S. D. W. v. the State of Texas

TEXAS COURT OF APPEALS, THIRD DISTRICT, AT AUSTIN

NO. 03-25-00544-CV

S. D. W., Appellant

v.

The State of Texas, Appellee

FROM THE 478TH DISTRICT COURT OF BELL COUNTY
NO. 24DCR89075, THE HONORABLE WADE NICHOLAS FAULKNER, JUDGE PRESIDING

OPINION

It is undisputed that S.D.W. is a woman who suffers from mental illness1 and

has been declared incompetent to stand trial under the Code of Criminal Procedure. See Tex.

Code of Criminal Proc. art. 46B.054 (“Uncontested Incompetency”). But to justify an order

involuntarily committing her to a state mental-health facility for extended inpatient treatment,

such as the order at issue in this appeal, the State must meet a rigorous set of proof requirements

beyond those undisputed facts. See Tex. Health & Safety Code § 574.035. This Court is tasked

with determining whether the State met that burden. We hold that it did not because the

evidence is legally insufficient to show either a recent overt act by S.D.W. or a continuing

pattern of behavior that tends to confirm the deterioration of her ability to function

1
Two experts opined about S.D.W.’s mental health in this case: one diagnosed her with
schizophrenia and the other diagnosed her with “either” schizophrenia or bipolar disorder with
manic symptoms.
independently. See id. § 574.035(e)(2). We therefore reverse the order of the trial court and

direct S.D.W.’s release from civil commitment.

BACKGROUND

S.D.W. was indicted for harassment of a public servant, a third-degree felony.

See Tex. Penal Code § 22.11(a)(3). S.D.W.’s attorney filed a motion suggesting incompetency,

and the trial court found her incompetent to stand trial. See Tex. Code Crim. Proc. art. 46B.054.

The trial court’s order finding S.D.W. incompetent to stand trial committed her to “the

appropriate facility”—Georgetown Behavioral Health Institute—“for further examination and

treatment toward the specific objective of attaining competency to stand trial.” After several

months at the facility and two doctors’ opinions that S.D.W. was still incompetent to stand trial

and was unlikely to regain competency, S.D.W. was returned to the Bell County Jail, where she

remained at the time of the hearing at issue.

The State filed an application for the civil commitment of S.D.W. and a motion to

appoint physicians to prepare “Certificates of Medical Examination for Mental Illness” (CMEs).

See Tex. Health & Safety Code § 574.011 (outlining requirements of CMEs). In the motion, the

State recited that it “has chosen not to dismiss the criminal charges against [S.D.W.] and to

proceed with civil commitment proceedings under Texas Code of Criminal Procedure art.

46B.071(b)(1).” See Tex. Code Crim. Proc. arts. 46B.071(b)(1), 46B.102; see also Tex. Health

& Safety Code § 574.035.

With the felony charge still pending, the trial court conducted a civil-commitment

bench trial on July 7–8, 2025. Pursuant to a bench warrant, S.D.W. appeared in person at the

start of the trial but became “disruptive” by repeatedly interrupting the court before evidence was

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presented. The court warned S.D.W. that she would be removed from the courtroom if her

disruptions continued; when her behavior persisted, the court had her removed from the

courtroom to appear for the remainder of the trial from jail via video. The evidence consisted of

the CMEs of two medical doctors—Robert E. Cantu, MD and John Pierson, DO—and the live

testimony of Dr. Cantu.

After trial, the court determined that S.D.W. is a person with mental illness who

meets the criteria for court-ordered inpatient mental-health services and ordered S.D.W.’s

involuntary commitment for twelve months to provide those services. See Tex. Code Crim.

Proc. art. 46B.102; Tex. Health & Safety Code § 574.035. Specifically, the trial court found

that S.D.W. is (a) suffering severe and abnormal mental, emotional, or physical distress;

(b) experiencing substantial mental or physical deterioration of her ability to function

independently, which is exhibited by her inability, except for reasons of indigence, to provide for

her basic needs, including food, clothing, health, or safety; and (c) unable to make a rational and

informed decision as to whether or not to submit to treatment. See Tex. Health & Safety Code

§ 574.035(a)(2)(c). S.D.W. perfected an appeal from that order, challenging the legal and factual

sufficiency of the evidence to support it.

