United States v. John Watson, Jr.

PUBLISHED

UNITED STATES COURT OF APPEALS
FOR THE FOURTH CIRCUIT

No. 14-4388

UNITED STATES OF AMERICA,

Plaintiff - Appellee,

v.

JOHN WATSON, JR.,

Defendant - Appellant.

Appeal from the United States District Court for the Eastern
District of Virginia, at Alexandria. T. S. Ellis, III, Senior
District Judge. (1:13-cr-00336-TSE-IDD-1)

Argued: December 11, 2014 Decided: July 17, 2015

Before TRAXLER, Chief Judge, and WYNN and HARRIS, Circuit
Judges.

Reversed by published opinion. Judge Harris wrote the majority
opinion, in which Judge Wynn joined. Chief Judge Traxler wrote
a dissenting opinion.

ARGUED: Nicholas John Xenakis, OFFICE OF THE FEDERAL PUBLIC
DEFENDER, Alexandria, Virginia, for Appellant. Julia K.
Martinez, OFFICE OF THE UNITED STATES ATTORNEY, Alexandria,
Virginia, for Appellee. ON BRIEF: Michael S. Nachmanoff,
Federal Public Defender, Kenneth P. Troccoli, Assistant Federal
Public Defender, OFFICE OF THE FEDERAL PUBLIC DEFENDER,
Alexandria, Virginia, for Appellant. Dana J. Boente, United
States Attorney, OFFICE OF THE UNITED STATES ATTORNEY,
Alexandria, Virginia, for Appellee.
PAMELA HARRIS, Circuit Judge:

Following his arrest for firing a handgun at a Coast Guard

helicopter, appellant John Watson, Jr. (“Watson”), who suffers

from Delusional Disorder, Persecutory Type, was found

incompetent to stand trial and committed to the custody of the

Attorney General for mental health treatment and evaluation.

After Watson refused to take antipsychotic medication in order

to render himself competent, the district court granted the

government’s request that he be medicated by force. Given the

critical liberty interests at stake, we require the government

to meet a heavy burden to justify forcible medication, and we

require courts to conduct a searching inquiry in order to ensure

that this burden is met. In this case, we conclude, the

government has not met its burden of proving that involuntary

medication is substantially likely to restore Watson’s

competency, as required by Sell v. United States, 539 U.S. 166

(2003). Accordingly, we reverse.

I.

“The forcible injection of medication into a nonconsenting

person’s body . . . represents a substantial interference with

that person’s liberty.” Riggins v. Nevada, 504 U.S. 127, 134

(1992) (quoting Washington v. Harper, 494 U.S. 210, 229 (1990)).

The interference is “particularly severe” when, as in this case,

2
the medication in question is an antipsychotic, Riggins, 504

U.S. at 134, for the use of such medications threatens an

individual’s “mental, as well as physical, integrity,” United

States v. White, 620 F.3d 401, 422 (4th Cir. 2010) (Keenan, J.,

concurring). On the physical side, there is the “violence

inherent in forcible medication,” id., compounded when it comes

to antipsychotics by the possibility of “serious, even fatal,

side effects,” Harper, 494 U.S. at 229. But it is the invasion

into a person’s mental state that truly distinguishes

antipsychotics, a class of medications expressly intended “to

alter the will and the mind of the subject.” United States v.

Bush, 585 F.3d 806, 813 (4th Cir. 2009) (quoting Harper, 494

U.S. at 238 (Stevens, J., concurring in part and dissenting in

part)).

For those reasons, as we have recognized, the forcible

administration of antipsychotic medication “constitutes a

deprivation of liberty in the most literal and fundamental

sense,” Bush, 585 F.3d at 813 (quoting Harper, 494 U.S. at 238

(Stevens, J., concurring in part and dissenting in part)),

justified only by a government interest that rises to the level

of “essential” or “overriding,” Sell v. United States, 539 U.S.

166, 178-79 (2003) (quoting Riggins, 504 U.S. at 134, 135). The

government’s interest in prison safety and security, the Supreme

Court held in Harper, qualifies as such an interest, and may

3
justify involuntary medication when an inmate suffering from a

“serious mental illness” is “dangerous to himself or others,”

and “the treatment is in [his] medical interest.” 494 U.S. at

227.

Under certain circumstances, a mentally ill defendant who

is not dangerous to himself or others within the meaning of

Harper may nevertheless be forcibly medicated for the sole

purpose of rendering him competent to stand trial. See Sell,

539 U.S. at 179. But that is the exception, not the rule.

Forcible medication is not justified every time an incompetent

defendant refuses treatment; on the contrary, “those instances

may be rare.” Id. at 180. As we have emphasized, forcible

medication under Sell is “a tool that must not be casually

deployed,” and courts must be vigilant to ensure that such

orders, which “carry an unsavory pedigree,” do not become

“routine.” United States v. Chatmon, 718 F.3d 369, 373-74 (4th

Cir. 2013).

To “minimize[] the risk of erroneous decisions in this

important context,” we have set a deliberately high standard for

the government to satisfy before it may forcibly medicate solely

to render an inmate competent to stand trial. Bush, 585 F.3d at

814. Like other courts of appeals to consider the issue, we

require that the government meet its burden by the “clear and

convincing” standard. Id.; see, e.g., United States v. Dillon,

4
738 F.3d 284, 292 (D.C. Cir. 2013) (“Holding the government to a

clear and convincing standard of proof affords due regard to the

nature of the liberty interest at stake in forced-medication

cases.”); United States v. Green, 532 F.3d 538, 545 (6th Cir.

2008) (applying clear and convincing standard); United States v.

Gomes, 387 F.3d 157, 160 (2d Cir. 2004) (same). That is a heavy

burden, requiring “evidence of such weight that it produces in

the mind of the trier of fact a firm belief or conviction,

without hesitancy, as to the truth of the allegations sought to

be established,” or “evidence that proves the facts at issue to

be highly probable.” United States v. Heyer, 740 F.3d 284, 292

(4th Cir. 2014) (quoting Jimenez v. DaimlerChrysler Corp., 269

F.3d 439, 450 (4th Cir. 2001)).

In this context, we require that the government prove by

clear and convincing evidence each of four factors. “First, the

government must show that ‘important governmental interests are

at stake’ and that special circumstances do not sufficiently

mitigate those interests.” White, 620 F.3d at 410 (quoting

Sell, 539 U.S. at 180). Second, the government must show that

“involuntary medication . . . significantly further[s] [its]

interests,” which requires proof that the medication is

“substantially likely to render the defendant competent to stand

trial” and “substantially unlikely to have side effects that

will interfere significantly with the defendant's ability to

5
assist counsel at trial.” Id. (quoting Sell, 539 U.S. at 181)

(internal quotation marks omitted). “Third, the involuntary

medication must be necessary to further the government's

interests, and less intrusive means must be unlikely to achieve

substantially the same results.” Id. (citing Sell, 539 U.S. at

181). Fourth and finally, “the court must conclude that the

administration of drugs is medically appropriate and in the

patient’s best medical interests in light of [his] medical

condition.” Id. (citing Sell, 539 U.S. at 181). With this

demanding standard in mind, we now consider whether the district

court properly found that forcible medication is justified in

this case. United States v. Watson, No. 1:13-cr-366, 2014 WL

1901256, at *1 (E.D. Va. Apr. 29, 2014).

II.

A.

On September 28, 2012, Watson was observed shooting a

handgun at a Coast Guard helicopter flying overhead. The

helicopter was not damaged, and none of the three Coast Guard

employees on board was injured. On August 15, 2013, Watson was

indicted for attempted destruction of an aircraft,

18 U.S.C. § 32(a)(1), (8); possession of a firearm by a felon,

18 U.S.C. § 922(g)(1); and use of a firearm during a crime of

violence, 18 U.S.C. § 924(c)(1)(A).

6
 Days after Watson’s arrest, the magistrate judge granted

the parties’ joint motion for a competency hearing, and Watson

was interviewed by licensed clinical psychologist Dr. Rebecca J.

Peterson (“Peterson”). Watson told Peterson that he had been a

covert operative for the British special forces since he was

seven years old, that the Coast Guard and Secret Service were

among the government agencies “working to help protect him from

danger and . . . guide him,” that certain “entities . . . ha[d]

‘tapped’ his phones and computer,” and “that someone ha[d] been

on his boat going through his letters and papers.” Watson

further indicated that this delusional system of beliefs had

been guiding his behavior since at least February 2009, when he

arrived in the Washington, D.C., area in order to seek the

protection of the British Embassy and was referred to St.

Elizabeth’s Hospital (“St. Elizabeth’s”) for mental health

treatment.

On the basis of this interview, Peterson concluded that

Watson was “unable to participate meaningfully and effectively

in his defense” as a result of his delusions, and in particular

his belief that his status as a covert operative for the United

Kingdom entitles him to diplomatic immunity. The magistrate

judge agreed, and Watson was transferred to the Federal Medical

Center in Butner, North Carolina (“FMC Butner”) for mental

health evaluation and treatment.

7
 Approximately six months later, on April 4, 2013, the

government submitted to the court a report completed by FMC

Butner staff psychiatrist Dr. Robert G. Lucking (“Lucking”),

which recommended that Watson be forcibly medicated in order to

render him competent to stand trial. Because the government

relies exclusively on Lucking’s opinion to show there is a

substantial likelihood that forcible medication would render

Watson competent as required by Sell, we review Lucking’s report

and testimony in some detail.

In his report, Lucking diagnosed Watson with Delusional

Disorder, Persecutory Type, 1 a rare mental illness characterized

by “the presence of one or more nonbizarre delusions that

persist for at least one month.” 2 Lucking further reported that

Watson’s delusions had not been treated with antipsychotic

medication at FMC Butner, and that Watson had refused to accept

1The experts in this case use the terms “Persecutory Type”
and “Paranoid Type” interchangeably. For clarity and
consistency with the Diagnostic and Statistical Manual of Mental
Disorders, we consistently refer to Watson’s condition as
“Persecutory Type.”
2A delusion is “nonbizarre” if it involves a situation that
can conceivably occur in real life, such as being followed,
poisoned, infected, conspired against — or, as here, being
recruited to work as a covert operative for a foreign
government. “Bizarre” delusions, by contrast, are clearly
implausible, not understandable, and not derived from ordinary
life experiences, such as the belief that one’s internal organs
have been removed and replaced by someone else’s organs without
leaving a scar or wound.

8
such treatment. Lucking believed Watson to be neither gravely

disabled nor a danger to himself or other inmates, as would be

required to justify forcible medication under Harper.

Nevertheless, he recommended that Watson be forcibly medicated

with the antipsychotic risperidone, 3 asserting that

“antipsychotic medication is substantially likely to render

[Watson] competent to stand trial.”

In support of his opinion, Lucking asserted that “there is

extensive support in the psychiatric literature that individuals

with the diagnosis of a psychotic illness obtain substantial

reduction in their psychotic symptoms when treated with

antipsychotic medication,” and that “a body of evidence”

supports the related proposition that such individuals “can be

restored to competency when treated with antipsychotic

medication.” Lucking also asserted that Watson had taken

risperidone during his 2009 admission to St. Elizabeth’s, from

which Lucking drew the “logical inference [that Watson]

responded positively to the use” of that drug. However, Lucking

admitted that he did not have the medical records from that

3The experts in this case use the generic name
“risperidone” and the brand name “Risperdal” interchangeably.
For clarity, we consistently refer to the drug by the generic
name “risperidone.”

9
admission, and later testified that he would have recommended

risperidone even if Watson had never received it before.

