PAUL L. FRIEDMAN, District Judge.
This matter is before the Court on the proposal of St. Elizabeths Hospital for the conditional release of John W. Hinckley, Jr., pursuant to 24 D.C. Code § 501(e) - a so-called "(e) proposal" or "(e) letter." Over the years, the Hospital has submitted a series of proposals to this Court, seeking to expand the scope or duration of Mr. Hinckley's activities outside the grounds of the Hospital. The government has consistently opposed these proposals in whole or in part. On some occasions, Mr. Hinckley has submitted his own petition for expanded conditions of release under 24 D.C. Code § 501(k) (a so-called "(k) petition"). On each occasion, the Court has considered the Hospital's proposal, the government's opposition, and Mr. Hinckley's position on the Hospital's proposal along with his own (k) petition, if any. After conducting an evidentiary hearing, the Court has either granted the Hospital's request, invariably with modifications or additional conditions imposed by the Court, or has denied the request.
Throughout these proceedings, the Court has expanded Mr. Hinckley's privileges outside the Hospital incrementally, always contingent upon careful monitoring and his and his family's compliance with the conditions imposed by the Court. The Hospital has characterized its requests for gradually expanding Mr. Hinckley's freedom as a series of phases, each of which entails greater integration into the world outside the Hospital. At first, the Court allowed local day visits by Mr. Hinckley with his parents outside of the confines of St. Elizabeths without the supervision of Hospital personnel and within a 50-mile radius of Washington, D.C. - so-called "Phase I" visits. The Court later permitted local overnight visits by Mr. Hinckley with his parents within a 50-mile radius of Washington, D.C. ("Phase II" visits). Each visit was thoroughly assessed by the Hospital and Mr. Hinckley's treatment team before a subsequent visit took place, and a written report on each visit was provided to the Court. There were a total of six Phase I visits and eight Phase II visits.
Beginning in 2006, the Court permitted visits outside of the Washington metropolitan area to the home of Mr. Hinckley's parents in Williamsburg, Virginia ("Phase III" visits). See Hinckley III, 407 F.Supp.2d at 265-68. The Court permitted three initial visits by Mr. Hinckley to his parents' home, with each visit lasting three nights in duration. See id. at 267. Thereafter, the Court permitted additional visits of four nights. See id.; Hinckley IV, 462 F.Supp.2d at 45-47. In 2007, the Court permitted six additional Phase III visits and expanded the duration of those visits to six nights. See Hinckley V, 493 F.Supp.2d at 77-78. After allowing several additional visits in 2008, later that year the Court permitted Mr. Hinckley to continue making Phase III visits under the same terms and conditions until further order of the Court. See Order at 1, United States v. Hinckley (Aug. 15, 2008).
The Court's most recent set of orders addressed so-called "Phase IV" visits, which have allowed Mr. Hinckley to make trips of up to ten days to Williamsburg. While Phase III was regarded as an opportunity for outings representing a "change of venue" from the Washington, D.C. area to Williamsburg, Phase IV was conceived of as a "transitional stage, " in which Mr. Hinckley would be expected to focus on social and vocational integration into his mother's community. See Hinckley VI, 625 F.Supp.2d at 6. To that end, in 2009 the Court authorized twelve Phase IV visits, each with a duration of ten days and nine nights, and each subject to the successful completion of the previous visit, with a written report to the Court. See Order at 2, United States v. Hinckley (July 20, 2009).
During these Phase IV visits, Mr. Hinckley was required to remain under the supervision of his mother or siblings at all times whenever outside of his mother's home, except for periods of limited duration in which he was allowed to engage in activities within a defined geographic area that were designed by the Hospital to acclimate him to the Williamsburg community. See Order at 1-2, United States v. Hinckley (July 20, 2009). Such activities included establishing therapeutic relationships with two Williamsburg-area treatment providers whose services had been arranged for him during his visits - a psychiatrist and a combined individual therapist and case manager. Mr. Hinckley also was permitted to spend four hours twice a week performing volunteer work with a local organization, which could increase if deemed appropriate by the treatment team and his participating employer. Id. at 11-12.
Contingent upon Mr. Hinckley's ongoing participation in local volunteer work, he also was afforded a limited amount of unsupervised time in the Williamsburg community to engage in social and recreational activities. Specifically, Mr. Hinckley was allowed up to three hours of unaccompanied time, twice a week, between the hours of 8:00 a.m. and 9:00 p.m., "for specific social, recreational, religious, or shopping related activities." Order at 12-13, United States v. Hinckley (July 20, 2009). At least two weeks before each Phase IV visit, the Hospital was required to submit a detailed, day-by-day itinerary of Mr. Hinckley's proposed activities to the Court, the government, and Mr. Hinckley's counsel. Id. at 4-5. In particular, the Hospital was required to provide specific details, including time and place, of the time Mr. Hinckley was to spend out of the supervision of his family members. Id. at 3.
