In re Lillie M.

NO. 4-06-0947 Filed 9/5/07
IN THE APPELLATE COURT
OF ILLINOIS
FOURTH DISTRICT
In re: LILLIE M., a Person Found Subject ) Appeal from
to Involuntary Admission, ) Circuit Court of
THE PEOPLE OF THE STATE OF ILLINOIS ) Sangamon County
Petitioner-Appellee, ) No. 06MH687
v. )
LILLIE M., ) Honorable
Respondent-Appellant. ) George H. Ray,
) Judge Presiding.
_________________________________________________________________
JUSTICE COOK delivered the opinion of the court:
Respondent, Lillie M., aged 43, appeals from the trial
court's order finding Lillie subject to involuntary admission at
St. John's Hospital (St. John's). At issue is whether the State
presented sufficient evidence to prove that Lillie was unable to
provide for her basic physical needs so as to guard herself from
serious harm (405 ILCS 5/1-119(2) (West 2006)) and whether the
court ordered the least-restrictive treatment alternative (405
ILCS 5/3-811 (West 2006)). We affirm.
I. BACKGROUND
According to Lillie's history and physical examination
report, Lillie has a history of mental illness. This report also
indicated that prior to the facts that gave rise to the instant
case, Lillie had been seen by a physician, Dr. Bland, as recently
as October 2, 2006. At that point in time, Lillie had been
taking her medication and had been doing well. The report noted
that Lillie is also mildly mentally retarded, which may contrib-
ute to her inability to answer questions appropriately.
On October 23, 2006, family members brought Lillie to
the emergency room after Lillie exhibited a change in behavior
and difficulty functioning. Specifically, Lillie had cut her
hair and began burning it in the sink. Lillie then ran away from
the emergency room and returned to her apartment. Lillie locked
herself in the bathroom with a pair of scissors and cut more
hair, this time putting it in the toilet.
Police officer C. Agans-Dominguez arrived at Lillie's
apartment to find Lillie with a bizarre haircut and the toilet
full of hair. Lillie was pacing the apartment and did not
respond to Agans-Dominguez's questions. Lillie's family ex-
pressed a concern for Lillie's well-being and told Agans-
Dominguez that Lillie earlier stated that "people put stuff in
her house." Agans-Dominguez then filed a petition for involun-
tary admission, reporting what he had just seen at Lillie's
residence. The petition alleged that Lillie could be reasonably
expected to harm herself or others due to her mental illness and
that Lillie appeared unable to take care of her own basic physi-
cal needs.
On October 27, 2006, the trial court held a hearing on
the petition for involuntary admission. The only issue at the
hearing was whether Lillie would be unable to care for her basic
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physical needs. Lillie and Dr. Laura Shea, a psychiatrist, were
the only two witnesses.
Dr. Shea testified that she had been a psychiatrist for
16 years and had first met and examined Lillie the morning after
her admittance, October 24, 2006. Dr. Shea also examined
Lillie's medical chart. Dr. Shea noted that Lillie had been
diagnosed with chronic paranoid schizophrenia or chronic undif-
ferentiated schizophrenia. Dr. Shea stated that Lillie's medical
history indicated that she had been "disabled" by schizophrenia
in the past. Dr. Shea stated that, during the interview, Lillie
had been "too determined" to say that "nothing was wrong."
Lillie's facial expression was very hard and Lillie stared at Dr.
Shea. Dr. Shea recounted the hair-cutting incident that had been
described in the petition and was contained in hospital records.
Dr. Shea stated that Lillie was not assertive in finding out how
Lillie's seven-year-old daughter was faring in Lillie's absence.
Dr. Shea stated that Lillie had been showering daily, though she
was not certain that was due to Lillie's own initiative. Lillie
initially refused food, telling Dr. Shea that the hospital had
"done something to it." On at least two occasions, Lillie asked
for food but then would refuse to eat it. However, Dr. Shea
stated that Lillie had been eating pretty well over the last
several days.