Finally, during a hearing on the government’s request for

forcible medication, Lucking testified that his past experience

as a psychiatrist supported the use of risperidone. Lucking

asserted that he had treated approximately ten other patients

suffering from Delusional Disorder with antipsychotic

medication, and that he “believe[d] all of them” had been

restored to competency. Lucking was, however, unable to provide

any further information about the ten other patients, explaining

that he could “not remember details of patients [he] treated

maybe five, six, seven, or eight years ago,” and that it would

in any event be “inappropriate” to share such “treatment [and]

clinical information” in a public forum, “even with the

[district court].”

Lucking’s opinion regarding the efficacy of involuntary

medication was challenged on several grounds by the report of

defense expert and licensed psychologist Dr. James H. Hilkey

(“Hilkey”). With respect to the academic literature, Hilkey

emphasized that “there is little in the literature referencing

well controlled, double-blind research studies as to the

efficacy of pharmacological treatment of persons suffering from

Delusional Disorders.” He also pointed out that the studies

that do exist have consistently shown the Persecutory Type of

10
the disorder — from which Watson suffers — to be the “most

resistant” to treatment.

With respect to Watson in particular, Hilkey opined that

“[t]he chronic nature of [Watson’s] illness and the fixed, well

established nature of his aberrant thoughts” make his condition

resistant to treatment, whether pharmacological or

psychological. He expressed concern that the involuntary

treatment plan did not adequately address Watson’s “strongly

held beliefs and reported personal experiences with psychotropic

medications,” including “pronounced fears of death,” and opined

that “[f]ailure to compassionately address these fears [would]

only contribute[] to fears of persecution” and thus aggravate

his condition. Finally, Hilkey indicated that it was his

“strongly held opinion” that supportive and cognitive behavioral

therapy would “increase the likelihood [Watson’s] competency

could be sufficiently restored,” given Watson’s apparent

“capacity to form a degree of therapeutic alliance,” as

demonstrated by his trusting relationship with his attorneys.

B.

On March 7, 2014, the magistrate judge recommended that

Watson be forcibly medicated in order to restore his competency.

Watson, 2014 WL 1901256, at *1, *4. The magistrate judge’s

findings with respect to the first two Sell factors are relevant

to Watson’s arguments on appeal.

11
 With respect to the first Sell factor, the magistrate judge

found “that an important government interest is at stake in the

prosecution of the defendant,” rejecting Watson’s argument that

that interest was mitigated by “the possibility of an

affirmative defense of not guilty by reason of insanity.” Id.

at *12, *14-15. In reaching this conclusion, the magistrate

judge assumed that such a defense could constitute a mitigating

special circumstance, but found that Watson had failed to prove

that the defense was “likely [to] be successful” because he had

not proffered expert testimony to that effect. Id. at *15.

With respect to the second Sell factor, the magistrate

judge found that the proposed treatment plan was substantially

likely to restore Watson’s competency. To reach this

conclusion, the magistrate judge relied entirely on Lucking’s

testimony and report, which, he noted, referenced the academic

literature and the experiences of Lucking’s other patients with

Delusional Disorder. Id. The magistrate judge held that

Hilkey’s forensic evaluation did not “undermine” Lucking’s

conclusion, solely on the ground that Hilkey’s report nowhere

“directly discredit[ed]” Lucking’s treatment plan. Id. at *16.

On April 29, 2014, the district court issued a brief order

adopting the recommendations and findings of the magistrate

judge and granting the government’s motion for involuntary

medication. Watson, 2014 WL 1901256, at *1, *4. The order has

12
been stayed pending resolution of this appeal. Order, United

States v. Watson, No. 1:13-cr-366 (E.D. Va. May 27, 2014), ECF

No. 76.

III.

On appeal, Watson challenges the district court’s findings

with respect to the first and second prongs of Sell. Because we

conclude that the district court clearly erred in finding that

the government had met its burden under the second prong of Sell

— and in particular, its burden of proving, by clear and

convincing evidence, that forcible medication is substantially

likely to restore Watson to competence 4 — we do not decide

whether a possible insanity defense is a special circumstance

that may mitigate the government interest in prosecution, or

4The dissent objects that this issue is not properly before
us, and that Watson’s argument on appeal is limited to the
district court’s failure to order that the government provide
supportive therapy in addition to forcible medication. We
respectfully disagree. While it is true that Watson emphasizes
Hilkey’s view that medication “must be combined with supportive
therapy in order to be successful,” he does so only in support
of his ultimate argument: that the only proposed treatment plan
actually before the court “will be unsuccessful,” and that “the
district court’s finding otherwise is clear error.” Watson Br.
26.

13
whether the district court otherwise erred in finding that the

government met its burden under the first prong of Sell. 5

A.

We have said that the second Sell factor involves factual

determinations subject to clear error review, see White, 620

F.3d at 410, and we recognize that our role is not to second-

guess a district court’s factual findings, see United States v.

Francis, 686 F.3d 265, 273 (4th Cir. 2012). We are, however,

charged with ensuring that the district court actually makes the

necessary findings, and that it makes them pursuant to the

proper legal standard — that it asks and answers the right

questions — in light of the record as a whole. See Jiminez v.

Mary Washington Coll., 57 F.3d 369, 379 (4th Cir. 1995) (“We

reverse a factual finding as being clearly erroneous if,

‘although there is evidence to support it, the reviewing court

on the entire evidence is left with the definite and firm

5In the decision below, the district court assumed that a
possible insanity defense could be considered in the special
circumstances analysis under the first prong of Sell, see
Watson, 2014 WL 1901256, at *2, as have other courts within this
circuit, see, e.g., United States v. Duncan, 968 F. Supp. 2d
753, 765-66 (E.D. Va. 2013); United States v. Rodman, 446
F. Supp. 2d 487, 496-97 (D.S.C. 2006). There is, however,
division among the courts of appeals on the question. Compare
United States v. Morrison, 415 F.3d 1180, 1186 (10th Cir. 2005)
(likely insanity defense diminishes government interest in
trial), with United States v. Mikulich, 732 F.3d 692, 699-701
(6th Cir. 2013) (potential insanity defense does not undermine
government interest).

14
conviction that a mistake has been committed.’” (quoting United

States v. United States Gypsum Co., 333 U.S. 364, 395 (1948))).

And in this highly sensitive context, governed by the exacting

clear and convincing standard, it is especially important that a

district court consider and contend with substantial evidence

that would undermine the case for forcible medication, and that

it ensure that the government’s burden actually has been met.

See id. (clear error may occur when a district court

“disregard[s] substantial evidence that would militate a

conclusion contrary to that reached” or otherwise reaches a

conclusion “contrary to the clear weight of the evidence

considered in light of the entire record”). On the basis of our

review of the entire record, we conclude that the district court

clearly erred in finding that the government had met its burden

of proving, by clear and convincing evidence, that the proposed

treatment is substantially likely to restore Watson’s

competency. We further conclude that on the record before us,

that exacting standard cannot be met.

B.

Under the second prong of Sell, the government must prove,

by clear and convincing evidence, that involuntary medication

significantly furthers its interests. See Chatmon, 718 F.3d at

374. And as part of that showing, the government must

“demonstrat[e] that the proposed treatment plan, as applied to

15
this particular defendant, is ‘substantially likely’ to render

the defendant competent to stand trial.” United States v.

Evans, 404 F.3d 227, 242 (4th Cir. 2005) (emphasis in original).

Merely showing a proposed treatment to be “generally effective”

against the defendant’s medical condition is insufficient to

meet this burden. Id. at 241-42; see Bush, 585 F.3d at 816

(“[I]n order to satisfy this second factor of the Sell test, the

government must not only show that a treatment plan works on a

defendant’s type of mental disease in general, but that it is

likely to work on this defendant in particular.”) (emphasis in

original); see also United States v. Ruiz-Gaxiola, 623 F.3d 684,

700 (9th Cir. 2010) (finding this burden unmet where the

government’s “experts rely on generalities and fail to apply

their views to [the defendant’s] condition with specificity”).

Instead, the government must “relate the proposed treatment plan

to the individual defendant’s particular medical condition,”

Evans, 404 F.3d at 242, which requires consideration of factors

specific to the defendant in question, including not only his

medical condition, but also his age and the nature and duration

of his delusions, see id. at 241.

What is missing from the proceedings below is any finding

assessing the likely success of the government’s proposed

treatment plan in relation to Watson’s particular condition and

particular circumstances. The district court did find that

16
“[t]he record convincingly reflects that the government has

satisfied” the second prong of Sell. Watson, 2014 WL 1901256,

at *3. But nothing in the district court’s decision indicates

that it actually considered whether the evidence proffered by

the government sufficiently addressed Watson’s particular

medical situation. Rather, the district court appears to have

concluded that the “substantially likely” requirement had been

met merely because Lucking testified that it was. See id.

(finding that government had shown involuntary medication to be

“substantially likely to render the defendant competent to stand

trial” because “Lucking . . . testified that the treatment plan

he designed for defendant . . . satisfies these requirements”).

And if we go behind the district court’s order to the magistrate

judge’s report and recommendation, the result is no better: In

adopting Lucking’s conclusion, the magistrate judge pointed for

support only to Lucking’s reliance on the academic literature

and his experience with his own patients, see id. at *15,

neither of which bears on Watson’s particular medical condition

or circumstances.

It is critical that in evaluating the government’s case for

forcible medication under Sell, courts engage in the proper

inquiry: not whether a proposed treatment plan is likely to work

in general, but whether it is likely to work as applied to a

particular defendant. Permitting the government to meet its

17
burden through generalized evidence alone would effectively

allow it to prevail in every case involving the same condition

or course of treatment. See Evans, 404 F.3d at 241. Because we

are obligated to ensure that a given case is “sufficiently

exceptional to warrant the extraordinary measure of forcible

medication,” we cannot permit such deference here. White, 620

F.3d at 413; see also Evans, 404 F.3d at 241.

C.

In this case, the requirement that the court assess the

efficacy of antipsychotics as applied “with specificity” to

Watson’s circumstances, Ruiz-Gaxiola, 623 F.3d at 700, is more

than a formality. The district court’s failure to look beyond

Lucking’s conclusory assertion that the government’s burden had

been met is problematic precisely because there is a near total

absence of evidence in Lucking’s report or testimony that

“relate[s] the proposed treatment plan to [Watson’s] particular

medical condition.” Evans, 404 F.3d at 242. This is not a

case, in other words, where the district court’s failure to

properly synthesize or distill the evidence is harmless because

we can see for ourselves that the government has met its burden

under the second Sell prong. On the contrary: There is

virtually nothing in Lucking’s report or testimony — the

entirety of the government’s case — that is sufficiently

specific to Watson that it could satisfy the government’s burden

18
of showing that Watson is substantially likely to be rendered

competent by forcible medication, let alone meet the rigorous

clear and convincing standard. 6

Lucking, for example, argues that risperidone is likely to

restore Watson’s competency because “there is extensive support

in the psychiatric literature that individuals with the

diagnosis of a psychotic illness obtain substantial reduction in

their psychotic symptoms when treated with antipsychotic

medication.” In other words, he asserts: (1) antipsychotic

medication effectively treats psychotic symptoms; (2) Watson has

psychotic symptoms; (3) therefore, antipsychotic medication will

effectively treat his psychotic symptoms. See also J.A. 75

(Lucking testifying that Watson “has a psychotic symptom;

therefore, he needs treatment with an antipsychotic”). This is

exactly the kind of nonspecific, syllogistic reasoning we deemed

insufficient in Evans, see 404 F.3d at 241, and it has not

become any more persuasive over time.

6
The dissent takes the position that the only question
before us is whether the district court properly synthesized the
record evidence, and not whether that evidence supports the
district court’s holding. In our view, however, those issues
are so closely interrelated in the context of this case that we
are justified in addressing them together. As Watson argues on
appeal, the district court’s synthesis errors matter precisely
because the evidence that the proposed treatment plan will
succeed is so thin.

