Court Opinion

ID: 9455118
Source: CourtListenerOpinion
Date Created: 2023-08-04 19:11:50.020313+00
Date Added: 2024-06-11T17:34:27.990311
License: Public Domain

FAHY, Senior Circuit Judge
(concurring specially):
I agree with Judge Bazelon that the case should be remanded for a fuller hearing, but I wish to state as now set forth my approach to the problem, albeit on the background of the more detailed discussion in the opinion of Judge Bazelon.
Deprivation of liberty by the government is authorized when consonant with
due process of law and applicable statutory provisions; and when ordered the deprivation is subject to examination as to its validity by proceedings other than those by which the deprivation initially occurred. Usually this is by appeal from the judgment or order requiring the deprivation; but judicial inquiry in many instances is available also by habeas corpus proceedings. This is so where there has been a previous civil commitment to St. Elizabeths, as here. The validity of continued confinement of the committed person in the maximum security ward there, rather than in a less restrictive facility, may be questioned and decided. Miller v. Overholser, 92 U.S.App.D.C. 110, 115, 206 F.2d 415, 419; and see Lake v. Cameron, 124 U.S.App.D.C. 264, 364 F.2d 657 (en banc). When, however, the deprivation of liberty is based on the person’s dangerousness to himself or others due to his mental condition, the degree of deprivation is not for the judiciary to pass upon except under a restraint consistent with the deep involvement of the medical discipline, that is, the discipline of those charged under the law with the administration of the institution. While the individual may bring the matter to court as a case or controversy under the Constitution, the court, in passing upon the validity of the deprivation of liberty, a judicial function, recognizes the responsibility the law places also upon those in charge of the institution. Thus, in Tribby v. Cameron, 126 U.S.App.D.C. 327, 379 F.2d 104, as pointed out by Judge Bazelon, the question was stated to be whether the administrator,
has made a permissible and reasonable decision in view of the relevant information and within a broad range of discretion.
It was appropriate, therefore, on the pleadings in this case, appellant having been confined in the maximum security *630ward for ten years, for the District Court to inquire whether appellant was being excessively deprived of liberty. The government does not contest this, as I understand, taking the position that the record supports appellant’s continued detention in John Howard Pavilion or, if not, that a fuller hearing would so disclose. Our question, then, is whether the hearing in the District Court did explore the problem fully enough to enable the court to decide, not whether appellant’s detention at St. Elizabeths is valid, which was not questioned in the District Court, but whether it should continue as at present in the John Howard Pavilion. As to this I agree to a remand for a fuller hearing, particularly with respect to possible alternative facilities with less restrictive deprivation of liberty. The hearing on the remand I think should bring the following into the record:
1. The reports regarding appellant required by law to be kept by the hospital ;
2. The history of appellant and of his illness, including his present condition, the treatment he is receiving at the hospital, and the efficacy of the treatment;
3. A comparison of the John Howard Pavilion and the treatment there available with possible alternative facilities at St. Elizabeths and the treatment there available,1 with an exploration of the differences in supervision and restrictions and the comparative therapeutic results likely to ensue;
4. The conclusion or conclusions of the hospital authorities as to the nature of the confinement appellant should have, with the reasons therefor, reached in recognition that no greater deprivation of liberty should be had than is reasonably required for his safety and the safety of others, in determining which consideration should be given to the desirability of seeking improvement in appellant’s condition.
The foregoing should not be considered as limiting the scope of the hearing if the parties or the court advance other data which the court in the exercise of a sound discretion deems admissible.2
As to the burden of proof, my view is that when the appropriateness of a particular deprivation of liberty has been drawn in question by supporting evidence, its continued validity depends upon a showing, in the circumstances of appellant’s confinement,3 that within a broad range of discretion of the hospital authorities, exercised upon the basis of the relevant information, the deprivation is supported by substantial evidence and is reasonable.
As to the validity of appellant’s original commitment, questioned for the first time on the appeal in this court, it is possible that on further consideration neither appellant nor counsel would desire to pursue this. I think our court should refrain from seeming to encourage its pursuit. It is a matter which I think should be left for the parties and the District Court in the light of such circumstances as might develop.

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RECOMMENDATIONS AND FINDINGS
A. Recommendations
1. The practical aspects of the treatment of the so-called security patients in separate facilities and the need for it. * * * Few professionals count these people in their problems or among their concerns. Efforts should be made to bring all patients requiring security services under an administrative officer who shall have four assistants responsible for recruitment and training, research, treatment services and legal matters.
2. Modification of John Howard Pavilion. The Committee study would indicate that approximately one-half of the patients confined in the JHP could be adequately cared for in the less secure units within the Security section or in other parts of Saint Elizabeths Hospital.
