Taylor, Rashik Ali

IN THE COURT OF CRIMINAL APPEALS

OF TEXAS

NO. PD-1370-07

RASHIK ALI TAYLOR, Appellant

v.

THE STATE OF TEXAS

ON APPELLANT'S PETITION FOR DISCRETIONARY REVIEW

FROM THE FIRST COURT OF APPEALS

HARRIS COUNTY

Price, J., delivered the opinion of the Court in which Meyers, Johnson,

Holcomb and Cochran, JJ., joined. Womack, J., filed a concurring opinion in which

Keller, P.J., and Keasler and Hervey, JJ., joined.

O P I N I O N

The appellant was convicted of the offense of aggravated sexual assault of a child

younger than fourteen. (1) The jury assessed his punishment at ten years' confinement in the

penitentiary. The evidence against the appellant consisted of the testimony of the

complaining witness, J.B., and a licensed professional counselor who had been counseling

J.B. for some months after the offense came to light. On appeal, the appellant argued that

certain testimony from the counselor, summarizing what J.B. had told her about the offense,

had been improperly admitted over his hearsay objection. The First Court of Appeals held

that the counselor's testimony was admissible under the hearsay exception for statements

made for purposes of medical diagnosis or treatment. (2) We granted the appellant's petition

for discretionary review to examine whether the hearsay exception embodied in Rule 803(4)

of the Texas Rules of Evidence should apply under the circumstances. (3)

FACTS AND PROCEDURAL POSTURE

At Trial

The complaining witness, J.B., was thirteen years old at the time of the offense, and

fourteen when she testified. She had been living mostly with her grandmother for the past

two or three years because her mother was a drug abuser and a prostitute, "in and out of jail."

She was a good student who admitted that she could probably do even better in school. At

least on a cold record, she gives the impression of possessing a certain street savvy. The

following account derives entirely from J.B.'s testimony, which made up the bulk of the

State's case against the appellant. There was no forensic evidence to back up her story.

Sometime in March of 2005, while J.B. was on her spring break from school, she met

the appellant, who was her mother's friend, for the first time. She knew him only by his

nickname, "Skinny Man." Several weeks after she first met the appellant, J.B. was in a motel

room one evening with her mother and "Uncle Lazy," a drug dealer who was the boyfriend

of J.B.'s aunt. J.B. and her mother were drinking wine. Soon J.B.'s mother begin to crave

drugs, so Uncle Lazy and J.B. drove her in a borrowed van to an apartment complex where

she could prostitute herself for cocaine. Later, J.B.'s mother called to say that her abusive

ex-boyfriend had abducted her and asked J.B. to call the appellant. The appellant drove to

the motel and picked up J.B. and Uncle Lazy. He offered them cocaine, then suggested that

Uncle Lazy go by himself to rescue J.B.'s mother. Uncle Lazy refused to leave J.B. alone

with the appellant, so all three of them got into the appellant's car. The appellant put his

hand on J.B.'s leg, but she pushed it off. They drove to the motel in which the appellant was

staying. J.B. accompanied the appellant to his room, where he retrieved a nine-millimeter

gun. While in the motel room, the appellant told J.B. that he wanted her and her mother to

move in with him. "And then he was like, well, I just want to spend time with you, all this

kind of stuff."

They left the motel and drove to another apartment complex that J.B. did not

recognize. The appellant and Uncle Lazy got out of the car and began a conversation at the

rear of the vehicle that J.B. did not pay attention to. But then she noticed that the appellant

had pulled out his gun and was pointing it at Uncle Lazy. J.B. then "jumped in front of the

gun and grabbed my uncle." The appellant tried to wrest her from Uncle Lazy, and pulled

out a different, smaller caliber gun and held it to J.B.'s head. J.B. let go of Uncle Lazy and

let the appellant put her back in the car. But she immediately jumped out of the window and

began to run through the apartment complex. She heard a gun shot and assumed that the

appellant had shot Uncle Lazy. (4) When it became clear to J.B. that the appellant was going

to catch her, she stopped running. He took her back to the car. She did not see Uncle Lazy

anywhere. The appellant then drove her back to his motel.

Once back at the motel, J.B. tried to run again, but the appellant found her and took

her to his room. There they did several lines of cocaine, (5) and then the appellant asked J.B.

to lie on the bed and disrobe. She did so because she felt "threatened and intimidated." The

appellant then disrobed and had sex with J.B. She testified that it hurt the entire time, and

she tried to push him off. "And every time I said stop or pushed harder, it would be - so I

just gave up. * * * I'm wasting my energy. The more - I knew the more I fight the longer

it would take. I knew that. So I just stopped." J.B. estimated that the assault lasted between

one-and-a-half and two-and-a-half hours. When it was over, the appellant threw a bag of

crack cocaine in her lap and told her it was for her mother, leading J.B. to suspect that her

mother may have prostituted her to the appellant in exchange for drugs. The appellant then

took J.B. back to her mother's motel, where her grandmother was waiting to take her home.

Because J.B. had been truant, a counselor from school called her over the weekend.

J.B. asked the counselor, "[W]hat does rape mean?" On Monday, J.B. disclosed her ordeal

to the school counselor, who in turn reported it to Child Protective Services. J.B. eventually

underwent a medical examination, but only to determine whether she was pregnant or had

contracted any sexually transmitted disease. About a month after the assault, J.B. began to

see a therapist "through Child Advocacy."

Q. Now, you also stated you started getting therapy. What were you

getting therapy for?

A. Post traumatic stress disorder. A little bit before all this had

happened like towards the end of February beginning of March I had been

diagnosed as bipolar. CPS thought it was best that I started to receive therapy.

They didn't want me to start cutting myself because of what had happened. (6)

Q. So did you start seeing a therapist?

A. I started seeing a therapist.

Q. Do you know when that was?

A. That was - it started - like it started like a month or so after

everything had happened. Like CPS got like really, really got involved and

everything.

Q. Are you still seeing a therapist to this day? (7)

A. Yes.

Q. What's your therapist's name?

A. Denise Fuller.

On cross-examination, J.B. confirmed that she had talked about "this incident" with Denise

Volet. It is not clear whether Denise Volet and Denise Fuller are one and the same. (8)

Denise Volet testified that she is a licensed professional counselor, formerly with

Child Protective Services and in private practice at the time of trial, with extensive

experience counseling victims of sexual assault and abuse. According to Volet, J.B. had

begun therapy with another therapist at the Child Advocacy Center, but "there was a conflict

of interest there since they work with CPS and everything, so [J.B.] was referred to me." (9)

J.B. began therapy with Volet on June 24, 2005, at least several months after the offense. (10)

Volet had been seeing J.B. on a weekly basis right up until the time of trial. The portion of

her testimony that is relevant to the issue in this case is as follows:

Q. And what sort of issues are you working with [J.B.] on?

A. The resolution of the rape and the sexual assault. The resolution of

the mother/daughter issues. Anger management. Learning how to control her

own behaviors and making the right choices. And judgment decisions.

Q. Did she tell you the facts about the rape?

A. She did give me some details.

Q. What details did she give you?

[DEFENSE COUNSEL]: Objection. Calls for hearsay.

[PROSECUTOR]: This is a statement made for diagnosis or treatment,

Your Honor.

[DEFENSE COUNSEL]: Although she is a licensed counselor, if I can

ask her a question or two on voir dire before you make a decision on this?

Would that be okay, Your Honor?

THE COURT: Okay. Take her on voir dire.

VOIR DIRE EXAMINATION

BY [DEFENSE COUNSEL]:

Q. Are you a medical doctor?

A. No, sir.

Q. Are you a psychiatrist?

A. No, sir.

Q. Are you under the supervision of a medical doctor or psychiatrist?

A. No, sir.

Q. You're not connected to any kind of medical doctor or psychiatrist

in any way?