19
 The insubstantiality of that reasoning is exacerbated here

by the weaknesses in the studies actually cited in Lucking’s

report. For one thing, many of those studies concern the

efficacy of antipsychotics in general, rather than risperidone

in particular, against psychotic illness in general, rather than

Delusional Disorder in particular. Cf. White, 620 F.3d at 421

(discounting probative value of doctor’s “professional

experience and expertise,” where doctor’s “area of expertise

[was] schizophrenia, not delusional disorders”). Because they

do not address the specifics of either the proposed treatment

plan or Watson’s condition, these studies cannot satisfy the

government’s burden of “relat[ing] the proposed treatment plan

to the individual defendant’s particular medical condition.”

Evans, 404 F.3d at 242.

Moreover, the cited studies that do specifically address

Delusional Disorder are equivocal at best. One study, Lucking

reports, finds a positive response to medication in fewer than

half of the cases reviewed, while another places the positive

response rate at less than 15%. Still another study identifies

Watson’s particular condition — the Persecutory Type — as having

an especially “poor response rate (50% improvement rate with no

reported complete recovery).” The one study cited by the

government that does unequivocally support the involuntary use

of antipsychotic medication to restore the competency of

20
defendants with the Persecutory Type of Delusional Disorder is,

by its own terms, vulnerable to “bias[] in favor of finding a

positive response to treatment” due to its experimental design.

Byron L. Herbel & Hans Stelmach, Involuntary Medication

Treatment for Competency Restoration of 22 Defendants With

Delusional Disorder, 35 J. Am. Acad. Psychiatry L. 47, 58

(2007).

This is not to say that these and other studies mentioned

in Lucking’s report are of no evidentiary weight at all. They

fairly could be understood to provide some evidence that

antipsychotic medication may be effective against Delusional

Disorder in general. But standing alone, without explanation or

analysis applying their findings to Watson as an individual, we

do not believe they can provide the requisite clear and

convincing proof that the forcible injection of risperidone is

substantially likely to succeed in treating Watson’s specific

persecutory delusions. Cf. Evans, 404 F.3d at 241-42 (finding

government report inadequate to prove that proposed treatment

plan was “substantially likely” to restore defendant’s

competency where it stated only that “such medication is the

‘primary’ way to treat Schizophrenia” and “nowhere addressed”

defendant’s individual concerns).

Lucking’s testimony regarding his past experience treating

patients with Delusional Disorder also fails to take account of

21
Watson’s particular condition and circumstances. The

experiences of similar patients treated with antipsychotics of

course could be relevant to Watson specifically — but here,

Lucking was unable to provide any information demonstrating that

his patients in fact were similarly situated to Watson. There

is, for instance, no evidence that they suffered from the same

type of Delusional Disorder, that they received the same

medication, that the medication was administered involuntarily,

or that their delusions were meaningfully similar in nature and

persistence. Indeed, Lucking indicated that he was unable to

recall any information about these patients, testifying that he

could “not remember details of patients [he] treated maybe five,

six, seven, or eight years ago,” and that it would, in any case,

be “inappropriate to share other people’s treatment [and]

clinical information,” “even with the [district court].” But

without information relating his patients’ experiences to

Watson’s own circumstances, that data set is just another form

of generalized evidence.

Nor do we think this gap can be filled with evidence that

is particularized to Watson but goes to an entirely different

question: not whether forcible medication is substantially

likely to render Watson competent to stand trial, but whether it

is substantially unlikely to have side effects that will

interfere with his ability to assist counsel. Those are two

22
separate and independent showings, each of which the government

must make under Sell’s second prong, 539 U.S. at 181, by clear

and convincing evidence, see Bush, 585 F.3d at 815; one cannot

substitute for the other. And as we have held, both showings

must be made “with respect to the particular defendant [the

government] seeks to medicate involuntarily,” id. at 815-16,

with the same “exacting focus on the personal characteristics of

the individual defendant and the particular drugs the

[g]overnment seeks to administer,” id. at 816 (quoting United

States v. Baldovinos, 434 F.3d 233, 240 n.5 (4th Cir. 2006)).

In this case, however, while the government does provide an

individualized analysis of Watson’s vulnerability to

counterproductive side effects from risperidone, that only

highlights its failure to provide comparable individualized

analysis of the likelihood that risperidone will actually

succeed in rendering Watson competent.

Finally, Lucking himself undermines the one section of his

report that purports to explain why risperidone was recommended

for Watson in particular. In that section, Lucking asserts that

risperidone is likely to be effective because Watson was treated

with risperidone during his 2009 admission to St. Elizabeth’s.

The report itself qualifies this assertion in at least two ways:

It admits that Lucking had not reviewed the hospital records

from that admission, and also that the mere fact that Watson

23
“was treated and released” by St. Elizabeth’s constitutes only

“indirect evidence of a positive response to antipsychotic

medication.” More importantly, the assertion was deprived of

significance during an April 30, 2013, hearing on the motion for

involuntary medication, when Lucking admitted that he would have

recommended risperidone even if he learned that Watson had never

taken it before. As Lucking made clear, his recommendation

rested not on any individualized assessment of Watson, but on

the belief that “antipsychotics are the treatment of choice for

psychotic symptoms” — the same nonspecific, syllogistic

reasoning we have previously rejected. See Evans, 404 F.3d at

241.

D.

We are concerned here not only with the deficiencies in the

government’s affirmative case for forcible medication, but also

with the substantial questions raised about the government’s

proposed treatment plan by Hilkey — questions never addressed by

the magistrate judge or district court. As we have recognized,

careful scrutiny by courts of proposed forcible administration

of antipsychotics is necessary to minimize the risk of error

where such important liberty interests are at stake. See Bush,

585 F.3d at 814. That scrutiny necessarily requires

consideration of any substantial and credible evidence that

24
undermines the case for forcible medication. But there is no

indication that such consideration occurred here.

The magistrate judge and district court did not examine and

then reject the concerns raised by Hilkey in his report, making

subsidiary factual determinations to which we would owe the

normal deference. Instead, they summarily disregarded Hilkey’s

report in its entirety, solely because Hilkey failed to state

expressly that the proposed treatment plan would not succeed.

Watson, 2014 WL 1901256, at *3, *16 (“As the Report and

Recommendation correctly notes, defendant’s medical expert, Dr.

Hilkey, did not state in his report that Dr. Lucking’s plan will

not succeed.”). But it is the government’s burden to prove, by

clear and convincing evidence, that its proposed treatment plan

is “substantially likely to render [Watson] competent to stand

trial,” White, 620 F.3d at 410 (quoting Sell, 539 U.S. at 181),

and not Watson’s burden to prove that it is not.

And by perfunctorily disregarding Hilkey’s report, the

district court here excluded from consideration significant

evidence that does indeed call into question whether forcible

medication is likely to “succeed” by restoring Watson’s

competency. For example, Hilkey disputes Lucking’s reading of

the scientific literature, asserting that “little is known about

[Delusional Disorder] compared to other psychotic disorders,”

and that what research does exist as to Delusional Disorder

25
indicates that individuals suffering from the Persecutory Type

are “most resistant” to treatment. Hilkey’s objections to the

scientific literature on the use of antipsychotic medication to

treat Delusional Disorder are particularly concerning in light

of Lucking’s heavy reliance on this research in his own report

and the magistrate judge’s second-order reliance on the same

research. Yet these concerns are barely acknowledged, let alone

adequately addressed, in the district court order.

The decisions below also failed to give adequate

consideration to Hilkey’s concern that Watson’s particular

persecutory delusions are especially unlikely to respond to

treatment. Hilkey opines that: (1) due to “[t]he chronic nature

of [Watson’s] illness and the fixed, well established nature of

his aberrant thoughts,” Watson’s condition is likely to be

“resistant to change,” and (2) without supportive therapy to

address Watson’s “strongly held beliefs and reported personal

experiences with psychotropic medications,” which “include

pronounced fears of death,” involuntary treatment will “only

contribute[] to [Watson’s] fears of persecution.” Those are

exactly the kind of individualized concerns that we have said

must be addressed by the government in order to meet its burden

of proving that the proposed treatment is substantially likely

to restore the defendant’s competency, see Evans, 404 F.3d at

241 (finding second-factor burden unmet where government

26
“nowhere addressed [the defense expert’s] concern that Evans’s

delusions of governmental conspiracies that ha[d] persisted

longer than 40 years [would] resist involuntary medication

precisely because the government administers the medication”) —

and yet they were summarily dismissed by the district court, see

Watson, 2014 WL 1901256, at *2-3, *16.

E.

In sum, the district court in this case did not undertake

the searching and individualized assessment of Watson’s likely

susceptibility to forcible medication that is required by our

case law. It took the government at its word when it argued

that the requirements of Sell had been met, without considering

whether the government had produced evidence “relat[ing] the

proposed treatment plan to the individual defendant’s particular

medical condition.” Evans, 404 F.3d at 242. This failure to

apply the proper legal standard exacerbated the district court’s

apparent failure to consider the concerns raised by Hilkey’s

report, which did relate to Watson specifically. See Chatmon,

718 F.3d at 376 (finding clear error where the district court

failed to “offer some reason why it did not” credit contrary

arguments). Perhaps as a result of these errors of synthesis,

the district court overlooked the issue lying at the heart of

this case: the meagerness of the evidence that forcible

treatment is substantially likely to restore Watson’s

27
competency, when his particular medical situation is taken into

account — especially as evaluated under the requisite clear and

convincing standard of proof.

Any one of these problems would raise questions under the

clear error standard of review, whether for misapprehension of

the relevant legal standard, failure to consider contrary

evidence, or reaching a conclusion against the clear weight of

the record. See Jiminez, 57 F.3d at 379. In this case, it is

enough to say that cumulatively, they leave us with “the

definite and firm conviction that a mistake has been committed,”

Francis, 686 F.3d at 273 (quoting United States v. Hall, 664

F.3d 456, 462 (4th Cir. 2012)), in a context where the costs of

error are exceedingly high. We therefore hold that the district

court clearly erred in finding that the government has met its

burden of proving by clear and convincing evidence — i.e.,

evidence of a sufficient weight to produce a “firm belief or

conviction, without hesitancy, as to the truth of the

allegations sought to be established,” Heyer, 740 F.3d at 292 —

“that the proposed treatment plan, as applied to this particular

defendant, is ‘substantially likely’ to render the defendant

competent to stand trial,” Evans, 404 F.3d at 242 (emphasis in

original).

We further conclude that this is the rare case in which a

remand is inappropriate because “the record permits only one

28
resolution of the factual issue”: that this burden cannot be

met. Pullman-Standard v. Swint, 456 U.S. 273, 292 (1982); see,

e.g., Ruiz-Gaxiola, 623 F.3d at 696 (declining to remand where

“[t]here is no explanation that the court could provide on

remand and no findings consistent with the record before us that

would allow us to conclude that the government has met its

burden under the second Sell factor”). In Bush, 585 F.3d at

817, 818, and Evans, 404 F.3d at 242-43, we remanded rather than

reversing after finding the record insufficient to support

forced medication under Sell. But in those cases, we

articulated new legal standards, Bush, 585 F.3d at 817; Evans,

404 F.3d at 241-42, and our remands, at least in part, afforded

the parties their first opportunities to present evidence and

make arguments under those standards. The standard we apply

today, by contrast, was established over ten years ago in Evans,

and we believe that the government has had ample opportunity to

assemble and defend the evidence necessary to meet it.

Because the government must prove that it has satisfied

each of the four Sell prongs before it may forcibly medicate a

defendant, we need not reach Watson’s remaining arguments to

conclude that the government has not justified forcible

medication in this case.

29
 IV.

Accordingly, the order of the district court is

REVERSED.

