ADDITIONAL CASES In the Matter of the Application of Danielle Dill Psy.D., Executive Director of Central New York Psychiatric Center, for an Order Authorizing the Involuntary Treatment of R.J., A Patient at Central New York Psychiatric Center. On June 16, 2021, this Court heard testimony and received evidence relative to the two above-captioned matters. Written summations were requested, and by letter dated June 17, 2021, this Court directed specific questions to the Attorney General’s Office and Mental Hygiene Legal Service to be addressed as part of their respective summations. Timely filings were received, and the Court is appreciative of the thoughtful responses from both sides. One initial question asked of the attorneys was whether the Court would be precluded as a legal matter from simultaneously granting the rehearing petition and the treatment over objection petition; i.e., whether the Court could discharge Respondent from the inpatient hospital facility with a treatment over objection order containing a traveling petition. Given the Court’s findings, as set forth below, that question is now moot and no such legal determination need be made in this case. Rehearing on Commitment Petition By Notice of Petition and Petition dated April 30, 2021, the Executive Director (Petitioner) of Central New York Psychiatric Center (CNYPC) applied pursuant to Correction Law §402 for an order to retain Respondent for involuntary care and treatment at CNYPC for a period not to exceed six months. Respondent opposed the petition, and a hearing was held before the Court (MacRae, J.) on May 25, 2021. A commitment order issued on May 28, 2021. On June 7, 2021, on Respondent’s behalf, Mental Hygiene Legal Service (MHLS) filed a petition for rehearing pursuant to Correction Law §402(11). The case was transferred to the undersigned. At the rehearing, Respondent confirmed on the record that he waived his right to a jury trial. In their written summations, both the Attorney General’s office and MHLS agreed with the Court’s observation that it is to conduct a de novo review of the commitment petition, without a review of the record from the May 25, 2021 hearing or the decision that issued thereafter. As such, although Respondent requested the rehearing and testified on his own behalf, Petitioner is required to show this Court by clear and convincing evidence that Respondent is mentally ill, is in need of care and treatment, and poses a substantial threat of physical harm to himself or others. (See Matter of William G., 196 Misc 2d 51, 54 [Sup Ct, Oneida County 2003]). To that end, Petitioner relies upon the testimony of Respondent’s treating psychiatrist Bibhuti Das, M.D., as well as various notes from the patient chart (admitted into evidence as Petitioner’s Exhibit 1) that were highlighted during the course of the hearing. 1. Mental Illness “Mental illness” is statutorily defined for these purposes to mean “an affliction with a mental disease or mental condition which is manifested by a disorder or disturbance in behavior, feeling, thinking, or judgment to such an extent that the person afflicted requires care and treatment.” (Corr. Law §400(6)). Respondent argues that because Dr. Das at the time of the hearing had not yet settled on a mental health diagnosis, Respondent cannot be found to suffer from a mental illness. Respondent points to his original diagnosis at CNYPC of Late Onset Schizophrenia, which Dr. Das changed on May 18, 2021 to Unspecified Schizophrenia Disorder. Dr. Das then testified before this Court that he was considering whether the more appropriate diagnosis was Delusional Disorder, but needed more time to observe Respondent before making a final determination. Article 16 of the Correction Law does not further define the terms “mental disease or mental condition” to include or exclude particular diagnoses. Nor could the Court find determinative caselaw as to whether a specific diagnostic label is required. Instead, the entirety of the definition in Correction Law §400(6) suggests a Court is to consider evidence not only as to symptomology (“mental disease or mental condition”), but also as to behavior (“disorder or disturbance in behavior, feeling, thinking, or judgment” to such an extent that treatment is required). Here, the description of Respondent’s mental health symptoms as they relate to his conduct has remained consistent leading up to and including his hospitalization, despite the shifting diagnostic labels. For example, the April 13, 2021 certification of Lawrence Farago, MD, DFAPA, who personally examined Respondent at Mid-State Correctional Facility and certified that his hospital admission was medically necessary, described Respondent’s psychotic symptoms to include “paranoid/grandiose delusional thinking; ideas of reference; disorganized thinking; and agitation.” Dr. Farago indicated that Respondent was spontaneously aggressive toward a peer and hostile toward mental health treatment providers. The April 13, 2021 certification of Marina Metelitsin, MD, who also personally examined Respondent at Mid-State Correctional Facility, described his symptoms to include “paranoid and grandiose delusions, irritability, emotional lability, hostility, physically assaultive behavior.” Dr. Das in his testimony also referred to instances