Dr. Shea stated she believed with a reasonable degree
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of psychiatric certainty that Lillie, due to her mental illness,
would be unable to provide for her physical needs so as to guard
herself from serious physical harm. 405 ILCS 5/1-119(2) (West
2006). Dr. Shea was aware that the petition originally alleged
that Lillie could be reasonably expected to harm herself or
others (405 ILCS 5/1-119(1) (West 2006)), but Dr. Shea did not
certify that allegation.
Dr. Shea recommended that commitment at St. John's for
a period not to exceed 90 days was the least-restrictive treat-
ment alternative. Specifically, Dr. Shea testified that she
supported the treatment plan prepared by St. John's. That
treatment plan stated that, prior to Lillie's admittance to the
emergency room, Lillie had been living with her adult sister and
had been "current with the Mental Health Center" and had seen Dr.
Bland. The plan's discharge strategy included a referral back to
the "Mental Health Center" and outpatient treatment once Lillie
demonstrated an ability to care for herself. The estimated
length of stay at St. John's was one week. At the hearing, Dr.
Shea further stated:
"Could we have [Lillie stay at St. John's]
but have leave to transfer her to McFarland
if we need to? I'd like to see [Lillie]
discharged from [St. John's] if we can since
she's taken her medicine for two days. I'm
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not sure how to handle that."
In addition to the petition, which stated it appeared
Lillie did not take care of herself and mentioned family members'
concern for Lillie's well-being, Dr. Shea based her conclusion
that Lillie needed to be admitted on Lillie's "basic paranoia."
Dr. Shea worried that if Lillie did not trust her family or other
care providers, Lillie would not be able to get shelter, food,
medicine, or other necessary care. Dr. Shea would like to see
evidence that Lillie's paranoia had cleared before Lillie left
St. John's.
Lillie testified that she lived alone with her seven-
year-old daughter. However, emergency-room records indicate that
Lillie also lives with her adult sister. Lillie has also told
hospital staff that she lives with her mother. Lillie stated
that she wanted to cut her hair short for a change, she had
merely flushed her hair down the toilet, and she had not burned
her hair in the sink. When asked why she put her hair in the
toilet, Lillie answered, "I didn't have nowhere else to put it.
I didn't want nobody doing nothing to it."
Lillie stated that, since admission into St. John's,
she has been showering and brushing her teeth daily. When asked
how frequently she has been eating, Lillie stated, "Off and on,
but--well, you might as well say every day." When asked on
cross-examination if she felt someone at the hospital was trying
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to poison her food, Lillie answered, "I don't know who to trust."
Lillie later contradicted these statements by saying, "I eat my
food all the time," and denying that she thought anyone was
trying to poison her. Lillie also stated that she took her
medication "sometimes" and did not feel like she needed it.
Lillie indicated that she did not plan on taking her medication
once home.
The transcripts reflect that Lillie often responded to
questions in an odd or inappropriate manner. For instance, when
asked what she did with her hair, Lillie stated, "Yeah, I flushed
it down the toilet. I swore on my bible." When asked whether
she cooked meals for her daughter, Lillie answered, "Yeah, I
cook. Cook, clean, wash, mop. Go for walk." Lillie also
interrupted and spoke out of turn three times during the proceed-
ings. Further, the history and physical examination report
indicated that Lillie was often "completely unreliable" in
providing information.
After closing argument, the trial court stated it found
by clear and convincing evidence that Lillie suffered from mental
illness, and as a result of that illness could not take care of
her basic needs. The court did not explain its finding further,
but it ordered Lillie to remain hospitalized at St. John's
Hospital for a period not to exceed 90 days. The court found
this to be the least-restrictive alternative. The trial court's
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written order only mentioned commitment at St. John's and did not
mention the possibility of a transfer. On October 31, 2006,
Lillie filed the instant appeal. On November 3, 2006, over
Lillie's objection, the trial judge signed an order transferring
Lillie to McFarland Mental Health Center under section 3-908 of
the Mental Health and Developmental Disabilities Code (405 ILCS
5/3-908 (West 2006)). Aside from the trial court's order, the
record contains no further information regarding the transfer.