A. No, sir.

[DEFENSE COUNSEL]: Your Honor, I object. These are hearsay

statements that are not made in the course of treatment.

[PROSECUTOR]: She is a licensed therapist treating [J.B.] for the

issues that she described.

THE COURT: Overruled.

DIRECT EXAMINATION (continued)

BY [PROSECUTOR]:

Q. What did she tell you about what had happened?

A. She referred to the gentleman as Skinny. That's the name that she

had for him. And how basically her mother had sent her to go with him. They

went to a motel. She talked about being in a car. Talked about there being a

gun. She talked about going upstairs into the room. Being afraid, knowing

that something wasn't right and was going to happen. Skinny asking her to

take her clothes off and her telling him she didn't want to. And trying to resist.

She talked about the gun being on the night stand on the table. Her taking her

clothes off. Getting on the bed. Skinny having sex with her. That it hurt.

And she tried to get away from him and just couldn't. Then when it was over

she talked about, you know, leaving. Being in the car. At some point the gun

was in her lap for some reason. And she talked about that she had the thought

of I just should shoot him now. She talked about doing drugs. Doing cocaine.

I remember cocaine. I don't remember exactly what it was they drank. But

she had been drinking and doing drugs. Had been given those things. She

remembered getting out of the car. And what's typical of a victim of rape or

abuse.

* * *

Q. What issues were you addressing with her regarding the rape? What

was her reaction to the rape?

A. Anger, number one. She was a very angry young lady. Betrayal she

felt from her mother.

Volet then went on to describe characteristics that are common to children who have suffered

from sexual abuse and indicated that J.B. displayed some of these characteristics. (11) Based

upon this evidence, (12) the jury convicted the appellant and, after a punishment hearing,

sentenced him to serve a term of ten years in the penitentiary.

On Appeal

On appeal, the appellant argued that the trial court erred in admitting Volet's

testimony as a statement made for the purpose of medical diagnosis or treatment over his

hearsay objection. The court of appeals affirmed his conviction, however, holding that the

trial court did not abuse its discretion to admit the testimony. (13) The court of appeals noted

that both the federal courts and some Texas courts have held that the hearsay exception at

issue may extend to statements made to professional counselors and psychotherapists. (14)

Noting also that J.B. testified that she was in therapy for post-traumatic-stress disorder, the

court of appeals found it reasonable to infer that she understood that the purpose of her

therapy was to treat a medical condition. (15) The court of appeals also found that J.B.'s

statements to Volet were reasonably pertinent to "her issues concerning the resolution of the

sexual assault." (16) Given this state of the record, the court of appeals held that the trial court

did not abuse its discretion to admit Volet's testimony recounting J.B.'s out-of-court account

of the circumstances of the sexual assault.

Justice Jennings concurred in the result only. (17) Noting his agreement with several

decisions from the Austin Court of Appeals, (18) he opined that the hearsay exception for

statements made for purposes of medical diagnosis or treatment should not be interpreted to

cover statements made for purposes of mental-health treatment. (19) He also rejected any

construction of the exception that would allow admission of statements made in the course

of long-term counseling or psychotherapy, after a diagnosis has been made and a course of

treatment decided upon, since, in his view, the rationale underlying the exception would no

longer apply. (20) Because he viewed the error as harmless, however, he concurred in the

majority's decision to affirm the trial court's judgment. (21) We granted the appellant's petition

for discretionary review in order to address and resolve the apparent conflict in the courts of

appeals with respect to the proper scope of Rule 803(4). (22)

THE LAW

The Rule

"Hearsay is not admissible except as provided by statute or [the Rules of Evidence]

or by other rules prescribed pursuant to statutory authority." (23) Once the opponent of hearsay

evidence makes the proper objection, it becomes the burden of the proponent of the evidence

to establish that an exception applies that would make the evidence admissible in spite of its

hearsay character. (24) One such exception is embodied in Rule 803(4), which provides:

The following are not excluded by the hearsay rule, even though the

declarant is available as a witness:

* * *

(4) Statements of Purposes of Medical Diagnosis or Treatment.

Statements made for purposes of medical diagnosis or treatment and

describing medical history, or past or present symptoms, pain, or sensations,

or the inception or general character of the cause or external source thereof

insofar as reasonably pertinent to diagnosis or treatment. (25)

In determining whether a trial court erred in admitting or excluding hearsay evidence under

such an exception to the hearsay rule, a reviewing court looks to see whether the trial court

clearly abused its discretion; before the reviewing court may reverse the trial court's decision,

it must find the trial court's ruling was so clearly wrong as to lie outside the zone within

which reasonable people might disagree. (26) Of course, the trial court's discretion must be

informed by a proper understanding of the law. In the instant cause, the disagreement

between the majority and concurring opinions below turned upon a difference in their

construction of Rule 803(4)--a disagreement as to the scope of the law--rather than a

dispute as to how well-settled law should be applied to the facts of this case.

Because our Rule 803(4) is identical to its federal counterpart in the Federal Rules of

Evidence, (27) it is appropriate to look to federal cases and commentary for guidance in its

proper construction. (28) When we canvass both the federal case law and also cases from our

own courts of appeals construing our Rule 803(4) in light of the federal case law, we find a

core area of consensus, but also some fundamental disagreements on the periphery. What

follows is a description of that case law, particularly as it bears upon the specific question

before us: Does Rule 803(4) provide for the admissibility of statements made to a licensed

professional counselor in the context of on-going, long-term therapy?

Federal Case Law

The Eighth Circuit Court of Appeals has taken the lead in construing Federal Rule

803(4). (29) In the seminal case of United States v. Iron Shell , (30) the nine-year-old victim of an

assault with intent to commit rape was examined by a physician on the same evening that the

offense occurred. The physician testified at trial to the victim's description of the offense

during the examination. (31) The issue in the appeal was whether that description was

"pertinent to the diagnosis or treatment" of the victim. (32) The court of appeals held that the

evidence constituted a description of the general character of the cause of the victim's

vaginal injury and therefore fell within the parameters of Rule 803(4). (33) Along the way, the

Eighth Circuit made the following observations about Rule 803(4):

The rationale behind the rule has often been stated. It focuses upon the patient

and relies upon the patient's strong motive to tell the truth because diagnosis

or treatment will depend in part upon what the patient says. It is thought that

the declarant's motive guarantees trustworthiness sufficient to allow an

exception to the hearsay rule. * * * Judge Weinstein, in his treatise, suggests

another policy ground. He writes that "a fact reliable enough to serve as the

basis for a diagnosis is also reliable enough to escape hearsay proscription."

[4] Weinstein & Berger, [Weinstein's Evidence] at 803-129 [1979]. This

principle recognizes that life and death decisions are made by physicians in

reliance on such facts and as such should have sufficient trustworthiness to be

admissible in a court of law. * * * Thus, two independent rationales support

the rule and are helpful in its application. A two-part test flows naturally from

this dual rationale: first, is the declarant's motive consistent with the purpose

of the rule; and second, is it reasonable for the physician to rely on the

information in diagnosis or treatment. (34)

Applying the first part of this test, the court of appeals observed that there were no facts in

the record that the victim's motives in describing the assault to the physician "was other than

as a patient seeking treatment." (35) Because the physician expressly explained in his testimony

that knowing the cause of the injury had been important in guiding his physical examination

of the victim, telling him what to look for and what not to look for, the court of appeals also

held that it had been reasonable for him to rely on the victim's statement in making his

diagnosis and deciding on treatment. (36)

The Advisory Committee Notes to Federal Rule 803(4) indicate that statements as to

"fault" are not typically pertinent to diagnosis or treatment, and are therefore not admissible

consistent with the rationale behind the rule. (37) In Iron Shell , the court of appeals had pointed

out that the victim's statement had not included information as to the identity of her assailant,

and observed in dicta, with specific reference to the Advisory Committee Note, that such

information would "seldom, if ever," be pertinent to diagnosis or treatment. (38) In United

States v. Renville , (39) the Eighth Circuit squarely confronted the question whether an eleven-year-old victim's statement made to a physician during an examination following a sexual

assault that actually identified her assailant was admissible under Rule 803(4).

