United States v. Gamarra

UNITED STATES DISTRICT COURT
FOR THE DISTRICT OF COLUMBIA

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UNITED STATES OF AMERICA

v. criminal No. 17-65 (JDB)

FIl..ED
0£1192013`

Clerk, U.S. District and
Bankruptcy Courts

JEAN-PAUL GAMARRA,

Defendant.

MEMORANDUM OPINION

The government moves to involuntarily medicate defendant Jean-Paul Gamarra, vvho
suffers from mental illness, to render him competent to stand trial. Pursuant to Sell v. United
Qat_e§, the Court must determine Whether “in light of the efficacy, the side effects, the possible
alternatives, and the medical appropriateness of a particular course of antipsychotic drug treatment,
[the government has] shown a need for that treatment sufficiently important to overcome the
individual’s protected interest in refusing it.” 539 U.S. 166, 183 (2003). Upon consideration of
the pleadings, the testimony presented at the &:_l_l hearing before Magistrate Judge Deborah A.
Robinson held on April 13, 18, and 20, 2018,] and the entire record herein, the Court Will grant

the govemment’s motion.2

l _S_Y Tr. of§e_u Hr’g, Apr. 13, 2018 (“4/13/18 Hr’g Tr.”) [ECF No. 18]; Tr. ofS_ell Hr’g, Apr. 18, 2018
(“4/18/1 8 Hr’g Tr.”) [ECF No. 24]; Tr. of§e_|l Hr’g, Apr. 20, 2018 (“4/20/18 Hr’g Tr.”) [ECF No. 21].

2 At the status conference held on October 17, 2018, counsel for both parties stated that they had no objection
to this Court deciding this motion based upon the record, including the transcripts of the §gll hearing

l

BACKGROUND3

Gamarra was arrested outside the White House on March 28, 2017, after approaching
United States Secret Service Officers with a package that he claimed contained a detonator for a
nuclear device. Gamarra, 308 F. Supp. 3d at 231. He was indicted for threatening the President
in violation of 18 U.S.C. § 871 and threatening and conveying false information concerning the
use of an explosive device in violation of 18 U.S.C. § 844(e). ld_. at 232. The government
represents that Gamarra’s “threatening conduct caused a significant area of the District [of
Columbia] to be closed to traffic and commerce for approximately an hour and forty minutes.”
Gov’t’s Mot. to Medicate lnvoluntarily Def. to Restore Competency [ECF No. 22] (“Gov"t’s
l\/Iot.”) at 6. Gamarra was found to have a mental disease that rendered him incompetent to stand
trial, and he was hospitalized at Federal Medical Center (“FMC”) Butner for further evaluation
pursuant to 18 U.S.C. § 4241(d). Gamarra, 308 F. Supp. 3d at 232.4

At FMC Butner, forensic psychologist Evan S. Du Bois, Psy.D., and predoctoral
psychology intern Kelsey L. Laxton completed a forensic evaluation, ultimately concluding that
Gamarra remained “not competent to proceed to trial” but that “his competency is likely to be
restored with adherence to a medication regimen.” Gov’t’s Ex. 2 (“Forensic Evaluation”) at 14.5
FMC Butner Staff Psychiatrist Dr. Logan Graddy provided a forensic addendum and treatment
plan that similarly concluded that administration of antipsychotic medication was medically

appropriate, that other interventions were unlikely to be beneficial without medication, and that

3 The Court incorporates by reference fuller recitations of the factual and procedural history of this case in
its prior opinions. w United States v. Gamarra, 308 F. Supp. 3d 230, 231~33 (D.D.C. 2018); United States v.
Gamarra, Crim. No, 17-65, 2018 WL 4954128, at *1-3 (D.D.C. Oct. 12, 2018).

4 Section 4241(d) permits a defendant to be hospitalized for up to four months, but Gamarra ultimately spent
more than six months at FMC Butner. §§ This Court held that his extended hospitalization violated the statute but
that this did notjustify dismissal ofthe charges against him. l_d_. at 233_34.

5 All cited exhibits were admitted without objection during SLll proceedings before Magistrate Judge
Robinson. _S_Q Apr. 13, 2018 Min. Entry (admitting Gov’t Exs. 1-3, 11); Apr. 18, 2018 Min. Entry (admitting Gov’t
Exs. 10, lOA); Apr. 20, 2018 Min. Entry (admitting Gov’t Exs. 4, 12).

2

the benefits of medication would outweigh the risks. Gov’t’s Ex. 11 (“Forensic Add. and
Treatment Plan”) at 1, 3.