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5. Decentralization of Security Decisions. The Committee views the decision-making of the Security section, particularly as it relates to security issues, to be too centralized. Security (degree of restrictions) is an integral part of the treatment process. Therefore, it is recommended that these decisions be made as closely as possible to the area (wards) where the treatment process takes place, by the personnel responsible for the care of the patient.
6. Reduction of Inpatient Pretrial Examinations. Much staff time and bed space seems to be utilized unnecessarily in the performance of psychiatric examinations for the courts. To greatly reduce the number of patients admitted to the Security section for psychiatric examination the Committee recommends that:
a. A service be developed to conduct screening examinations on an out*632patient basis by the comprehensive community mental health centers.
b. Admission to the Security service of Saint Elizabeths Hospital of only those patients requiring more comprehensive psychiatric evaluations or who are actually psychotic.
e. Place those admitted to the Hospital in the appropriate custody level of housing.
d. Develop a jail-located psychiatric service to screen misdemeanants (optional for civil commitment whenever possible).
7. Improved Aftercare Service. * * * The Committee recommends that an effective aftercare service be developed through clinics and mental health services, and social workers on the staff of the Hospital itself.
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10. Use of All Hospital Services. Integration of clinical services should be accomplished to the end that all treatment modalities within Saint Elizabeths Hospital will be available for the patients requiring security services.
11. Program Goal. The Committee recommends that the long range goal should be the transition of patients committed upon acquittal of criminal charges by reason of insanity to the same status and treatment as other patients in the general hospital wards. So far as possible the same should be true of persons committed because they are mentally incompetent to stand trial.
B. Findings of the Committee
The National Institute of Mental Health is responsible for the implementation of the treatment program at Saint Eliza-beths Hospital. This is a 7,000 bed federal mental hospital of which 700 beds are currently designated as a Security section. The study of this Committee concerns evaluation and programming as these relate to this section of the Hospital.
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1. Security Facilities. The section designated for Security currently consists of three divisions: the John Howard Division, in a maximum security building with 395 beds; the West Side Division (in the Center Building), with 422 beds; and the Cruvant Division with 123 beds.
a. John Howard Division is occupied by criminal proceedings patients which include those committed for pretrial examinations, not guilty by reason of insanity, prisoners from the D. C. Department of Corrections and the Federal Bureau of Prisons, those found to be incompetent to stand trial and those committed under the sexual psychopath laws. As a general practice those male criminal proceedings patients involved in felonies are treated in the John Howard Division. There are a number of potentially dangerous civil patients treated here also.
b. Of the 422 patients of the West Side Division approximately 150 are civil commitments transferred from other sections of Saint Elizabeths Hospital to this area because of peculiar management problems and the need for more security. The remaining 275 patients in this building are misdemeanant criminal proceedings patients committed for pretrial examination, not guilty by reason of insanity, incompetent to stand trial and sexual “psychopaths.” * * *
c. The Cruvant Division is composed of four wards, three of which are occupied almost exclusively by female criminal proceedings patients. * * * and there are some sexual psychopaths as well as potentially dangerous civil patients. One ward is occupied by a small group of male patients who have been transferred from John Howard Division into the terminal phases of treatment involving minimal security prior to release into the community.
2. Major Issues for Staff. * * * The values of the court-prison system and those of the Hospital conflict in an uneasy balance. There is a confused definition of the patients as either “prisoners” or “patients.” The contingencies of each value system trammel up the tasks of the others. The Hospital staff does not seem to have optimal communication with the courts it serves or a suf*633ficiently knowledgeable and critical understanding of the legal principles it helps to administer. * * *
A second major concern of the staff is the lack of space and facilities to implement treatment involving the concept of the therapeutic milieu or therapeutic community at a satisfactory level. The Committee saw evidence which validated this opinion; for example, the space in John Howard. Division is largely occupied by patients, leaving inadequate space for adjunctive therapy.
A third major concern of the staff is an insufficient number of hospital personnel in all categories. For example, as related to professional personnel, the Security section finds it most difficult to have psychiatric residents from the training program of Saint Elizabeths Hospital rotated through the Security sections.
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3. Semiautonomy of Security Section. The security facilities seem to be islands of autonomy, hardly linked to each other and markedly shielded from the rest of the Hospital. They hardly share each other’s resources and seem deprived from sharing those from the Hospital at large. * * * A semiautonomous status of security services would facilitate implementation of those matters largely peculiar to the section, e. g., relationships to law enforcement agencies and the courts. Integration of clinical services should be accomplished to the end that all treatment modalities within Saint Eliza-beths Hospital will likewise be available for the security patients.