Notwithstanding its dicta in Iron Shell , the Eighth Circuit held in Renville that "[s]tatements

by a child abuse victim to a physician during an examination that the abuser is a member of

the victim's household are reasonably pertinent to treatment." (40) The physician in Renville

had specifically testified that child abuse involves more than just physical injury, and that

part of the medical evaluation includes an assessment of "the emotional and psychological

injuries which accompany the crime." (41) Furthermore, the doctor testified, "[t]he exact nature

and extent of the psychological problems which ensue from child abuse often depend on the

identity of the abuser." (42) Indeed, if the abuser is a family member, it would be important to

intervene to see that the child is removed from harm's way. (43) For these reasons, the court of

appeals in Renville concluded that the victim's statement, including the identity of the

perpetrator, was shown to be pertinent to her diagnosis and treatment. (44)

The Renville court then turned to the question of whether the victim had been

motivated by the knowledge that her statement had been made for purposes of diagnosis or

treatment. The court of appeals observed that the physician had expressly explained to the

victim that the questions he asked her as part of his examination "were necessary to obtain

information to treat her and help her overcome any physical and emotional problems which

may have been caused by the recurrent abuse." (45) At least "where the physician makes clear

to the victim that the inquiry into the identity of the abuser is important to diagnosis and

treatment, and the victim manifests such an understanding[,]" the court of appeals concluded,

the rationale behind the hearsay exception is served. (46) Because nothing in the record

suggested that the victim's motive during the examination had been anything "other than as

a patient responding to a physician questioning for prospective treatment[,]" the court of

appeals held that her out-of-court statements to the doctor were wholly admissible. (47)

The first Eighth Circuit opinion dealing with the out-of-court statement of a child

victim made to a non-physician, but nevertheless offered under Rule 803(4), is United States

v. DeNoyer . (48) After he was abused by his father, the five-year-old victim was placed in a

foster home and was interviewed by several social workers while he was there. Without any

discussion of the fact that the social workers were not doctors, or that they had not even

interviewed the child at the behest of any doctor, the Eighth Circuit merely cited Renville for

the proposition that statements of child victims that identify the assailant may be reasonably

pertinent to diagnosis or treatment, and therefore admissible under Rule 803(4), and affirmed

the conviction. (49) Over the next few years, the Eighth Circuit held "that statements about

abuse, including the identity of the abuser, made by a child to a trained social worker or

psychologist pursuant to diagnosis or treatment for emotional or psychological injuries are

admissible under Rule 803(4)." (50) These holdings are consistent with the position of the

Advisory Committee that statements for the purpose of diagnosis and treatment need not

necessarily be made to a physician. (51) But they do not discuss whether the social workers,

counselors, or psychologists made clear to the children the importance of telling the truth

about the identity of their assailants, or whether the children manifested such an

understanding, so as to satisfy the first part of the two-part test from Iron Shell , viz ., that the

declarant's motive is consistent with a purpose of facilitating diagnosis or treatment. (52)

More recent Eighth Circuit holdings, however, have returned to the explicit two-part

test first announced in Iron Shell and elaborated on in Renville . These more recent holdings

have emphasized the requirement that the record reflect, in cases involving child victims,

both 1) that the physician (or counselor or psychologist) explained the importance of

knowing the true identity of the assailant to the efficacy of the diagnosis or treatment and 2)

that the child manifested an understanding of the need to be truthful. For example, in Olesen

v. Class , (53) the court of appeals held that a physician's testimony that a five-year-old victim's

statement identifying the defendant as her assailant was inadmissible. The doctor's testimony

should not have been admitted, the court of appeals declared, because there was "no evidence

in the record that he explained to [the victim] that his questions regarding the identity of her

abuser were important to diagnosis or treatment, or that [the victim] . . . understood the

medical significance of being truthful in identifying her abuser to her doctor." (54)

Similarly, in United States v. Gabe , (55) while acknowledging that a statement

identifying an abuser may be admissible under Rule 803(4), the court of appeals held the

physician's testimony in that case inadmissible because the Government, as proponent of the

evidence, failed to satisfy the "rigorous standard" of Renville to show that the doctor

explained to the child-victim the importance of that information to his diagnosis or treatment

and that the child manifested an understanding of same. (56) Responding to the Government's

argument that the fifteen-year-old victim was old enough to understand the importance of

telling the truth to a medical care-giver, the court of appeals observed:

We agree that most adults and older children generally understand a

physician's role in providing diagnosis and treatment. But not even an adult

necessarily understands the connection between a sex abuser's identity and her

medical treatment. Rule 803(4) is premised on the patient's selfish motive in

receiving proper medical treatment; therefore, the proponent must establish

that the declarant's frame of mind when making the hearsay declaration "was

that of a patient seeking medical treatment." (57)

The Eighth Circuit has recently applied the same "rigorous standard" in the context of out-of-court statements that child victims have made to psychologists and counselors. (58)

Other federal courts of appeals have determined that a child-victim's statement

identifying her assailant to a treating or diagnosing doctor, psychologist, therapist, or

counselor is admissible under Federal Rule 803(4). They have generally done so without

resort to the "rigorous standard" that the Eighth Circuit applies; instead, they have found such

child-victims--as a class--to be motivated to tell the truth, without inquiring about the

particulars of the individual medical or therapeutic evaluation. (59) Indeed, the Tenth Circuit

has expressly rejected the Eighth Circuit's two-part test as "not contemplated by the rule and

. . . not necessary to ensure that the rule's purpose is carried out." (60) The Ninth Circuit has

opined that the fact that a child may actually be too young to appreciate that her statements

given for purposes of medical diagnosis or treatment should be truthful goes only to "the

weight of the hearsay statements rather than their admissibility." (61)

Texas Case Law

This Court has rarely construed Rule 803(4); (62) we have yet to speak to the questions

raised in this petition. But a number of the courts of appeals have. The courts of appeals

have long held that the witness relating an out-of-court statement made for the purpose of

diagnosis or treatment need not be a physician for the statement to be admissible. The out-of-court statements of child-abuse victims identifying the perpetrator of the abuse to

psychologists, (63) therapists, (64) licensed professional counselors, (65) and even, under some

circumstances social workers, (66) have all been admitted into evidence under Rule 803(4)--so

long as the statement at issue otherwise met the criteria of the rule.

The earliest Texas cases to address the criteria for admissibility of child-victim

statements to treating physicians cited Renville for the proposition that out-of-court

statements relating the identity of the assailant are "reasonably pertinent to diagnosis or

treatment" in contemplation of Rule 803(4). (67) Without further discussion, each of these cases

held that the statements were admissible. Thus, early Texas cases seemed to rely only on the

second part of the two-part test from Iron Shell . (68) None of these early cases went on to

inquire (as the Eighth Circuit did in Renville ), as to the first part of the two-part Iron Shell

test--whether the record showed that the child-victim had understood that she had made the

statement for the purpose of diagnosis or treatment, or had been made aware of the

importance for that purpose of telling the truth about the identity of her assailant (where that

fact is indeed pertinent to diagnosis or treatment).

A little later the courts of appeals did begin to pay some heed to the first part of the

Iron Shell test. They began to recognize the need for a record that would establish that the

child-victim appreciated that her statement was made for the express purpose of diagnosis

or treatment. (69) Even so, the cases did not require, as the later Eighth Circuit cases do, that

the record show that the physician, psychologist, counselor, etc., expressly informed the child

that the purpose of her statements was to facilitate diagnosis or treatment, or that she

manifested an understanding of that purpose. Especially with older children, so long as the

record circumstantially supports an inference that the child understood the purpose of her

statement, the courts of appeals have held that Rule 803(4) is satisfied. (70) Moreover, we have

yet to find a Texas case that has addressed the specific question of whether, as a prerequisite

to admitting a child-victim's out-of-court statement that identifies her assailant , the record

must show that she was specifically informed by her physician (or psychologist or counselor),

and manifested an understanding, of the importance of that particular information to her

diagnosis or treatment.