DISCUSSION

The applicable statute specifies four criteria that the factfinder must find from

clear and convincing evidence before the court may order a proposed patient to receive court-

ordered extended inpatient mental-health services:

(1) the proposed patient is a person with mental illness;

(2) as a result of that mental illness the proposed patient:

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(A) is likely to cause serious harm to the proposed patient;

(B) is likely to cause serious harm to others; or

(C) is

(i) suffering severe and abnormal mental, emotional, or physical
distress;

(ii) experiencing substantial mental or physical deterioration of the
proposed patient’s ability to function independently, which is
exhibited by the proposed patient’s inability, except for reasons of
indigence, to provide for the proposed patient’s basic needs,
including food, clothing, health, or safety; and

(iii) unable to make a rational and informed decision as to whether
or not to submit to treatment;

(3) the proposed patient’s condition is expected to continue for more than 90
days; and

(4) the proposed patient has received court-ordered inpatient mental health
services under this subtitle or under Chapter 46B, Code of Criminal Procedure,
for at least 60 consecutive days during the preceding 12 months.

See id. § 574.035(a). The factfinder must specify which criterion listed in Subsection (a)(2)—

that is, A, B, or C—forms the basis for its decision. See id. § 574.035(c). Here, the trial court

specified in its order that the three-part criterion in Subsection (a)(2)(C) formed the basis of its

decision. See id. § 574.035(a)(2)(C).

In proving the above four criteria, the statute specifies what the State’s evidence

must include:

(e) To be clear and convincing under Subsection (a), the evidence must include
expert testimony and evidence of a recent overt act or a continuing pattern of
behavior that tends to confirm:

(1) the likelihood of serious harm to the proposed patient or others; or

(2) the proposed patient’s distress and the deterioration of the proposed
patient’s ability to function.

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See id. § 574.035(e) (emphases added).

S.D.W. does not take issue with the State’s meeting its evidentiary burden on the

first, third, and fourth criteria. However, S.D.W. asserts on appeal that the State did not meet its

evidentiary burden on the second criterion. The State concedes, and the record reflects, that it

did not produce evidence that S.D.W.’s mental illness presented any likelihood of serious harm

to S.D.W. or to others. We therefore consider whether the State met its burden to prove the three

sub-elements of the second criterion through clear and specific evidence of a recent overt act or a

continuing pattern of behavior. That is, we consider whether the State proved that S.D.W. is

(1) suffering severe and abnormal mental, emotional, or physical distress; (2) experiencing

substantial deterioration of her ability to function independently, exhibited by her inability to

provide for her basic needs; and (3) unable to make a rational and informed decision as to

whether to submit to treatment. See id. § 574.035(a)(2)(C).

Standard of review

The heightened burden of proof—clear and convincing evidence—requires that

we utilize a heightened standard of review. See State v. K.E.W., 315 S.W.3d 16, 20 (Tex. 2010)

(holding that “clear and convincing evidence” requirement in civil-commitment statute requires

same heightened legal-sufficiency standard that applies in termination-of-parental-rights cases);

see also In re J.F.C., 96 S.W.3d 256, 264–65 (Tex. 2002) (outlining heightened standard in

termination-of-parental-rights cases). Clear and convincing evidence is “that measure or degree

of proof which 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.” K.E.W., 315 S.W.3d at 20 (quoting State v.

Addington, 588 S.W.2d 569, 570 (Tex. 1979) (per curiam)). “Evidence that merely exceeds a

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scintilla is not legally sufficient when the burden of proof is clear and convincing.” Id. (citing

J.F.C., 96 S.W.3d at 264–65). This heightened standard is constitutionally required because civil

commitment constitutes a significant deprivation of liberty that requires due-process protection.

See Addington v. Texas, 441 U.S. 418, 425, 432–33 (1979).

