United States v. Mikel Bolander , 722 F.3d 199 ( 2013 )


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  •                                PUBLISHED
    UNITED STATES COURT OF APPEALS
    FOR THE FOURTH CIRCUIT
    No. 12-6146
    UNITED STATES OF AMERICA,
    Petitioner - Appellee,
    v.
    MIKEL BOLANDER,
    Respondent - Appellant.
    Appeal from the United States District Court for the Eastern
    District of North Carolina, at Raleigh.    Bernard A. Friedman,
    Senior District Judge, sitting by designation.   (5:07-hc-02032-
    FL-JG)
    Argued:   May 15, 2013                         Decided:   July 5, 2013
    Before NIEMEYER and KEENAN, Circuit Judges, and HAMILTON, Senior
    Circuit Judge.
    Affirmed by published opinion. Judge Hamilton wrote the opinion
    in which Judge Niemeyer and Judge Keenan joined.
    ARGUED:     Walter Hoytt Paramore, III, Jacksonville, North
    Carolina, for Appellant.  Edward D. Gray, OFFICE OF THE UNITED
    STATES ATTORNEY, Raleigh, North Carolina, for Appellee.      ON
    BRIEF: Thomas G. Walker, United States Attorney, Raleigh, North
    Carolina, for Appellee.
    HAMILTON, Senior Circuit Judge:
    The     government       certified       Mikel    Bolander          as   a    “sexually
    dangerous person” under the Adam Walsh Act, 
    18 U.S.C. § 4248
    (the    Act).        In    the    ensuing      civil     commitment         proceeding,    the
    district court found that the government had proven by clear and
    convincing evidence that Bolander is a sexually dangerous person
    under the Act.            As a result, he was committed to the custody of
    the Attorney General of the United States.                          On appeal, Bolander
    challenges this ruling, and others, by the district court.                                  We
    affirm.
    I
    A
    The Act provides for the civil commitment of a “sexually
    dangerous        person”     following         the     expiration      of    their     federal
    prison sentences.            
    Id.
     § 4248(a).             A sexually dangerous person
    is   one      “who   has    engaged       or    attempted    to     engage       in   sexually
    violent         conduct    or     child     molestation       and      who       is   sexually
    dangerous to others.”              Id. § 4247(a)(5).          A person is considered
    “sexually dangerous to others” if “the person suffers from a
    serious mental illness, abnormality, or disorder as a result of
    which      he    would     have    serious       difficulty       in    refraining        from
    sexually violent conduct or child molestation if released.”                                 Id.
    § 4247(a)(6).
    - 2 -
    The Attorney General, his designee, or the Director of the
    Federal Bureau of Prisons (BOP) may initiate a § 4248 commitment
    proceeding in the district court for the district in which the
    person is confined by filing a certification that the person is
    sexually     dangerous       within      the    meaning      of     the    Act.         Id.
    § 4248(a).        The filing automatically stays the release of the
    person from custody pending a hearing before the district court.
    Id.       “If,   after    the   hearing,       the   court       finds    by    clear   and
    convincing       evidence    that    the   person      is    a    sexually       dangerous
    person, the court shall commit the person to the custody of the
    Attorney General.”          Id. § 4248(d). 1
    B
    Bolander      was     born    in   Minnesota      in       1964.         During   his
    adolescence, he abused alcohol and marijuana.                            At the age of
    twelve, he began to experience attraction to prepubescent boys,
    and   he   began    to    collect     pictures       from   art    books       and   nudist
    1
    If an order of commitment is obtained, the Attorney
    General must first attempt to release the person to “the State
    in which the person is domiciled or was tried if such State will
    assume responsibility for his custody, care, and treatment.” 
    18 U.S.C. § 4248
    (d).       However, if the Attorney General is
    unsuccessful in this effort, he “shall place the person for
    treatment in a suitable facility, until” a state assumes
    responsibility or until “the person’s condition is such that he
    is no longer sexually dangerous to others, or will not be
    sexually dangerous to others if released under a prescribed
    regimen of medical, psychiatric, or psychological care or
    treatment.” 
    Id.
    - 3 -
    magazines at that time.              His mother described her son as a
    loner, who typically had no more than one male friend at a time.
    As    a   teenager,    Bolander        was   suspended       from   school       for
    selling marijuana, and his parents placed him in a substance
    abuse    program    which   he     failed    to   complete.        At    the    age    of
    sixteen, his parents divorced.               His mom moved to California and
    remarried, and Bolander lived in California with his mother,
    sister, and step-father.
    At the age of nineteen, he enlisted in the Navy and was
    stationed in San Diego.             Although he refrained from marijuana
    use while in the Navy, he continued to abuse alcohol.                           He was
    referred to a Navy psychologist after pedophilic literature was
    found in his foot locker.             Bolander received approximately six
    counseling     sessions     over    the     course    of    six   months       and    was
    discharged from treatment after he was transferred to a new duty
    station.
    After his honorable discharge in late 1985 or early 1986,
    Bolander continued to abuse alcohol. 2                     At the same time, he
    became preoccupied with his sexual urges and desires for young
    boys,    and   he   began   to     collect    child   pornographic        films       and
    pictures by contacting a distributor of such material.                         Bolander
    2
    In May 1986, Bolander was convicted of driving while under
    the influence of alcohol (DUI). He was fined $675 and sentenced
    to time-served (two days).
    - 4 -
    began to visit arcades and other places where young boys were
    present, which would enable him to befriend a potential victim.
    In December 1988, at the age of twenty-four, Bolander was
    charged     with   numerous       sexual      offenses    in   San   Diego       County
    (California) Superior Court.                He pled guilty to one count of
    engaging in a lewd and lascivious act with a child under the age
    of fourteen.       The California state court records indicate that
    Bolander molested an eleven-year old boy over a six-month period
    at   his    residence    and     place   of    employment.      Such      molestation
    involved both oral and anal sex, and Bolander often videotaped
    and took pictures of these encounters.                  Bolander kept the videos
    and pictures of these encounters, along with a host of other
    child pornographic material he had obtained, at his residence.
    In April 1989, he was sentenced to six years’ imprisonment.
    While he was incarcerated in the California Department of
    Corrections, Bolander was transferred on April 12, 1990 to the
    Sex Offender Treatment and Evaluation Project at the Atascadero
    State      Hospital     (ASH).     During       his    treatment,    he    expressed
    rationalizations         for       his        illicit     behaviors        and      his
    “‘philosophy’” about consensual relationships with young boys.
    (J.A. 494).        He stated that boys as young as nine-years old
    “‘know what homosexuality is and know what they are doing.’”