The government orally moved to have defendant involuntarily medicated, and the
defendant opposed the motion. Magistrate Judge Robinson held a gil hearing over three days in
April 2018 at which Dr. Du Bois, Laxton, and Dr. Graddy testified for the govemment. The
defendant did not present any witnesses.

Dr. Du Bois, whom the court qualified as an expert in clinical forensic psychology, testified
that, in his opinion and to a degree of professional certainty, Gamarra suffers from “schizophrenia,
continuous,” based on observations of delusional ideation, disorganized speech, and possible
auditory hallucinations. 4/13/18 Hr’g Tr. at 55:9-11; 58:3~10. Dr. Du Bois opined that Gamarra
was not competent to stand trial because, although Gamarra exhibited a basic factual understanding
of court proceedings in general, his understanding of his case and the charges against him were
“rooted in his delusional beliefs, which were a result of his schizophrenia.” § at 64:1-23. Dr.
Du Bois further opined that Gamarra would have difficulty testifying because he “would have
difficulty communicating clearly and organizing his thoughts and testimony” and because his
mental illness made it possible he would incriminate himself. l_d. at 64:24-65:14. Dr. Du Bois
concluded that Gamarra’s disorganized speech would also impair his ability to consult with
counsel. § at 65:15-25.

Dr. Du Bois testified that he did not recommend individual therapy in place of
antipsychotic medication because delusional beliefs, like those to which Gamarra ascribed, “often
don’t respond to behavioral or therapy techniques.” Ld. at 94:24-95:1 1. He and Laxton “attempted

to challenge some of [Gamarra’s delusional] beliefs or introduce evidence that would oppose them,

which is the recommended method for opposing or trying to change delusional beliefs, . . . [but
this course of treatment was] not effective.” § at 95112-17.

Laxton, who was qualified as an expert in clinical forensic psychology without objection,6
testified that, in her opinion and based on a reasonable degree of professional certainty, Gamarra
suffers from “schizophrenia, continuous,” and was not competent to stand trial. § at 13:10-115,
18:8-19, 20:12-18. ln particular, Laxton testified that while Gamarra had a factual understanding
of the court proceedings, including an understanding of basic legal terminology and concepts,. he
had “some difficulty rationally understanding the proceedings against him, especially the potential
consequences of his case.” § at 21:6-22. She explained that Gamarra’s understanding of the
charges against him and his defenses to those charges were themselves rooted within his delusional
belief system. § at 22:23-23:10. As a consequence, she opined that Gamarra lacked capacity to
testify because his condition made it difficult for him to communicate “in a clear and coherent way

. . without discussing further his delusional belief systems” and because he would “likely ~. . .
incriminate himselfwithout realizing that he was doing so.” § at 23114-24:8. For essentially the
same reasons, Laxton concluded that Gamarra also lacked capacity to consult with counsel. § at
2419-19. In addition, Laxton noted that Gamarra’s delusional beliefs around electric waves,
computers, and telephones would affect his competency to stand trial; for example, “in the
courtroom, he thought that the presence of the telephone would be detrimental to him or his case
or even have some physical impact on [the] judge . . . .” § at 22:6-22.

Laxton also testified that, in her opinion, administration of antipsychotic medication was a

“key piece” of Gamarra’s treatment plan that would be “necessary to get [Gamarra’s] symptoms

6 The magistrate judge received Laxton, who served as an intern under Dr. Du Bois, as an expert “with the
understanding that the licensed clinical psychologist who approved the report will also be a witness in this
proceeding.” § at 13:13~15.

in control to a point that he would be competent to stand trial,” and it was “unlikely” that Gamarra’s
condition would improve without medication. § at 37:10-38:9. Though staff had “encouraged
Mr. Gamarra to take medications,” Laxton explained that Gamarra refused to take antipsychotic
medications at various times while at Butner because ofhis beliefs that “he had . . . died previously

33 44

taking another medication, that he does not have a mental illness and does not need those
medications,” and that his religion prohibited taking what he believed were addictive medications
§ at 26:21-27:10; 37:20. l\/ls. Laxton observed, however, that during her examination Gamarra
communicated more clearly on medication and that this improvement was corroborated by reports
from Gamarra’s family (and Gamarra himself) that antipsychotic medication improved Gamarra’s
condition. § at 27:23_28:18. Gamarra’s family members reported that he was “highly intelligent
and functioned well when he [had] complied with medications” in the past. § at 2814-8. Laxton
herself observed that Gamarra “communicated slightly better” during the brief periods at FMC
Butner when he was “more compliant with [prescribed antipsychotic] medication.” § at 28:16-
18.