Mr. Hinckley also was permitted up to two hours of unaccompanied time twice daily within the confines of his mother's housing subdivision during specified hours. Order at 2, 13, United States v. Hinckley (July 20, 2009). Mr. Hinckley also was given permission, subject to a number of conditions, to obtain a driver's license and to drive the Hinckley family's car with a family member or treatment provider with him at all times. Id. at 14. Among many other restrictions imposed on Mr. Hinckley during his visits to Williamsburg and during his use of unsupervised time in the community, Mr. Hinckley was required to carry a GPS-enabled cell phone anytime that he was not accompanied by his mother or siblings. Id. at 2. After each visit, the Hospital was responsible for submitting a detailed report of the visit to the Court, the government, and Mr. Hinckley's counsel prior to the next visit. Id. at 10.
During each Phase IV visit, Mr. Hinckley was ordered to meet at least once with his Williamsburg-area psychiatrist, Dr. John J. Lee. After interviewing and assessing Mr. Hinckley during these sessions, Dr. Lee was required to complete a checklist describing his observations and fax it to the Hospital within a week of the appointment. Dr. Lee also was required to participate in a telephone conference call with Mr. Hinckley's treatment team after each visit to discuss the visit and any concerns or issues relating to Mr. Hinckley or his treatment goals, and to participate by telephone in the meetings of the treatment team to discuss Mr. Hinckley's Individual Recovery Plan every three months or as scheduled. Order at 3-5, United States v. Hinckley (July 20, 2009). Mr. Hinckley also was ordered to meet at least once during each visit with his Williamsburg-area case manager and individual therapist, Mr. Carl Beffa. Mr. Beffa was required to communicate after each visit with Mr. Hinckley's primary therapist at St. Elizabeths, Dr. Sidney Binks, to discuss and collaborate on the course of therapy for Mr. Hinckley. He also was required to complete a checklist of observations, communicate with the treatment team after each visit, and participate in treatment team meetings in the same manner as Dr. Lee. Id. at 5-7.
Although the Court's authorization of Phase IV visits expanded the duration of Mr. Hinckley's visits to Williamsburg to ten days, St. Elizabeths remained Mr. Hinckley's residence and the Hospital treatment team remained his primary clinicians. The Court ordered that if there were any signs of "decompensation" or deterioration in Mr. Hinckley's mental condition during his visits, no matter how slight, or any indication of danger to himself or to others, or of elopement (that is, attempt to escape or abscond), Mr. Hinckley would immediately be returned to the Hospital. Order at 7, United States v. Hinckley (July 20, 2009).
Mr. Hinckley began making Phase IV visits in late 2009. He soon began volunteering two days a week, for four hours each day, at the hospital library of Eastern State Hospital, a psychiatric hospital located in Williamsburg. Although Eastern State is a psychiatric hospital, Mr. Hinckley's relationship with the institution is that of a volunteer employee, not a patient. Beginning in 2012, with the imminent closure of the hospital library due to staffing and funding changes, Mr. Hinckley began volunteering in the cafeteria at Eastern State, where he has been helping at the cash register and taking orders from patrons. He has received positive reviews from his supervisors in both volunteering capacities about his work and his interaction with patrons and employees. Hospital's Revised (e) Letter at 10-11. According to the Hospital, Mr. Hinckley has also made use of his twice-weekly periods of unsupervised time in the community, as well as his daily periods of unsupervised time within his mother's subdivision. He has obtained his driver's license and has operated the Hinckley family's vehicle during his visits, accompanied by a family member. Id. at 19.
In 2010, the Hospital and Mr. Hinckley's Williamsburg case manager, Carl Beffa, initiated discussions with Colonial Behavioral Health, a regional mental health services provider, about the possibility of providing therapeutic services to Mr. Hinckley. Colonial operates a non-residential day program of group therapeutic activities in the Williamsburg area known as People's Place. Mr. Hinckley participated in an orientation session with Colonial, which was followed by communication between Colonial and Mr. Hinckley's unit clinical administrator at St. Elizabeths, Mr. Kevin Shamblee, to facilitate his acceptance to participate in therapeutic activities at People's Place during his Williamsburg visits.
By May 2011, Mr. Hinckley had completed twelve Phase IV visits, without any reported incidents of misbehavior and in compliance with all of the Court's specific directives. Upon motion by Mr. Hinckley and the Hospital, the Court entered an interim order permitting an indefinite number of additional Phase IV visits under the terms and conditions specified in the Court's July 2009 Order. Such visits were authorized to continue until the Court ruled on the Hospital's next petition for expanded conditions of release. See Order at 2, United States v. Hinckley (May 13, 2011). Since then, Mr. Hinckley has completed an additional 21 Phase IV visits without any reported incidents of misbehavior and in compliance with all of the Court's specific directives - with two notable exceptions discussed below.