    (J.A.      494).      During      his    time     at    ASH,   Bolander     stole    a
    substantial amount of pornographic stimulus material from the
    - 5 -
    program (in total, twenty-two magazines, 297 loose pictures, six
    35 mm black and white slides, two booklets, and two flyers).                           He
    was arrested on June 6, 1991, but the state prosecutors declined
    to prosecute the case.               Bolander was paroled in May 1992 after
    serving a little more than three years. 3
    While     on      parole,     Bolander       was    required       to     complete
    outpatient sex offender therapy.                   Upon completion, the program
    facilitator         opined    that    Bolander      was    in    need    of    long-term
    treatment, that his problem had not been fully resolved, and
    that there was continued risk for relapse.                      Reportedly, Bolander
    became      angry    and    agitated      when    discussing     the    course    of   his
    treatment.          Such conduct prompted his parole officer to search
    his residence.             There the parole officer discovered computer
    disks that contained child pornography, letters indicating how
    to   import     and     export     child    pornography,        pornographic       videos
    featuring       minor      males,     a    copy    of     the   video     of     Bolander
    performing sexual acts with the boy who was the victim of the
    1988       conviction,     and   magazines,       posters,      and    books   featuring
    nude boys.
    3
    Upon   release   from   the  California   Department of
    Corrections, Bolander enrolled in college, studying computer
    programming. He maintained a 3.37 GPA and completed thirty-six
    credit hours before withdrawing in the Fall of 1994.
    - 6 -
    The   discovery   of   this   material    led   to   the   January     1995
    revocation of Bolander’s state parole.          It also formed the basis
    of a February 1996 arrest on federal charges for distribution of
    child pornography and possession of child pornography.               Bolander
    pled guilty to the distribution offense in the United States
    District Court for the Southern District of California and was
    sentenced to thirty-seven months’ imprisonment.
    While in federal prison, Bolander voluntarily participated
    in the Sex Offender Treatment Program (SOTP) at FCI-Butner.                  His
    participation, which began on November 5, 1997, required him to
    sign an “INFORMED CONSENT FORM.”        (J.A. 168).       In relevant part,
    the form provides:
    I hereby consent to voluntary participation in the
    Sex-Offender Treatment Program and agree to adhere to
    all conditions stipulated in this document.        My
    signature     below    acknowledges   my    voluntary
    participation in the program.
    I understand that I may withdraw from treatment at any
    time.    I understand that my confidentiality will be
    protected at all times, except in cases where there is
    potential harm to myself or others, or when the
    security    of    the   correctional   institution  is
    threatened.    I also understand that the staff of the
    SOTP and the Federal Bureau of Prisons, Department of
    Justice, and United States Probation Office may share
    information regarding my case.
    (J.A. 168).
    Bolander’s participation in the SOTP was hampered by his
    hostility,    argumentativeness,      and   arrogance.          According    to
    psychological   records,    he     displayed   the   following      behaviors
    - 7 -
    while    in   treatment:       asserting      that    the    victim     initiated   the
    sexual    contact;       maintaining     that     child      molestation      was   not
    harmful and that the worst children might suffer was some slight
    embarrassment; admitting at one point that he would continue to
    molest     boys,    if    it    were    not     for    the    legal     consequences;
    declaring that he was the victim of societal persecution for his
    sexual    attraction      to    children;     refusing       to   complete    homework
    assignments; insisting that therapeutic assignments were of no
    benefit;      and   a    lack    of    respect        towards     treatment     staff.
    Bolander      was   manipulative       during    treatment        and   “absolute[ly]
    fail[ed] to empathize with his victims.”                     (J.A. 536) (internal
    quotation marks omitted).              As a result, he was expelled from
    treatment in April 1998 by Dr. Andres Hernandez, the Director of
    SOTP at that time. 4
    Bolander was released from federal prison in October 1998.
    While on supervised release, Bolander was indicted on federal
    child pornography charges in the United States District Court
    for the Western District of New York.                  These charges arose after
    it was discovered that Bolander was exchanging child pornography
    with a co-defendant that resided in New York.                      In October 1999,
    4
    Two reports generated at the SOTP are relevant here. The
    first is the “Psychosexual Evaluation” dated January 29, 1998;
    the second is the SOTP “Discharge Summary” dated April 13, 1998.
    (J.A. 518).
    - 8 -
    Bolander pled guilty to one count of attempting to receive child
    pornography and was sentenced to twelve months’ imprisonment.
    Following      his   release   from      federal    custody,       Bolander’s
    supervised    release     again   was    rescinded     following    a    May    2001
    search   of   his   residence.          The   search    was   prompted     by   the
    probation officer’s concern that Bolander was living in close
    proximity to children and that he refused to participate in a
    recommended      treatment   program.         During    the    search,    it    was
    discovered that Bolander maintained a second phone line through
    which he obtained unauthorized Internet access.                 An analysis of
    Bolander’s computer equipment revealed a large cache of child
    pornography. 5      Most of the child pornography seized involved
    prepubescent boys, some as young as toddlers. 6               The analysis also
    5
    The probation officer was informed that Bolander’s
    computer equipment contained “‘possibly the largest seizure of
    child pornography recorded in San Diego County.’” (J.A. 527).
    6
    Bolander meticulously categorized his collection of child
    pornography.   He used a ratings system (“G-clothed, non-sexual;
    PG-clothed,   sexual;   R-nude,  non-sexual   (nudist);   X-nude,
    provocative    (lewd   poses);    XX-nude,   sexual    (erection,
    masturbation, kissing); and XXX-nude, hardcore sex (sucking,
    f***ing, licking)),   and separated the materials based on the
    age of the participants (“0-2 years old; 3-5 years old; 6-8
    years old, and so on”). (J.A. 504, 527).
    - 9 -
    revealed that Bolander was participating in Internet news groups
    and chat rooms that catered to pedophiles. 7
    As    a   result     of    the    search,       more    federal      charges      were
    brought against Bolander.                   He was convicted of possession of
    child pornography in February 2002 and was sentenced to sixty
    months’ imprisonment.               This sentence was imposed consecutive to
    two sentences totaling twenty-six months that Bolander received
    for supervised release violations.
    Bolander’s projected release date from prison (with good-
    time credits factored) was February 9, 2007.                            On that day, the
    BOP certified that he was a “sexually dangerous person” pursuant
    to   §       4248(a),   automatically           staying        his   release    pending      an
    evidentiary hearing.                According to the certification, based on
    psychological         assessments         of    Bolander,       he   would     have   serious
    difficulty         refraining       from    sexually      violent       conduct    or      child
    molestation if released.