Dr. Graddy, whom the court qualified as an expert in the field of forensic psychiatry,
testified that, in his opinion and based on a reasonable degree of medical certainty, Gamarra suffers
from “schizophrenia, multiple episodes, currently in[ an ]active episode.” § at 1 12:2-11; l 1418-
15. Dr. Graddy did not meet Gamarra in person, but he “reviewed the full record” before making
his diagnosis § at 114:8~115110. His diagnosis, in contrast to Dr. Du Bois and Laxton’s
diagnosis of “schizophrenia, continuous,” was based on his observation that “Gamarra has gotten

better in the past on medications, significantly better, such that l have classified him as having

multiple distinct episodes rather than one continuous episode.” § at 115:19-25.7

7 Dr. Samantha DiMisa diagnosed Gamarra with schizoaffective disorder, a related but distinct condition,
during his time at the Metropolitan Correctional Center (“MCC”) in New York, New York. Forensic Add. and

5

Dr. Graddy noted several studies indicating that antipsychotic medications restored
competency in more than seventy-five percent of defendants suffering from schizophrenia and
other psychotic disorders. Of particular relevance, Dr. Graddy cited a 2012 study in which 62 of
81 defendants diagnosed with schizophrenia Were restored to competency with antipsychotic
medications, for a restoration rate of approximately 76%. gee 4/18/18 Hr’g Tr. at 40:20~41:18
(discussing Gov’t’s Ex. 10 at 3). Although Dr. Graddy did not directly evaluate Gamarra’s
competency, Dr. Graddy noted that Gamarra “appears . . . to be consistent With other . . . defendants
who did regain their competency when treated with antipsychotic medication” and that this
conclusion was “stronger” because Gamarra “has documented improvement on antipsychotic
medication in the past.” 4/13/18 Hr’g Tr. at 116:1-11. Dr. Graddy testified that antipsychotic
medications “are generally safe and effective” and that “patients with schizophrenia or
schizoaffective disorder . . . need medications to improve” because “[o]ther treatments are not very
effective for these conditions.” § at 118211-24. Dr. Graddy did not believe that other, less-
invasive treatments would be effective. § at l2l:10-l3; 143:4-8. Dr. Graddy stated that he
would propose beginning Gamarra’s treatment with the antipsychotic medication risperidone
because it “is a medicine he took in the past” that he “appeared to tolerate . . . well” and that had
been documented to “improv[e] . . . his mental state.” § at 123:15-18.

ln addition, Dr. Graddy opined that medication would be “medically appropriate,”
particularly since “he appears . . . to be a patient who does get better with treatment.” § at 120:1 l-
19. Dr. Graddy explained that antipsychotic medication is the course of treatment he would

recommend to Gamarra “if he were to come and see me with this complaint in the community"` or

Treatment Plan at 2 nr2. Dr. Graddy’s report explained that “this diagnosis and the treatment required for it are not
significantly different from [his] diagnosis” of schizophrenia § Furthermore, Dr. Graddy noted that the “diagnostic
difference” between his conclusion that Gamarra suffered from schizophrenia, multiple episodes, currently in active
episode, and Dr. Du Bois’s diagnosis of schizophrenia, continuous, “is minor.” I_d_.

6

“[i]f his family were to approach me” seeking advice on treatment § at 122:11-23. He also
noted that antipsychotic medications were prescribed to Gamarra “every time he’s gone into -the
hospital.” § Dr. Graddy also highlighted that he considered risperidone “one of our best
medications” for treating patients with schizophrenia-type diagnoses, even in light of the potential
risk of side effects. 4/20/18 Hr’g Tr. at 43:1-12.

As to potential side effects, Dr. Graddy testified that antipsychotic medications are known
to have a significant risk of serious side effects, including acute dystonic reactions (involuntary
muscle contractions), parkinsonism (characterized by muscle rigidity, tremors, and decreased
spontaneous facial expressions), dyskinesias (characterized by involuntary grimacing, tongue
movements, rapid blinking, and rapid limb movement), and akathisia (uncomfortable inner
restlessness). 4/18/18 Hr’g Tr. 22115~24:6; 31:22-32:16; 38:6-40:19. Dr. Graddy testified that
various studies suggested that the reaction rates for antipsychotic medications generally ranged
from two to ten percent for dystonic reactions, up to fifty percent for parkinsonism, up to thirty-
two percent for dyskinesias, and up to thirty percent for akathisia. § at 24:23-25:1; 33:7-25;
39:3~9; 40:6-11.