On two separate occasions - in July 2011 and in September 2011 - the Secret Service observed Mr. Hinckley deviating from the terms of the itineraries that governed the use of his unsupervised time in the Williamsburg community. It was also discovered that Mr. Hinckley had lied to St. Elizabeths staff and others about these deviations. On each occasion, Mr. Hinckley was scheduled to attend a movie during his three-hour window of unsupervised time, and on each occasion, Mr. Hinckley reported afterward to his clinical unit administrator at the Hospital, Kevin Shamblee, that he had attended the movie, even describing and recommending it. See Patient's Ex. 5; Transcript of Hearing at 96 (Nov. 30, 2011 p.m.); Transcript of Hearing at 102 (Dec. 8, 2011 a.m.); Transcript of Hearing at 201 (Feb. 25, 2013). Mr. Hinckley made similar misrepresentations to the expert witnesses retained by the government when they later interviewed him in preparation for the upcoming evidentiary hearing before this Court. See Transcript of Hearing at 23-24 (Jan. 30, 2012 p.m.); Forensic Psychiatric Evaluation Concerning Expansion of Terms of Conditional Release under 501(e) ("Phillips Rpt.") at 72; Independent Forensic Psychiatric Evaluation of John W. Hinckley, Jr. ("Patterson Rpt.") at 34.
The Secret Service had been monitoring Mr. Hinckley on both occasions, and their surveillance reports showed his claims to be false. On both days, as the Secret Service reported, Mr. Hinckley arrived at the movie theater and spoke with someone in the ticket booth but did not buy a ticket. Instead, he spent the remaining hour or two of his unsupervised free time at a nearby chain bookstore, Barnes & Noble, and a fast-food establishment, before being picked up by his mother to return home. See Patient's Exs. 9, 26; see also Transcript of Hearing at 73-75 (Jan. 23, 2012 p.m.) (Special Agent Bordeaux). When confronted with this evidence, Mr. Hinckley later admitted being dishonest about the deviations from his itineraries. See Patterson Rpt. at 34; Psychological Risk Assessment Update ("Montalbano Rpt.") at 27. These incidents occurred after the Hospital submitted its July 2011 (e) letter to the Court, but before the evidentiary hearing held with respect to that (e) letter. Considerable time was devoted to the incidents during the hearing.
As noted above, Mr. Hinckley was permitted in 2009 to advance to his current regime of 10-day Phase IV visits "with the purpose of acclimating him to his mother's community and permitting him to engage in the Phase IV activities discussed in [this Court's] June 16, 2009 Opinion and Order." Order at 2, United States v. Hinckley (July 20, 2009). The ultimate goal of these visits and activities was to determine if Mr. Hinckley is ready to be released from the Hospital to live independently in Williamsburg with the support of his mother (so long as she is healthy and alive), his siblings, and psychiatric and counseling professionals in the community. See Hinckley VI, 625 F.Supp.2d at 6; Hinckley V, 493 F.Supp.2d at 66.
II. THE HOSPITAL'S PROPOSAL FOR EXPANDED CONDITIONS OF RELEASE
A. The Hospital's July 2011 (e) Letter
On July 29, 2011, the Hospital submitted the original version of its current proposal for expanded conditions of release for Mr. Hinckley (the "Hospital's (e) Letter"). The core of the Hospital's proposal was to gradually increase the length of Mr. Hinckley's visits to Williamsburg from their current 10-day duration to visits lasting nearly a month, followed by conditional discharge from the Hospital on "convalescent leave" in that community. Specifically, the plan called for two visits to Williamsburg of 17 days each, followed (if successful) by six visits of 24 days each, followed thereafter (if successful, and upon an assessment by Mr. Hinckley's treatment providers) by release from the Hospital to reside on permanent convalescent leave with his mother in Williamsburg, with psychiatric and therapeutic services to be provided by professionals in that area, rather than by St. Elizabeths, with whom Mr. Hinckley would only periodically need to touch base as an outpatient.
On September 30, 2011, the government filed an opposition to the Hospital's proposal, to which Mr. Hinckley's counsel filed a reply the next month. The Court commenced an evidentiary hearing in late November 2011. For a variety of reasons, including delays caused by the schedules of counsel and witnesses, the hearing proceeded intermittently until its conclusion in February 2012. Furthermore, because the Hospital had to revise its (e) proposal in December 2012, it was necessary to reopen the hearing for additional testimony in February 2013.
B. Withdrawal of Colonial Behavioral Health
An important component of the Hospital's original (e) proposal was Mr. Hinckley's anticipated participation in therapeutic group activities at People's Place, the day program run by Williamsburg-area mental health treatment provider Colonial Behavioral Health. It was contemplated that Mr. Hinckley's participation in these activities would replicate the therapeutic experiences that he now receives by taking part in similar group activities at the Therapeutic Living Center at St. Elizabeths (the so-called "treatment mall"), while also providing structure to his Williamsburg routine, opportunities for social interaction, and an additional set of clinicians monitoring his mental and emotional status.
During the evidentiary hearing, the government and its expert witnesses expressed serious concern over the lack of specificity in the Hospital's plan for Mr. Hinckley to receive services from Colonial Behavioral Health. These concerns arose not only from uncertainty about what specific activities Mr. Hinckley would participate in, but also from doubts about whether Colonial even offered groups that were appropriate for Mr. Hinckley, and - most fundamentally - whether the organization had committed to providing services to him or had merely reached an agreement in principle subject to further negotiation. A significant portion of the evidentiary hearing focused on these questions as they related to whether the Hospital's plan adequately managed Mr. Hinckley's risk of dangerousness.