The Austin Court of Appeals has taken a somewhat narrower view of Rule 803(4)

than have other Texas courts of appeals. In Moore v. State , (71) two teenage sexual-assault

victims began therapy sessions with a licensed clinical psychotherapist/social worker within

weeks of their outcry. (72) They remained in therapy, once or twice a week, sometimes

individually and sometimes in a group, right up to the time of trial. (73) The court of appeals

held that the therapist's testimony of statements made by the two girls describing specific

instances of abuse was inadmissible under Rule 803(4) because the State did not carry its

burden to demonstrate that the therapist was engaged in medical diagnosis or treatment. The

court reasoned that "to ensure that the medical treatment exception's assumption that patients

seeking medical care will be honest and truthful in relaying symptoms in order to obtain

proper and effective treatment remains intact, the offered witness's qualifications must be

shown to conform to the rule." (74) But "[b]ecause the record does not have sufficient

information for us to determine that [the therapist] has received medical training and can

qualify as a member of the medical profession," the court of appeals held that Rule 803(4)

was not satisfied. (75)

In a separate, concurring opinion in Moore , Justice Patterson expressed the view that

the statements in issue were also inadmissible for a different reason. (76) Pointing out that the

statements had been made in the context of on-going, long-term therapy occurring years after

the offenses alleged, she argued that there was no reason to believe that the assumption

underlying the rule would still apply "or that [the victims'] frame of mind was comparable

to a patient seeking treatment." (77) In Jones v. State , (78) writing for a majority, Justice Patterson

elevated the view she expressed in Moore to a holding of the court, reasoning that the selfish

motive to tell the truth "is no longer present once a diagnosis has been made and treatment

has begun. The details a patient may report during an extended course of treatment may be

prompted by other motives, such as denial or deception, or be influenced by the treatment

process itself." (79) Accordingly, the court of appeals held that the statements made by the nine-year-old complainant to a licensed professional counselor over the course of a ten-month

period of therapy, continuing up to the time of trial, were inadmissible.

Soon the Austin Court would consolidate the holdings of Moore and Jones , in Perez

v. State . (80) There, the twelve-year-old declarant began therapy with a licensed professional

counselor nine months after her initial outcry. (81) The counselor was not licensed to practice

medicine and was not working under the supervision of a physician or psychologist. (82) The

court of appeals held that the trial court erred in admitting the declarant's hearsay statements

to the counselor both because the counselor was "not shown to be a medical professional,"

and because "the statements were made during an extended period of counseling and did not

possess the guarantees of the trustworthiness on which the medical diagnosis and treatment

exception to the hearsay rule is founded." (83) Not surprisingly, it is these three cases from the

Austin Court of Appeals that the appellant in this case relies upon most prominently.

ANALYSIS

Based upon the Austin Court of Appeals cases, the appellant argues that Volet's

testimony relating the details of what J.B. told her in therapy sessions was inadmissible for

two reasons. First, Volet's qualifications as a medical professional were not shown to

"conform to the rule." (84) Second, because the therapy sessions occurred at least several

months after the charged offense, any statements J.B. made in that context lack the

guarantees of trustworthiness that otherwise undergird the hearsay exception. We reject the

appellant's first argument as contrary to the intent of the drafters and the weight of

persuasive case authority. But, at least on the facts of this case, we agree with the appellant

with respect to his second argument.

Medical Qualifications?

We reject the notion, implicit in the Austin Court's holdings, that before a witness can

relate the out-of-court statement made for purposes of medical diagnosis or treatment under

Rule 803(4), the witness must be shown to have medical "qualifications" that "conform to

the rule." (85) It is clear that the drafters of the federal rule did not think so, for they expressly

designated that in order for the exception to apply "the statement need not have been made

to a physician." (86) Indeed, "[s]tatements to hospital attendants, ambulance drivers, or even

members of the family might be included." (87) Certainly a family member will not typically

have any "qualifications" in the medical profession. The essential "qualification" expressed

in the rule is that the declarant believe that the information he conveys will ultimately be

utilized in diagnosis or treatment of a condition from which the declarant is suffering, so that

his selfish motive for truthfulness can be trusted. That the witness may be a medical

professional, or somehow associated with a medical professional, is no more than a

circumstance tending to demonstrate that the declarant's purpose was in fact to obtain

medical help for himself. A declarant's statement made to a non-medical professional under

circumstances that show he expects or hopes it will be relayed to a medical professional as

pertinent to the declarant's diagnosis or treatment would be admissible under the rule, even

though the direct recipient of the statement is not a medical professional. (88) To the extent that

Moore and Perez may be read to hold otherwise, we expressly overrule them.

Here, J.B. did not make her statements to Volet with the understanding that Volet

would relay them to a medical doctor. But we do not regard it as absolutely essential under

the rule that the ultimate diagnosing or treating entity be a physician , or that the statement

be made for purposes of diagnosing or treating a strictly physical ailment. As it has been

universally recognized since the Eighth Circuit first addressed the issue in Renville , the

medical community "must be attentive to treating the emotional and psychological injuries

which accompany" crimes against children. (89) A statement made for the purpose of

facilitating a child-declarant's own mental health may carry the same self-interested motive

as a statement made to facilitate the declarant's physical well-being. If so, there is no reason

to exclude it from Rule 803(4)'s ambit, regardless of whether the care-giver is a psychiatrist

(and hence, a physician) or some other trained mental-health professional.

Of course, there may be other considerations to take into account in the case of a

statement made for purposes of mental-health diagnosis or treatment. For example, the

declarant's mental illness or disorder must not be of such a nature or degree as to disable him

from appreciating his own self-interest in telling the truth to his care-giver. This is so both

for purposes of diagnosis and treatment. Moreover, and especially in the context of mental-health treatment (as opposed to diagnosis), it must be the case that truth-telling is important

to the efficacious treatment of the mental illness or disorder, and that the declarant has an

awareness (and is competent to appreciate the fact) that truth-telling is important. The focus,

in short, is on the declarant's perception. If a child-declarant can and does believe that his

statement to a mental-health professional will facilitate his diagnosis or treatment, we think

that his out-of-court statement should be admissible under Rule 803(4), whether or not the

mental-health professional is, strictly speaking, a member of the "medical profession." (90)

Again, to the extent that the opinions of the Austin Court of Appeals can be read to the

contrary, we overrule them.

J.B. testified that she was in therapy for post-traumatic-stress disorder (PTSD), a

recognized mental disorder. (91) Volet, a licensed professional counselor with extensive

experience counseling sexual-abuse victims, testified that J.B. had been referred to her for

help in resolving certain psychological issues attendant to the sexual assault. So long as

J.B.'s out-of-court statement to Volet implicating the appellant in the sexual assault

otherwise satisfies the two-part test of Iron Shell / Renville , we do not think that it should be

inadmissible simply because Volet is not a psychiatrist or otherwise a member of the medical

profession. However, we do not think that the State, as proponent of the hearsay evidence,

has ultimately met its burden in demonstrating that J.B.'s out-of-court statements to Volet

identifying the appellant as the perpetrator of her sexual assault do satisfy the Iron

Shell / Renville test.

Made for Purposes of Diagnosis or Treatment?

We agree with the Austin Court of Appeals that, consistent with the rationale for

admitting statements made for purposes of medical diagnosis or treatment over a hearsay

objection, it is appropriate to require the proponent of the evidence to show that the out-of-court declarant was aware that the statements were made for that purpose and that "proper

diagnosis or treatment depends upon the veracity of such statements." (92) This is the first part

of the Iron Shell/Renville test. Absent such an awareness on the declarant's part, we cannot

be sure that the self-interested motive to tell the truth, making such statements sufficiently

trustworthy to overcome a hearsay objection, is present.