II. ANALYSIS
Lillie argues that (1) clear and convincing evidence
did not warrant involuntary admission, and (2) involuntary
admission did not constitute the least-restrictive treatment
alternative. 405 ILCS 5/3-811 (West 2006). The State has the
burden of proving the need for involuntary admission by clear and
convincing evidence. In re Schumaker, 260 Ill. App. 3d 723, 727,
633 N.E.2d 169, 172 (1994). Because the trial court is in the
best position to weigh the evidence and determine the credibility
of the witnesses in an involuntary admissions proceeding, the
trial court's decision "'will not be set aside at the appellate
level, even if the reviewing court, after applying the clear and
convincing standard, would have ruled differently' [citation],
unless it is against the manifest weight of the evidence." In re
Bennett, 251 Ill. App. 3d 887, 888, 623 N.E.2d 942, 944 (1993),
quoting In re Orr, 176 Ill. App. 3d 498, 505, 531 N.E.2d 64, 69
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(1988).
Lillie argues that even if she were mentally ill, the
State did not prove that she was unable to care for her own basic
physical needs. A mentally ill person cannot be confined against
her will merely because she suffers from a mental illness if she
can live safely in freedom. In re Tuman, 268 Ill. App. 3d 106,
110, 644 N.E.2d 54, 58 (1994). A person with a mental illness
is, however, subject to involuntary admission where she, because
of her mental illness, is unable to provide for her basic physi-
cal needs so as to guard herself from serious harm without the
assistance of family or outside help. 405 ILCS 5/1-119(2) (West
2006). "[The] illness must prevent her from caring for her basic
physical needs by substantially impairing her thought process,
perception of reality, emotional stability, judgment, behavior,
or ability to cope with life's ordinary demands." In re
Ingersoll, 188 Ill. App. 3d 364, 368, 544 N.E.2d 409, 412 (1989).
In determining whether a person can provide for her basic physi-
cal needs under section 1-119(2), the court should look to
whether the person can obtain her own food, shelter, and medical
care, whether the person has a place to live or family to assist
her, whether she can function in society, and whether the person
has an understanding of money as a means of sustenance. In re
Rovelstad, 281 Ill. App. 3d 956, 968, 667 N.E.2d 720, 727 (1996)
(Second District). The court may look to evidence of a person's
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repeated past pattern of specific behavior and actions related to
that person's illness. 405 ILCS 5/1-119 (West 2004). Similarly,
the court is not required to wait until actual harm results
before hospitalization is warranted. In re Manis, 213 Ill. App.
3d 1075, 1077, 572 N.E.2d 1213, 1214 (1991).
Here, the State's evidence that Lillie could not take
care of her physical needs consisted largely of Dr. Shea's
observations and Dr. Shea's interpretation of the facts contained
in the petition and medical report. While the underlying factual
support of the testifying expert's opinion need not, as a matter
of law, be substantively admissible, the expert's opinion must be
supported by a sufficient factual basis to render it clear and
convincing. Tuman, 268 Ill. App. 3d at 110-11, 644 N.E.2d at 59;
see also In re Cutsinger, 186 Ill. App. 3d 219, 223-24, 542
N.E.2d 414, 417 (1989) (medical opinion was not clear and con-
vincing where expert, without reference to any factual basis,
merely gave the opinion that the patient could not care for basic
physical needs). In balance, we are mindful that "[diagnosis and
treatment of a mental disorder] is a highly specialized area of
medicine which is better left to the experts ***. In the absence
of a reason to the contrary, [the] physician's diagnosis and
treatment plan of hospitalization should be given credence and
followed." Ingersoll, 188 Ill. App. 3d at 368, 544 N.E.2d at
412; see also In re C.E., 161 Ill. 2d 200, 229, 641 N.E.2d 345,
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358 (1994) (different issue).
Though Lillie's medical records prior to the instant
occurrence are not part of the record, Dr. Shea testified that
Lillie had a history of being "disabled" by her schizophrenia.
After observing Lillie and witnessing her "basic paranoia," Dr.