After the conclusion of the evidentiary hearing in February 2012, but before the Court had ruled on the Hospital's proposal, the Hospital's discussions with Colonial fell apart. As reported to the Court, this result stemmed in part from the inability of the Hospital and Colonial to agree on certain terms regarding Colonial's role in Mr. Hinckley's mental health care treatment - specifically, whether Colonial would assume responsibility for Mr. Hinckley's case management and therapy, as it wished, in addition to providing therapeutic group services. Another contributing factor cited by Colonial in withdrawing its participation in the Hospital's plan was what it perceived as a "general lack of coordination of oversight and management of the plan at the local level." Hospital's Revised (e) Letter at 2 (quoting letter from Colonial). In early June 2012, Colonial informed the Hospital that it would not be participating in the Hospital's plan.
After the Hospital notified the Court of Colonial's withdrawal, the Court informed the Hospital that it had two options: it could either withdraw its pending proposal and submit an entirely new one, or it could proceed with its original proposal but modify it to provide alternatives to fill the role that had been contemplated for Colonial. See Memorandum Opinion and Order at 3-4, United States v. Hinckley (Sept. 19, 2012). The Court also admonished the Hospital that, regardless of which route it chose, it needed to provide assurances that concrete agreements had been reached with whatever providers in Virginia were included in the plan, along with more specifics about these providers' roles than had previously been offered regarding Colonial. Id. at 4. As the Court explained, the Hospital was "on notice that the lack of specificity it provided about Colonial Behavioral Health, People's Place, earlier in these proceedings was a significant concern to the United States and its experts, as well as to the Court." Id.
The Hospital opted to proceed with a modified version of its original proposal, and it submitted a revised (e) letter on December 14, 2012 (the "Hospital's Revised (e) Letter"). The revised proposal is essentially the same as the original, but it accounts for the loss of Colonial's participation by adding a weekly group therapy session led by Mr. Beffa and music therapy with Ms. Elizabeth Haley, a board-certified music therapist with whom Mr. Hinckley began meeting in late 2012. The revised proposal also marks a significant change by transferring the role of Mr. Hinckley's case manager from Mr. Beffa to Mr. Jonathan Weiss, a licensed clinical social worker who has practiced social work and case management since the late 1960s and was the clinical director of what is now Colonial Behavioral Health for over 25 years. This change will leave Mr. Beffa in the exclusive role of therapist. Hospital's Revised (e) Letter at 11-13; Supplemental Report ("Murphy Supp. Rpt.") at 2.
The government opposes the Hospital's revised proposal for the same reasons that it opposed the original. In late February 2013, the Court held a supplemental evidentiary hearing that focused on the modifications to the Hospital's proposal and on new events that had occurred in the intervening year since the conclusion of the original evidentiary hearing.
C. The Hospital's December 2012 Revised (e) Letter
The Hospital believes that after more than six years of visits by Mr. Hinckley to Williamsburg, including visits of substantial duration that have included periods of unsupervised time in the community, Mr. Hinckley is now ready to "begin to transition to spending more time in that area and less time at the Hospital in D.C." Hospital's Revised (e) Letter at 16. As the Hospital stated in its proposal:
Mr. Hinckley has utilized twelve visits on his July 2009 Court order and ongoing visits since being granted a continuance of that order in May of 2011. His family have reported no symptoms of attention-seeking behavior, attempts to contact Jodie Foster, or returning late from his unaccompanied times. He has refused interaction with the media[.] His mood has remained uplifted and his mental status stable while on these outings. The visits to Williamsburg have assisted Mr. Hinckley in achieving various treatment goals including the establishment of closer, more connected relationships with his family members, to become more independent in his operating of a motor vehicle, to increase his opportunities to make good judgments, to establish therapeutic relationships with a psychiatrist in Williamsburg, Virginia, Dr. Debbie Giorgi-Guarnieri, and a therapist, Carl Beffa, LCSW, to utilize mature and effective coping strategies, to become more open and less secretive with the treatment team, to continue his vocational pursuits through volunteering at the Eastern State Hospital Library, to become more familiar and therefore more confident in navigating the Williamsburg community by automobile and, more recently in developing a therapeutic relationship with Elizabeth Haley, music therapist.
Id. at 20-21.
Accordingly, the Hospital proposes expanding the length of Mr. Hinckley's conditional release visits, while affording him greater freedom during those visits. The increased duration of the visits will, in the Hospital's view, allow Mr. Hinckley to more fully develop social, vocational, and therapeutic relationships in the Williamsburg community, facilitating the goal of moving him toward permanent residence there. Hospital's Revised (e) Letter at 21. It further proposes that upon successful completion of eight of these expanded visits - two of 17 days' duration and six of 24 days - the Hospital have the authority, without seeking further approval from the Court, to determine whether Mr. Hinckley should be placed on "convalescent leave" status, permitting him to live full-time in Williamsburg as long as he adheres to the conditions and restrictions placed upon him. Id. at 26-27.