We disagree with the Austin Court, however, to the extent that it has held that such

a self-interested motive "is no longer present once a diagnosis has been made and treatment

has begun." (93) This is too categorical. It is inconsistent with the plain language of the rule,

which admits hearsay made for the purpose of "diagnosis or treatment," not "diagnosis or

determining a course of treatment," or "diagnosis or devising a treatment plan." Moreover,

the motive for self-preservation that fuels the hearsay exception does not necessarily

extinguish once a course of treatment has been determined and has commenced. The

effectiveness of on-going treatment, and especially of mental-health treatment, we have no

doubt, will at least sometimes depend, in some particulars, upon the patient's veracity. When

that is the case, and so long as the patient can be made to understand that dependency, there

is little reason to question his motive to be truthful in the interest of improving his own

mental health. (94)

Still, we recognize that reclining on a therapist's or psychiatrist's couch is not quite

the same as sitting in the emergency room in the immediate aftermath of an injury or on the

physician's cold examination table in the interest of diagnosing and curing some exigent

disease or ailment. In the latter contexts, it seems only natural to presume that adults, and

even children of a sufficient age or apparent maturity, will have an implicit awareness that

the doctor's questions are designed to elicit accurate information and that veracity will serve

their best interest. This explains the almost universal tendency of courts under these

circumstances to assay the record, not for evidence of such an awareness, but for any

evidence that would negate such an awareness, even while recognizing that the burden is on

the proponent of the hearsay to show that the Rule 803(4) exception applies. (95)

In the therapist's office, however, this tacit presumption is far less compelling. It is

not always so readily apparent (indeed, it may not always be accurate ) in the mental-health

context that truth-telling is vital. Not even an older, more mature child (maybe not even an

adult) will necessarily recognize and appreciate the necessity (assuming there is a necessity)

always to tell a mental-health provider the truth in order to assure the efficacy of treatment. (96)

In this context we think it is incumbent upon the proponent of the hearsay exception to make

the record reflect both 1) that truth-telling was a vital component of the particular course of

therapy or treatment involved, and 2) that it is readily apparent that the child-declarant was

aware that this was the case. Otherwise, the justification for admitting the out-of-court

statement over a valid hearsay objection is simply too tenuous.

Pertinent to Diagnosis or Treatment?

The Austin Court of Appeals was also correct to say that not every statement made

in the course of mental-health treatment will be admissible just because they are likely to be

truthful. (97) By the express terms of Rule 803(4), as elaborated by the second part of the Iron

Shell / Renville test, the proponent of hearsay evidence must show that the particular statement

proffered is also "pertinent to . . . treatment," (98) --that is to say, that it was reasonable for the

therapist to rely on the particular information contained in the statement in treating the

declarant. (99) This includes showing that a statement from a child-declarant revealing the

identity of the perpetrator of sexual abuse is pertinent. In Renville , the Eighth Circuit made

it clear that this information might be pertinent because it is important for a physician to

discover the extent of the child's "emotional and psychological injuries"--particularly when

the perpetrator might be a family or household member and it is important to remove the

child from the abusive environment. (100)

It is far less obvious how that information will necessarily be pertinent, long after the

fact of the abuse, in an on-going course of mental-health treatment or therapy. At that point,

knowing who is at fault for the emotional or psychological trauma may not be critical to

every treatment plan, especially if the perpetrator was not a family or household member.

We think it is appropriate, therefore, to require that the proponent of the hearsay exception

make the record reflect that it was important to the efficacy of the treatment that the mental-health professional know the identity of the perpetrator. Moreover, returning to the first part

of the Iron Shell / Renville test, we also think it is appropriate, at least in the context of long-term, on-going, after-the-fact mental-health treatment, that the proponent should make it

readily apparent on the record 1) that it was important to the efficacy of the treatment (if, in

fact, it was important) for the child-declarant to disclose the true identity of the perpetrator

and 2) that the child, prior to the disclosure, understood that importance. (101) In this way we

avoid the categorical approach adopted by the Austin Court of Appeals in this context, but

are still assured that the rationale underlying the Rule 803(4) hearsay exception will be

vindicated.

Conclusion

Volet testified that she was counseling J.B. to help her deal with the psychological

aftermath of "the rape and the sexual assault." She was also attempting to help J.B. cope

with the anger she felt towards her mother and not let that anger adversely affect her behavior

and judgment. The appellant was not a family or household member--he was, in fact, barely

more than a stranger to J.B. It is not readily apparent that knowing the appellant's identity

was pertinent to Volet's treatment of J.B. for the trauma of the sexual assault, and it seems

unlikely to have aided Volet in any material way in treating the residual anger issues that J.B.

had with her mother. This is not to say that Volet could not have testified to establish that

appellant's identity was pertinent to J.B.'s treatment in a way that is not obvious to us. But

she was never asked to do so during her testimony, and it is not otherwise apparent on the

record how it might be pertinent. Moreover, there is nothing in this record that makes it

readily apparent that J.B. understood that truthfulness about the identity of her assailant was

important to the efficacy of her treatment for these issues. We cannot presume these

predicate facts without effectively relieving the proponent of the hearsay evidence (here, the

State) of its burden to establish the existence of a valid exception to the hearsay rule. On this

state of the record, we conclude that the trial court abused its discretion to admit Volet's

testimony of J.B.'s out-of-court declarations, at least to the extent that they identified the

appellant as the perpetrator.

HARM ANALYSIS

Ordinarily, having found error for the first time in a petition for discretionary review,

we would remand a case to the lower appellate court to conduct a harm analysis in the first

instance. But this is not an absolute rule. (102) In his concurring opinion below, Justice

Jennings expressed the view that the trial court erred in admitting Volet's testimony, but that

the error was harmless. (103) The parties have briefed the question of harm in this Court, and

we think that Justice Jennings's conclusion that the error was harmless is sufficiently clear-cut on the instant record that it would constitute a needless expenditure of judicial resources

to remand the cause.

The error here is not of constitutional dimension. The appropriate harm analysis is

therefore the one set out in Rule 44.2(b) of the Texas Rules of Appellate Procedure, which

dictates that a non-constitutional error "that does not affect substantial rights must be

disregarded." (104) We have construed this to mean that an error is reversible only when it has

a substantial and injurious effect or influence in determining the jury's verdict. (105) We should

not overturn the conviction if we have fair assurance from an examination of the record as

a whole that the error did not influence the jury, or had but slight effect. (106) Here we believe

the error in allowing Volet's testimony would have had but slight effect.

The appellant argues that Volet's testimony would have influenced the jury because

it provided the only corroboration for J.B.'s testimony implicating him, and the prosecutor

emphasized this fact during his final summation at the guilt phase. The prosecutor argued:

Let's talk about the factors that weigh in favor of [J.B.'s] credibility.

One, just the story she told you from the stand itself. Very detailed.

Very long. And she has told this story over and over again when she was

interviewed at the Children's Assessment Center in Fort Bend County, to CPS,

to law enforcement, to her therapist. Every opportunity to get tripped up in a

lie. If she had changed that story you would have heard about it. She would

have been impeached with it. She was not. The reason that 13 year old child

was able to get on that stand and talk about those events so matter of factly like

she did is because truth is easier to tell. Lies are difficult . . .

* * *

You heard from her therapist. She has been seeing a therapist for

months now to deal with the post traumatic stress disorder. She shows the

signs and symptoms of a child who has been sexually abused . . .

* * *

Now, her therapist says she shows all the signs. She was consistent

with her therapist about what happened . . .