Shea did not believe Lillie would be able to ask others for the
help she needed to secure her physical well-being. It is clear
that Lillie suffered from paranoia. Dr. Shea testified that
Lillie had stated that "something had been done to [the food at
the hospital]." At the hearing, when asked if anybody at the
hospital was trying to poison her food, Lillie answered "I don't
know who to trust." When asked why she put her hair in the
toilet, Lillie explained that she "didn't want nobody doing
nothing to it."
We recognize that, in Rovelstad, the court found that
evidence that a person has paranoid or delusional thoughts absent
evidence that a person is reasonably likely to act on those
thoughts to her own detriment is insufficient to warrant an
involuntary admission. Rovelstad, 281 Ill. App. 3d at 970, 667
N.E.2d at 728-29. However, the instant case is distinguishable
from Rovelstad. In Rovelstad, the respondent testified that he
heard voices that told him to run around naked, to stop eating
and sleeping, and to commit suicide. Rovelstad, 281 Ill. App. 3d
at 970, 667 N.E.2d at 728. Evidence suggested that the respon-
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dent acted on odd beliefs in the past. For instance, the respon-
dent had marked doorways and household items with mineral oil for
"protection" because he believed mineral oil to be blessed.
Rovelstad, 281 Ill. App. 3d at 960, 667 N.E.2d at 722. However,
the court held that because the respondent had never acted or
attempted to act in response to the voices telling him to run
around naked, stop eating and sleeping, and commit suicide, it
was against the manifest weight of the evidence for the trial
court to find that the respondent was unable to care for his
basic physical needs. Rovelstad, 281 Ill. App. 3d at 970, 667
N.E.2d at 728-29.
In contrast, Lillie did act upon potentially harmful
paranoid thoughts. Lillie believed that hospital staff had been
tampering with her food, and Dr. Shea testified to at least two
occasions where Lillie had ordered food and then refused to eat
it. Similarly, Lillie held the unrealistic belief that "someone"
would "do something" to her hair, and so Lillie acted by dispos-
ing of it in an odd and potentially dangerous manner. True,
these actions are not extreme in the sense that they were guaran-
teed to cause harm. However, as stated above, the court does not
need to wait until actual harm results. Moreover, to the extent
that the Second District in Rovelstad implied that the facts must
show the respondent acted upon dangerous beliefs or delusions (a
voice that tells a person to commit suicide), as opposed to
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harmless beliefs or delusions (mineral oil provides protection),
we simply disagree. To hold as much would not give the medical
expert the ability to properly treat and diagnose nuanced and
"abstract" symptoms of those they believe to be dangerously
afflicted. See Ingersoll, 188 Ill. App. 3d at 368-69, 544 N.E.2d
at 412.
Here, Dr. Shea, in her 16 years of experience, believed
that Lillie would be unable to physically care for herself, the
trial court agreed, and we cannot say that an opposite finding is
clearly apparent.
Finally, Lillie argues that the State failed to prove
that involuntary admission to St. John's was the least-restric-
tive alternative. If a person is subject to involuntary admis-
sion, the court is required to order the least-restrictive
treatment that is appropriate. 405 ILCS 5/3-811 (West 2006). In
addition to hospitalization, the court may also consider out-
patient treatment or placement in the care of a relative. A
statutory preference exists for treatment other than hospitaliza-
tion, and therefore the court may order hospitalization only
where it has been shown to be the least-restrictive treatment
alternative. In re Nancy A., 344 Ill. App. 3d 540, 556, 801
N.E.2d 565, 580 (2003).
Case law is somewhat split on exactly how much evidence
is required to support a finding that a given treatment is the
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least-restrictive alternative. In In re Devine, 214 Ill. App. 3d
1, 7, 572 N.E.2d 1238, 1242 (1991), the Second District held that
the trial court's failure to specify in its order of commitment
that the admission constituted the least-restrictive means of
treatment was not fatal where the State's primary witness re-
sponded affirmatively when asked whether hospital confinement
constituted the least-restrictive treatment. But see In re Long,
237 Ill. App. 3d 105, 112, 606 N.E.2d 1259, 1264 (1992) (Second
District, stating that Devine only stands for the proposition
that the court is not required to make an explicit finding that
the treatment is the least-restrictive alternative and not that
the least-restrictive alternative requirement is met when an
expert merely opines that it is such). Other courts have re-
quired more than an expert's statement at hearing that the
proposed treatment is the least-restrictive alternative, requir-
ing that the expert's opinion be supported by further explana-
tion. See Long, 237 Ill. App. 3d at 112, 606 N.E.2d at 1264(Second District); In re Lawrence S., 319 Ill. App. 3d 476, 484,
746 N.E.2d 769, 776 (2001) (Second District); In re Luttrell, 261
Ill. App. 3d 221, 227, 633 N.E.2d 74, 78-79 (1994) (Fourth
District).