30
TRAXLER, Chief Judge, dissenting:

The district court granted the government’s petition to

involuntarily medicate John Watson in order to restore his

competency to stand trial. The majority reverses that order,

concluding that the government’s evidence was insufficient to

prove that the proposed treatment plan was substantially likely

to render Watson competent. In his appeal, however, Watson does

not challenge the sufficiency of the government’s evidence

establishing the necessity of medication. Instead, he argues

that the district court erred by not requiring supportive

therapy in addition to medication, which Watson contends would

increase the likelihood that he would be restored to competency.

This court generally does not address issues not raised by the

parties, and I believe it inappropriate in this case for the

majority to reverse the district court on an issue raised sua

sponte, particularly without giving the government notice of the

change in issues or an opportunity to address it. If the issue

were properly before us, however, I would find the evidence in

the record sufficient to support the district court’s order.

As to the issues actually raised by Watson, I conclude

that, as to one narrow issue, the district court failed to make

the necessary findings. However, I believe the proper course in

this circumstance is to vacate and remand for additional

31
findings, not simply reverse the district court outright.

Accordingly, I respectfully dissent.

I.

When seeking to involuntarily medicate a defendant for the

purpose of restoring his competency to stand trial, the

government must establish four factors by clear and convincing

evidence. See Sell v. United States, 539 U.S. 166, 180-81

(2003); United States v. Bush, 585 F.3d 806, 813-14 (4th Cir.

2009). First, the government must prove that “important

governmental interests are at stake” that are not mitigated by

“[s]pecial circumstances.” Sell, 539 U.S. at 180. Second, the

government must establish that forced medication “significantly

further[s]” the government’s interests because it is

“substantially likely to render the defendant competent to stand

trial” and “substantially unlikely” to have side effects that

would undermine the fairness of a trial. Id. at 181. Third, it

must show that forced medication is “necessary to further” the

government’s interests because “less intrusive means are

unlikely to achieve substantially the same results.” Id.

Fourth, the government must prove that the administration of the

requested drug is “medically appropriate, i.e., in the patient’s

best medical interest in light of his medical condition.” Id.

To carry its burden under Sell, the government must submit

a proposed treatment plan specifying the particular drug and

32
dosage it intends to administer. See United States v. Evans,

404 F.3d 227, 241 (4th Cir. 2005). For the treatment plan to

satisfy the requirements of the second factor, the government

must show that the plan relates

to the individual defendant’s particular medical
condition. In other words, the government,
considering all of the particular characteristics of
the individual defendant relevant to such a
determination, must first show that the treatment plan
will significantly further its interests. It must do
so by demonstrating that the proposed treatment plan,
as applied to this particular defendant, is
substantially likely to render the defendant competent
to stand trial and substantially unlikely to produce
side effects so significant as to interfere with the
defendant’s ability to assist counsel in preparing a
defense.

Id. at 242 (first emphasis added; footnote and internal

quotation marks omitted).

The question posed by the first Sell factor is a legal one,

and we therefore review the district court’s ultimate answer de

novo and any subsidiary factual determinations for clear error.

The remaining three factors pose factual questions subject to

clear error review. See United States v. White, 620 F.3d 401,

410 (4th Cir. 2010).

Clear error, of course, is a very deferential standard. “A

court reviewing for clear error may not reverse a lower court’s

finding of fact simply because it would have decided the case

differently. Rather, a reviewing court must ask whether, on the

entire evidence, it is left with the definite and firm

33
conviction that a mistake has been committed.” United States v.

Wooden, 693 F.3d 440, 451 (4th Cir. 2012) (internal quotation

marks and alteration omitted). “If the district court’s account

of the evidence is plausible in light of the record viewed in

its entirety, the court of appeals may not reverse it even

though convinced that had it been sitting as the trier of fact,

it would have weighed the evidence differently.” Anderson v.

City of Bessemer City, 470 U.S. 564, 573–74 (1985). “In cases

in which a district court’s factual findings turn on assessments

of witness credibility or the weighing of conflicting evidence

during a bench trial, such findings are entitled to even greater

deference.” Helton v. AT & T, Inc., 709 F.3d 343, 350 (4th Cir.

2013).

II.

Given the fact-bound nature of this appeal, I will first

summarize the primary evidence before the district court: the

report and testimony of Dr. Robert Lucking, the government’s

expert witness and staff psychiatrist at the Federal Medical

Center in Butner, North Carolina, the facility where Watson is

housed; a study by Byron L. Herbel and Hans Stelmach (the

“Herbel Study”) 1 that was relied upon by Lucking; and the report

1 See Byron L. Herbel & Hans Stelmach, Involuntary
Medication Treatment for Competency Restoration of 22 Defendants
With Delusional Disorder, 35 J. Am. Acad. Psychiatry & L. 47

34
of Dr. James Hilkey, a psychologist who served as Watson’s

expert witness.

A.

Dr. Lucking submitted a report detailing his views and

testified at the two Sell hearings conducted by the magistrate

judge. In his report, Lucking diagnosed Watson as suffering

from delusional disorder, paranoid (or persecutory) type and a

“substantial thought disorder.” J.A. 357. Lucking described

the nature of delusional disorder and stated his opinion that

Watson was incompetent to stand trial because his “paranoid

delusional beliefs” prevented Watson from “understand[ing] the

nature and consequences of the proceedings against him” and

prevented him from assisting his attorney. J.A. 359, 360.

Lucking stated his opinion that there was a “substantial

probability Mr. Watson’s competency can be restored” through

treatment with an antipsychotic medication. J.A. 376.

Lucking explained that antipsychotic medications can

restore the competency of those with active psychotic illnesses,

and he summarized various studies supporting this general

principle. As to delusional disorder more specifically, Lucking

(2007). The Herbel Study was submitted to the district court as
part of Watson’s opposition to the government’s petition.

35
noted in his report that “[p]ast opinion of the treatment of

delusional disorder with antipsychotic medication was

pessimistic. The prevailing opinion was that only a fraction of

individuals with delusional disorder would respond to treatment

(approximately 10%).” J.A. 371 (emphasis added). Lucking

explained, however, that “more recent literature indicates a

significantly better response rate,” J.A. 372, and he summarized

those more recent studies, which included several with rates of

successful treatment (i.e., full or partial remission of

symptoms) 2 exceeding 75%. Lucking acknowledged that there are

“no double-blind placebo-controlled or non-blinded placebo-

controlled trials in the literature related to the treatment of

delusional disorder,” and that the more recent literature

involved case studies, which yield “lower quality” evidence than

the evidence obtained through placebo-controlled trials. J.A.

372. These shortcomings notwithstanding, Lucking believed the

more recent studies “indicate delusional disorder can be treated

effectively with antipsychotic medication.” J.A. 374.

2
Lucking explained that “it is generally psychotic symptoms
which render an individual incompetent,” and that “the fewer
psychotic symptoms present, and the less intense the symptoms,
the more likely that individual is to be competent. Therefore,
even a partial response to antipsychotic medication can result
in a restoration of competency.” J.A. 370.

36
 The report explained the difference between first- and

second-generation antipsychotic drugs and noted that second-

generation antipsychotics “are considered to be the first line

treatment for psychotic conditions due to [their] less onerous

side effect profile.” J.A. 376. The report discussed the three

antipsychotic medications that could be administered

involuntarily and noted that risperidone is the only second-

generation antipsychotic that could practicably be administered

involuntarily. Lucking stated in the report that Watson had

previously been admitted to a hospital in Washington, D.C.,

where he was treated with risperidone. Lucking inferred from

the fact that Watson was released from the hospital that he

responded positively to the drug, and his treatment plan for

Watson recommended the use of risperidone.

Lucking’s report stated that treatment with an

antipsychotic would not produce side effects that would

interfere with Watson’s ability to assist his attorney; that

Watson had no underlying disease that would preclude the

standard treatment of any side effects or make him susceptible

to particular side effects; that risperidone would not interact

with any of the other medications prescribed for Watson; and

that Watson had no “underlying medical illness or conditions

which would preclude or be worsened by the use of antipsychotic

medication.” J.A. 375.

37
 In the report, Lucking explained that no less-intrusive

treatments were likely to achieve the same results as treatment

with risperidone. While acknowledging that psychotherapy can be

beneficial as an adjunct to treatment with antipsychotics,

Lucking noted that there is “no evidence that psychotherapeutic

techniques alone are effective alternatives for treatment with

antipsychotic agents.” J.A. 375 (emphasis added). Lucking also

indicated that therapy would not succeed in this case because

Watson does not understand that he has a mental illness, does

not believe he needs treatment, and would not participate in any

form of therapy.

During the Sell hearings held before the magistrate judge,

Lucking testified about the matters set out in his report and

reiterated his views that Watson’s delusional disorder rendered

him incompetent to stand trial and that treatment with an

antipsychotic medication was substantially likely to restore

Watson’s competency. Lucking also testified that he had treated

“[o]n an involuntary basis” approximately ten delusional-

disorder patients with antipsychotic medication, all of them

successfully. 3 J.A. 32. Lucking’s testimony also elaborated on

3 The majority questions whether Lucking’s testimony
establishes that the ten patients were treated involuntarily.
In my view, it clearly does. See J.A. 32 (“Q. How many patients
suffering from delusional disorder have you treated with
antipsychotic medication? A. On an involuntary basis, it’s not

38
the position expressed in the report that therapy would not be

helpful for Watson. Lucking explained that because thought

disorders and delusions respond positively to antipsychotic

medications but are not helped by therapy, he did not believe

therapy would be effective to restore Watson’s competency to

stand trial.

Although Lucking’s report recommended risperidone because

Watson had previously been treated with it and apparently

responded positively to it, Lucking testified at the hearing

that he would recommend risperidone even if Watson had never

taken the drug. As Lucking explained,

[t]he reason the risperidone was chosen is because we
are very limited. The fact that he had received it
before is a fraction of the reason for choosing that
medication. That medication is chosen, one, because
it’s appropriate to treat his delusional disorder;
two, the side effects are more tolerable than ones
from the 1st generation; the medicine is effective;
and I use it a lot, and I get [a] good response [to]
it. The fact that he had been on it is not the main
reason I chose it for the treatment plan.

J.A. 64-65; see also J.A. 76 (“[C]linically, I believe

[risperidone] is the best choice for treatment at this point in

time for Mr. Watson.”).

a lot of them because many of them – it’s a rather rare disorder
that you don’t see very often. So probably somewhere around ten
patients over the course of my career here I've treated with
antipsychotics.” (emphasis added)).

39
 B.

Dr. James Hilkey, Watson’s expert witness, prepared a

report after interviewing Watson for nearly ten hours over the

course of four separate interviews. Hilkey agreed that Watson

was suffering from delusional disorder, persecutory type, and

that Watson was incompetent to stand trial.

Hilkey’s report confirmed that Watson had been previously

treated with risperidone during an inpatient hospital stay. The

hospital records reviewed by Hilkey noted that Watson had an

adverse reaction to higher dosages of lithium but mentioned no

adverse reaction to the risperidone. Watson, however, told

Hilkey that he was “terrified” of the side effects of

antipsychotic medications and that he had “severe reactions” to

the single dose of risperidone he took under court order. J.A.

381. In Hilkey’s view, Watson’s fears about the medication

“interfaced with his conspiratorial belief system.” Id.

As to treatment with antipsychotics, Hilkey stated that

“pharmacological treatment of Delusional Disorders [is] less

efficacious than with typical psychotic disorder[s] such as

Schizophrenia.” Id. Hilkey noted the “paucity of controlled,

double-blind studies on treatment of individuals with delusional

disorders,” id., and observed that the “existing studies” show

that the persecutory type of the delusional disorder is the most

resistant to treatment, J.A. 382.