He opined, however, that if Gamarra were medicated, any side effects that Gamarra might
experience would be closely monitored and managed by medical staff, either by adjusting the
dosage of antipsychotic medication, prescribing a different antipsychotic medication, or by treating
the side effects with other medications 4/13/18 Hr’g Tr. at 122:24-123:25. Dr. Graddy
acknowledged that Gamarra’s medical records noted that he had “complained of some

5

neuromuscular symptoms,” particularly “stiffness,’ in response to risperidone, which a treating
physician would “watch closely if we have to treat him with that” medication. 4/20/18 Hr’g Tr. at

36:19-37:3. But because negative reactions tend to “occur early in treatment” and would be noted

by medical providers, Dr. Graddy believed the risk of Gamarra experiencing, for example, a
dystonic reaction while taking risperidone to be “fairly low since he’s tolerated [this] medicine in
the past.” § at 25:12-16; 28:2~4; 4/20/18 Hr’g Tr. at 3617-13; see also 4/20/18 Hr’g Tr. 19:22-
2012 (Dr. Graddy explaining his use of past medical records in recommending medication to
patients). Furthermore, any side effects from the medication would be “very unlikely to cause him
to not be able to be competent” to stand trial. 4/13/18 Hr’g Tr. at 120:20-7. ln all, despite the
risks of side effects, Dr. Graddy stated that “from a medical perspective, benefits of treatment, in
my opinion, outweigh the risks.” § at 120:16~19.
DISCUSSION
“Although an individual has a constitutionally protected interest in avoiding involuntary

medication, that interest can be overcome by an ‘essential’ or ‘overriding’ state interest in some
circumstances.” United States v. Dillon, 943 F. Supp. 2d 30, 34 (D.D.C. 2013), aff’d, 738 F.3d
284 (D.C. Cir. 2013) (quoting §e_l_l, 539 U.S. at 179-80). The Supreme Court in S§ll “prescribed
a detailed, four-part inquiry for district courts to undertake prior to authorizing involuntary
medication to restore defendants to competency.” United States v. Dillon, 738 F.3d 284, 290 (D.C.
Cir. 2013). Pursuant to §§_l_l,

a court may order the administration of medication to render a mentally ill

defendant competent to stand trial on criminal charges if:

(l) doing so advances an important government interest, such as bringing to trial

an individual accused of a serious crime;

(2) the medication is substantially likely to render defendant competent to stand

trial[] and substantially unlikely to have side effects that will interfere

significantly with defendant’s ability to assist counsel in conducting a trial

defense;

(3) alternative less intrusive treatments are unlikely to achieve substantially the

same result; and

(4) administration ofthe medication is medically appropriate, i.e., in the patient’s
best interest in light of his medical condition.

M, 943 F. Supp. 2d at 34~35 (citing _S_e_ll, 539 U.S. at 180~82). The government must prove
each M factor by clear and convincing evidence. Qi_ll§n, 738 F.3d at 291-92.8
I. IMPoRTANT GovERNMENT INTEREST

The first S§ll factor requires a court to “find that important government interests are at
stake."’ M, 539 U.S. at 180. “The [g]overnment’s interest in bringing to trial an individual
accused of a serious crime is important,” but courts “must consider the facts of the individual
case,” as “[s]pecial circumstances may lessen the importance of that interest.” § In particular,
“the defendant already having been confined for a significant period oftime” may “undermine the
importance of the government’s interest in prosecution.” wm 943 F. Supp. 2d at .35.
Furthermore, the possibility that a defendant might face “lengthy confinement in an institution for
the mentally ill” notwithstanding his inability to stand trial can “diminish the risks that ordinarily
attach to freeing without punishment one who has committed a serious crime.” §§L 539 U.S. at
180.

The government asserts that important governmental interests are at stake in this case
because it seeks to bring Gamarra to trial on charges of serious offenses The crimes with which
he is charged involve threats to health and safety, and “the government has a significant interest in
bringing . . . to justice” defendants charged with “[a]ny threat on a governmental official,

particularly the President.” Gov’t’s l\/lot. at 6. Furthermore, “[f]ailure to bring such offenders to

3 As a threshold inquiry, the Supreme Court in §ej directed that a court should consider whether forced
medication might be warranted on dangerousness grounds_that is, due to the danger defendant poses to himself or
others-~before determining whether involuntary medication to restore competency is appropriate §