Additionally, the legislature has mandated that satisfying the clear-and-

convincing standard requires expert testimony, Tex. Health & Safety Code § 574.034(d), which

includes the expert’s opinion regarding the necessity of committing the patient, as well as the

factual support for the opinion. K.E.W., 315 S.W.3d at 20; State ex rel. D.W., 359 S.W.3d 383,

386 (Tex. App.—Dallas 2012, no pet.). Furthermore, as noted above, the statute specifies the

type of evidence the State is required to produce to satisfy the clear-and-convincing burden:

evidence of a recent overt act or a continuing pattern of behavior that tends to confirm the

proposed patient’s severe and abnormal mental, emotional, or physical distress and the

deterioration of the proposed patient’s ability to function independently. See Tex. Health &

Safety Code § 574.035(d); K.E.W., 315 S.W.3d at 20; see also State ex rel. E.D., 347 S.W.3d

388, 392–93 (Tex. App.—Dallas 2011, no pet.) (noting that evidence of recent physical or verbal

overt act that is probative of jury’s findings, when perceived objectively, will satisfy State’s

burden). A proposed patient’s verbal statements as well as physical actions are “overt acts,”

K.E.W., 315 S.W.3d at 24, and verbal statements may support a finding of mental illness and

predict future actions resulting from such mental illness, id. at 22.

When evaluating evidence for legal sufficiency under a clear-and-convincing

standard, we review all the evidence in the light most favorable to the finding to determine

whether a reasonable factfinder could have formed a firm belief or conviction that the finding

was true. See In re J.F.C., 96 S.W.3d at 266. We resolve disputed fact questions in favor of the

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finding if a reasonable factfinder could have done so, and we disregard all contrary evidence

unless a reasonable factfinder could not have done so. City of Keller v. Wilson, 168 S.W.3d 802,

817 (Tex. 2005); J.F.C., 96 S.W.3d at 266.

A factual-sufficiency review requires that we weigh disputed evidence contrary to

the challenged finding against all the evidence favoring the finding. In re A.C., 560 S.W.3d 624,

631 (Tex. 2018). Evidence is factually insufficient if, in light of the entire record, the disputed

evidence a reasonable factfinder could not have credited in favor of a finding is so significant

that the factfinder could not have formed a firm belief or conviction that the finding was true. Id.

The evidence2

Dr. Cantu testified that he met once with S.D.W. for thirty to forty-five minutes

on June 13, 2025, to “perform a psychiatric evaluation in the context of completing” a CME.

Dr. Cantu diagnosed S.D.W. with “either schizophrenia or bipolar disorder with manic

symptoms.” In his CME, Dr. Cantu concluded that S.D.W. “was experiencing substantial mental

or physical deterioration as a consequence of [her mental] illnesses” and is not “capable of

making rational, informed decisions on her own regarding her treatment.” To support his

conclusions, Dr. Cantu cited the following statements that S.D.W. made during the evaluation:

“MHMR is trying to cure me,” “I have trichomonas and AIDS,” “they injected me with

something,” and “my skin is a high yellow.” Dr. Cantu testified that S.D.W. was “unable to give

me the year, the month, the day or the current president”; “was extremely disorganized and

2
At the bench trial, the trial court announced it was taking judicial notice of its file in this
proceeding. While a court may take judicial notice that a pleading or other documents have been
filed in the case, it may not take judicial notice of the truth of the factual statements and
allegations contained in the pleadings, affidavits, or other documents in the file. See Abila v.
Miller, 683 S.W.3d 842, 849 (Tex. App.—Austin 2023, no pet.). We therefore outline and
consider only the evidence admitted at trial.

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delusional in her thinking”; “was not able to describe or report to me her past psychiatric or

medical history”; and “was irrational and non-goal-directed in her responses to my simple

questions regarding her current situation and her psychiatric and medical history.” Dr. Cantu

opined in his CME that S.D.W.’s condition is likely to continue for more than ninety days and

that she will benefit from inpatient treatment.