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The Committee believes that the criminal behavior of the mentally ill is simply another form (out of many forms) of deviant behavior characteristic of severe mental illness.
As certain forms of mental illness can best be treated in the hospital setting the Committee recommends that the long range direction of the Saint Elizabeths Hospital program should be towards development of a modern psychiatric hospital program in which all patients can freely participate regardless of the type of deviant behavior they have manifested.
In other words, the separation of so-called “criminally insane,” in a special unit separate and apart from the rest of the patient population at Saint Eliza-beths Hospital, should be considered as a temporary and transitional measure which eventually will lead towards complete integration of both groups of patients within a uniform and therapeutic hospital program.
4. Staff Organization. A more integrated continuum of care and record keeping is necessary for the security units. It is recommended that all Security services be placed under a chief administrative officer charged with the responsibility of coordinating administrative and clinical functions within the section. He should have at least four professional assistants, one devoted to recruitment and training, one to research, one an attorney devoted to relationships with the courts and consultation for the professional staff of the three units, and one concerned with treatment services.
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5. Legal Rights of Patients. A special assistant to the chief administrative officer should be a legal officer who would have the function of protecting the legal rights of patients, informing them what their legal rights are, and checking as to whether these rights are being observed; and to act as their spokesman in making complaints. To carry out these functions without constraint, this legal officer should not be a part of the Hospital staff but should be autonomous. These services could be obtained by contract with private law firms or with the law departments of the academic community.
6. Treatment. The present treatment program in the Security sections is better than the treatment provided in many such institutions. This is due to the dedication of a limited number of profes*634sional staff laboring under many disadvantageous circumstances. The John Howard Pavilion needs to make its environment more “livable” and less prison-like. There is too much “sitting around” on the wards at the present time. Ad-junctive therapy should be greatly expanded including academic education, vocational training and rehabilitation, religious instruction, recreation, arts, music, etc. All adjunctive treatment must be related to therapeutic goals and not be merely time fillers. While it is amply clear that individuals in the maximum Security unit now suffer from massive social deprivations of all sorts, merely supplying them with socializing experience is no substitute for interpreted experience which will modify personality operations. Extensive development of these resources should only be carried out in the context of their explicit utilization for treatment.
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Too often, the law and the legal professional seem to focus their concern on the number of escapes, the quality and quantity of controls, sufficient length of confinement, etc., to the exclusion of therapeutic considerations.
Recent opinions from the Court of Appeals have explicitly stated that a person committed for treatment must receive treatment or be discharged. Medically adequate treatment is that which at least does not worsen the condition and which either limits the extension of the disease process, or, ideally, eliminates the patho-logicial situation. It is carried out with skill and competency commensurate with the standards of the community, and in concurrence with the implied or explicit contractual agreement between the parties.
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* * * q>he balance between dangerousness and treatability is now demanded by the law of the District of Columbia. It is a dynamic type of question and it may not be met by any absolute and categorical criteria. To make the balanced judgments regarding these two questions which have both medical and legal implications, is a task for persons highly trained in both the medical and legal issues involved.
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The Committee is not cognizant of the data which would establish the minimal number of clinical and other personnel which would qualify as adequate at the security facilities at Saint Elizabeths Hospital. We would stress that quality is a more important consideration than quantity with respect to the adequacy of treatment. We would observe, however, that in comparison to similar institutions the number of personnel attached to the Security division, particularly in the social work and attendant categories, ranks low.
Medically adequate treatment itself is probably going to have to be reassessed in the mental hospital. Programming should proceed on the assumption that the institution will be a hospital and will treat mentally ill persons. It is true that criminally committed patients are more likely to be dangerous than most of those civilly committed; and special precautions and procedures will continue to be required for patients who are dangerous to others or to themselves. Suffice it to say that in addition to the ■ modalities used in the care of the mentally ill in general psychiatric hospitals, there are available special methods and techniques which have proved effective in security settings. There should be combined the best features of a quality “corrections” approach and mental hospital program.
7. Individual Treatment Plan. While we have not presumed to establish generalized clinical positions which might or might not be appropriate for a particular patient, we would affirm that:
a. There should be a recorded assessment of the pathology and assets of the individual.
b. There should be a recorded treatment plan.
c. The treatment plan should be implemented in good faith within the limits of available resources.
*635d. There should be a periodic recorded assessment of treatment progress or the lack of it.
e. Significant modifications to the treatment plan and their rationale should be recorded.
f. Where available resources fall below the standards acceptable to the individual clinician, he should communicate the realistic needs of the situation to proper authorities.
