United States of America v. Johnathan Dewayne Mitchell

United States Court of Appeals
For the Eighth Circuit
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No. 21-1174
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United States of America
lllllllllllllllllllllPlaintiff - Appellee
v.
Johnathan Dewayne Mitchell
lllllllllllllllllllll
Defendant - Appellant
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Appeal from United States District Court
for the Northern District of Iowa – Cedar Rapids
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Submitted: June 15, 2021
Filed: August 25, 2021
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Before LOKEN, KELLY, and ERICKSON, Circuit Judges.
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KELLY, Circuit Judge.
Johnathan Mitchell was indicted in April 2016 for Hobbs Act robbery, see 18
U.S.C. § 1951, and is currently detained pending trial. On January 21, 2021, the
district court1 ordered that Mitchell—who has been diagnosed with schizophrenia
and antisocial personality disorder—be involuntarily medicated pursuant to Sell v.
1 The Honorable Leonard T. Strand, Chief Judge, United States District Court
for the Northern District of Iowa.

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United States, 539 U.S. 166 (2003), to maintain his competency for trial. See id. at
180 (holding that “involuntary administration of drugs solely for trial competence
purposes” is permitted “in certain instances”). We affirm. See United States v. Coy,
991 F.3d 924, 926 (8th Cir. 2021) (noting that we “[h]av[e] jurisdiction over
interlocutory appeals of orders for involuntary medication under the collateral order
doctrine” (cleaned up)).
I.
Since being detained on the Hobbs Act charge, Mitchell has twice been found
incompetent to stand trial. Defense counsel first moved to have Mitchell’s
competency evaluated in July 2016. The next month, after a 30-day evaluation
period, then-Chief Magistrate Judge Jon Stuart Scoles found Mitchell incompetent
and committed him to the Bureau of Prisons’ (BOP) medical facility in Springfield,
Missouri, for competency restoration. In September 2017, based on a July 2017
BOP psychologist’s report that Mitchell’s competency had been restored, the
magistrate judge found Mitchell competent to stand trial.
Fewer than two months later, however, defense counsel again moved for an
evaluation of Mitchell’s competency, reporting that Mitchell had stopped taking his
medication and had begun engaging in “unusual behavior.” Magistrate Judge Kelly
K.E. Mahoney granted the motion. After a 30-day evaluation period, a BOP
psychologist opined that Mitchell’s time in transit to the BOP medical facility in
Butner, North Carolina, contributed to his decompensation.2 In February 2018, the
magistrate judge found Mitchell incompetent and committed him for competency
restoration at the BOP facility in Butner. Later that year, the court received two
reports from Mitchell’s psychologist at BOP-Butner—one in July and the other in
2 As relevant here, decompensation is “a breakdown in an individual’s defense
mechanisms, resulting in progressive loss of normal functioning or worsening of
psychiatric symptoms.” Decompensation, APA Dictionary of Psychology, Am.
Psych. Ass’n, https://dictionary.apa.org/decompensation (last visited Aug. 20,
2021).

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October—both of which concluded that Mitchell remained incompetent. The latter
also opined that Mitchell’s level of voluntary compliance with antipsychotic
medication was around 50% and that his competency was unlikely to be restored at
that rate. In March 2019, the government requested a hearing to determine whether
involuntary medication of Mitchell was warranted under Sell.
At the Sell hearing, which did not take place until June 25, 2019, a BOP
psychiatrist testified that Mitchell had become 90% compliant with his medications
and that this was sufficient to restore his competency. In light of this information,
the magistrate judge recommended denying the government’s motion to
involuntarily medicate Mitchell, finding that it had failed to prove the necessity for
doing so. The district court accepted this recommendation in October 2019.
In early December 2019, the magistrate judge received an updated report from
a psychologist at BOP-Butner opining that Mitchell was competent and that his
continued competence was contingent upon his willingness to take his medications.
In the two months leading up to that report, Mitchell’s level of voluntary compliance
had fallen back down to between 60% and 65%. The magistrate judge thus
scheduled a competency hearing for January 2, 2020, and Mitchell was transported
from BOP-Butner to the Linn County Jail in Iowa in a single day, on December 18,
2019. At the hearing, the magistrate judge found Mitchell competent based on a
November 2019 report from the BOP psychologist. That report did not reflect,
however, that Mitchell’s voluntary compliance had declined further while at the Linn
County Jail: in December 2019 and January 2020, Mitchell took his medications
only 20% of the time. As a result, three weeks after finding Mitchell competent, the
magistrate judge granted defense counsel’s request for another competency
evaluation.
Mitchell arrived at the SeaTac Federal Detention Center in Seattle,
Washington, on February 6, 2020, for a 30-day evaluation period that was later
extended. Though Mitchell’s voluntary compliance with medication while at BOP-
SeaTac was around 62% and he “presented more stable,” Mitchell refused to