40
 Hilkey had “some question about the efficacy of

pharmacological treatment with Mr. Watson,” J.A. 383, noting

that “[t]he chronic nature of Mr. Watson’s illness and the

fixed, well established nature of his aberrant thoughts make

response to treatment (pharmacological and psychological)

resistant to change,” J.A. 383. However, Hilkey never directly

stated an opinion on the likely success of the treatment plan

proposed by Lucking. Hilkey instead focused on the need for

“[s]upportive therapy,” which “has been shown to be an effective

treatment.” J.A. 382. As Hilkey explained,

[t]he general goals of supportive therapy are to
facilitate the treatment adherence and develop a
therapeutic alliance, to provide education about the
disorder, to improve social skills (i.e. not talking
about delusional systems in social places) and to
manage behavioral and psychological problems
associated with the delusions. This is a slow
process; failure to offer this type of supportive
treatment in lieu of more aggressive therapy only
reinforces the established fears that characterize
persecutory delusional disorders.

J.A. 382-83 (footnote omitted). Given Watson’s “strongly held

beliefs and reported personal experiences with psychotropic

medications to include pronounced fears of death,” Hilkey

believed that “any treatment approach be it pharmacological or

psychological must be offered in a supportive manner designed to

mitigate the fears of the individual being treated. Failure to

compassionately address these fears only contributes to fears of

persecution.” J.A. 383. In Hilkey’s view, Watson’s relationship

41
with his attorneys showed his ability to form some degree of the

“therapeutic alliance” required for therapy to succeed, and

Hilkey “strongly believed” that supportive therapy “could

increase the likelihood his competency could be sufficiently

restored.” J.A. 384.

C.

The Herbel Study reported findings from an evaluation of

the case files of twenty-two men involuntarily medicated at FMC-

Butner, the same facility where Watson is housed and Dr. Lucking

works. Of the twenty-two cases studied, sixteen of the patients

suffered from delusional disorder, persecutory type; one had

delusional disorder, grandiose type; and five were mixed

persecutory and grandiose type. Overall, seventeen of the

twenty-two patients (77%) were reported restored to competency.

And of the sixteen patients diagnosed with delusional disorder,

persecutory type, eleven (69%) were reported restored to

competency. Of the five patients who were not restored to

competency, one was mixed type and the other four were

persecutory type.

The information reviewed was sufficient in nineteen cases

for the authors of the Herbel Study to determine how long before

treatment the symptoms had begun. The symptoms had been present

for five years or less for nine patients, seven of whom were

restored to competency. Six patients had had symptoms for seven

42
to ten years, and all six of those patients were restored to

competency. Of the four patients who were symptomatic for a

much longer period of time (thirteen to twenty-four years), only

one was restored to competency. 4

The study reported that seven patients were restored to

competency within six weeks of beginning treatment, but that the

other ten who were restored to competency did not shows signs of

improvement until undergoing at least three months of continuous

treatment, and that some of the patients required five months of

treatment before regaining competency. The authors thus

recommended treatment trials of at least four months, and noted

that many previous studies involved significantly shorter

medication trials. In the authors’ view, the too-short duration

of medication in the previous studies provided a “plausible

explanation” for the incorrect “conventional wisdom that these

patients are refractory to treatment with antipsychotic

medication.” J.A. 147; see also J.A. 141 (describing as

“empirically unsupported” the opinion asserted in forensic

psychiatric literature that “Delusional Disorder is notoriously

treatment resistant”).

4
The evidence in the record establishes that Watson had
been suffering from delusions since 2008 or 2009. Thus, when
the district court issued its order in April 2014, Watson had
been suffering from the disorder for five to six years.

43
 The authors noted that some experts have expressed concern

that patients whose core delusion involves a belief that they

are victims of a governmental conspiracy were not likely to

respond to forced medication “‘precisely because the government

administers the medication.’” J.A. 149 (quoting United States

v. Evans, 404 F.3d 227, 241 (4th Cir. 2005)). As to the twenty-

two cases studied, sixteen had delusions of governmental

persecution, eleven of whom (65%) were restored to competency;

the five patients who were not restored to competency all had

such delusions. In light of that data, the authors concluded

that “the presence of delusions involving themes of persecution

by the same government that is implementing involuntary

medication does not appear to be a useful predictor of

nonresponse to treatment.” J.A. 149.

The authors noted that their study was subject to the

“usual limitations” inherent in “retrospective inpatient chart

review,” including the “lack of standardized clinical

assessments with rating scales and diagnostic instruments, as

well as lack of interrater reliability studies.” Id. Because

of those limitations,

some patients may have been misdiagnosed and wrongly
included or excluded from this study population.
Standard research methods to reduce bias, such as
random assortment to assigned treatment groups, the
use of a placebo control group, and blinded outcome
measures, were not possible in this study. Without
these safeguards, the opinions of the forensic

44
 examiners may have been biased in favor of finding a
positive response to treatment.

J.A. 149-50. The authors, however, also pointed out a strength

of the study:

[T]he patient cohort was selected in a real-world
manner by criminal prosecution, after which they were
assessed and involuntarily treated in a real-world
manner at a forensic mental health facility. The main
contribution of this study was the observation of
treatment response in patients with delusional
disorder who, in contrast to the usual protocols in
community research studies, were not permitted to drop
out of treatment. That 10 of the 17 patients who
responded to treatment required continuous
antipsychotic treatment for at least three months, and
some up to five months, was unexpected. This result
provides a plausible explanation for the presumed
refractory nature of delusional disorder symptoms.
The real obstacle to a positive treatment response in
delusional disorder may not be the intrinsic
biological features of the illness, but may instead be
the difficulties in convincing these patients to
adhere to an adequate trial of medication.

J.A. 150 (emphasis added).

III.

When considering whether the government’s proposed

treatment plan was “substantially likely to render the defendant

competent to stand trial,” Sell, 539 U.S. at 181, the district

court concluded that Dr. Hilkey strongly recommended supportive

therapy but that he never opined that medication alone would not

restore Watson’s competency. On appeal, Watson contends that

the district court’s analysis reflects a clearly erroneous

understanding of Hilkey’s testimony. See Brief of Appellant at

45
2 (“[T]he district court clearly err[ed] by misunderstanding the

opinion of the defense expert about the necessity of holistic

treatment.”); id. at 25 (“The district court’s misunderstanding

of Dr. Hilkey’s conclusions constitutes clear error.”).

Acknowledging that Hilkey never directly stated that the

proposed treatment plan would not work, Watson contends that

when Hilkey’s report is considered in its entirety, its meaning

is clear: “Dr. Hilkey does not disagree with Dr. Lucking that

Mr. Watson should be medicated. To the contrary, Dr. Hilkey

agrees that medication is necessary, but it must be combined

with supportive therapy in order to be successful.” Brief of

Appellant at 24. Watson thus argues the district court clearly

erred by misinterpreting Hilkey’s report and by not requiring

the government to provide supportive therapy as part of the

treatment plan.

Rather than focusing on the need for supportive therapy,

however, the majority reverses the district court’s order after

concluding that the government’s evidence was insufficiently

related to Watson himself and his particular medical condition,

and that the government’s “generalized” evidence was

insufficient to carry its burden of proof under Sell. See

Majority Op. at 2 (“[T]he government has not met its burden of

proving that involuntary medication is substantially likely to

restore Watson’s competency . . . .”); id. at 17-18 (“Permitting

46
the government to meet its burden through generalized evidence

alone would effectively allow it to prevail in every case

involving the same condition or course of treatment.”).

A challenge to the overall sufficiency of the evidence,

however, is very different from a challenge to the sufficiency

of the district court’s distillation of the evidence. A

challenge to the sufficiency of the evidence asks whether there

is any plausible view of the evidence that supports the district

court’s decision. See Anderson, 470 U.S. at 573-74; United

States v. Springer, 715 F.3d 535, 545 (4th Cir. 2013); see also

VICI Racing, LLC v. T-Mobile USA, Inc., 763 F.3d 273, 283 (3d

Cir. 2014) (“A finding of fact is clearly erroneous when it is

completely devoid of minimum evidentiary support displaying some

hue of credibility or bears no rational relationship to the

supportive evidentiary data.” (internal quotation marks

omitted)). A challenge to sufficiency of the district court’s

distillation of the evidence, however, asks whether the district

court as factfinder properly “synthesize[d] the evidence in a

manner that accounts for conflicting evidence or the gaps in a

party’s evidentiary presentation.” Doe v. Menefee, 391 F.3d

147, 164 (2d Cir. 2004) (Sotomayor, Circuit Judge); accord

Miller v. Mercy Hosp., Inc., 720 F.2d 356, 361 (4th Cir. 1983)

(explaining that clear error may be found where “the findings

under review . . . were made without properly taking into

47
account substantial evidence to the contrary”). An insufficient

distillation of the evidence is an error that can be corrected

by the district court, through an order on remand that considers

all evidence and properly accounts for contrary evidence.

Insufficient evidence, by contrast, cannot be corrected by the

district court -- insufficient evidence is insufficient,

regardless of the thoroughness of the order evaluating it.

In this case, Watson simply does not challenge the

sufficiency of the government’s evidence. Watson does not argue

on appeal that the government’s evidence, standing alone, was

insufficient to satisfy the Sell requirements, nor does he

contend that the government’s evidence was not sufficiently

individualized to him and his condition. Instead, by arguing

that the district court failed to grasp the import of Hilkey’s

report, Watson is challenging only the district court’s

synthesis of the evidence, not the existence of the evidence.

Indeed, Watson’s argument that Hilkey’s report establishes the

need for medication and supportive therapy effectively concedes

that the record contains evidence sufficient to establish that

Watson’s competency can be restored.

Thus, without acknowledging what it is doing, the majority

disregards the argument actually made by Watson and resolves the

appeal on an entirely different basis involving an entirely

different kind of error -- the government’s failure to carry its

48
burden of proof, rather than the district court’s failure to

properly synthesize the evidence. 5 Moreover, by reversing the

district court’s order without remanding, the majority is

granting relief that no one has sought, as Watson does not seek

a reversal, but instead asks this court to vacate and remand for

further proceedings. 6

It is well-settled that this court may affirm a district

court’s order on any basis appearing in the record. See, e.g.,

Blum v. Bacon, 457 U.S. 132, 137 n.5 (1982) (“[A]n appellee may

rely upon any matter appearing in the record in support of the

judgment below.”); Scott v. United States, 328 F.3d 132, 137

(4th Cir. 2003) (“We are, of course, entitled to affirm on any

ground appearing in the record, including theories not relied

5 While the majority does note some deficiencies in the
district court’s order and briefly mentions the cumulative
effect of the errors it identifies, the opinion nonetheless
makes it clear that the majority is reversing for insufficient
evidence. See Majority Op. at 2 (“In this case, we conclude,
the government has not met its burden of proving that
involuntary medication is substantially likely to restore
Watson’s competency.”); id. at 25 (“We therefore hold that the
district court clearly erred in finding that the government has
met its burden of proving, by clear and convincing evidence, . .
. that the proposed treatment plan, as applied to this
particular defendant, is substantially likely to render the
defendant competent to stand trial.” (internal quotation marks
omitted)).
6 Although Watson’s opening and reply briefs ask us to
vacate without mentioning remand, counsel made clear at oral
argument that Watson is asking us to vacate the district court’s
order and remand for further proceedings.

49
upon or rejected by the district court.”). When it comes to

reversing a district court’s order, however, our discretion is

much more constrained. As a general rule, this court does not

consider non-jurisdictional issues that are not properly

presented in an appellant’s opening brief, see, e.g., Suarez-

Valenzuela v. Holder, 714 F.3d 241, 248-49 (4th Cir. 2013), much

less issues that the appellant never even attempts to raise.

