finding R.H. suffered from a mental
illness or identify the mental illness it determined warranted her continued civil
commitment, even though those findings are essential to a determination the
commitment should be continued. See N.J.S.A. 30:4-27.2(m) and R. 4:74-
7(f)(1). Similarly, the court did not make a finding as to causation; that is, the
court did not make findings as to whether R.H.'s mental illness caused her to be
dangerous to self. Again, such a finding is a prerequisite to the continuation of
an involuntary civil commitment under N.J.S.A. 30:4-27.2(m) and R. 4:74-
7(1)(2), because the County is required to prove such causation by clear and
convincing evidence to justify the continued involuntary commitment of a
patient. R. 4:74-7(f)(1).
The lack of requisite findings did not end there. The court did not make
any findings supporting its determination R.H. posed a danger to self, other than
its oblique, conclusory determination that her "non-recognition of her mental
illness" satisfied the court "she is a danger to self." The court added that there
"appears" to be "at least in [R.H.'s] mind, indications of domestic violence" but
the court does not make any findings as to whether there was domestic violence
A-3230-19 14 as R.H. testified there was, or there was no domestic violence based on Dr.
Rehman's vague testimony about what he heard from others. Last, the court
noted R.H.'s reported statements and testimony she would live with her son if
released, and Dr. Rehman's testimony R.H. would not provide contact
information for her son, as an apparent basis for its finding R.H. was a danger
to self. But the court does not explain how her failure to provide the contact
information rendered her a danger to self under the N.J.S.A. 30:4-27.2(h)
standard.
What is also missing from the court's analysis are findings addressing the
legal standard for dangerous to self under N.J.S.A. 30:4-27.2(h). See D.M., 313
N.J. Super. at 456 (reversing an order continuing an involuntary civil
commitment because the testifying treating physician did not "focus upon a
functional analysis of [the patient's] condition within the context of the[]
statutory definitions" in N.J.S.A. 30:4-27.2).
To satisfy its burden of proving R.H. was a danger to self, the County was
required to clearly and convincingly establish that "by reason of" R.H.'s mental
illness she threatened or attempted suicide or behaved in a manner that indicates
she is unable to satisfy her need for nourishment, medical care or shelter, "and
it is resultantly probable that substantial bodily injury, serious physical harm or
A-3230-19 15 death will result within the reasonably foreseeable future." N.J.S.A. 30:4-
27.2(h). The court, however, made no findings addressed to this essential
element of the County's proofs. In its failure to make such findings, the court
did not honor its obligation to cull through the evidence presented, make factual
determinations based on the evidence it deemed credible, and correlate those
determinations to the applicable legal standards in support of an order grounded
in competent evidence and the law. See Curtis, 83 N.J. at 570; D.M., 313 N.J.
Super. at 454. As we have explained,
[t]he importance of the individual and public interests implicated by civil commitment "demonstrate the particular necessity . . . for the trial judge to comply assiduously with the mandate of . . . [the] myriad [of] cases pointing out the importance of findings." In re Commitment of S.D., 212 N.J. Super. 211, 218-19 (App. Div. 1986). A judge presiding over a commitment hearing is vested with extraordinary responsibility; when the judge does not apply the legal standards and find the relevant facts, our subsequent correction of the abuse of discretion is a poor remedy for the ill.
[M.M., 384 N.J. Super. at 332-33 (alterations in original).]
Here, the dearth of proper and complete findings would otherwise require
a remand for further findings by the court, see, e.g., D.M., 313 N.J. Super. at
454, but a remand is unnecessary because R.H. has been released and we are
A-3230-19 16 otherwise convinced the County failed to present clear and convincing evidence
R.H. was a danger to self under the statutory standard in N.J.S.A. 30:4-27.2(h).
Most simply stated, the County failed to present evidence that by reason
of a mental illness R.H. threatened or attempted suicide or otherwise behaved in
a manner indicating an inability to satisfy her need for shelter "so that it is
probable that substantial bodily injury, serious physical harm, or death will
result in the reasonably foreseeable future." N.J.S.A. 30:4-27.2(h). The best
the County could muster in support of its claim R.H. was a danger to self is Dr.
Rehman's testimony that R.H. "could" be a danger to self if released.