8. Degrees of Security. As has been observed in other mental hospitals, in the practice concerning the housing of patients committed by the criminal courts, it seems to be assumed that a court order committing a person for criminal purposes (pretrial examination, hospitalization of those found incompetent to stand trial, and of those found not guilty by reason of insanity) necessarily means that such patients be kept under maximum security. The court order does not in fact say this. It merely orders the person “ * * * committed to * * * the mental hospital designated by the court * * * ” nor is there any reason to read a special security requirement into the order. Patients so committed are as fully subject to the Hospital’s administrative discretion as to where to house them as are civilly committed persons. As with the civilly committed, the Hospital has the duty of determining whether the individual person is in fact dangerous and in need of greater restraint than others, but there is no reason for the assumption that, merely because the patient comes to the Hospital by way of commitment from the criminal courts, as distinguished from the civil, he must ipso facto be placed in maximum security, without the diagnosis or prognosis of actual dangerousness. At the present time it is primarily the Registrar who makes the decision that a person should go to maximum security. The determination is in fact a mechanical one: new admissions from the U.S. District Court are assigned to the John Howard Division; misdemeanants from the Court of General Sessions are committed to the West Side Division. The clinical directors, however, of these two divisions may, and do, exchange patients, if after a period of observation these are determined to be in need of either greater or lesser security.
It appears that security is both overused and underused at the Hospital. It is estimated that one half of the men at JHP do not require maximum security. On the other hand, the escapes from Cruvant Division and the West Side Division are astonishingly high (President’s Commission on Crime in the District of Columbia). It seems clear that there is excessive security at one end of the spectrum and little or no security elsewhere — an all or none situation. It would seem clear that medium security facilities are called for — an intermediate and graduated step system. * * *
Reevaluation of the current “patient load” in the Howard unit would permit a sizable number of these people to be treated in a less secure or even in an open setting. The security of those remaining should be transferred from the inside to the periphery. With few exceptions, whatever controls are needed on the inside should be incorporated in therapeutic measures inherent in the total treatment program.
.Any rational approach to the problem must pay cognizance to the history of this institution and its current physical plant. The JHP, built to provide security which could not be surpassed even by most prisons, automatically forces upon the staff a form of treatment that is less than desirable. However, it represents such a large number of beds it will probably have to be used in the immediate future. Extensive modification of the physical structure will be required to make it optimally effective within its current character.
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10. Decisions Decentralized. At the present time the decision-making, particularly as it relates to security issues (transfers, releases, ground privileges, etc.), is too centralized. In a mental *636hospital, security (degree of restrictions) is an integral part of the treatment process. Therefore, decisions about restrictions should be made by the personnel who regulate the area (wards) where treatment processes (milieu therapy) take place. Milieu therapy should provide the opportunity of training the emotionally disturbed through planned management of the structure and processes of the situation in which they live.
11. Care for Conditionally Released. A certain number of the criminally committed patients is conditionally released. There is no very effective follow-up or aftercare, either of the conditionally released or of those finally discharged. * * * Tlig effective way is to bring the aftercare service into the neighborhood through the clinics and mental health services, or through social workers on the staff of the Hospital itself who can go to the patient’s home and into the neighborhood. This means an extensive development and enlargement of social services.
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15. Hospital-Court Relationships. * * As legal personnel begin to learn about mental health concepts, they can build more effective legal procedures to cope with obedience, prevent the preventable, and at least carry out their activities with people in more effective ways. Similarly, the “legal education” of Hospital personnel should be developed so that they know exactly what social values are built into legal concepts with which they deal. Such relevant roles as “expert witness” should be clearly understandable by mental health persons. Psychiatrists and other behavioral staff should be able to go into court understanding completely what their function is to be so that they may carry it out without inappropriate anxieties and with a sense of appropriate participation.
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18. Community Tolerance. Every mental hospital, but particularly one with a security unit, must be aware of and sensitive to the community level of tolerance for its programs and patients. As the community’s tolerance greatly influences formulation of treatment programs, the Hospital, through a public education program, must endeavor to improve the degree of its acceptance by the community. Development of as many as possible hospital-community contacts will help not only the intramural programs but also open doors to a much more extensive and effective pos.thospitalization program for discharged patients.

. Though appellant makes no issue as to his treatment, intertwined with the evaluation of his present confinement is the consideration of appellant’s general right to treatment. See Rouse v. Cameron, 125 U.S.App.D.C. 366, 373 F.2d 451; Ragsdale v. Overholser, 108 U.S.App.D. C. 308, 315, 281 F.2d 943, 950 (concurring opinion).

. I hope the hospital itself will find itself able to establish internal procedures such as suggested in Rouse v. Cameron, supra note 1, repeated in Judge Bazelon’s present opinion.

. Compare Ragsdale v. Overholser, supra note 1 (concurring opinion).