Specifically, the Hospital's Revised (e) Letter of December 2012 asks the Court to expand Mr. Hinckley's conditional release privileges as follows:
1. The duration of the visits to Williamsburg will increase from their current 10-day duration to 17 days for the next two visits and to 24 days for six additional visits.
2. Mr. Hinckley will be allowed to volunteer at Eastern State Hospital for up to five days a week, depending on the availability of suitable work activities.
3. During each of the first two visits (of 17 days), Mr. Hinckley will be permitted up to six unsupervised outings lasting 4 hours each outside his mother's housing subdivision, for social, recreational, shopping, and dining activities, "or for the purpose of securing other related activities, " between 9:00 a.m. and 9:00 p.m.
4. During the third and fourth visits ( i.e., the first two 24-day visits), after his treatment providers have assessed the progress of his previous visits, Mr. Hinckley will be permitted up to nine unsupervised outings lasting 4 hours each under the same conditions.
5. During the remainder of the visits or until the issuance of a new conditional release order, Mr. Hinckley will be permitted up to twelve unsupervised outings lasting 8 hours each, within a 30-mile radius and to a specific geographic location, under the same conditions.
6. The increases in the frequency and duration of Mr. Hinckley's unsupervised outings, noted above, will take effect only after Mr. Hinckley meets certain treatment goals, including but not limited to attending his scheduled therapy sessions and contributing financially to the cost of his treatment.
7. The activities in which Mr. Hinckley engages during the periods of unsupervised time "will be listed in a general menu of current areas of interest approved by [the] Hospital/Mr. Weiss in advance or with notice on the day of a special activity." The Hospital will no longer provide the Court and the government with an itinerary prior to each visit that sets forth the specific date, time, address, and phone number of each activity in which Mr. Hinckley will engage outside of his mother's subdivision. Rather, Mr.
Hinckley will be free to choose from a range of pre-approved options that have been included in a list of activities that he will develop in consultation with his treatment providers. In addition, special activities not included within this list will be permitted if approved on the day of the activity.
8. During these unaccompanied outings, Mr. Hinckley will avoid traveling to government centers in Richmond or to areas where the President or members of Congress may be visiting.
9. When Mr. Hinckley is not involved in structured activities, he will be allowed to remain unaccompanied in his mother's subdivision while she is away from the residence pursuing her own activities. His mother or a sibling need not remain at home at all times, as now. Mr. Hinckley's mother will not, however, be away from the home overnight.
10. Mr. Hinckley will be allowed the unaccompanied use of an automobile while traveling to and from his volunteer activities and his appointments with his treatment providers; while utilizing his unsupervised free time; and while traveling to and from musical activities that he may hear about from his music therapist.
11. Mr. Hinckley may be driven between Washington, D.C. and Williamsburg by a professional driver without his mother or siblings in the vehicle.
12. A minimum of two weeks will occur between each visit to allow for the preparation of feedback reports by the Hospital.
13. The Hospital will be permitted to submit to the Court reports that summarize two visits at a time, rather than submitting a separate report after every visit, unless an emergency occurs requiring that the information be communicated immediately.
14. The Hospital will provide 7-day notice to the Court, the government, and Mr. Hinckley's counsel prior to each visit to Williamsburg, rather than the 14-day notice that it currently provides.
15. The Hospital will provide 1-day notice to the Court, the government, and Mr. Hinckley's counsel prior to each Hospital staff-accompanied outing in Washington, D.C. in which Mr. Hinckley takes part, rather than the 4-day notice that it currently provides.
16. Dr. Giorgi-Guarnieri will continue to serve as Mr. Hinckley's psychiatrist in the Williamsburg area. Mr. Hinckley will meet with Dr. Giorgi-Guarnieri weekly during his visits of 17 days and at least once during his visits of 24 days. Additional visits may occur as clinically necessary. Dr. Giorgi-Guarnieri will monitor Mr. Hinckley for any signs of deterioration or decompensation in his mental condition and will be especially alert for anger, psychosis, depression, any ideas of elopement, endangerment to self or others, noncompliance with conditions of release, or rejection of the supervision provided to Mr. Hinckley by his responsible persons. If any such items are detected, she will telephone the Hospital. Dr. Giorgi-Guarnieri will continue to assess and monitor the risk factors identified in the Hospital's checklists, which she will complete and return to the Hospital after each visit, along with written feedback summarizing her contact with Mr. Hinckley. Dr. Giorgi-Guarnieri also will participate in post-visit telephone conference calls with the Hospital treatment team to discuss Mr. Hinckley's progress, and will participate by phone in the Hospital treatment team's Individual Recovery Plan meetings scheduled every two months for Mr. Hinckley. Dr. Giorgi-Guarnieri will verify with Mr. Hinckley that he has been taking his medications as prescribed. If necessary, Dr. Giorgi-Guarnieri may prescribe medication for emergency psychiatric situations and may facilitate acute hospitalization for psychiatric emergencies.