Dr. Rehman's testimony does not constitute clear and convincing evidence
R.H. was a danger to self under N.J.S.A. 30:4-27.2(h) for two reasons. First,
Dr. Rehman did not testify R.H. was a danger to self under the statutory
standard. Dr. Rehman's testimony R.H. could be a danger to self if released was
made without reference to the statutory standard, without correlating any facts
pertaining to R.H. under the standard, and without any functional analysis under
the statute. See D.M., 313 N.J. Super. at 456. For example, Dr. Rehman did not
testify that if released, it was probable R.H. would suffer the injuries or death in
the reasonably foreseeable future as required to establish dangerousness to self
under N.J.S.A. 30:4-27.2(h).
A-3230-19 17 Second, Dr. Rehman's testimony is insufficient to satisfy the dangerous-
to-self standard because she opined only that R.H. "could" be a danger to self if
released. That is not enough. The County was required to present clear and
convincing evidence it was "probable" R.H. would suffer the defined injuries or
death within a reasonably foreseeable time after her release. See N.J.S.A. 30:4-
27.2(h); R. 4:74-7(f)(1). Evidence R.H. "could" be a danger to herself allows
nothing more than a conclusion it is possible R.H. was danger to self. See Could,
Merriam-Webster, https://www.merriam-webster.com/dictionary/could (last
visited Oct. 29, 2021) (defining "could" as "past tense of can"); see Can,
Merriam-Webster, https://www.merriam-webster.com/dictionary/can (last
visited Oct. 29, 2021) (defining "can" as "used to indicate possibility" and
"sometimes used interchangeably with may"); see May, Merriam-Webster,
https://www.merriamwester.com/dictionary/may (last visited Oct. 29, 2021)
(defining "may" as "used to indicate possibility"). N.J.S.A. 30:4-27.2(h)
requires evidence establishing a probability of the injuries supporting a finding
of dangerous to self, and the County offered no evidence, and certainly not clear
and convincing evidence, permitting such a finding as to R.H.
We are not persuaded by the County's claim the evidence established R.H.
was dangerous to self under N.J.S.A. 30:4-27.2(h) because she suffered from a
A-3230-19 18 mental illness and did not have a place to stay if released. The County's
argument finds no support in the evidence, and, in fact, is undermined by the
evidence.
Dr. Rehman was fully aware of the circumstances surrounding R.H.'s
mental illness, including her alleged psychosis, delusions, and paranoia; R.H.'s
refusal to provide contact information for the son with whom she said she would
live if released; and all the other circumstances pertaining to R.H.'s civil
commitment. Dr. Rehman, however, opined only that R.H.'s release "could"
result in a danger to self for R.H. if the involuntary commitment was not
continued. Again, the record lacked any evidence that, given all the
circumstances the County now argues supported R.H.'s continued commitment,
it was probable R.H. would suffer the consequences required to render her
dangerous to self under the statute N.J.S.A. 30:4-27.2(h). The County's only
witness, Dr. Rehman, did not offer testimony permitting a finding R.H. was
dangerous to self under the statute. See T.J., 401 N.J. Super. at 119 (explaining
an order continuing a civil commitment must clearly and convincingly establish
that the danger the patient poses constitutes "a substantial risk of dangerous
conduct within the reasonably foreseeable future") (quoting In re S.L., 94 N.J.
128, 138 (1983)).
A-3230-19 19 Because the County failed to present sufficient competent evidence
establishing R.H. was dangerous to self, see N.J.S.A. 30:4-27.2(h), the court
abused its discretion by finding the County satisfied its burden of demonstrating
an entitlement to the continuation of R.H.'s involuntary commitment under
N.J.S.A. 30:4-27.2(m). See U.S. Bank Nat. Ass'n v. Guillaume, 209 N.J. 449,
467-68 (2012) (explaining a court abuses its discretion "when a decision is 'made
without a rational explanation, inexplicably departed from established policies,
or rested on an impermissible basis'" (quoting Iliadis v. Wal-Mart Stores, Inc.,
191 N.J. 88, 123 (2007))). "[W]e have not hesitated to reverse involuntary
commitments when the record failed to contain clear and convincing evidence
of 'a substantial risk of dangerous conduct within the reasonably foreseeable
future,'" T.J., 401 N.J. Super. at 119 (quoting S.L., 94 N.J. at 139), and are
compelled to do so again here based on the record presented. That conclusion
renders it unnecessary to address R.H.'s remaining arguments.
Reversed.
A-3230-19 20