While we have the power to address issues not raised by the

appellant, see A Helping Hand, LLC v. Baltimore Cnty, 515 F.3d

356, 369 (4th Cir. 2008), we do not exercise that power in civil

cases unless the issue “establishes fundamental error or a

denial of fundamental justice,” In re Under Seal, 749 F.3d 276,

285-86 (4th Cir. 2014) (internal quotation marks omitted). 7

The majority does not contend that the error it identifies

rises to the level of a fundamental error, nor does it otherwise

attempt to explain why the facts of this case justify such a

departure from our settled practice. This court should not be

in the business of re-writing the parties’ briefs and raising

7 Of course, “[w]hen an issue or claim is properly before
the court,” a reviewing court “is not limited to the particular
legal theories advanced by the parties, but rather retains the
independent power to identify and apply the proper construction
of governing law.” Kamen v. Kemper Fin. Servs., Inc., 500 U.S.
90, 99 (1991) (emphasis added). This rule has no application in
this case because Watson does not challenge the sufficiency of
the evidence, and the sufficiency issue thus is not properly
before this court.

50
issues we think they should have raised. Watson does not

challenge the sufficiency of the evidence on appeal, and I

believe it is improper in this case for the majority to reverse

the district court on an issue the majority has raised sua

sponte, particularly where the government has been given no

notice of the change in the direction of this appeal nor an

opportunity to address the issue the majority finds dispositive.

IV.

As discussed above, I do not believe the sufficiency-of-

the-evidence question is properly before us. But if it were, I

would disagree with the majority’s analysis. In my view, the

evidence before the district court was sufficient to support the

court’s factual determination that involuntary medication was

“substantially likely to render the defendant competent to stand

trial.” Sell, 539 U.S. at 181.

A.

In finding the government’s evidence insufficient, the

majority focuses on our requirement that the government “show

that a treatment plan works on a defendant’s type of mental

disease in general, [and] that it is likely to work on this

defendant in particular.” Bush, 585 F.3d at 816. To show the

appropriate consideration of the defendant “as an individual,”

Evans, 404 F.3d at 240, the evidence must establish that the

experts recommending involuntary medication “actually considered

51
[the defendant’s] particular mental and physical condition in

reaching [their] conclusions,” id. In my view, Lucking’s

report, fairly read, is replete with evidence of his

consideration of Watson himself and his particular medical

condition.

According to the majority, the entirety of Lucking’s

analysis justifying the proposed treatment plan was that

“(1) antipsychotic medication effectively treats psychotic

symptoms; (2) Watson has psychotic symptoms; (3) therefore,

antipsychotic medication will effectively treat his psychotic

symptoms,” an analysis the majority rejects as “nonspecific,

syllogistic reasoning.” Majority Op. at 19. I disagree.

While Lucking did note in his report that “there is

extensive support in the psychiatric literature that individuals

with the diagnosis of a psychotic illness obtain substantial

reduction in their psychotic symptoms when treated with

antipsychotic medication,” J.A. 369, that was not the entirety

of his analysis when recommending medication. Lucking’s report

discussed delusional disorder in general, but also described how

the disorder presented itself in Watson and the nature of

Watson’s delusions. Lucking considered the general efficacy of

antipsychotic medications on psychotic illnesses generally, but

he then went on to consider the efficacy of antipsychotic

medications on Watson’s specific condition by discussing the

52
limited scientific literature addressing the treatment of

delusional disorder, acknowledging studies to the contrary, but

noting that the more recent literature shows a high rate of

improvement in response to medication. Indeed, as Lucking’s

report indicates, the Herbel Study shows a high treatment

response rate by patients with the persecutory subtype (69%

restored to competency) and high response rates by patients

whose delusions had persisted for approximately as long as

Watson’s. 8 Lucking therefore supported his proposed treatment

plan with scientific literature involving similarly situated

patients suffering from Watson’s specific disorder, as we

require. See Bush, 585 F.3d at 816 (concluding that Herbel

Study did not “relate[] to the particular circumstances” of the

defendant with 13-year history of untreated persecutory type of

delusional disorder, because Herbel Study showed 25% recovery

rate for defendants with “duration of untreated psychosis

greater than 13 years”); White, 620 F.3d at 421 (finding Herbel

Study to be of “limited assistance” in case involving female

defendant suffering from grandiose type of delusional disorder

8
As noted, Watson had been delusional for five or six years
prior to the district court’s ruling. Nine patients in the
Herbel Study had been symptomatic for five years or less, seven
of whom (77%) were restored to competency. Six patients been
symptomatic for seven to ten years before treatment, all of whom
(100%) were restored to competency.

53
because Herbel Study involved male defendants, only one of whom

had the grandiose form of the disorder).

In addition, Lucking considered whether Watson was taking

medication that would adversely interact with his proposed

treatment or had other medical conditions that would place him

at special risk for developing the more serious side effects or

preclude the standard treatment for managing any side effects.

Lucking also considered Watson’s beliefs about himself and his

illness when concluding that therapy would not be beneficial.

Cf. Bush, 585 F.3d at 818 (finding proposed treatment plan

inadequate where it recommended medication that can cause

diabetes without acknowledging that defendant had diabetes,

addressing how the medications would affect his diabetes, or

outlining a plan for controlling his condition).

And after considering all the circumstances, Lucking

determined, in his expert opinion, that treating Watson with

risperidone was substantially likely to restore his competence.

As Lucking explained, it was the delusional beliefs that were

rendering Watson incompetent, and risperidone

produces beneficial clinical effects such as
decreasing delusional beliefs. . . . By decreasing
delusional beliefs this decreases the influence they
have on decisions, judgements, and perceptions. This
will allow Mr. Watson to make reasonable, rational,
reality based decisions regarding the processing of
his legal charges. By decreasing delusional beliefs
and restoring more normal thought processes,

54
 risperidone can improve the level of communication
between the client and his attorney.

J.A. 369. Given the amount of detailed information contained in

Lucking’s report and testimony, I fail to understand how the

majority can reject Lucking’s analysis as “nonspecific,

syllogistic reasoning.”

The majority contends that its rejection of Lucking’s

evidence is warranted because his report and testimony failed to

relate[] the proposed treatment plan to Watson’s
particular medical condition. . . . There is
virtually nothing in Lucking’s report or testimony . .
. that is sufficiently specific to Watson that it
could satisfy the government’s burden of showing that
Watson is substantially likely to be rendered
competent by forcible medication, let alone meet the
rigorous clear and convincing standard.

Majority Op. at 17-18 (emphasis added). While the majority

finds the government’s evidence insufficiently specific, it

provides no concrete example of how the evidence is inadequate

or what other information should have been presented. The

closest the majority comes to actually identifying the perceived

deficiencies is its suggestion that the evidence failed to

connect the proposed treatment plan “not only [to Watson’s]

medical condition but also [to] his age and the nature and

duration of his delusions.” Majority Op. at 16.

As recounted above, however, the evidence in the record

does precisely that. The government’s evidence addresses the

efficacy of involuntary treatment of those with the persecutory

55
form of delusional disorder, which is Watson’s “medical

condition.” The government’s evidence, particularly the Herbel

Study, shows success in treating the persecutory subtype of

delusional disorder and thus addresses the “nature” of Watson’s

delusions. The Herbel Study likewise shows success in

involuntarily treated defendants whose delusions have persisted

approximately as long as Watson’s, thus addressing the

“duration” of Watson’s illness. 9

While the majority contends that the district court did not

explicitly address questions raised by Dr. Hilkey about whether

Watson’s “particular persecutory delusions” would respond to

medication, Majority Op. at 26, a failure by the district court

to address a given issue cannot be equated to a failure of

proof. The evidence presented by the government provided bases

for the district court to conclude, despite the questions raised

by Hilkey, that the government’s proposed treatment plan was

substantially likely to restore Watson’s competency. Given the

wealth of information showing the government’s consideration of

9
As to age, the record shows that the government properly
recorded and reported Watson’s age in the relevant forms and
reports. Beyond the possible connection of age to the duration
of symptoms, however, there is nothing in the record suggesting
that a patient’s age is relevant to issues in this case. That
is, nothing in the record suggests, for example, that older
patients are more prone to suffer from the side effects of
antipsychotics, or that patients of a particular age are more
or less responsive to antipsychotic drugs.

56
Watson’s specific diagnosed psychological condition as well as

his physical condition, the majority’s rejection of the

government’s evidence simply cannot be squared with our highly

deferential standard of review.

B.

The majority draws support for its conclusion on Lucking’s

testimony at the Sell hearing that he would have recommended

risperidone for Watson whether or not Watson had previously

taken it. In the majority’s view, this testimony shows that

Lucking’s recommendation “rested not on any individualized

assessment of Watson, but on the belief that ‘antipsychotics are

the treatment of choice for psychotic symptoms’ -- the same

nonspecific, syllogistic reasoning we have previously rejected.”

Majority Op. at 24.

Lucking’s risperidone recommendation was based on Lucking’s

belief that Watson had previously taken it without incident and,

as discussed above, on an individualized assessment of the

particular disorder affecting Watson, the other medications

Watson was taking, and whether Watson had any underlying

conditions that would cause or complicate the treatment of any

side effects. Moreover, Lucking reached his recommendation by

relying on studies involving treatment of patients suffering

from Watson’s specific disorder. Lucking’s recommendation was

therefore based on a consideration of Watson’s particular

57
diagnosis and physical condition. That Lucking also had more

generalized reasons to chose risperidone 10 does not somehow

negate the individualized aspects of Lucking’s analysis and

render it insufficient as a matter of law.

C.

The majority also suggests that the government’s evidence

is insufficient because the academic literature relied upon by

Lucking does not “bear[] on Watson’s particular medical

condition or circumstances,” Majority Op. at 17, and because of

“weaknesses” the majority perceives in the studies that support

Lucking’s conclusions, id. at 20. Again, I disagree.

1.

As noted by the majority, not all of the studies cited in

Lucking’s report specifically address the treatment of

delusional disorder, and not all of those specifically

addressing delusional disorder show a positive response to

treatment by a majority of the patients. Nonetheless, Lucking’s

report discusses several studies, including the Herbel Study,

that provide clear support for the use of antipsychotic drugs in

the treatment of delusional disorder generally and more

10As Lucking’s report and testimony established, second-
generation antipsychotics are preferred over first-generation
antipsychotics because of their less-severe side-effect profile,
and risperidone is the only second-generation medication that
can practicably be administered involuntarily.

58
specifically in the treatment of the persecutory form of the

disorder. 11

While the studies that discuss the general efficacy of

antipsychotics in the treatment of psychotic illnesses may not

bear on Watson’s particular medical condition, I am perplexed by

the majority’s claim that the other studies do not bear on

Watson’s condition. The issue in this case is whether Watson,

who suffers from delusional disorder, should be involuntarily

treated with antipsychotic medication. Lucking relied on

literature addressing the treatment of delusional disorder with

antipsychotic medication, including the Herbel Study, which

11
As the majority concedes, the Herbel Study “unequivocally
support[s] the involuntary use of antipsychotic medication to
restore the competency of defendants with the Persecutory Type
of Delusional Disorder.” Majority Op. at 20-21. In addition to
the Herbel Study, Lucking’s report discusses a 1995 article
reviewing 209 cases of delusional disorder being treated with
antipsychotics, which determined that 53% of the patients fully
recovered, 28% partially recovered, and 20% did not improve.
While there is no indication of how many of the patients
suffered from the persecutory form of the disorder, the study
revealed that “[t]reatment was positive regardless of delusional
content,” J.A 372 (emphasis added), thus indicating that the
persecutory form of the disorder is no less responsive to
medication. And since the record establishes that “even a
partial response to antipsychotic medication can result in a
restoration of competency,” J.A. 370, the study’s 81% full-or-
partial recovery rate clearly supports Lucking’s opinion that
delusional disorder can be successfully treated with
antipsychotics. Lucking’s report also discusses a 2006 study
involving eleven patients with delusional disorder, ten of whom
had a complete remission of symptoms after being treated with a
first-generation antipsychotic.