17. Mr. Beffa will continue to serve as Mr. Hinckley's individual therapist in the Williamsburg area. Mr. Hinckley will meet at least once weekly with Mr. Beffa for therapy sessions until the completion of his first six 24-day visits, after which the frequency of the sessions may be decreased based on the assessment of treatment team members in Virginia and at the Hospital. After each visit, Mr. Beffa will provide written feedback to Mr. Hinckley's Hospital treatment team that will summarize his weekly contact with Mr. Hinckley. This feedback also will be shared with Dr. Giorgi-Guarnieri. Mr. Beffa also will participate by phone in the Hospital treatment team's Individual Recovery Plan meetings scheduled every two months for Mr. Hinckley. Any emergency issues that may be disclosed during the sessions with Mr. Hinckley will be shared with the Hospital and Dr. Giorgi-Guarnieri.
18. Mr. Beffa, in addition to the individual therapy that he will provide to Mr. Hinckley, will conduct group psychotherapy sessions in which Mr. Hinckley will be included. The goals of these sessions will be to improve socialization and relationship-building and to foster community reintegration.
19. Mr. Jonathan Weiss, a licensed clinical social worker, will assume the role of Mr. Hinckley's Williamsburg case manager, taking this duty over from Mr. Beffa. Mr. Weiss will make recommendations to Mr. Hinckley and the Hospital for opportunities to increase Mr. Hinckley's socialization, enrichment, or mental health support in the Williamsburg community; these recommendations will be made after first-hand investigation of the appropriateness of Mr. Hinckley's participation in the activities in question and their relevance to the objectives of the visits. Mr. Weiss also will monitor Mr. Hinckley's progress in his volunteer and scheduled daytime activities by communicating at least once per visit with the relevant supervisor. He may also accompany Mr. Hinckley on outings in the community. After each visit, Mr. Weiss will provide written feedback to the Hospital treatment team summarizing any contact with Mr. Hinckley related to case management and providing recommendations.
20. Ms. Elizabeth Haley, a board-certified music therapist, will provide individual music therapy sessions during his conditional release visits. She will conduct at least one music therapy session during each visit, and will provide written feedback to the treatment team afterward. She will report to the Hospital any emergency issues that may be disclosed during the sessions. She also may communicate with Mr. Hinckley's music therapist at St. Elizabeths to promote continuity in this therapy.
The Hospital also recommends that certain conditions of Mr. Hinckley's Williamsburg visits that are presently in force remain unchanged with respect to future visits:
21. Mr. Hinckley will be required to travel with his GPS-equipped cell phone during all unaccompanied outings.
22. Mr. Hinckley's mother, brother, and sister will remain as the identified "responsible persons" supervising him in Williamsburg. They will continue to submit feedback forms to the Hospital after each visit as well as participate in telephone or in-person conversations with Mr. Hinckley's treatment team members after the visits.
23. Before each visit, Mr. Hinckley will continue to receive an amount of medication from the pharmacy at the Hospital to cover the duration of the visit.
24. Mr. Hinckley will be allowed to continue his daily unaccompanied walks within his mother's subdivision. Presently, Mr. Hinckley is allowed two such walks each day, of up to 2 hours in duration, except on the days in which he utilizes his unaccompanied community time, when he is permitted only one such walk.
25. The restrictions on Mr. Hinckley's internet use during his trips to Williamsburg will remain in force. These restrictions require that a family member be present in the room with him whenever Mr. Hinckley uses the internet.
26. The Individual Relapse Prevention and Media plans that were previously developed will remain in effect for the duration of Mr. Hinckley's time spent in Williamsburg.
Finally, the Hospital proposes that after the successful completion of two 17-day visits and eight 24-day visits to Williamsburg, the following additional conditions take effect:
27. Upon "an assessment by the Hospital staff and providers in Virginia indicating that Mr. Hinckley is experiencing a good mental status and that he does not present a danger to himself or others, " at the discretion of the Hospital Mr. Hinckley will be conditionally released to reside permanently on convalescent leave to reside with his mother in Williamsburg.
28. While residing in Williamsburg on convalescent leave, Mr. Hinckley will continue to receive psychiatric "follow up" from Dr. Giorgi-Guarnieri, who will meet with Mr. Hinckley twice a month for the first three months and no less than monthly afterwards. At the outset of convalescent leave, Dr. Giorgi-Guarnieri will begin to prescribe Mr. Hinckley's psychiatric medication, which will be obtained at a local pharmacy.
29. Mr. Hinckley will continue to receive weekly individual and group therapy from Mr. Beffa.
30. Case-management services will be provided on an as-needed basis.
30. Mr. Hinckley will make weekly calls to the Hospital's Outpatient Department of Clinical Operations ("OPDCO") for the first three months of his convalescent leave and no less than monthly thereafter, at the discretion of the OPDCO. Mr. Hinckley also will travel to Washington, D.C. monthly to meet with OPDCO staff members at the Hospital. He will be allowed to travel unaccompanied to Washington, D.C. for these regularly scheduled appointments. A current member of Mr. Hinckley's inpatient treatment team will be present at these meetings, for at least the first six months or longer, at the discretion of the OPDCO. Dr. Giorgi-Guarnieri and Mr. Beffa will communicate with the OPDCO "via a monthly checklist and summary as well as telephone contact prior to his visiting the staff in D.C."