With respect to this final argument, Justice Jennings observed:

The State, in arguing about "the factors that weigh[ed] in favor" of the

complainant's credibility, did mention that the jury "heard from" the

complainant's therapist and that the complainant had not changed her "story."

However, the State explained that the complainant told her version of events

"over and over again" to different agencies, "law enforcement," and the jury

itself. The State's point was that if the complainant had changed her story, the

jury would have "heard about it" and her testimony would "have been

impeached." Moreover, the State also argued that Volet testified that the

complainant showed "the signs and symptoms of a child who has been

sexually abused," and this evidence is generally admissible if supported by

reliable expert testimony. See Hernandez v. State , 53 S.W.3d 742, 751 (Tex.

App.--Houston [1 st Dist.] 2001, pet. ref'd). (107)

On the basis of these observations, Justice Jennings concluded that the trial court's error in

admitting the objectionable portion of Volet's testimony did not have a substantial and

injurious effect or influence on the jury in reaching its verdict. We agree that the error

would have had but slight effect, and on that basis we hold that the error was harmless.

Accordingly, we affirm the judgment of the court of appeals.

Delivered: October 29, 2008

Publish

1. See Tex. Penal Code § 22.021(a)(1)(B)(i) & (a)(2)(B) ("A person commits an offense . .

. if the person . . . causes the penetration of the . . . sexual organ of a child by any means . . . and .

. . the victim is younger than 14 years of age[.]").

2. Taylor v. State , ___ S.W.3d ___, 2007 WL 2214859 (Tex. App.--Houston [1 st ], delivered

August 2, 2007). See Tex. R. Evid. 803(4). In a separate concurring opinion, Justice Jennings

disagreed that the counselor's testimony fit the exception under Rule 803(4), but he believed that the

error in admitting that testimony was harmless.

3. Tex. R. App. P. Rule 66.3 (d), (e).

4. Uncle Lazy turned up later, unharmed.

5. J.B. testified that at this point she was "needing for it," because she had been using cocaine

"for practically every day that month" while in the company of her mother, including earlier that

evening. "I was like I know when I do coke I'm okay. So I did it. I did a couple of lines. He did

a couple of lines." On cross-examination J.B. admitted that she used cocaine, marijuana and Xanax.

6. When she was ten years old, J.B. had apparently cut herself on an unspecified number of

occasions. Uncle Lazy had given her marijuana and Xanax in an effort to calm her down.

7. The trial occurred in December of 2005, some eight or nine months after the assault.

8. The appellant argues that they are not, and that the record therefore fails to establish that J.B.

was receiving counseling from Volet for PTSD. The court of appeals did not address this contention.

In view of our ultimate disposition, we need not resolve this ambiguity in the record.

9. Volet was not asked to identify the initial therapist whom J.B. saw. It is conceivable that

this initial therapist was the "Denise Fuller" whom J.B. named in her direct testimony. This seems

unlikely, however, given that she identified "Denise Fuller" as the therapist whom she was "still

seeing . . . to this day[.]"

10. The indictment alleges that the sexual assault occurred on or about May 27, 2005. But from

J.B.'s testimony it is apparent that the offense must have occurred sometime in the latter part of

March or early part of April, not in May, of 2005.

11. The appellant objected to this latter testimony as well, but did not complain of the trial

court's ruling overruling his objection on direct appeal.

12. The only other witness was a Houston police officer who testified that, in May of 2005, she

showed J.B. a photo spread to see whether J.B. could identify the perpetrator, and J.B. made a

positive identification of the appellant's photograph.

13. Taylor v. State , supra , at *5.

14. Id . at *4-*5. See, e.g., Wilder v. State , 111 S.W.3d 249 (Tex. App.--Texarkana 2003, pet.

ref'd); Puderbaugh v. State , 31 S.W.3d 683 (Tex. App.--Beaumont 2000, pet. ref'd); Gohring v.

State , 967 S.W.2d 459 (Tex. App.--Beaumont 1998, no pet.); United States v. Kappell , 418 F.3d

550 (6 th Cir. 2005).

15. Id . at *5.

16. Id .

17. Id . at *8-*11.

18. Perez v. State , 113 S.W.3d 819 (Tex. App.--Austin 2003, pet. ref'd); Moore v. State , 82

S.W.3d 399 (Tex. App.--Austin 2002, pet. ref'd).

19. Taylor v. State , supra , at *8-*9. Justice Jennings concluded that "[t]he rationale behind the

hearsay exception for statements made for purposes of 'medical diagnosis or treatment' regarding

a patient's physical condition simply has nothing to do with mental processes and behavior or the

providing of guidance and advice by a counselor." Id . at *9.

20. Id . at *9. Quoting from the Austin court's opinion in Perez v. State , supra , at 830, which

in turn quotes Jones v. State , 92 S.W.3d 619, 623 (Tex. App.--Austin 2002, no pet.), Justice

Jennings observed:

"Rule 803(4) is premised on the patient's selfish motive in receiving appropriate

treatment." This motive is no longer present once a diagnosis has been made and

treatment has begun. The details a patient may report during an extended course of

treatment may be prompted by other motives, such as denial or deception, or be

influenced by the treatment process itself.

21. Id . at *10-*11.

22. Tex. R. App. P. 66.3 (a), (e).

23. Tex. R. Evid. 802.

24. E.g., Martinzez v. State , 178 S.W.3d 806, 815 (Tex. Crim. App. 2005); Cofield v. State , 891

S.W.2d 952, 954 (Tex. Crim. App. 1994).

25. Tex. R. Evid. 803 (4).

26.

Zuliani v. State , 97 S.W.3d 589, 595 (Tex. Crim. App. 2003).

27. See Fed. R. Evid. 803(4).

28. E.g. , Coffin v. State , 885 S.W.2d 140 , 147 n.4 (Tex. Crim. App. 1994) ("Cases and

commentaries interpreting the Federal Rules of Evidence are instructive in our construction of

similarly worded provisions in our own rules.").

29. A high proportion of the relevant federal cases involve prosecutions for crimes committed

by or against Native Americans on Indian reservations, over which the federal courts have exclusive

jurisdiction. See 18 U.S.C. § 1153 . For this reason, many of the cases construing Federal Rule

803(4) have arisen in the Eighth and Tenth Circuits.

30. 633 F.2d 77 (8 th Cir. 1980).

31. Id . at 81-82.

32. Id . at 83.

33. Id .

34. Id . at 83-84. The United States Supreme Court has observed that "a statement made in the

course of procuring medical services, where the declarant knows that a false statement may cause

misdiagnosis or mistreatment, carries special guarantees of credibility that a trier of fact may not

think replicated by courtroom testimony." White v. Illinois , 502 U.S. 346, 356 (1992).

35. Id . at 84.

36. Id . at 84-85.

37. Fed. R. Evid. 803 (4) advisory committee notes ("Statements as to fault would not ordinarily

qualify [as a statement for purposes of diagnosis or treatment]. Thus, a patient's statement that he

was struck by an automobile would qualify, but not his statement that the car was driven through a

red light.").

38. 633 F.2d at 84 .

39. 779 F.2d 430 (8 th Cir. 1985).

40. 779 F.2d at 436 .

41. Id . at 437.

42. Id .

43. Id . at 438.

44. Id .

45. Id . at 438-39.

46. Id . at 438.

47. Id . at 439.

48. 811 F.2d 436 (8 th Cir. 1987).

49. Id . at 438.

50. United States v. Balfany , 965 F.2d 575, 581 (8 th Cir. 1992), citing United States v. Provost ,

875 F.2d 172, 176-77 (8 th Cir. 1989) and DeNoyer , supra . See also United States v. Yellow , 18 F.3d

1438, 1442 (8 th Cir. 1994); United States v. Running Horse , 175 F.3d 635, 638 (8 th Cir. 1999).

51. Fed. R. Evid. 803 (4) advisory committee notes ("Under the exception the statement need

not have been made to a physician. Statements to hospital attendants, ambulance drivers, or even

members of the family might be included.").