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participate in the evaluation process, so the BOP psychologist could not determine
his competency. The psychologist noted that Mitchell still seemed to be
experiencing psychotic symptoms, had poor hygiene, “exhibited fluctuating
medication compliance,” and engaged in hoarding and other “questionable
behaviors.” On April 17, 2020, based on “the latest report” from BOP-SeaTac “as
well as past forensic evaluations,” the magistrate judge found Mitchell incompetent
to stand trial.
Mitchell returned to BOP-Butner on July 28, 2020, for a third round of
competency restoration. His voluntary compliance with medication was 90% in
August 2020 and 50% in the first half of September, with an overall compliance rate
of 76.6% by September 18, 2020. On October 19, 2020, after holding a competency
hearing, the magistrate judge found Mitchell competent to proceed.
That same month, though, the government also filed a second motion for
involuntary medication pursuant to Sell. At the Sell hearing on November 20, 2020,
the chief psychiatrist at BOP-Butner, Dr. Logan Graddy, testified that Mitchell
would decompensate if he stopped taking his medications, but that he could not
identify the precise rate of voluntary compliance necessary to maintain Mitchell’s
competency. Dr. Graddy also testified that, though Mitchell had been found
competent while 60% compliant in the past, at other times he had decompensated
rapidly after missing only a few doses. Dr. Graddy submitted a treatment plan
setting out the maximum and minimum dosages of antipsychotic medication to be
involuntarily administered in the event of Mitchell’s noncompliance.
In a detailed report issued on December 22, 2020, the magistrate judge
recommended granting the government’s motion for involuntary medication under
Sell. The magistrate judge explained that unlike the evidence presented at the first
Sell hearing in June 2019, the evidence—namely, Dr. Graddy’s testimony—“now
establishes . . . that Mitchell’s previous episodes of decompensation were caused by
medication noncompliance.” The magistrate judge previously denied the
government’s first motion for involuntary medication in part because “Mitchell’s

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noncompliance and decompensation” at the time “could have been triggered by the
lengthy transport process—it took eleven days and stays at three different facilities
to move him from BOP-Springfield back to the local jail.” This time, however, the
evidence showed that Mitchell had decompensated in December 2019—after the
second round of competency restoration—despite having been transported from
BOP-Butner to the Linn County Jail in a single day. Considering Dr. Graddy’s
testimony that “noncompliance caused [Mitchell’s] symptoms,” the magistrate judge
ruled out transport as a trigger for Mitchell’s decompensation. The magistrate judge
also rejected Mitchell’s argument that “as a categorical rule, a court cannot order
involuntary medication under Sell when the defendant is competent,” and ultimately
concluded that Mitchell’s “past history demonstrates that without an involuntary-
medication order, it is only a matter of time before his voluntary compliance
deteriorates and he is rendered incompetent for a fourth time.”
On January 21, 2021, the district court accepted the magistrate judge’s
recommendation and ordered that “[i]f Mitchell does not voluntarily comply with
his medication regimen, the Bureau of Prisons is authorized and directed to
involuntarily administer antipsychotic medication as deemed appropriate by
Mitchell’s treating psychiatrist, consistent with Dr. Graddy’s proposed treatment
plan, until and while Mitchell stands trial.” The district court further specified that
Mitchell’s “medication compliance rate shall not be allowed to fall below 76% per
month.”
II.
“[A]n individual has a significant constitutionally protected liberty interest in
avoiding the unwanted administration of antipsychotic drugs.” Sell, 539 U.S. at 178
(cleaned up) (quoting Washington v. Harper, 494 U.S. 210, 221 (1990)). In Sell,
“[t]he Supreme Court articulated a four-element test for determining the
circumstances in which the government may obtain a court order to involuntarily
medicate a defendant to render him competent to stand trial.” Coy, 991 F.3d at 928
(cleaned up). “Those elements are: (1) that an important governmental interest is at

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stake; (2) that involuntary medication will significantly further that governmental
interest; (3) that involuntary medication is necessary to further that interest; and (4)
that administration of the drugs is medically appropriate.” Id. at 928-29 (cleaned
up). “We review de novo a court’s legal determination that important governmental
interests are at stake.” United States v. Mackey, 717 F.3d 569, 573 (8th Cir. 2013).
Because “[t]he government must prove the other three elements by clear and
convincing evidence, . . . we review the district court’s findings” on those elements
“for clear error.” Id.
A.
Mitchell argues that Sell does not permit a court to order the involuntary
medication of a competent defendant. He emphasizes that the question before the
Sell Court was whether “forced administration of antipsychotic drugs to render [a
defendant] competent to stand trial unconstitutionally deprive[s] him of his liberty
to reject medical treatment.” 539 U.S. at 177 (emphasis added) (cleaned up).
Because “render” means, in relevant part, “to cause to be or become: make,”
Render, Merriam-Webster’s Collegiate Dictionary (11th ed. 2003)—implying a
change from one state of being to another—Mitchell asserts that Sell did not
contemplate the use of involuntary medication to maintain or preserve a defendant’s
competency. He points to the Sell Court’s discussion of competency restoration as
further support for this argument. See, e.g., Sell, 539 U.S. at 185 (explaining that
whether a drug has certain side effects, such as whether it “will tend to sedate a
defendant,” is “important in determining the permissibility of medication to restore
competence”). In short, Mitchell maintains that “incompetence is a condition
precedent to forcible administration of antipsychotics” and, at the time of the Sell
hearing, he had been declared competent.
By focusing solely on the word “render,” Mitchell overlooks an important
aspect of the Sell standard: “whether involuntary administration of drugs is
necessary significantly to further a particular governmental interest, namely, the
interest in rendering the defendant competent to stand trial.” Id. at 181 (emphasis