On cross-examination, Dr. Cantu admitted that he had not reviewed any of

S.D.W.’s patient files from her most recent inpatient stay and that he did not perform “any

diagnostics” because he is “not a psychologist.” His diagnosis was not based on testing but on

his evaluation of S.D.W. and was a “presumptive” or “working diagnosis”—“subject to

additional information”—rather than a “formal diagnosis.” He explained that for a formal

diagnosis “the symptoms hit each of the requirements of the DSM,” whereas a presumptive

diagnosis is based on “what you have in front of you, what you can see by observation and by the

responses to your diagnostic questions.” The only background information Dr. Cantu received

about why he was asked to evaluate S.D.W. was to determine “whether or not she should

continue involuntary treatment with the hopes of her—restoring her to competency.” Dr. Cantu

corrected himself when S.D.W.’s attorney reminded him that the State had previously informed

him that S.D.W. cannot be restored to competency. Dr. Cantu conceded that he was not aware of

the diagnoses S.D.W. had previously received or for which she was being treated at Georgetown

Behavioral while attempts were made to restore her to competency. Dr. Cantu explained that

S.D.W.’s records from her treatment at Georgetown Behavioral do “not necessarily have

significant bearing [on his evaluation of her] if I’m examining the defendant and she is

psychotic.”

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Dr. Cantu testified that jail—where S.D.W. had been residing for months

preceding trial—is not typically a “therapeutic environment.” He did not know whether S.D.W.,

after her release from Georgetown Behavioral to jail, had been offered the same medications that

she had been receiving at the institution and did not know what those medications were. He

agreed that it is possible S.D.W. had not been receiving any treatment in jail, although it was his

“understanding” from jail staff that S.D.W. had “been refusing” medications while in jail. He

had not reviewed any of her medical records from jail or from Georgetown Behavioral and did

not know what, if any, medications she had been offered in jail or had been prescribed to her.

In addition to the testimony and CME of Dr. Cantu, the trial court admitted

Dr. Pierson’s CME. The State did not call Dr. Pierson to testify. In his CME, Dr. Pierson stated

that he examined S.D.W. in jail on June 14, 2025, and explained the “detailed basis” for his

opinion that S.D.W. meets the civil-commitment requirements:

Patient is currently psychotic. She is delusional in multiple facets. She suffers
from grandiose delusions—she believes she is a physician, psychologist, dentist,
judge, military police, etc. She suffers from somatic delusions—she believes that
her body is broken, she has bugs crawling in and out of her body, that she has
multiple infections [sic] diseases (Ebola, AIDS, and COVID 19). She currently is
living in a false sense of reality. She is not oriented to date or time. She believes
she has committed no crime warranting to be placed in jail. When provider made
her aware of upcoming court she believed it was for a settlement she is owed.
Provider attempted to discuss her current charges and to this date she has no
concept of these charges or any wrongs she has committed. Patient is well known
to provider. She spent more than 9 months in inpatient unit in 2022 due to
severity of her mental illness. She is not currently tanking [sic] any medications,
and dies [sic] not believe she has any mental illness requiring treatment. Patient
is gravely disable[d], unable to make appropriate decisions.

In his CME, Dr. Pierson stated that S.D.W. “currently has orders for medications (Perphenazine

and Vaproic [sic] Acid)” and that a “brief diagnosis” of her “physical and mental condition” is

“Schizophrenia—Paranoid Type.” Neither Dr. Pierson’s CME nor other evidence explained

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what conditions Perphenazine and Valproic Acid are prescribed for or which symptoms they are

used to treat.

Analysis

Having reviewed all the evidence, we have identified the following as being

arguably probative of the trial court’s finding that S.D.W. committed a recent overt act or

demonstrated a continuing pattern of behavior that tends to confirm that she is experiencing

substantial mental or physical deterioration of her ability to function independently, see Tex.