where Respondent expressed delusional paranoid beliefs, such as when Respondent accused hospital staff of “messing” with his food, toothbrush and phone. Progress notes in the patient chart document Respondent’s expression that his hospitalization is a conspiracy. Other notes describe how Respondent can become belligerent with Dr. Das and treatment team staff. He has accused correction officers of injecting him with the Coronavirus. He believes his conditional release date was improperly extended as the result of a conspiracy in Albany. Dr. Das further described incidents where Respondent has been loud and disruptive, become agitated and aggressive, and failed to follow staff direction. Respondent has been placed in restraints and given STAT medications on several different occasions, with good effect. Respondent’s own testimony corroborated the medical opinions. He told the Court that the day before the hearing, he was talking with a staff member about how to avoid having to talk to Dr. Das. He accused the doctor in court of filing false reports. He believes the incident of aggression at Mid-State that precipitated his hospitalization was a “set up” by the correction officers. While the Court can envision scenarios in which the absence of a consistent diagnosis might be concerning, in this case, each diagnosis contains a common delusional component. Indeed, Dr. Das testified that he felt Schizophrenia may be a less accurate diagnosis because Respondent appears to suffer predominantly from delusions, with no hallucinations. The Court appreciates that he wants to confirm the most accurate diagnosis. Equally important, the Court does not want a treating physician to settle upon an inaccurate diagnostic label for the sole purpose of trying to show a patient suffers from a “mental disease or mental condition.” Without intending to predict outcomes in future unrelated cases where diagnoses may be in flux, the Court here finds Petitioner has clearly and convincingly established that Respondent suffers from deep-seated paranoid delusions that cloud his judgment and directly affect his perceptions toward the people around him. Those perceptions in turn lead him to think that he is the target of deceitful practices, which then drive his irritable and aggressive behaviors. Given these symptoms and corresponding actions, the Court deems Respondent to suffer from a “mental illness” as provided in Correction Law §402. 2. Threat of Harm to Self or Others The Court then turns to the question of whether Respondent, as a result of his mental illness, presents a substantial threat of physical harm to himself and/or others. Respondent argues that he was never the aggressor in the incidents that led either to his transfer to CNYPC or being placed in restraints and administered STAT medication once admitted to the hospital. He denies having any mental illness or any mental health history, and he rebuffs all attempts by staff to discuss antipsychotic medication. He states that he can advocate for himself and make his needs known in a prosocial way. Petitioner on the other hand, argues that Respondent’s aggression is less visible only because he is in the closely-monitored setting of CNYPC where staff can intervene and diffuse potentially harmful situations more quickly than in the prison setting. For example, according to a May 10, 2021 Progress Note written by SHTA Scott Koenig, Respondent became “over productive and inappropriate” during a phone call with MHLS personnel, to the point where staff had to redirect him “numerous times” to stay on task. Once the call concluded, Mr. Koenig talked with Respondent about his behavior. Respondent grew more agitated, to the point where he became verbally aggressive, was placed in restraints, and was given STAT medication by injection as he refused an oral dose. He received STAT medication the next day as well, due to agitation. After a fight with a peer on May 25, 2021, Respondent was administered STAT medications and transferred to a different ward. Although the Court is unaware of any incidents of aggression after May 25, 2021, at the same time, Respondent is not engaged in mental health treatment. As such, he has failed to develop skill sets that would help him manage delusional thoughts and corresponding behaviors. For this reason, the Court credits Petitioner’s argument that Respondent’s risk of harm to others is reduced only because of the hospital setting and not because the risk fails to exist. Without any basis to conclude, other than Respondent’s bald assertions, that he is better equipped to manage his mental illness outside the hospital setting, the Court considers his risk of harm to others to remain unchanged from when he was transferred to CNYPC in the first instance. (See, e.g., Matter of Consilvio v. Diana W., 269 AD2d 310, 313 [1st Dept 2000] [reversing the trial court's determination and finding that continued retention was appropriate, in part because "[t]he fact that a patient’s condition can be stabilized in a hospital setting of continual treatment and care does not necessarily lead to the conclusion that the patient can function normally on [his] own in an outpatient setting”]; see also Matter of Commr. of the Office of Mental Health v. Glenn B., 44 AD3d 517, 518 [1st Dept 2007] [permitting continued hospitalization where evidence showed the patient still engaged in volatile behavior, felt no remorse, took no responsibility for his actions and was non-compliant with medication]; Matter of Carpinello v. Floyd A., 23 AD3d 179, 183 [1st Dept 2005] [finding retention should have been ordered because the patient, while hospitalized, continued to minimize his criminal behavior and refused to take responsibility for his actions]). 