    The procedural history of this case gets muddled following
    the filing of the certification, as it took nearly five years to
    hold         the   evidentiary      hearing.            Such    delay    is    relevant      to
    Bolander’s due process claim, so we will set forth that relevant
    procedural          history    in    Part       IIIB     of    the   opinion.         At    the
    7
    The record reflects that Bolander endorsed pro-pedophilic
    beliefs.   He believes adult-child sexual relations are natural
    and beneficial.
    - 10 -
    conclusion       of    the         January    19,       2012    evidentiary        hearing,      the
    district court found that the government had proven by clear and
    convincing       evidence           that     Bolander      was     a   “sexually         dangerous
    person” under the Act.                Bolander noted this timely appeal.
    II
    A
    To   obtain            a    commitment          order     against       Bolander,        the
    government was required to establish three elements by clear and
    convincing       evidence.             First,      the     government        was    required      to
    establish that Bolander had “engaged or attempted to engage in .
    .   .   child    molestation”           in    the       past,    
    18 U.S.C. § 4247
    (a)(5).
    Next, the government was required to prove that he currently
    “suffers        from       a       serious     mental          illness,      abnormality,        or
    disorder,”       
    id.
           §       4247(a)(6).           Finally,      the    government         was
    required to show that Bolander, as a result of the illness,
    abnormality,          or   disorder,         “would       have     serious       difficulty      in
    refraining from . . . child molestation if released.”                                   Id.
    “[C]lear and convincing has been defined as evidence of
    such weight that it produces in the mind of the trier of fact a
    firm belief or conviction, without hesitancy, as to the truth of
    the     allegations        sought       to    be    established,          and,     as    well,    as
    evidence that proves the facts at issue to be highly probable.”
    Jimenez v. DaimlerChrysler Corp., 
    269 F.3d 439
    , 450 (4th Cir.
    - 11 -
    2001)    (citations,    alterations,        and   internal     quotation   marks
    omitted).
    On appeal, we review the district court’s factual findings
    for   clear    error   and   its    legal   conclusions   de    novo.      United
    States v. Hall, 
    664 F.3d 456
    , 462 (4th Cir. 2012).                   “A finding
    is    ‘clearly   erroneous’        when   although   there     is   evidence   to
    support it, the reviewing court on the entire evidence is left
    with the definite and firm conviction that a mistake has been
    committed.”      United States v. United States Gypsum Co., 
    333 U.S. 364
    , 395 (1948).         “This standard plainly does not entitle a
    reviewing court to reverse the finding of the trier of fact
    simply because it is convinced that it would have decided the
    case differently.”       Anderson v. Bessemer City, 
    470 U.S. 564
    , 573
    (1985).       “If the district court’s account of the evidence is
    plausible in light of the record viewed in its entirety, the
    court of appeals may not reverse it even though convinced that
    had it been sitting as the trier of fact, it would have weighed
    the evidence differently.”          
    Id.
     at 573–74.
    “When findings are based on determinations regarding the
    credibility of witnesses,” we give “even greater deference to
    the trial court’s findings.”          
    Id. at 575
    .    We do this because
    only the trial judge can be aware of the variations in
    demeanor and tone of voice that bear so heavily on the
    listener’s understanding of and belief in what is
    said. This is not to suggest that the trial judge may
    insulate his findings from review by denominating them
    - 12 -
    credibility determinations, for factors other than
    demeanor and inflection go into the decision whether
    or not to believe a witness.    Documents or objective
    evidence may contradict the witness’ story; or the
    story itself may be so internally inconsistent or
    implausible on its face that a reasonable factfinder
    would not credit it. Where such factors are present,
    the court of appeals may well find clear error even in
    a   finding   purportedly  based   on   a  credibility
    determination.   But when a trial judge’s finding is
    based on his decision to credit the testimony of one
    of two or more witnesses, each of whom has told a
    coherent and facially plausible story that is not
    contradicted by extrinsic evidence, that finding, if
    not internally inconsistent, can virtually never be
    clear error.
    
    Id.
     (citations and alterations omitted).     As with lay witnesses,
    “[e]valuating the credibility of experts and the value of their
    opinions is [also] a function best committed to the district
    courts, and one to which appellate courts must defer,” and we
    “should be especially reluctant to set aside a finding based on
    the trial court’s evaluation of conflicting expert testimony.”
    Hendricks v. Central Reserve Life Ins. Co., 
    39 F.3d 507
    , 513
    (4th Cir. 1994).
    B
    Here, there is no dispute that Bolander engaged in a past
    act of child molestation, as evidenced by his prior conviction
    in California state court for engaging in a lewd and lascivious
    act with a child under the age of fourteen.      Thus, the district
    court correctly found that the government established the first
    element   of   sexual   dangerousness   by   clear   and   convincing
    - 13 -
    evidence.     
    18 U.S.C. § 4247
    (a)(5).                  There is also no dispute
    that Bolander presently “suffers from a serious mental illness,
    abnormality,     or   disorder.”             
    Id.
        § 4247(a)(6).        Bolander     was
    diagnosed by several clinical psychologists as suffering from
    pedophilia   and      antisocial        personality         disorder,    and   Bolander
    does not challenge these findings on appeal.                          Accordingly, the
    district court correctly found that the government established
    the second element by clear and convincing evidence.
    Thus, the outcome of this appeal largely turns on whether
    the   district   court     erred        in   finding    that    the     government    had
    proven, by clear and convincing evidence, that Bolander, as a
    result of these disorders, “would have serious difficulty in
    refraining    from     .   .   .   child       molestation      if     released”     from
    custody.    Id. § 4247(a)(6).
    The   final     element      of    the       sexual   dangerousness      analysis
    turns on the degree of the person’s “volitional impairment,”
    which impacts the person’s ability to refrain from acting upon
    his deviant sexual interests.                  Kansas v. Hendricks, 
    521 U.S. 346
    , 358 (1997); Hall, 
    664 F.3d at 463
    .                         A person’s lack of
    control or inability to control his behavior
    will not be demonstrable with mathematical precision.
    It is enough to say that there must be proof of
    serious difficulty in controlling behavior. And this,
    when viewed in light of such features of the case as
    the nature of the psychiatric diagnosis, and the
    severity of the mental abnormality itself, must be
    sufficient   to  distinguish   the   dangerous sexual
    - 14 -
    offender whose serious mental illness, abnormality, or
    disorder subjects him to civil commitment from the
    dangerous but typical recidivist convicted in an
    ordinary criminal case.