59
studied the efficacy in the prison context of involuntary

medication to restore the competency of defendants suffering

from delusional disorder. The scientific literature thus

directly addresses Watson’s specific condition and was properly

relied on by Lucking and the district court. Indeed, if these

studies do not bear on Watson’s particular medical condition, it

seems unlikely that any academic literature short of a paper

devoted entirely to the treatment of the actual defendant in

question would meet the majority’s unexplained standard for

“bearing” on an incompetent defendant’s particular medical

condition.

2.

More troubling than the majority’s claim that the academic

literature does not bear on Watson’s particular condition,

however, is the majority’s failure to give any weight to the

supportive studies when determining the sufficiency of the

evidence before the district court. The majority concedes that

the Herbel Study provides unequivocal support for the

government’s proposed treatment plan, but it dismisses that

study as “vulnerable to bias in favor of finding a positive

response to treatment.” Majority Op. at 21 (alteration and

internal quotation marks omitted). The majority does not

mention the other supportive studies, presumably because of the

unidentified “weaknesses” perceived by the majority.

60
 The majority’s treatment of these studies, particularly its

rejection of the Herbel Study, fails to respect the limited role

of an appellate court applying clear-error review. The question

in this case is not whether the majority itself is persuaded by

Dr. Lucking and the studies he relied on, but whether there is

any plausible view of the record that clearly and convincingly

establishes the propriety of the proposed treatment plan. See

Anderson, 470 U.S. at 573–74. And when answering that question,

we are required to view the evidence in the light most favorable

to the government, the prevailing party. See United States v.

Antone, 742 F.3d 151, 155 n.1 (4th Cir. 2014) (reviewing

district court’s order finding defendant subject to indefinite

civil commitment as a sexually violent predator).

As noted above, Lucking’s report discussed studies that

concluded that delusional disorder, including the persecutory

subtype, can be successfully treated with antipsychotic

medications, and he also discussed studies reaching the opposite

conclusion. The district court was thus presented with

conflicting evidence about the efficacy of treating delusional

disorder with antipsychotic medications, a conflict that the

court implicitly, but nonetheless undeniably, resolved in the

government’s favor. And under our standard of review, this

court is obliged to defer to the district court’s resolution of

the conflict. See Anderson, 470 U.S. at 574 (explaining that

61
deference to district court’s factual findings is required “even

when the district court’s findings do not rest on credibility

determinations, but are based instead on physical or documentary

evidence or inferences from other facts”).

Rather than treating the positive studies as evidence

supporting the proposed treatment plan, however, the majority

treats the conflict in the evidence as an opportunity for

factfinding. The majority weighs the conflicting scientific

literature and declares it “equivocal,” and then rejects the

equivocal evidence as insufficient to support Lucking’s opinion.

This approach is inconsistent with our role as a reviewing

court, “for our function is not to reweigh the evidence

presented to the district court.” United States v. Charleston

County, 365 F.3d 341, 349 (4th Cir. 2004); see Ceraso v. Motiva

Enters., LLC, 326 F.3d 303, 316 (2d Cir. 2003) (“The weight of

the evidence is not a ground for reversal on appeal, and the

fact that there may have been evidence to support an inference

contrary to that drawn by the trial court does not mean that the

findings are clearly erroneous.” (citation omitted)).

Moreover, the majority’s specific criticism of the Herbel

Study -- that it is vulnerable to bias -- provides no basis for

removing the Study from the sufficiency-of-the-evidence

equation. As noted above, the authors of the Herbel Study

acknowledged that “[s]tandard research methods to reduce bias,

62
such as random assortment to assigned treatment groups, the use

of a placebo control group, and blinded outcome measures, were

not possible” given that the study consisted of a “retrospective

inpatient chart review.” J.A. 149-50. These criticisms,

however, could be levelled against all of the studies, positive

or negative, addressing the treatment of delusional disorder.

As the record makes clear, delusional disorder is very rare, and

there are no controlled studies of the use of antipsychotic

medication to treat delusional disorder, only case studies,

which yield “lower quality” evidence than do controlled studies.

Notwithstanding the limitations inherent in the limited

available scientific literature, both Dr. Lucking and Dr. Hilkey

relied on the available literature when reaching their

conclusions. There is no evidence in the record raising any

question about the propriety of that reliance, nor is there any

other evidence that otherwise would permit us to reject the

Herbel Study or the other studies supporting Lucking’s position

and exclude them from consideration when evaluating the

sufficiency of the evidence.

The majority suggests that the supportive studies would be

entitled to some evidentiary weight if there had been some

“explanation or analysis applying their findings to Watson as an

individual.” Majority Op. at 21. However, all of the

information necessary to apply to the findings of these studies

63
to Watson is found in Lucking’s report, which makes it clear

that the studies involved the use of antipsychotic medications

to treat those suffering from delusional disorder, including the

persecutory subtype of the disorder. Lucking’s report does not

use impenetrable scientific jargon when describing the studies,

and the district court was thus more than capable of reading

Lucking’s report and drawing its own conclusions about the

various studies discussed in the report. See, e.g., United

States v. Bales, 813 F.2d 1289, 1293 (4th Cir. 1987) (explaining

that where the district court acts as factfinder, “the judge

weighs the evidence, determines the credibility of the

witnesses, and finds the facts . . . [and] may select among

conflicting inferences to be drawn from the testimony”). While

it perhaps would have been helpful if Lucking had explicitly

testified that the studies addressed the very condition

affecting Watson, his failure to do so cannot be grounds for

reversal when that information was otherwise presented to the

district court.

When the scientific evidence is considered along with

Lucking’s report and testimony and viewed in the light most

favorable to the government, see Antone, 742 F.3d at 155 n.1, I

believe that evidence is sufficient to support the district

court’s order.

64
 D.

To the extent the majority’s real complaint is that the

government’s evidence is not compelling enough to constitute

clear and convincing evidence as a matter of law, then I again

disagree.

Evidence crosses the clear and convincing threshold if it

is “of such weight that it produces in the mind of the trier of

fact a firm belief or conviction, without hesitancy, as to the

truth of the allegations sought to be established, and, as well,

as evidence that proves the facts at issue to be highly

probable.” Springer, 715 F.3d at 538 (internal quotation marks

omitted).

In my view, a factfinder could reasonably find the Herbel

Study more compelling and its conclusions more persuasive than

the earlier studies questioning the efficacy of medication for

delusional disorder. As previously noted, ten of the seventeen

Herbel-Study patients restored to competency took three months

or longer to respond to the medication, a period significantly

longer than the medication trials involved in the earlier, more

pessimistic studies. See J.A. 150 (“That 10 of the 17 patients

who responded to treatment required continuous antipsychotic

treatment for at least three months, and some up to five months,

was unexpected. This result provides a plausible explanation

for the presumed refractory nature of delusional disorder

65
symptoms.”). Moreover, unlike earlier studies of voluntary

treatment for delusional disorder, the Herbel Study demonstrates

the efficacy of medication when the subjects are not permitted

to drop out of treatment. Because the Herbel Study assessed the

success of involuntary treatment administered under

circumstances largely identical to those at issue in this case

and provides a reasonable basis for discounting the more

pessimistic conclusions of other studies, I believe a factfinder

could reasonably find that the Herbel Study clearly and

convincingly supports the government’s position. Cf. United

States v. Gillenwater, 749 F.3d 1094, 1103 (9th Cir.) (O’Connor,

J.) (finding district court did not clearly err in accepting

testimony of Dr. Lucking over defense expert who “relied

exclusively on older studies,” when Lucking “relied on more

recent studies indicating that the older negative view was

mistaken”), cert. denied, 135 S. Ct. 222 (2014).

Similarly, there is evidence in the record making it

reasonable for the factfinder to assign significant weight to

Lucking’s recommendation. As noted above, Lucking testified

that he had involuntarily medicated approximately ten

defendants suffering from delusional disorder, all of whom were

restored to competency. His personal success in treating the

same disorder as Watson’s, under the same circumstances that

Watson would be treated, could reasonably be viewed by the

66
factfinder as strong evidence that the treatment plan proposed

by the government was substantially likely to restore Watson’s

competency.

The majority, however, dismisses the evidence of Lucking’s

experience because Lucking provided no details about those

patients and we therefore do not know how many of his patients

suffered from the persecutory type of disorder or what type of

medication was used. While more detail would be helpful, I do

not believe the lack of detail somehow renders Lucking’s

experience irrelevant, particularly since the Herbel Study shows

a high response rate for all delusional-disorder patients,

including those with the persecutory subtype, and finds that the

presence of delusions of governmental persecution “does not

appear to be a useful predictor of nonresponse to treatment.”

J.A. 149. Because the factfinder would be entitled to consider

Lucking’s testimony in light of the other evidence presented at

trial, see, e.g., Davis v. Richmond, Fredericksburg & Potomac

R.R. Co., 803 F.2d 1322, 1327 (4th Cir. 1986), the findings of

the Herbel Study make the lack of detail in Lucking’s testimony

less significant than the majority suggests. Under these

circumstances, I believe it is improper for the majority to

refuse to consider Lucking’s testimony about his experience

treating defendants with delusional disorder as part of its

evaluation of the sufficiency of the evidence.

67
 In my view, then, the record thus provides a plausible

basis for the factfinder to slide extra weight over to the

government’s side of the scale and conclude that the evidence

clearly and convincingly establishes the propriety of the

proposed treatment plan. Although there is evidence supporting

a contrary conclusion and raising questions about certain

aspects of the government’s proposed plan, that contrary

evidence does not raise such substantial questions about the

government’s evidence as to render it insufficient as a matter

of law, but instead simply creates questions of fact for

resolution by the factfinder. See, e.g., United States v.

Heyer, 740 F.3d 284, 292 (4th Cir. 2014) (“[E]valuating the

credibility of experts and the value of their opinions is a

function best committed to the district courts, and one to which

appellate courts must defer.” (internal quotation marks

omitted)). I therefore disagree with the majority’s conclusion

that the government’s evidence was insufficient to carry its

burden of proof.

V.

I now turn to the merits of Watson’s argument that the

district court clearly erred by misinterpreting Hilkey’s report

and the need for supportive therapy in addition to medication.

68
 A.

In its order, the district court acknowledged that while

Hilkey “strongly support[ed] the use of supportive . . .

psychotherapy alongside pharmacological treatments, Hilkey “did

not opine in his forensic evaluation that Dr. Lucking’s

treatment plan will be unsuccessful.” J.A. 340. Citing

Lucking’s report and testimony, the district court held that the

proposed treatment plan was substantially likely to render

Watson competent to stand trial, and the court granted the

government’s motion to involuntarily medicate Watson without

requiring the government to provide supportive therapy.

On appeal, Watson argues that the district court erred by

finding that Hilkey only suggested supportive therapy in

addition to medication. Watson contends that Hilkey’s report

made it clear that medication must be combined with supportive

therapy for the medication to succeed in restoring his

competency. Watson argues that because the district court

misunderstood Hilkey’s report, the district court never gave

proper consideration to the evidence contradicting Lucking’s

evidence and thus clearly erred. 12 See, e.g., Wooden, 693 F.3d

12The majority touches on this issue in the course of
identifying various deficiencies in the district court’s order.
According to the majority, the district court “summarily
disregarded Hilkey’s report in its entirety, solely because
Hilkey failed to state expressly that the proposed treatment

69
at 454 (finding clear error where district court ignored

substantial amount of contradictory evidence). In support of

his argument, Watson points to Hilkey’s statement that “any

treatment approach be it pharmacological or psychological must

be offered in a supportive manner designed to mitigate the fears

of the individual being treated.” J.A. 383 (emphasis added).