52. The Eighth Circuit did not completely lose sight of this requirement. In Ring v. Erikson , 983

F.2d 818, 820 (8 th Cir. 1992), the court of appeals held that the statement of a three-year-old victim

to an examining physician was not pertinent to her diagnosis or treatment for purposes of Rule

803(4) because she was simply too young to grasp that she was talking to a doctor, and therefore

could not be assumed to possess the self-interested motive necessary to guarantee trustworthiness.

See also United States v. White , 11 F.3d 1446, 1450 (8 th Cir. 1993) (statement made by nine-year-old

declarant to social worker in an automobile did not satisfy Rule 803(4) hearsay exception where no

explanation given to child by which he could have understood that interview conducted by a medical

professional and was for purposes of medical diagnosis or treatment).

53. 164 F.3d 1096 (8 th Cir. 1999).

54. Id . at 1098.

55. 237 F.3d 954 (8 th Cir. 2001).

56. Id . at 958.

57. Id ., quoting Oleson v. Class , supra , at 1098.

58. United States v. Beaulieu , 194 F.3d 918, 920-21 (8 th Cir. 1999); United States v. Sumner ,

204 F.3d 1182, 1185-86 (8 th Cir. 2000); United States v. Turning Bear , 357 F.3d 730, 738-39 (8 th

Cir. 2004).

59. E.g. , Morgan v. Foretich , 846 F.2d 941, 949 (4 th Cir. 1988) (categorically stating that "a

young child will have the same motive to make true statements for purposes of diagnosis or

treatment as an adult[,]" without inquiring whether circumstances showed that the child understood

she was even being evaluated for purposes of diagnosis or treatment, much less whether she had

been told the importance of truthfulness to the efficacy of the evaluation); United States v. Norman ,

129 F.3d 1099, 1105 (10 th Cir. 1997) (Rule 804(3) will apply to out-of-court statements of five-year-old victim without particularized inquiry whether child was old enough to appreciate the need to tell

the truth to evaluating physician); United States v. Pacheco , 154 F.3d 1236, 1240-41 (10 th Cir. 1998)

(same); United States v. Edward J. , 224 F.3d 1216, 1219-20 (10 th Cir. 2000) (same). See also United

States v. Kappell , 418 F.3d 550, 557 (6 th Cir. 2005) (in holding that psychologist could testify as to

three-year-old and six-year-old victims' out-of-court statements made during evaluations by licensed

psychotherapist, court of appeals observed that "[t]here is no evidence in the record-and Kappell has

not cited any-that the children were not aware of the need to be truthful in their interviews with" the

psychotherapist).

60. United States v. Joe , 8 F.3d 1488 , 1494 n.5 (10 th Cir. 1993). See also United States v.

Edward J. , supra , at 1220 n.3 ("Because we decline to accept the Eighth Circuit's presumptions, the

government had no burden here to show the girls understood the medical importance of telling the

truth.").

61. United States v. George , 960 F.2d 97, 100 (9 th Cir. 1992).

62. See Garcia v. State , 126 S.W.3d 921, 927 (Tex. Crim. App. 2004) (out-of-court statement

to employee of battered women's shelter not admissible under Rule 803(4) because no indication

that declarant was seeking medical treatment).

63. Burns v. State , 122 S.W.3d 434, 437-39 (Tex. App.--Houston [1 st ] 2003, pet. ref'd).

64. Fleming v. State , 819 S.W.2d 237, 243-44, 247 (Tex. App.--Austin 1991, pet. ref'd);

Gohring v. State , 967 S.W.2d 459, 461 (Tex. App.--Beaumont 1998, no pet.).

65. Wilder v. State , 111 S.W.3d 249, 256-57 (Tex. App.--Texarkana 2003, pet. ref'd).

66. Puderbaugh v. State , 31 S.W.3d 683, 685 (Tex. App.--Beaumont 2000, pet. ref'd); Horner

v. State , 129 S.W.3d 210, 217-220 (Tex. App.--Corpus Christi 2004, pet. ref'd). But see Gohring

v. State , supra , at 462-63.

67. See Macias v. State , 776 S.W.2d 255, 259 (Tex. App.--San Antonio 1989, pet. ref'd)

(observing that Federal Rule 803(4) "has been interpreted to allow a physician to testify to a child's

statements relevant to the external event causing an injury[,]" citing , inter alia , United States v.

Renville , supra ); Tissier v. State , 792 S.W.2d 120, 125 (Tex. App.--Houston [1 st ] 1990, pet. ref'd)

( citing United States v. Renville , supra , for proposition that child statement identifying abuser as a

member of her household was "reasonably pertinent to treatment" and hence admissible under Rule

803(4)); Fleming v. State , supra , at 247 (same); Turner v. State , 924 S.W.2d 180, 182 (Tex.

App.--Eastland 1996, pet. ref'd) ( citing Fleming , supra , and Macias , supra , for the proposition that

"[s]tatements describing abusive acts are pertinent to medical diagnosis and treatment"); Castoreno

v. State , 932 S.W.2d 597, 602 (Tex. App.--San Antonio 1996, pet. ref'd) (under Macias , supra ,

Tissier , supra , and Renville , supra , "the testimony of a child's treating physician concerning the

child's statement that the defendant had caused his injuries was admissible as a hearsay exception

under Rule 803(4)). See also Mendoza v. State , 69 S.W.3d 628, 633-34 (Tex. App.--Corpus Christi

2002, pet. ref'd) ( citing , inter alia , Tissier , supra , in support of holding that child's out-of-court

statement to nurse identifying defendant as her abuser was admissible under Rule 803(4); Guzman

v. State , 253 S.W.3d 306, 308-09 (Tex. App.--Waco, no pet.) (citing Tissier to hold that statement

of fourteen-year-old identifying the defendant as her abuser was "reasonably pertinent" to diagnosis

or treatment).

68. That is, first, whether the declarant's motive in making the out-of-court statement was

consistent with the rationale underlying the rule, and, second, whether a physician or other treating

professional would reasonably rely on that statement as information pertinent to diagnosis or

treatment of the declarant. 633 F.2d at 84 .

69. Gohring v. State , supra , at 461; Molina v. State , 971 S.W.2d 676, 683-84 (Tex.

App.--Houston [14 th ] 1998, pet. ref'd); Beheler v. State , 3 S.W.3d 182, 188-89 (Tex. App.--Fort

Worth 1999, pet. ref'd); Puderbaugh v. State , supra , at 685; Wilder v. State , supra , at 256-57;

Horner v. State , supra , at 219; Barnes v. State , 165 S.W.3d 75, 82-83 (Tex. App.--Austin 2005,

no pet.).

70. Conversely, courts of appeals in Texas have occasionally held out-of-court statements from

child-victims to be inadmissible under Rule 803(4) because there was no reason to believe that the

child would (or even could) have appreciated that the purpose of the statement was to facilitate

diagnosis or treatment. E.g. , Gohring v. State , supra , at 462-63 (even assuming that investigating

Child Protective Services social worker was engaged in diagnosis or treatment of declarant (a

dubious proposition in the court's view), "it would not be reasonable" in that context "to assume the

child would be aware" of it unless explicitly told so); Powell v. State , 88 S.W.3d 794, 800 (Tex.

App.--El Paso 2002, no pet.) (3-year-old child was too young to justify "the presumption of

reliability that forms the basis for the Rule 803(4) exception" because he could not possibly

comprehend "the need to be truthful" even in the context of medical diagnosis or treatment).

71. 82 S.W.3d 399 (Tex. App.--Austin 2002, pet. ref'd).

72. Id . at 403-05.

73. Id .

74. Id . at 404.

75. Id . at 405.

76. Id . at 409-16.

77. Id . at 414.

78. 92 S.W.3d 619 (Tex. App.--Austin 2002, no pet.).