    Kansas      v.    Crane,   
    534 U.S. 407
    ,    413   (2002).          “Whether     [an]
    individual is mentally ill and dangerous to either himself or
    others and is in need of confined therapy turns on the meaning
    of the facts which must be interpreted by expert psychiatrists
    and   psychologists.”            Addington       v.   Texas,     
    441 U.S. 418
    ,    429
    (1979).
    C
    Three       psychologists        evaluated      Bolander,        prepared   expert
    reports, and testified at the evidentiary hearing, two on behalf
    of the government, Dr. Christopher North and Dr. Lela Demby, and
    one on behalf of Bolander, Dr. John Warren. 8                       Bolander testified
    on his own behalf.               There were no objections raised to the
    qualifications of the expert witnesses, and the district court
    found each expert to be qualified to offer opinions on the issue
    of    Bolander’s       sexual      dangerousness.              In      reaching     their
    respective         opinions,     the    experts       utilized      actuarial     tests,
    psychological tests, and their clinical judgment.                        Of note, each
    of    the        psychologists     used     the       reports       generated     during
    Bolander’s participation in the SOTP at FCI-Butner.                            Dr. North
    8
    Dr. North and Dr. Warren are in private practice.                               Dr.
    Demby is employed by the BOP.
    - 15 -
    and Dr. Demby testified that Bolander met the criteria for civil
    commitment under the Act.           Dr. John Warren declined to offer an
    opinion on the third element of sexual dangerousness. 9
    1
    In forming his opinion, Dr. North considered the voluminous
    documents referenced in his reports as well as other evidence.
    Such       evidence    included     information     related      to   Bolander’s
    criminal      history,    medical    history,     social   history,    substance
    abuse history, institutional adjustment, and other records.                  Dr.
    North also considered the forensic evaluations of Dr. Demby and
    Dr. Warren.       Dr. North’s report was prepared on March 14, 2011
    and    updated    on     October    11,   2011.      His   testimony    at   the
    evidentiary      hearing     was    consistent     with    the    findings   and
    conclusions contained in his report and updated report.
    Dr. North determined that Bolander had previously engaged
    in child molestation.         He also determined that Bolander suffers
    from pedophilia, male exclusive type.               According to Dr. North,
    9
    According to Dr. Warren, as a psychologist, it was not his
    place to offer an opinion on the third element.      He testified
    the third element was “legal jargon” and an “ultimate issue”
    created by the courts, and that the third element did not “mesh
    well with medical or psychological nomenclature.”     (J.A. 399).
    As noted below, Dr. Warren did opine, however, that Bolander had
    volitional control over his actions, as evidenced by the period
    of time that had elapsed since Bolander’s only molestation
    offense.
    - 16 -
    Bolander “‘lacks any internal prohibitions against engaging in
    sexual activity with a child.’”           (J.A. 190).
    In     determining    whether        Bolander     would     have     serious
    difficulty refraining from sexually violent conduct, Dr. North
    used several risk tools that have at least a moderate degree of
    accuracy.     Application    of    such    tools     placed    Bolander   in   the
    comparison group of offenders with a moderate-high to high risk
    of reoffending.
    Dr.    North   used   three   actuarial       scales     aimed   mainly   at
    examining static risk factors for sex offender risk assessment:
    the Static–99R, the Static–2002R, and the Minnesota Sex Offender
    Screening    Tool–Revised     (MnSOST–R). 10           Static    risk     factors
    typically are historical and do not change.                   For example, the
    Static-99R examines ten static risk factors and gives scores for
    each category. 11   Such tests enabled Dr. North to calculate group
    recidivism rates of sexual offenders considered by him to be
    10
    According to Dr. North, the use of multiple “actuarial
    measures can provide increased confidence in those results.”
    (J.A. 540).
    11
    The ten static risk factors examined by the Static-99R
    are: (1) age at release from instant sex offense; (2) past
    habitation with a lover for at least two years; (3) convictions
    for index non-sexual violence; (4) convictions for prior non-
    sexual violence; (5) prior sex offenses; (6) prior sentencing
    dates; (7) convictions for non-contact sex offenses; (8) any
    unrelated victims; (9) any stranger victims; and (10) any male
    victims.
    - 17 -
    most    analogous    to    Bolander,       and    he   found    a     group    rate     of
    recidivism of 42% within ten years under Static–99R, 40% within
    ten years under Static–2002R, and 20% within six years under
    MnSOST–R.
    In addition to these static risk tools, Dr. North also used
    the Stable-2007, a dynamic risk assessment tool.                        According to
    Dr. North, unlike static factors, which typically are historical
    and do not change, a dynamic risk factor refers to something
    that has the capacity to change over time, for example with
    treatment.      The presence of dynamic risk factors increases an
    offender’s     risk.        The    following      dynamic      risk    factors        were
    considered by Dr. North: (1) significant social influences; (2)
    intimacy deficits; (3) sexual self-regulation; (4) cooperation
    with supervision; and (5) general self-regulation.
    Dr.   North   determined      that       Bolander’s     significant        social
    influences    were     “minimal     or    primarily     negative       in     that    they
    consist of other men interested in child pornography.”                               (J.A.
    552).    Dr. North recognized Bolander’s close relationship with
    his mother and step-father, but opined that these relationships
    never exerted any significant influence over his sexual life or
    behavior.
    Dr.   North     determined        that     intimacy      deficits        were     a
    significant     risk      factor   for     Bolander     because       he    had      never
    established or maintained a committed, reciprocal relationship
    - 18 -
    with a partner that was not abusive.                        Dr. North noted that
    Bolander had indicated in the past that he was not interested in
    developing intimate or sexual relationships with adults.                               Dr.
    North    also   noted     Bolander’s      lack    of       remorse      and    that    his
    dependency needs may motivate him to seek contact with other
    children.
    According to Dr. North, Bolander had a “severe problem[]”
    with sexual self-regulation.             Dr. North noted that Bolander had
    been    obsessed   with       child   pornography      for    many    years     and    had
    collected child pornography while on probation and parole.                              He
    further noted that Bolander “has shown a high degree of sexual
    preoccupation      and    is     exclusively      attracted        to     prepubescent
    boys.”    (J.A. 553).
    Dr. North determined that Bolander’s lack of cooperation
    with    supervision      was    problematic.          He   noted     that     Bolander’s
    institutional behavior was “fairly good,” but was poor while on
    probation/parole,        as    demonstrated      by    his    numerous        violations
    while on supervised release.            (J.A. 553).
    With regard to general self-regulation, Dr. North indicated
    that Bolander’s problem-solving skills were poor because he is
    unwilling to meaningfully address his pedophilia and obsessive
    involvement     with      child       pornography.           Overall,         Dr.     North
    described Bolander’s general-self regulation as “poor.”                               (J.A.