The instant case is distinguishable from Lawrence S.
and Luttrell. In those cases, the State did not present a
written treatment plan. Lawrence S., 319 Ill. App. 3d at 484,
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746 N.E.2d at 775; Luttrell, 261 Ill. App. 3d at 226, 633 N.E.2d
at 78. Further, in Luttrell, the expert who merely opined the
treatment was the least-restrictive alternative, without explana-
tion or discussion of other treatment options, was contradicted
by another expert who had investigated the possibility that the
patient could stay with a relative. Luttrell, 261 Ill. App. 3d
at 226-27, 633 N.E.2d at 78. Here, Dr. Shea's opinion that
hospitalization was the least restrictive alternative did not
"stand alone" (Luttrell, 261 Ill. App. 3d at 227, 633 N.E.2d at
78) in the same way that the experts' opinions in Lawrence S. and
Luttrell stood alone. Compare Lawrence S., 319 Ill. App. 3d at
484, 746 N.E.2d at 776. Dr. Shea endorsed the treatment plan,
which recognized that Lillie had a supportive family and had
previously worked with Dr. Bland at the "Mental Health Center."
Despite these alternative treatment options, Dr. Shea still
recommended hospitalization, stating that she would like to see
Lillie's paranoia cleared before Lillie left the hospital.
Without such supervision, Dr. Shea was afraid that Lillie would
not be able to properly care for herself.
Further, the evidence in this case supports hospital-
ization. Lillie does apparently have a supportive family.
However, ordering Lillie to reside with her family while undergo-
ing outpatient treatment does not seem like a reasonable treat-
ment alternative because that appears to be the treatment Lillie
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was receiving before her family brought her to the emergency
room. See In re David D., 307 Ill. App. 3d 30, 34, 716 N.E.2d
1245, 1248-49 (1999) (respondent's aunt's offer to care for
respondent was not a reasonable treatment alternative where
respondent's aunt had been caring for respondent until respondent
ran away and respondent's aunt later brought respondent in for
treatment because she felt she could not manage respondent).
Accordingly, the State presented sufficient evidence that invol-
untary admission to St. John's was the least-restrictive treat-
ment alternative.
III. CONCLUSION
For the aforementioned reasons, we affirm the trial
court's order.
Affirmed.
STEIGMANN, P.J., concurs.
KNECHT, J., dissents.
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JUSTICE KNECHT, dissenting:
The State failed to present sufficient evidence to
prove the mentally ill respondent was unable to provide for her
basic physical needs so as to guard herself from serious harm.
There is likely more evidence that could have been presented, but
the State took the oft-used shortcut of having only the psychia-
trist testify.
A history of mental illness, an odd haircut, and a
degree of paranoia may be enough to suggest respondent would
benefit from treatment, but it does not prove by a clear-and-
convincing standard that she needs to be involuntarily committed.
Some staff at St. John's believed she would be dis-
charged to her home with follow-up outpatient treatment. Even
the psychiatrist believed she would stay at St. John's for no
more than one week. Yet just days after the hearing, respondent
was ordered transferred to McFarland Mental Health Center by the
trial court even though the order of October 27, 2006, found St.
John's was the least-restrictive alternative. The transfer is
curious, but that issue is not before us.
This court has commented with some frequency on proce-
dural deficiencies in mental-health cases. Those deficiencies
and mistakes sometimes do not require reversal. However, they
suggest a lack of attention to process. This case, where I
contend the evidence is lacking, suggests a failure to understand
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the quality and quantity of evidence required to meet the high
burden of proof in such cases.
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