30. Mr. Hinckley will continue to attend his regularly scheduled activities at Eastern State Hospital until employment or an alternative constructive daytime activity is arranged.
31. If the Hospital's proposal for convalescent leave is approved by the Court, a designee of the Hospital will work with Mr. Hinckley to ensure that he has applied for Social Security and Virginia Medicaid benefits prior to his release.
32. If the Hospital's proposal for convalescent leave is not approved by the Court at this time, the proposed visits of 24 days will continue until the Court issues another conditional release order.
Hospital's Revised (e) Letter at 9-27.
In the Hospital's opinion, Mr. Hinckley has sufficiently recovered from his mental illness to be granted the proposed expansions of his conditional release freedom without danger to himself or others, under the conditions outlined above. Hospital's Revised (e) Letter at 27. "If Mr. Hinckley's condition warrants, or if he violates the conditions of this release, the Hospital will return him to total inpatient care with due notice to the Court." Id.
Mr. Hinckley supports the Hospital's proposals and has not submitted his own, separate petition for expanded conditional release privileges under 24 D.C. Code § 501(k), as he has sometimes done in the past. See John W. Hinckley's Reply Memorandum in Support of Hospital's Request for Enlargement of Terms of Conditional Release (Oct. 21, 2011). Mr. Hinckley has, however, expressed the view that the proposed extended visits of 17 and then 24 days should take place on a regular monthly basis, in order to ensure predictability in his availability for vocational, employment and therapeutic activities. Transcript of Hearing at 19-20 (Nov. 30, 2011 a.m.). This recommendation is inconsistent with the Hospital's proposal that Mr. Hinckley's 24-day visits be scheduled at least two weeks apart, in order to afford the Hospital time to prepare the feedback reports submitted to the Court.
The government opposes the Hospital's proposal, deeming it "premature and ill conceived." See Government's Opposition to St. Elizabeths Hospital's Request for Expanded Conditions of Release at 4 (Sept. 30, 2011) ("Opp."). In particular, the government believes that the proposal fails adequately to address the persistence of key behaviors by Mr. Hinckley that have been recognized as risk factors for dangerousness on his part. Chief among the government's concerns is that Mr. Hinckley remains prone to secretiveness and deception about his thoughts, actions, and intentions - a trait that may stymie the efforts of his treatment providers to detect signs of decompensation or dangerousness on his part during any lengthy conditional release. Mr. Hinckley's deceptiveness and lack of candor, as the government sees it, are tied to his ongoing diagnosis of narcissism, and they continue to manifest themselves in particular with respect to his relationships with and interest in women.
Pointing to the record of Mr. Hinckley's Phase IV visits to Williamsburg, the government further argues that these visits have utterly failed in their therapeutic objective of integrating Mr. Hinckley into that community. The government contends that Mr. Hinckley, rather than engaging in activities to foster social and vocational integration, has adhered to an isolated and repetitive pattern of activities during each of his visits, with the result that he has failed to develop any social ties in Williamsburg that would ameliorate his risk of isolation and depression. As the government puts it, Mr. Hinckley "has developed a routine of engaging in solitary pursuits that have no likelihood of permitting him to make friends or increase the support system that his treating physicians, and Hinckley himself, view as critical to preventing him from decompensating." Opp. at 11. According to the government, as a result of his lack of initiative and unwillingness to broaden the scope of his activities - even when prompted with specific suggestions by his treatment providers - Mr. Hinckley has not established the social ties necessary to alleviate the concern that, should he be conditionally released into his mother's community as proposed by the Hospital, he may become isolated, depressed, and ultimately unstable.
In light of what the government views as Mr. Hinckley's ongoing deception and secretiveness, his lack of meaningful integration in Williamsburg, and the potentially destabilizing influence of his relationships with women, the government faults the Hospital for failing to devise a detailed plan with sufficient monitoring, oversight, and structured activity to provide assurances that his risk of decompensation is being adequately managed.
In sum, the government argues, between Mr. Hinckley's continued demonstration of troubling risk indicators and the Hospital's failure to adequately account for those risks, it is "impossible to find, even by a preponderance of the evidence, that Hinckley will not become a danger to himself or others if he is permitted to transition into the community in his mother's hometown." Opp. at 12. Indeed, the government raises the question of whether the "experiment" of transitioning Mr. Hinckley to Williamsburg has proven a failure, because, as the government puts it, "the Hospital appears to be unable to knit together either a web of effective mental-health providers or meaningful activities that Hinckley can use to integrate himself into the community." Id.