    553).
    - 19 -
    Dr. North also examined potentially protective factors.               A
    protective factor decreases the risk of future sexual offending.
    The three potentially protective factors examined by Dr. North
    are: (1) having been in the community for ten years without
    sexually reoffending; (2) having less than fifteen years left to
    live due to illness or physical conditions that significantly
    decrease the motivation and/or ability to sexually reoffend; and
    (3) very advanced age.        Dr. North opined that none of these
    factors were particularly mitigating for Bolander.              Bolander had
    no medical problems that would serve to decrease his ability or
    motivation to commit a new sexual offense.          Although it had been
    more ten years since Bolander’s last hands-on conviction, Dr.
    North   noted   that   Bolander’s    obsession   with   child    pornography
    placed him in positions where there was considerable risk to
    children.   Dr. North further noted that Bolander chose to live
    close to children, an act which placed him at high risk of
    reoffending.     He also noted that Bolander’s total time in the
    community since his last hands-on conviction was limited, and
    during this time Bolander was under supervision, which made it
    more difficult for him to make contact with a child.
    In the “SUMMARY” and “CONCLUSION” sections of his March 14,
    2011 report, Dr. North stated:
    Bolander is a 47-year-old pedophile who is exclusively
    attracted to boys.   He was convicted of molesting an
    11-year-old boy in California in 1989 and sentenced to
    - 20 -
    six years in prison.   Since then he has obsessively
    collected child pornography despite repeated arrests
    and returns to custody for this behavior.         His
    pedophilia is ego-syntonic meaning he accepts it and
    is not distressed by his sexual attraction to boys.
    He believes it is society that has the problem and
    told Dr. MacLaren in 1989 that boys over the age nine
    or ten “know what homosexuality is and know what they
    are doing.” Mr. Bolander is attracted to boys between
    the ages of 6 and 12.
    The critical issue in this case is Mr. Bolander’s risk
    of committing a new “hands-on” sex offense.      Although
    he obtained moderate to high scores on the actuarial
    instruments used to assess risk for sexual reoffense,
    these instruments do not predict the type of sexual
    offense to be committed and he clearly appears to be
    more likely to commit a “hands-off” offense (involving
    pornography) than a “hands-on” crime.      On the other
    hand, he has not been in the community for very long
    since paroling for his molest offense in 1992 and was
    supervised   closely   enough   that   it  was   probably
    difficult for him to establish contact with a child.
    It was easier for him to believe that he could escape
    detection by collecting pornography. . . . He is 47
    years old and appears to be in good health, and
    barring any unforeseen circumstances, his opportunity
    time (at risk) could be 30 to 40 years.        Given the
    lack of any internal prohibitions against sexual
    activity with a child and Mr. Bolander’s intense
    sexual   interest   in   male   children,  it   is   this
    evaluator’s opinion that eventually Mr. Bolander is
    indeed likely to commit a new “hands-on” sex offense
    with a prepubescent boy.      His pedophilia will cause
    him serious difficulty in refraining from child
    molestation if released to the community.
    * * *
    Based on the above information, it is my opinion that
    Mikel Bolander does meet the criteria as a Sexually
    Dangerous Person.
    (J.A. 554-55).
    Following the preparation of this report, Dr. North met
    with Bolander.   During the interview, Bolander clarified some
    - 21 -
    minor    factual     inaccuracies      in       Dr.    North’s    report.      He   also
    stressed to Dr. North that he was trying to increase his sexual
    arousal to adults, had not masturbated in five to six years,
    knew child molestation and possession of child pornography were
    wrong, felt remorse for victims, and was “truly motivated to
    never molest again.”         (J.A. 580).          Although Dr. North noted that
    Bolander      “presented     well,”     he       was    skeptical     of    Bolander’s
    claims, noting that he had made reformation claims in the past
    yet     still    went   on    to    amass        large     collections       of     child
    pornography.         Ultimately, Dr. North concluded that Bolander’s
    “exclusive sexual interest in prepubescent boys is so strong
    that    he    will   have    serious    difficulty         refraining       from    child
    molestation if released to the community.”                   (J.A. 581).
    2
    Dr. Demby, a BOP forensic psychologist, also testified at
    the evidentiary hearing.           Her testimony was consistent with the
    findings and conclusions contained in her report dated March 9,
    2011.
    In her report, Dr. Demby examined Bolander’s developmental
    history,      relationship     history,         education        history,   employment
    history, substance abuse history, non-sexual criminal history,
    sexual       criminal   history,       psychiatric/psychological              history,
    mental health history, and medical history.                         Because Bolander
    refused to participate in a clinical evaluation with Dr. Demby,
    - 22 -
    she     was    not   able    to        interview           Bolander     as    part        of     her
    evaluation.
    Dr. Demby made the following diagnoses: “(1) Pedophilia,
    Sexually       Attracted         to     Males,        Exclusive       and     (2)     Schizoid
    Personality Disorder.”                 (J.A. 195).            Dr. Demby explained the
    bases for each of her diagnoses and opined that each qualify as
    a serious mental illness, abnormality, or disorder.                                   Further,
    she concluded that, as a result of these diagnoses, Bolander
    would    have    serious         difficulty           in    refraining       from     sexually
    violent conduct.
    With      regard      to        the   pedophilia             diagnosis,       Dr.        Demby
    explained that Bolander meets the diagnosis based, in part, on
    his   recurrent      and     intense        sexually          arousing       fantasies,          and
    sexual urges and actions involving prepubescent males.                                Further,
    she opined that the evidence shows he constructed his lifestyle
    to    obtain     maximum         exposure        to        young     children       and        child
    pornography, even while on supervised release.                                He engaged in
    sophisticated techniques to avoid financial disclosure of his
    activities to his probation officers.                              She specifically noted
    that treatment providers have reported that he has demonstrated
    little guilt or remorse for his crimes, except for self-focused
    regret concerning the negative consequences he has endured.                                      In
    spite of efforts at treatment, he has continued to engage in
    sexually inappropriate attraction to young boys even when the
    - 23 -
    threat of detection and sanctions are high, as indicated by his
    theft of sexual stimuli at ASH and his numerous revocations of
    supervised release.
    Dr. Demby utilized the Static-99R to assess Bolander’s risk
    of sexual reoffense.      She found a group rate of recidivism of
    49% within ten years under this test.