Health & Safety Code § 574.035(e):

• Dr. Pierson’s statement in his CME that S.D.W. is not taking any medications and does
“not believe she has any mental illness requiring treatment”;

• Both doctors’ statements that S.D.W. was not oriented to date or time during their
evaluations and that she is delusional and psychotic, including the lists of alleged
delusions she has;

• Dr. Pierson’s statement that S.D.W. has a false sense of reality and Dr. Cantu’s statement
that she was irrational and non-goal oriented in responding to his questions about her
“current situation”;

• Dr. Cantu’s statement that S.D.W. was unable to recite her past psychiatric or medical
history;

• Dr. Cantu’s “understanding” from jail staff that S.D.W. had been refusing unspecified
medications;

• Dr. Pierson’s statement that S.D.W. had spent more than nine months in inpatient
treatment in 2022 due to the “severity of her mental illness”;

• Dr. Pierson’s statement that S.D.W. is “unable to make appropriate decisions”; and

• S.D.W.’s in-court behavior that prompted the trial court to remove her from the
courtroom.

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We have found nothing else in the record that arguably supports the challenged

finding, and we cannot conclude that the above constitutes legally sufficient, clear and specific

evidence of an overt act or a continuing pattern of behavior tending to confirm that S.D.W. is

experiencing substantial mental or physical deterioration of her ability to function independently.

While Dr. Cantu testified that S.D.W. does not believe she has any mental illness

requiring treatment, the factual basis underlying such a statement is absent—that is, Dr. Cantu

does not explain how he came to know that S.D.W. holds such a belief. Also lacking is any

explanation of why her mental illness requires treatment and what such treatment might entail.

See In re F.M., 183 S.W.3d 489, 497 (Tex. App.—Houston [14th Dist.] 2005, no pet.) (“The

significance of a refusal to accept, not only psychiatric medication, but any other kind of

medication or medical procedure, cannot be assessed in the absence of expert opinion concerning

recommended treatment, risks, alternatives, and consequences.”). Moreover, even assuming that

S.D.W. told Dr. Cantu she believes she does not have a mental illness requiring treatment—such

statement constituting an “overt act,” see K.E.W., 315 S.W.3d at 24—the statement is not

probative, without more, of her ability to function independently enough to meet her own basic

food, clothing, health, and safety needs. That a person may deny having a mental illness does

not, without more, demonstrate they cannot function independently with respect to providing for

their own basic needs. And although Dr. Cantu testified that it is his “understanding” that

S.D.W. had been “refusing medications” in jail, the facts supporting such refusals—which

medications, on which occasions, and under what circumstances—are not in the record. These

statements are not supported by the necessary factual bases to support them as required by

the statute.

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An expert diagnosis of mental illness, standing alone, is not sufficient to confine

a patient for treatment. State ex rel. E.R., 287 S.W.3d 297, 302 (Tex. App.—Texarkana 2009,

no pet.). Likewise, evidence that merely reflects a patient’s mental illness and need for

hospitalization is insufficient to meet the State’s burden. Id. “[T]he Health and Safety Code

requires that mental illness be shown as a separate inquiry from the issue of a person’s

deterioration of ability to function.” Armstrong v. State, 190 S.W.3d 246, 252 (Tex. App.—

Houston [1st Dist.] 2006, no pet.). “That a person is mentally ill or has been previously

hospitalized for mental illness, therefore, is no evidence of the person’s inability to function

independently.” Id. “Moreover, evidence of the effects of mental illness does not necessarily

establish evidence of substantial mental or physical deterioration unless the effects impair a

person’s ability to function independently to provide for basic needs.” Id. (holding that evidence

of proposed patient’s mental illness, oppositional behavior, poor hygiene, poor insight and

judgment, lack of trust towards others, diminished weight and insomnia, physical-health

problems, and prior hospitalization were legally insufficient absent testimony that she was

unable to function independently to provide for her basic needs).

Additionally, the statements in Dr. Pierson’s and Dr. Cantu’s CMEs about

S.D.W.’s delusional beliefs—assuming they truly are delusional—do not, without more, tend to

confirm that she is experiencing substantial deterioration in her ability to function independently

with respect to feeding and clothing herself and keeping herself safe and healthy. See E.R.,

287 S.W.3d at 306 (“Assuming that these scenarios are, in fact, hallucinations . . . we note that

evidence of hallucinations or delusions alone is insufficient to justify involuntary commitment on

the grounds of mental distress and the deterioration of the ability to function independently.”).