3. Mental Health Treatment in an Inpatient v. Outpatient Setting A person in need of care and treatment is one who “has a mental illness for which inpatient care and treatment in a hospital is necessary.” (Corr. Law §400(4)). In the cases summarized above, the First Department identified treatment goals that would best be addressed through hospital retention. Here, given Respondent’s refusal to interact with his treatment team providers — to the point where he is trying to determine how to avoid interacting with Dr. Das — the Court finds Respondent still has progress to make. Furthermore, considering that Respondent is refusing treatment even with CNYPC providing a better patient/staff ratio than can be found within a DOCCS facility, the Court has no confidence that Respondent would participate in mental health services in a prison setting. 4. Conclusion Having considered the totality of the evidence as it pertains particularly to this Respondent, and against the backdrop of controlling caselaw, the Court finds Petitioner has met her burden of proof. Accordingly, Respondent’s petition for release is denied. Treatment Over Objection After Respondent’s initial commitment hearing, but before the petition for rehearing was filed, the Executive Director filed a petition to treat Respondent with prescribed antipsychotic medication that he consistently refuses. In this regard, the Court must decide whether Petitioner has proven by clear and convincing evidence that (1) Respondent lacks the capacity to make a reasoned decision with respect to the proposed treatment; and (2) the proposed treatment is narrowly tailored to give substantive effect to Respondent’s liberty interest, taking into consideration all relevant circumstances. The fact that Respondent suffers from a mental illness and is being involuntarily committed does not constitute a sufficient basis to conclude he lacks the mental capacity to comprehend the consequences of his decision to refuse medication. (See generally Rivers v. Katz, 67 NY2d 485 [1986]). 5. Capacity The Court incorporates by reference its discussion in the preceding section as to the nature of Respondent’s mental illness and his conduct at CNYPC. Petitioner further presented evidence that Respondent, besides denying his present need for treatment, also denies past mental health treatment despite documented records to this effect. He shows no ability to understand or take responsibility for how his behavior led to his hospitalization. Respondent instead blames conspiracy theories rooted in his paranoid and persecutory delusions. He fails to recognize the positive effect of STAT medications received at CNYPC and refuses to discuss the potential benefits of a medication regimen. Based upon the totality of the record, Petitioner has proven by clear and convincing evidence that Respondent lacks capacity to make a reasoned decision with respect to the proposed course of treatment. He shows no insight as to his mental illness and cannot understand the consequences of his choices. 6. Proposed Course of Treatment The Court further concludes that the proposed course of treatment, as outlined in Dr. Das’ report and that of reviewing physician Noor Anabtawi, MD, is narrowly tailored to meet Respondent’s needs while also giving substantive effect to his liberty interest. Dr. Das recommends administering Haldol, which Respondent has received as part of his STAT medications and which has helped reduce his psychotic symptoms. Dr. Das would first offer the medication orally, and only upon refusal would he resort to an injectable form. He described potential side effects and indicated that although Respondent has not experienced adverse effects to date, staff will continue to monitor for any such reaction. Dr. Das anticipates medication will help improve Respondent’s thinking and relations with others, along with helping to minimize delusional thinking. The ultimate goal is a return to a less restrictive environment in the prison setting. The Court credits Dr. Das’ conclusion that there is no less intrusive alternative treatment available which could be implemented with any degree of success. 7. Conclusion Given the totality of the record, the Court grants Petitioner’s relief to treat Respondent as outlined in her petition and supporting papers. The order will remain in effect for 12 months, to include a traveling provision. In accordance with the foregoing, it is hereby ORDERED that the Attorney General’s office is directed to e-file proposed orders in each of the above-captioned cases pending before this Court, after obtaining the consent of MHLS as to form; and it is further ORDERED that the court record of this proceeding shall be sealed by the Oneida County Clerk’s office and will only be available to the parties in this proceeding or upon further order of this court. Dated: July 14, 2021