    In considering the applicability of dynamic risk factors,
    Dr. Demby utilized an empirically guided risk assessment tool
    called the “SVR-20.”       (J.A. 511).     The SVR–20 does not yield
    quantitative predictions in the same way that the Static–99 and
    Static–2002R do.      Instead, the scorer evaluates twenty factors
    weighing them in their totality to form an overall opinion about
    whether an offender will likely reoffend. 12       Dr. Demby concluded
    that    Bolander   had   eight   factors   that   were   considered   to
    12
    The twenty factors include: (1) the presence of sexual
    deviance; (2) whether the respondent had been a victim of child
    abuse; (3) psychopathy traits; (4) the presence of a major
    mental illness; (5) endorsement of suicidal or homicidal
    ideation; (6) a history of substance abuse; (7) the presence of
    a stable relationship; (8) a stable employment history; (9) a
    history of nonsexual violent offenses; (10) a history of
    nonviolent   and  nonsexual   offenses; (11)   past  supervision
    failure; (12) a high density of sexual offenses within a
    relatively short period; (13) multiple types of sexual offenses;
    (14) causing victims physical harm; (15) the use of weapons or
    threats; (16) the presence of escalating sexual offenses or
    severity of sexual offenses; (17) extreme minimization or denial
    of responsibility; (18) attitudes that support or condone sexual
    offenses; (19) negative attitudes towards intervention; and (20)
    release and relapse prevention plans.
    - 24 -
    exacerbate his risk of reoffending (Factors (1), (7), (10), (11)
    (13), (17), (18), and (19)), eleven that were considered not to
    exacerbate his risk of reoffending (Factors (2), (3), (4), (5),
    (6)    (8),     (9),    (12),    (14),     (15),    and    (16)),      and     one    factor
    (Factor 20) that was not assessed because Bolander refused to be
    interviewed.            After    weighing    the     number      and     nature      of    the
    exacerbating factors, Dr. Demby concluded that Bolander’s risk
    of future sexual violence was “High” on the SVR-20.                          (J.A. 515).
    With    regard    to     the   factors      in    exacerbation,        Dr.        Demby
    emphasized       Bolander’s       sexual    deviance,       as    evidenced          by    his
    history of sexual arousal to young children and his lack of an
    interest in engaging in a sexual or intimate relationship with
    an    adult.      She     also   emphasized        that   Bolander       had    no    stable
    relationships that would provide him support upon release, as
    evidenced by his history as a loner and his desire to “continue
    [life]     in    this     vein.”        (J.A.     513).       Dr.      Demby    noted       as
    exacerbating        Bolander’s         history     of     non-violent,         non-sexual
    offenses, which included juvenile delinquency, substance abuse,
    and a DUI conviction.              Also exacerbating were Bolander’s past
    supervision failures, namely, his “violat[ion of] supervision on
    two occasions by sexually reoffending.”                    (J.A. 514).          Dr. Demby
    noted that Bolander had multiple types of offenses involving
    child          abuse/pornography           (molestation,            possession             and
    distribution       of    pornography,       and    attempting       to    receive         child
    - 25 -
    pornography through the mail) and that Bolander continued to
    minimize and deny responsibility for his conduct.                            Dr. Demby
    also examined Bolander’s long history of supporting a right to
    adult-child relationships:
    “[C]opious treatment records indicate that he believes
    that he is entitled to sex, and that he is a
    preferential, fixated, same-sex pedophile.   When told
    that he needed to recondition his pedophilic urges, he
    has sabotaged treatment, stolen sexual stimuli, and
    twice    refused    to    participate    in    arousal
    reconditioning.   He has stated several times the he
    would continue to molest boys if he thought he could
    get away with it.
    (J.A. 514).     Relying on much of the same evidence, Dr. Demby
    concluded   that   Bolander    harbored        a    negative      attitude      toward
    intervention.
    With regard to the factors that did not exacerbate, Dr.
    Demby noted that Bolander was not a victim of sexual abuse.                        She
    noted that, although Bolander displayed signs of psychopathy,
    such signs were insignificant to find the psychopathy factor
    exacerbating.      Dr. Demby found no presence of a major mental
    illness, suicidal or homicidal ideation, or a recent history of
    substance   abuse.     She    noted      Bolander’s       ability       to    maintain
    steady   employment   and    that   he   had       no   history    of    non-violent
    sexual offenses.      Dr. Demby also noted that Bolander had not
    committed sexual offenses frequently in a short period of time,
    had not physically injured his victims, and used no weapons or
    threats during the commission of his offenses.                          Finally, Dr.
    - 26 -
    Demby noted that Bolander’s sexual offenses did not escalate or
    become more severe over time.
    At the conclusion of her report, Dr. Demby gave a “Summary
    of Risk Assessment & Prognosis” and an “Opinion on the Issue of
    Sexual Dangerousness.”    (J.A. 516-17).    The report states:
    Mr. Bolander is a 47-year-old, life-long pedophile and
    child abuser whose past history and high scores on the
    Static-99R and the SVR-20 indicate a very high
    probability that his past patterns of sexually abusing
    children    will    continue.       His   paraphilic    sexual
    attraction to children began in his early adolescence,
    and   has    led    to   numerous    charges,    convictions,
    incarceration, and revocations of his release. He has
    unsuccessfully attempted therapy to address his sexual
    attraction to young boys.         He continues to endorse
    sexually     deviant     beliefs,     and    minimizes     his
    responsibility     by blaming      his   child    victim   for
    initiating the sexual molestation.         He has behaved in
    sexually inappropriate ways even when the risk of
    detection was high, as seen in his residential
    proximity      to    children,     and     downloading     and
    distribution of a massive amount of child pornography,
    while    on    supervised     release.        His    pervasive
    personality     style   of   exploiting     his    environment
    displays itself in his repeated violations of social
    norms, expectations, and rules, including the sexual
    coercion    of    those   most    vulnerable    around    him.
    Cumulatively, his overall history, criminal record,
    offense       characteristics,        lifestyle       choices,
    personality patterns, sexual relapses, and treatment
    failures indicate an extremely high risk of future
    sexual reoffense. His prognosis at this time is very
    poor.
    *   *   *
    It is highly likely that Mr. Bolander will continue
    the sexual abuse of young children, particularly
    prepubescent boys.   His diagnosis of Pedophilia   and
    Schizoid Personality Disorder are chronic, pervasive,
    and deeply engrained.     He has continued to sexually
    reoffend after receiving sex offender treatment and
    - 27 -
    intensive community supervision.    He has stated and
    demonstrated his intent to continue to indulge his
    pedophilic sexual deviance. It is the opinion of this
    evaluator that Mr. Bolander is a person suffering from
    a serious mental illness, abnormality, or disorder, as
    a result of which he would have serious difficulty in
    refraining from sexually violent conduct or child
    molestation.