III. THE EVIDENTIARY HEARING
As has been its practice, the Court held an evidentiary hearing on the Hospital's original (e) letter in order to permit all parties to substantiate and elaborate upon their positions with respect to the Hospital's proposal. That hearing included opening statements by counsel for the government and counsel for Mr. Hinckley, more than ten full days of live testimony (making this by far the longest hearing that the Court has held in this matter), and closing arguments. Counsel for Mr. Hinckley called the following witnesses: (1) Dr. Tyler Jones, Director of Psychiatric Services at St. Elizabeths Hospital and a member of St. Elizabeths Hospital Review Board, which oversees the development and submission of petitions for conditional release; (2) Kevin Shamblee, a Clinical Administrator at St. Elizabeths Hospital with responsibilities for Mr. Hinckley, and the author of the Hospital's (e) letter and revised (e) letter; (3) Dr. Katherine Murphy, Clinical Staff Psychologist at St. Elizabeths Hospital, who prepared an extensive risk assessment with respect to Mr. Hinckley; (4) Dr. Deborah L. Giorgi-Guarnieri, the aforementioned psychiatrist in private practice in the Williamsburg area who has been Mr. Hinckley's psychiatrist in that area since 2010; (5) Carl Beffa, the aforementioned therapist and social worker in private practice in the Williamsburg area who is Mr. Hinckley's case manager and individual therapist in that area; (6) Diane Sims, Mr. Hinckley's sister; (7) Scott Hinckley, Mr. Hinckley's brother; and (8) Dr. Paul Montalbano, Deputy Director of the Forensic Psychology Postdoctoral Fellowship Program at Walter Reed Medical Center, formerly Pretrial Chief of the Forensic Service Unit at John Howard Pavilion, St. Elizabeths Hospital, who testified as a rebuttal expert witness for Mr. Hinckley.
Counsel for the government called the following witnesses: (1) Dr. Raymond Patterson, a psychiatrist retained as an expert witness by the government and the former Medical Director and former Acting Associate Superintendent at St. Elizabeths Hospital, the former Commissioner of Mental Health in the District of Columbia, and the former Forensic Director for the State of Maryland; (2) Dr. Robert Phillips, a psychiatrist retained as an expert witness by the government and the former Director of Forensic Services, State of Connecticut Department of Mental Health, Deputy Medical Director, American Psychiatric Association, Adjunct Professor of Law and Psychiatry at the University of Maryland School of Law, and Visiting Lecturer in Psychiatry at the Yale University School of Medicine; (3) Anthony Bordeaux, Special Agent with the United States Secret Service, who testified about his surveillance of Mr. Hinckley in Williamsburg, Virginia; (4) Jason Clickner, Special Agent with the United States Secret Service, who testified on the same topic; and (5) Richard Rolfes, an employee of a bookstore located in Williamsburg, who testified about a 2011 encounter with a customer whom he identified as Mr. Hinckley.
A. Witnesses for the Hospital and Mr. Hinckley
1. Witnesses from St. Elizabeths Hospital
Dr. Tyler Jones, the Director of Psychiatric Services at St. Elizabeths, testified on behalf of the Hospital and its Forensic Review Board, which oversees the work of individual patients' treatment teams as they formulate recommendations for conditional releases. In addition to describing the work of Mr. Hinckley's treatment team, Dr. Jones was permitted to offer expert testimony on the issue of whether Mr. Hinckley will be dangerous to himself or others as a result of a mental disease under the Hospital's proposed terms of conditional release. Dr. Jones testified that in his opinion, to a reasonable degree of medical certainty, Mr. Hinckley represents a low risk of dangerousness to himself or others if conditionally released under those terms. Transcript of Hearing at 64-65 (Nov. 30, 2011 a.m.).
Dr. Jones testified about Mr. Hinckley's psychiatric diagnoses and prescribed medications. Transcript of Hearing at 13 (Nov. 30, 2011 p.m.). According to Dr. Jones, Mr. Hinckley is currently diagnosed with two "Axis I" conditions: major depressive disorder recurrent, in full remission; and psychotic disorder not otherwise specified, also in full remission. Being in full remission, Dr. Jones explained, "means that there are no signs or symptoms of the disorder." Id. at 14. Such conditions, although they no longer present any signs or symptoms, often continue to be included in a patient's diagnosis for a variety of reasons, including, as in Mr. Hinckley's case, for purposes of ongoing monitoring or prophylactic treatment. Id.
Mr. Hinckley also is diagnosed by the Hospital as having one Axis II condition, narcissistic personality disorder. While the signs of this disorder are still evident in Mr. Hinckley, in the Hospital's opinion the condition is attenuated and by itself represents less of a risk factor for dangerousness than his Axis I conditions once presented. Transcript of Hearing at 14-15 (Nov. 30, 2011 p.m.).
Since May 1999, Dr. Jones testified, Mr. Hinckley has taken one milligram of Risperdal daily, which is an antipsychotic medication for the treatment of psychotic disorders but which is also approved for other purposes. This prescription is in the low range of possible doses. Transcript of Hearing at 16 (Nov. 30, 2011 p.m.). At the time Mr. Hinckley began taking Risperdal in 1999, his psychotic disorder was already in full remission and Mr. Hinckley had shown no symptoms of psychosis for many years. According to Dr. Jones, the treatment team believes that the medication serves a useful prophylactic function: if Mr. Hinckley's clinical depression were to return and he were to experience a severe decompensation, the medication would be helpful in preventing symptoms of psychosis, such as delusions. Id. at 19. In addition, the class of medications of which Risperdal is a part "has been approved for the use of adjunctive therapy for depression, that is for cases where one medication ...