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omitted). Under Sell, the mere competency of a defendant, standing alone, is not the
governmental interest at stake. Competency to stand trial is. And as Mitchell
acknowledges, Sell authorizes the government not only to involuntarily medicate an
incompetent defendant, but also to continue doing so during trial. See id. at 185
(discussing how antipsychotic medication may affect a defendant during trial and
how this might bear on the second Sell element). Permitting involuntary medication
through the conclusion of trial ensures, at the risk of stating the obvious, that the
defendant will remain—at all necessary times—“competent to stand trial.” Id. at
177. As the magistrate judge explained, it prevents the very type of situation at risk
of happening here: a defendant who cycles in and out of competency indefinitely
and who may never be able to stand trial if the cycle continues. Given that the
purpose of involuntary medication under Sell is to ensure the defendant is competent
enough to participate in trial, adopting a rule that categorically prohibits the
involuntary medication of a defendant who has regained competency for some
period of time, but who is unable to maintain it, would frustrate that purpose where
an important governmental interest is at stake.
We recognize that the issue Mitchell raises is one of first impression for this
court, and both sides say the other is unable to cite to any published cases in support
of its position. But even if Mitchell’s case presents an uncommon fact pattern, the
Sell standard provides the applicable framework for determining whether
“involuntary administration of drugs solely for trial competence” is appropriate. Id.
at 180. This is not to say that a defendant’s restoration to competency before trial is
not relevant to the Sell analysis. Whether the government has met its burden in
proving the necessity of forced medication is a challenging and important decision
for the district court, with weighty considerations in the mix. See United States v.
Chatmon, 718 F.3d 369, 373 (4th Cir. 2013) (“The question of when the government
may involuntarily administer psychotropic drugs to a defendant for the purpose of
rendering him competent to stand trial entails a difficult balance between the
defendant’s interest in refusing mind-altering medication and society’s interest in
bringing the accused to trial.”). Indeed, the nature of mental illness is such that an
individual defendant’s condition may change significantly over time, and, depending

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on the circumstances, a defendant’s restoration to competency may factor differently
into the question of whether involuntary medication is necessary to further the
government’s interests. But Mitchell’s proposed bright-line rule, which treats
competency as static, does not comport with the careful, fact-specific balancing of a
defendant’s and the government’s competing interests that Sell requires.
Accordingly, the district court did not err in concluding that it had the
authority to order the involuntary medication of Mitchell for the purpose of
rendering and maintaining his competency for trial.
B.
Next, we consider Mitchell’s argument that the district court clearly erred in
finding that involuntary medication is necessary to further the government’s interests
in timely prosecution under the third Sell element. See Mackey, 717 F.3d at 573.
Involuntary medication is “necessary” when “alternative, less intrusive means are
unlikely to achieve substantially the same results.” Sell, 539 U.S. at 181. The
district court reasonably credited Dr. Graddy’s testimony that, while therapy or
supportive housing may be beneficial for schizophrenia, antipsychotic medication is
the “mainstay” and the “best” treatment for the condition. Considering Dr. Graddy’s
testimony “that Mitchell has ‘acted out’ after missing just one dose” and “that
Mitchell will decompensate if he does not adhere to his medication regimen,” the
district court plausibly concluded that Mitchell “clearly risks decompensating upon
missing a relatively small number of doses.” Mitchell’s sporadic compliance also
supports the district court’s finding that “Mitchell has demonstrated a pattern of
failing to voluntarily maintain a medication regimen upon becoming competent.”
And given Mitchell’s indigency and the fact that he “will remain in custody
regardless,” it was reasonable for the district court to reject the less-intrusive threat
of a contempt order as a viable alternative to forcible medication.
The district court’s order is narrowly and carefully tailored to minimize the
intrusion on Mitchell’s protected liberty interests. The order does not mandate the

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forcible administration of every prescribed dose of antipsychotic medication.
Rather, it provides that Mitchell’s “medication compliance shall not be allowed to
fall below 76% per month,” meaning Mitchell can avoid involuntary medication so
long as he complies with his medication regimen at the rate specified. On this record,
the district court’s finding that involuntary medication is necessary to achieve the
government’s interests was not clearly erroneous. Because Mitchell does not
challenge the district court’s conclusions as to the first, second, and fourth Sell
elements, we need not address them.
III.
The district court’s order is affirmed.
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