    (J.A. 516-17).
    3
    Dr.     Warren        testified     at       the    evidentiary         hearing     as
    Bolander’s expert witness.              His testimony was consistent with
    the findings and conclusions contained in his report dated July
    25, 2011. Dr. Warren opined that Bolander met the first two
    elements necessary for sexual dangerousness.                           As part of his
    evaluation, Dr. Warren used the Static-99R test.                            He calculated
    Bolander’s    group    rate     of    recidivism        to     be   14.7%    within    five
    years.      Dr. Warren also identified six dynamic factors, four
    lessening    the    recidivism       risk     (significant          social    influences,
    sexual self-regulation, general self-regulation, and cognitive
    problem     solving        skills)     and       two    increasing      the     risk    of
    recidivism (intimacy deficits and cooperation with supervision).
    Dr. Warren opined that Bolander had certain strengths that would
    enable him to function normally in society by maintaining his
    volitional    control.          Dr.     Warren         noted    that    Bolander:      (1)
    functioned     in     an     incarcerated         setting       without       significant
    disciplinary issues; (2) had been able to control his behavior
    - 28 -
    in   terms    of    hygiene,    his    activities,        and    his    vocational
    interests within the facility; (3) had a four-year period of
    non-contact    offending;      (4)    earlier      in   life    decided    to    stop
    marijuana    use;    (5)   earlier     in   life    decided     to     further    his
    education; and (6) made decisions earlier in life to advance his
    vocational    interests.       In     the   “Summary     and    Recommendations”
    section of his report, Dr. Warren states:
    Mikel James Bolander is a 47-year-old, Caucasian male
    with a history of completion of sentencing for
    conviction of Possession of Child Pornography. He has
    a   previous  conviction   for  one,  sexually-related
    contact offense and two other child pornography (one
    possession, one mailing) offenses.
    He does not have a mental disorder that [impairs] his
    volitional ability to control his behavior.   He does
    not have a personality disorder.
    Mr. Bolander’s risk for sexual re-offending with child
    pornography offenses is higher than that of contact
    offending, and overall slightly higher than all sexual
    offenders taken as a group. However, his risk for all
    sexual re-offending upon release from incarceration is
    more likely than not lower than the published
    recidivism risk of non-sexual offenders released from
    prison.
    Mr. Bolander has a history of gainful and consistent
    employment. He has interpersonal and technical skills
    that can be applied to future employment. If released
    from incarceration Mr. Bolander reported his plan to
    reside in Las Vegas due to the multiple opportunities
    for employment . . . and to the proximity of his
    parents’ residence about one and a half hours away.
    (J.A. 560-61).       As noted above, Dr. Warren did not offer an
    opinion on the third element of the commitment test, but he did
    indicate that, whether Bolander was committed or released, he
    - 29 -
    needed sexuality psychoeducation in the context of a strength
    based individual and/or group treatment approach, and cognitive
    behavioral treatment.
    D
    Bolander also testified at the evidentiary hearing.                                 He
    described the details of his only hands-on offense and expressed
    remorse over what had happened.                 He testified that, around 2004
    or 2005, he had a change of heart that caused him to think
    differently      about      child     molestation.                 He    read       numerous
    psychological journals and books on victim empathy.                                 Bolander
    testified      that   he    now     knows    child      molestation            is   “totally
    wrong,” (J.A. 342), and that he had not thought about children
    in a sexual way in over seven years.                    He testified he would not
    molest another child again.                 He also testified that, for the
    first   time    in    his   life,    he     has      been   able    to    develop      close
    friendships with adults.
    E
    Dr. Andres Hernandez, who was the Director of SOTP while
    Bolander was enrolled in the program, testified as a lay witness
    at   the   evidentiary       hearing.           He    testified         that    Bolander’s
    participation in the SOTP was “rather memorable.”                              (J.A. 358).
    He   found      “striking”        Bolander’s           “pedophilic         drive,”      his
    resistance to treatment, and “the degree to which his pedophilic
    beliefs were so entrenched.”                (J.A. 358).            Dr. Hernandez also
    - 30 -
    found that Bolander was not in the SOTP to change, but rather to
    challenge the beliefs of others.
    F
    At the conclusion of the evidentiary hearing, the district
    court ruled from the bench.    With respect to the third element
    of the commitment test, the district court stated:
    Respondent [has] continued to commit criminal offenses
    while on parole or supervised release, . . .
    Respondent has not successfully completed a sex
    offender program. Both Doctors Demby and North opined
    that Respondent would have serious difficulty in
    refraining from sexual violent conduct or child
    molestation if released.   The Court finds that both
    doctors are credible and adopts their conclusions as
    they are well-reasoned and supported by the evidence
    in this case.
    Both Doctors Demby and North found that, using
    actuarial instruments, the Respondent is in the
    moderate to high range. However, [t]he Court believes
    though these instruments are important, the greater
    weight should be placed on factors outside the
    actuarial scheme as indicated in those instruments.
    These include the areas discussed before, i.e., the
    relapse, failure to complete the offenders program.
    Respondent believes on his “oath to himself” that it –
    this will ensure that he does not reoffend.    This is
    certainly a good start, but his lack of completion of
    a sex offender program leaves him without the tools to
    accomplish his oath.       Respondent’s self-help by
    reading books and developing victim empathy is good,
    but [t]he Court finds that this is not a substitute
    for a sex offender program, and Respondent has failed
    to seriously complete a program.
    The Court finds that Respondent places himself in a
    slippery slope situation, and it appears that that’s a
    word that comes up very often in these cases.     It’s
    defined by the way his conduct was while he was
    released into the community and has not developed the
    necessary skills to remain free if released.
    - 31 -
    The Court finds that Respondent talks the talk, but,
    again, does not have the skills to remain crime free
    without meaningful mainstream treatment.     And I say
    mainstream treatment as opposed to Dr. Warren, who I’m
    sure was very knowledgeable and so forth, but
    suggested treatment that was not that mainstream and
    not in the sense that it was not good treatment. But
    it was certainly an unreasonable expectation to have
    that kind of one-on-one kind of treatment while he’s
    incarcerated, though he does get one-on-one . . . when
    needed, and it would be unrealistic to release him
    until such time as he has this treatment and develops
    the skills necessary so that he does not reoffend.
    For these reasons, [t]he Court finds that Respondent
    is sexually dangerous and that he suffers from a
    serious mental illness, abnormality or disorder and as
    a result of this, he would have serious difficulty in
    refraining from sexually violent conduct or child
    molestation if he was released.
    (J.A. 425-27).