79. Id . at 623.

80. 113 S.W.3d 819 (Tex. App.--Austin 2003, no pet.).

81. Id . at 828

82. Id . at 830.

83. Id . at 827.

84. Moore v. State , supra , at 404.

85. Id .

86. Fed. R. Evid. 803(4) advisory committee notes.

87. Id .

88. This is to be distinguished from the scenario under which the declarant is a parent of a child

who relays to a medical professional for purposes of diagnosis or treatment what the child has told

him. See , e.g. , Sandoval v. State , 52 S.W.3d 851, 855-57 (Tex. App.--Houston [1 st ] 2001, pet.

ref'd), and federal cases cited therein. Certainly parents who convey information to a doctor for

purposes of treating their child will have a compelling (albeit not wholly selfish) motive to tell the

truth. To the extent they have first-hand knowledge of, e.g., the child's medical history, there is no

reason their out-of-court statements should not be admissible under the rule. On the other hand, if

they are only relating, e.g., the cause of an injury as they themselves have been told by the child, it

is arguable that the hearsay exception should not apply. For while there is no reason to question the

truth-telling motive of the parents, the child's statement to the parents may not have been made with

the intention (or even an awareness) that it would be passed on to a medical professional for

purposes of diagnosis or treatment. Under those circumstances, the initial declarant of the hearsay-within-hearsay statement may not have shared the selfish motive essential to guarantee its

trustworthiness.

89. 779 F.2d at 437 .

90. See Moore v. State , supra , at 405.

91. See American Psychiatric Association Diagnostic and Statistical Manual of

Mental Disorders (Text Revision, 4 th ed. 2000) at 463.

92. Jones v. State , supra , at 623.

93. Id .

94. Again, this assumes that the declarant's mental illness or disorder does not itself impair his

ability to appreciate the need for veracity with his care-giver.

95. Even the earliest cases did not hesitate to infer such an awareness from the circumstances.

See United States v. Iron Shell , supra , at 84 ("We find no facts in the record to indicate that [the

nine-year-old child-declarant's] motive in making these statements was other than as a patient

seeking treatment. * * * There is nothing in the content of the statements to suggest that [the child]

was responding to the doctor's questions for any reason other than promoting treatment."); United

States v. Renville , supra , at 439 ("Nothing in the record indicates that the [eleven-year-old] child's

motive in making these statements was other than as a patient responding to a physician questioning

for prospective treatment."). See also Morgan v. Foretich , supra , at 949 (categorically stating that

"a young child will have the same motive to make true statements for purposes of diagnosis or

treatment as an adult[,]" even though concurring and dissenting opinion complained that there was

"no evidence in the record that her frame of mind was comparable to a patient seeking treatment");

United States v. Tome , supra , at 1457 (Holloway, J., concurring and dissenting) (complaining that

there was no record showing that very young child-declarant understood that the efficacy of her

medical treatment depended upon the accuracy of the information she provided); United States v.

Norman T. , supra , at 1105 ("Norman T. also fails to point to any actual evidence in this case to show

specifically this victim did not understand she was seeking medical treatment."); United States v.

Pacheco , supra , at 1241 ("Pacheco has not pointed to any actual evidence indicating that [five-year-old child-declarant] did not understand she was being examined by doctors and needed to be truthful

in her discussions with them."); United States v. Edwards , supra , at 1220 n.3 ("Edwards fails to

point to any evidence in the record tending to show the girls did not understand they were seeking

medical treatment, or the importance of being truthful when talking to a doctor."); United States v.

Kappell , supra , at 557 (even though psychotherapist had explained to children the need to be truthful

and followed protocol to make sure they understood, court of appeals nevertheless observes that

"[t]here is no evidence in the record--and Kappell has not cited any--that the children were not

aware of the need to be truthful in their interviews" with him).

Texas cases have been equally quick to infer the requisite awareness under the circumstances.

E.g. , Gohring v. State , supra , at 463 (ordinarily it is reasonable to "assume" that child will

understand that a statement given to a "recognized health professional, such as a physician, nurse,

psychologist, or mental health therapist" will be for purpose of medical diagnosis or treatment);

Beheler v. State , supra , at 188 ("there is no requirement that a witness expressly state that the

hearsay declarant recognized the need to be truthful in her statements for the medical exception to

apply[,]" even if that declarant is a child); Wilder v. State , supra , at 257 ("reasonable to infer" under

the circumstances that nine-year-old declarant understood her statements to therapist were for

purposes of medical treatment); Horner v. State , supra , at 220 (trial court could have found that

statement that eight-year-old child gave to "medical social worker" in same suite as diagnosing

physician "appreciated that the effectiveness of the treatment depended on the accuracy of the

information she provided"); Barnes v. State , supra , at 83 (because she was ten years old, and mature

enough "to be interviewed outside her grandmother's presence," trial court could have found that

child-declarant understood the need to be truthful in statements made to physician).

96. In his concurring opinion, Judge Womack asks the rhetorical question whether it would be

more important in an emergency-room situation for a thirteen-year-old victim of a stabbing or a

thirteen-year-old victim of sexual abuse to tell her health care provider the truth about the identity

of the perpetrator. Obviously it would be more important for the sexual abuse victim to tell the truth.

(Indeed, a statement about the perpetrator of the stabbing would not even be admissible under the

hearsay exception for statements made for purposes of medical diagnosis or treatment because, as

we have noted previously, statements of "fault" in that context do not ordinarily fit the exception.

See note 37, ante .) But the relevant question is not which victim's treatment would be best

facilitated by truthful identification of the perpetrator, but whether the latter victim would be likely

to realize and understand the importance to proper diagnosis and treatment of being truthful to her

health care provider about the identity of the perpetrator.

97. Jones v. State , supra , at 623 (medical diagnosis or treatment exception does not "encompass

every statement made by a child victim of sexual abuse to a therpist").

98. Tex. R. Evid. 803(4).

99. United States v. Iron Shell , supra , at 84.

100. 779 F.2d at 438 .

101. From the outset, part of the Eighth Circuit's "rigorous standard" required a showing that a

child-declarant was made aware of the importance of information about the identity of the

perpetrator. United States v. Renville , supra , at 438. While the Eighth Circuit has sometimes lost

sight of this requirement, more recent Eighth Circuit cases have acknowledged and implemented it.

See Olesen v. Class , supra , at 1098; United States v. Gabe , supra , at 958; United States v. Turning

Bear , supra at 738. Whether this "rigorous standard" should apply to child-declarants generally in

Texas is a question not presented on the facts of this case, and we need not decide it. But, for

reasons given in the text, we do think it appropriate to apply it at least in the context of a child-declarant's long-term, on-going, after-the-fact mental-health therapy.

102. Johnston v. State , 145 S.W.3d 215, 224 (Tex. Crim. App. 2004); McDonald v. State , 179

S.W.3d 571, 579-80 (Tex. Crim. App. 2005) (Cochran, J., concurring). See also George E. Dix &

Robert O. Dawson, 43A Texas Practice: Criminal Practice and Procedure § 44.80 (2 nd ed..,

Supp. 2007-2008), at 374-75.

103. Taylor v. State , supra , at *10-*11.

104. Tex. R. App. P. 44.2(b).

105. King v. State , 953 S.W.2d 266, 271 (Tex. Crim. App. 1997).

106. Johnson v. State , 967 S.W.2d 410, 417 (Tex. Crim. App. 1998).

107. Taylor v. State , supra , at *11. There was no direct evidence at trial that J.B. told her story

"over and over again" to different state agencies and law enforcement, although the jury might

reasonably have inferred it. In any event, the appellant did not object to the prosecutor's final

argument on this basis. Although the appellant did object to Volet's testimony that J.B. displayed

some of the characteristics common to children who have suffered sexual abuse, the trial court

overruled the objection and the appellant did not press the matter on appeal. See note 11, ante .