Furthermore, S.D.W.’s being disoriented as to date and time, being unable to recite her medical

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and psychiatric history, exhibiting disruptive behavior at the start of trial, and believing she has

not committed a crime—although perhaps demonstrative of her mental illness—also do not

constitute clear and specific evidence of an overt act or continuing pattern of behavior tending to

show that she cannot function independently with respect to providing for her basic needs.

An expert’s opinions and recommendations must be supported by a showing of

the factual bases on which they are grounded, and the State must show more than delusions or

other facts that merely confirm a proposed patient’s mental illness. Id. at 303. The State’s

evidence of an overt act or continuing pattern of behavior “must relate to the criterion on which

the judgment is based,” which here is the alleged substantial deterioration of S.D.W.’s ability to

independently function. Id.; In re F.M., 183 S.W.3d at 492; J.M. v. State, 178 S.W.3d 185, 193

(Tex. App.—Houston [1st Dist.] 2005, no pet.). The requirements for involuntary commitment

are strict because involuntary commitment is a drastic measure; accordingly, the evidentiary

standards for involuntary commitment are high. See State ex rel. H.S., 484 S.W.3d 546, 549

(Tex. App.—Texarkana 2016, no pet.). The doctors’ CMEs and Dr. Cantu’s testimony do not

detail how S.D.W.’s delusions or mental illness—“grandiose” or severe though they may be—

impair her ability to function independently. Moreover, the CMEs and testimony do not show

the factual bases on which the ultimate conclusions are based, much less any clear and specific

evidence of overt acts or behavioral patterns to show substantial deterioration of S.D.W.’s ability

to function independently. Although the record reflects some confusion and disruptive behavior

by S.D.W. at the trial, which the trial court could consider as “overt acts” in making its

determination, see State ex rel. H.S., 484 S.W.3d at 551 (noting that proposed patient’s demeanor

and behavior while testifying may support required findings), again we cannot conclude that

such behavior demonstrates substantial deterioration of her ability to function independently.

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And finally, even though Dr. Pierson noted in his CME that S.D.W. is “known” to him, he did

not explain the extent of his familiarity with her or identify any pattern of behavior or overt act

she has committed to support the required statutory finding.

Reviewing the evidence under the heightened standard of review required to

protect S.D.W.’s due-process rights, see Addington, 441 U.S. at 425; K.E.W., 315 S.W.3d at 20,

we hold that there is legally insufficient evidence in the record of any overt act or continuing

pattern of behavior by S.D.W. tending to confirm that she is experiencing substantial mental

deterioration of her ability to function independently, exhibited by her inability to provide for her

basic needs, including food, clothing, health, and safety, as required by statute. See Tex. Health

& Safety Code § 574.035(e); E.R., 287 S.W.3d at 305–06 (determining that analogous evidence

was legally insufficient to show recent overt act or continuing pattern of behavior tending

to confirm proposed patient’s distress and deterioration of ability to function); Armstrong,

190 S.W.3d at 253–54 (same). That is, viewing the clear and specific evidence in the light most

favorable to the trial court’s finding about S.D.W.’s ability to function independently, we

conclude that a reasonable factfinder could not have formed a firm belief or conviction that the

finding was true. See J.F.C., 96 S.W.3d at 266. We sustain S.D.W.’s legal-sufficiency issue and

therefore need not address her factual-sufficiency issue. See Tex. R. App. P. 47.1.

CONCLUSION

Having sustained S.D.W.’s legal-sufficiency issue, we reverse the trial court’s

order and render judgment denying the State’s application for extended inpatient mental-health

services. See Tex. R. App. P. 43.2(c). Having rendered such judgment, we order S.D.W.’s

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immediate release from the institution to which she has been committed. See Tex. Health &

Safety Code § 574.033.

__________________________________________
Karin Crump, Justice

Before Chief Justice Byrne, Justices Crump and Ellis

Reversed and Rendered

Filed: February 5, 2026

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