According to Watson, this statement “unequivocal[ly]” shows

Hilkey’s view that “[a]ny treatment must be offered in a

supportive manner. Otherwise, forcible medication just

reinforces fears of persecution.” Brief of Appellant at 24.

In my view, Hilkey’s report is much less conclusive on this

point than Watson contends. Regarding supportive therapy,

Hilkey stated that “[s]upportive therapy has been shown to be an

effective treatment” for delusional disorder, J.A. 382, and that

“[t]he literature on treatment of persons with delusional

[disorder] strongly encourages the use of supportive and

plan would not succeed.” Majority Op. at 25. The majority
contends that the district court thus failed to address Hilkey’s
questions about Lucking’s reading of the scientific literature,
Hilkey’s view that “the fixed, well established nature” of
Watson’s delusions made them “resistant to change,” J.A. 383, or
Hilkey’s belief that supportive therapy was required to maximize
the likelihood that medication would be effective. As
previously noted, however, insufficiency of the government’s
evidence, not inadequacy of the district court’s findings, is
the basis for the majority’s reversal of the district court’s
order.

70
cognitive behavioral psychotherapy for the treatment of

Delusional Disorder,” J.A. 384. Noting that “Watson has the

capacity to form a degree of therapeutic alliance should someone

attempt to do so,” Hilkey stated his “strongly held opinion”

that such supportive therapy “could increase the likelihood his

competency could be sufficiently restored.” Id. (emphasis

added).

While it is apparent that Hilkey thought supportive therapy

was very important, the district court correctly observed that

Hilkey never directly stated that the proposed treatment plan of

medication without therapy would not work. Indeed, Hilkey’s

statement that supportive therapy could increase the likelihood

of success suggests that medication alone has at least some

likelihood of success. And the statement that Watson emphasizes

-- that “any treatment approach be it pharmacological or

psychological must be offered in a supportive manner,” J.A. 383

(emphasis added) -- seems to implicitly acknowledge that there

are supportive and non-supportive ways to administer either

approach to treatment, medication or therapy. Under this

reading, Hilkey’s recommendation that medication be administered

in a supportive manner does not amount to a statement that

supportive therapy is required. Given the lack of clarity in

Hilkey’s report, I cannot find clear error in the district

court’s conclusion that Hilkey did not opine that medication

71
alone would not be effective to restore Watson’s competency.

See Anderson, 470 U.S. at 573-74 (factual findings are not

clearly erroneous “[i]f the district court’s account of the

evidence is plausible in light of the record viewed in its

entirety”); id. at 579 (deferring to trial court’s

interpretation of ambiguous testimony).

Although I do not believe that the district court’s

interpretation of Hilkey’s report is clearly erroneous, I

nonetheless agree with Watson that the district court’s findings

are inadequate to show that it properly considered the entire

range of evidence relating to supportive therapy. While

Hilkey’s report is ambiguous as to whether supportive therapy is

required, the report unambiguously establishes that supportive

therapy is beneficial as an adjunct to medication in that it

can, inter alia, encourage compliance with the treatment plan

and help mitigate the persecutory fears that might otherwise be

exacerbated by the government forcibly administering the

medication. Dr. Lucking made the same point in his report,

noting that “there is evidence” that psychotherapy is

“beneficial to an individual with psychotic symptoms . . . as an

adjunctive treatment to the antipsychotic agents to improve such

things as insight, compliance, or coping skills.” J.A. 375.

The district court thus had before it evidence from both

the government and the defense establishing that supportive

72
therapy is a beneficial addition to a medication-based treatment

plan for patients suffering from delusional disorder, with no

evidence raising any doubts about that conclusion. The court

also had before it Dr. Hilkey’s undisputed 13 opinion that

including therapy in the treatment plan would increase the

likelihood that the plan would succeed in restoring Watson’s

competency to stand trial. The district court noted Hilkey’s

strong preference for using therapy along with medication, but

it did not acknowledge the additional benefits obtained when

supportive therapy is added to a medication plan or the

medication-success-enhancing nature of supportive therapy. And

while the district court noted Lucking’s view that therapy alone

would not help Watson, the court did not explain why it

determined that therapy should not be required in addition to

medication. 14

13Lucking did not affirmatively state that therapy
increases the likelihood that medication will be successful, but
nothing in his report or testimony contradicts or raises
questions about Hilkey’s view.
14
Lucking testified that therapy alone would be ineffective
because delusions respond to medication, but not therapy, and
because Watson did not agree that he was mentally ill and would
not participate in therapy. While using therapy as an adjunct
to medication would seem to eliminate at least a portion of
these concerns, Lucking did not address whether adjunctive
therapy would be appropriate in this case.

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 In my view, the evidence of the benefits of adjunctive

supportive therapy is, at the very least, relevant to the

factual question of whether the government’s medication-without-

therapy plan was not merely likely, but “substantially likely,”

Sell, 539 U.S. at 181 (emphasis added), to restore Watson’s

competency. Given the sensitive nature of “an involuntary

medication order, which trenches upon the elemental individual

liberty interest in refusing the invasive administration of

mind-altering medication,” United States v. Chatmon, 718 F.3d

369, 376 (4th Cir. 2013), it is important for the district court

to fully consider treatment options that maximize the likelihood

the treatment will succeed. And in this case, where there is

disagreement over the medication-success-rates in the limited

available scientific literature, but agreement among the expert

witnesses that adjunctive therapy can increase treatment

compliance, it seems especially important for the district court

to give explicit consideration to the value of adjunctive

therapy. Cf. Herbel Study, J.A. 150 (“The real obstacle to

positive treatment response in delusional disorder may not be

the intrinsic biological features of the illness, but may

instead be the difficulties in convincing these patients to

adhere to an adequate trial of medication.”).

While I do not suggest that the district court was required

to order adjunctive supportive therapy, the court was at least

74
required to acknowledge the evidence establishing its benefits.

See Chatmon, 718 F.3d at 376 (“Of course, a district court need

not credit a defendant’s evidence or accept his arguments, but

its findings should offer some reason why it did not.”); Wooden,

693 F.3d at 454 (“Although the district court might not have

been required to accept that the evidence recounted above proved

Wooden’s ongoing pedophilia, the court was required to at least

consider the evidence, and account for it, when concluding

otherwise.”). The district court’s failure to consider relevant

evidence when determining that the government’s plan was

substantially likely to succeed means that the court’s factual

finding cannot be sustained. See United States v. Francis, 686

F.3d 265, 273 (4th Cir. 2012) (“A court commits clear error when

it makes findings without properly taking into account

substantial evidence to the contrary.” (internal quotation marks

omitted)); Jiminez v. Mary Washington Coll., 57 F.3d 369, 379

(4th Cir. 1995) (explaining that district court clearly errs

when it “disregard[s] substantial evidence that would militate a

conclusion contrary to that reached”).

B.

I turn now to the question of remedy. The majority,

finding the government’s evidence insufficient, reverses the

district court’s order without remanding for additional

proceedings. As I have explained, however, the sufficiency of

75
the government’s evidence is not properly before this court.

Instead, the only issue properly before this court is whether

the district court’s factual findings are sufficient to support

the court’s substantially-likely-to-succeed conclusion.

When an appeal turns on an error by the district court, the

proper remedy would normally be to vacate the district court’s

order and remand for further proceedings, so as to give the

district court the opportunity to reconsider the issue; only in

unusual cases would this court render judgment for a party after

identifying an error by the district court. See Pullman-

Standard v. Swint, 456 U.S. 273, 291-92 (1982) (noting that when

a district court fails to make required factual findings, “a

remand is the proper course unless the record permits only one

resolution of the factual issue”); aaiPharma Inc. v. Thompson,

296 F.3d 227, 235 (4th Cir. 2002) (noting, after finding error

by district court, that “[o]rdinarily, the proper course would

be to vacate the district court’s judgment and to remand,” but

concluding that “special circumstances allow us to put aside the

district court’s procedural error and render a decision on the

merits” (emphasis added)); see generally Chatmon, 718 F.3d at

376 (“Because the district court erred in its analysis of the

third Sell factor, we vacate the involuntary medication order

and remand for further findings.”); Wooden, 693 F.3d at 463

76
(vacating and remanding for reconsideration after identifying

numerous deficiencies in district court’s factual findings).

In this case, the record is not so one-sided that it

renders the district court’s error harmless, nor is there any

other reason to bypass the usual remand route. 15 Accordingly,

because I believe that the only error in this case is the

district court’s failure to address the issue of adjunctive

supportive therapy, I would vacate the district court’s order

and remand for further proceedings to permit the district court

reconsider the issue and make the findings necessary to support

its ultimate conclusion.

VI.

For the reasons set out above, I believe that the

sufficiency of the government’s evidence is not properly before

15 In the majority’s view, “remand is inappropriate because
the record permits only one resolution of the factual issue:
that this burden cannot be met.” Majority Op. at 28-29
(internal quotation marks omitted). For the reasons previously
discussed, I strongly disagree with the majority’s assessment of
the record. Even if the evidence were insufficient, however,
this court in such circumstances has previously remanded rather
than reversed. See Bush, 585 F.3d at 817-18 (finding
government’s proof deficient in several respects and
“remand[ing] this issue for consideration of further evidence,
if it is deemed appropriate, and findings by the court”); Evans,
404 F.3d at 242-43 (finding government’s evidence insufficient
to carry Sell burden and “remand[ing] with instructions for the
district court to reassess the motion after affording the
parties the opportunity to supplement the record in a manner
consistent with this opinion”).

77
this court and that it is improper for the majority to reverse

the district court on an issue the majority has raised sua

sponte. The majority’s reversal is particularly inappropriate

since the government has had no opportunity to brief the issue

or defend the sufficiency of its evidence before this court.

Indeed, counsel for the government will surely be surprised by

the outright reversal in this case, given that the only relief

sought by the appellant was the vacating and remanding for

reconsideration of the district court’s order. Nonetheless,

even if the sufficiency of the evidence were properly before us,

I believe that the evidence is more than sufficient to survive

appellate review. And as to the issues actually raised by

Watson, 16 I would vacate the district court’s order and remand

16Watson also challenges the district court’s analysis of
the first Sell factor, which requires the government to show
that important interests are at stake that are not mitigated by
special circumstances. See Sell v. United States, 539 U.S. 166,
180 (2003). Watson contends that he would likely succeed in
establishing an insanity defense, which would subject him to
civil commitment, see 18 U.S.C. § 4243(a), and that the district
court therefore erred by not treating that defense as a special
circumstance that mitigated the government’s interest in
prosecution. As the district court noted, however, an insanity
defense and the competency-to-stand-trial inquiry focus on
different questions, and there is nothing in the record
establishing or even suggesting that the delusions prevented
Watson from recognizing the wrongfulness of his actions. See
United States v. Mackey, 717 F.3d 569, 574 (8th Cir. 2013)
(“That Mackey was delusional at the time of his arrest does not
necessarily mean that he could mount a successful insanity
defense.”). I see no error in the district court’s conclusion
that the record established only the possibility that Watson

78
for reconsideration and additional findings by the district

court on the necessity of adjunctive therapy.

Accordingly, I hereby respectfully dissent from the

majority’s decision to reverse the district court’s order

granting the government’s petition to involuntarily medicate

Watson.

would assert and ultimately succeed on an insanity defense, and
that the mere possibility of establishing the defense did not
substantially undermine the government’s strong interest in
prosecuting Watson. Cf. United States v. Evans, 404 F.3d 227,
239-40 (4th Cir. 2005) (explaining that the “unlikely future
civil confinement” of the defendant does not “make unimportant
the Government’s interest in prosecuting [the defendant] on the
serious charges against him”).

79