    G
    Bolander     maintains      that        the   district    court       erred   in
    concluding that he would have serious difficulty refraining from
    future   acts      of   child    molestation.         Reduced    to   its     essence,
    Bolander posits that the district court did not adequately take
    into    account     his   time    in     the     community   without     a    hands-on
    offense.
    “Serious difficulty” refers to the degree of the person’s
    volitional      impairment       which    impacts     the    person’s    ability     to
    refrain from acting upon his deviant sexual interests.                           Hall,
    
    664 F.3d at 463
    .      Here,       there    were   facts   in   evidence,      if
    credited by the district court, that would support a finding
    - 32 -
    that Bolander would have serious difficulty refraining from acts
    of     child     molestation       if    he     was     released      because     of    his
    pedophilia.         The record is replete with examples of Bolander’s
    inability      to    refrain    from         engaging    in    acts   involving        child
    pornography.          Whether      it    was     his     stealing     of    pornographic
    materials from the treatment lab while at ASH or his repeated
    possession of child pornography while on supervised release, the
    record is clear that he has serious difficulty refraining from
    trying to find an appropriate outlet for his sexual desires.                             He
    has an admitted attraction to adolescent males between the ages
    of six and twelve and has not participated in any treatment
    which    would      assist   him    in       managing    these    volitional      control
    issues.        Moreover, the intense nature of Bolander’s obsession
    with     child      pornography,        in    particular       his    large     cache    of
    materials      and    the    meticulous         manner    in    which      he   kept    such
    materials, understandably was a concern of Dr. North and Dr.
    Demby.      In view of this evidence, it was reasonable for the
    district court to find by clear and convincing evidence that
    Bolander’s pedophilia would cause him to have serious difficulty
    refraining from acts of child molestation.
    Bolander’s       argument        that     the     district       court    did    not
    adequately consider the fact that he had no hands-on offense in
    over twenty years misses the mark.                      As noted by Dr. North, the
    absence of a more recent hands-on offense has more to do with
    - 33 -
    the strict supervision placed on Bolander than a true change of
    heart.      Considering          Dr.    North’s       reasonable     explanation,       the
    district court was at liberty to reject Bolander’s no hands-on
    offense   argument.         Anderson,          
    470 U.S. at 573-75
    .     Along     a
    similar vein, the district court was free to reject Bolander’s
    testimony    that      he   is    a    reformed       man.     The    success     of    his
    rehabilitation         efforts    largely       are    suspect      considering    he    is
    doing them on his own.
    In sum, as we noted in Hall, the “question of whether a
    person is ‘sexually dangerous’ is ‘by no means an easy one,’ and
    ‘there is no crystal ball that an examining expert or court
    might consult to predict conclusively whether a past offender
    will recidivate.’”          
    664 F.3d at 467
     (quoting United States v.
    Shields, 
    649 F.3d 78
    , 89 (1st Cir. 2011), cert. denied, 
    132 S. Ct. 1586
     (2012)).           In this case, the district court carefully
    considered       the   evidence        before    it,    and   its    factual    findings
    represent    a    permissible          and    reasonable      interpretation      of    the
    evidence presented at the hearing.                      Because we are not “left
    with the definite and firm conviction that a mistake has been
    committed” by the district court, United States Gypsum Co., 
    333 U.S. at 395
    , we cannot say that the district court clearly erred
    in finding, by clear and convincing evidence, that Bolander is
    sexually dangerous within the meaning of the Act.
    - 34 -
    III
    Having concluded that the district court did not err when
    it found by clear and convincing evidence that the government
    met each of the three elements for sexual dangerousness, we turn
    to   Bolander’s       remaining    arguments            challenging          his    civil
    commitment.
    A
    Bolander      contends    that        §    4248    deprives       him     of   equal
    protection    under    the    Fifth    and        Fourteenth     Amendments.           In
    pressing this argument, Bolander acknowledges that this argument
    is foreclosed by our decision in United States v. Timms, 
    664 F.3d 436
     (4th Cir.), cert. denied, 
    133 S. Ct. 189
     (2012).                              In
    Timms, we held that § 4248 does not violate the Equal Protection
    Clause   because    individuals       in       BOP   custody    are    not     similarly
    situated to individuals who are not in BOP custody.                          Id. at 449.
    In so holding, we emphasized that “Congress rationally limited
    § 4248’s scope to sexually dangerous persons within BOP custody
    based on Congress’ limited police power and the federal interest
    in protecting the public from reasonably foreseeable harm from
    such persons.”      Id.      Because Timms forecloses Bolander’s equal
    protection argument, we reject it.
    Bolander       also      contends          that     §      4248     levies        an
    unconstitutional      criminal    punishment.            This    argument       also   is
    foreclosed by our decision in Timms.                   Id. at 455.      In Timms, we
    - 35 -
    clarified any ambiguity concerning this question created by our
    decision in United States v. Comstock, 
    627 F.3d 513
     (4th Cir.
    2010), cert. denied, 
    131 S. Ct. 3026
     (2011) (Comstock II).                               
    Id.
    We further noted that § 4248’s use of the clear and convincing
    evidence       standard       rather   than    the      proof       beyond   a    reasonable
    doubt standard rendered the overall design of § 4248 civil in
    nature.       Id. 13
    B
    Second, Bolander argues that his due process rights were
    violated because the January 12, 2009 evidentiary hearing took
    place       almost     five    years   after       he    was    due     to   be    released
    (February 9, 2007).            This argument has no merit.
    In    Timms,     we     noted   that       the   “civil       commitment      process
    clearly impacts an individual’s due process rights.”                                 Id. at
    450.        “Because     an     adverse   outcome        in     a    commitment     hearing
    results in a massive curtailment of a person’s liberty, whether
    the respondent is already a prisoner or not, the Supreme Court
    has held that due process . . . affords respondents in [civil
    commitment]       proceedings      several        procedural         protections.”      Id.
    13
    To the extent Bolander challenges the actual conditions
    of his confinement under § 4248, this civil/criminal argument
    similarly is foreclosed by Timms. 
    664 F.3d at 455
    . That is not
    to say, however, that Bolander is without a remedy.       As the
    government concedes, Bolander may challenge the conditions of
    his confinement in an action under Bivens v. Six Unknown Named
    Agents of the Federal Bureau of Narcotics, 
    403 U.S. 388
     (1971).
    - 36 -
    (citation and internal quotation marks omitted).                            “Once it is
    determined that due process applies, the question remains what
    process is due.”        Morrissey v. Brewer, 
    408 U.S. 471
    , 481 (1972).
    In    assessing     what      due     process     is    due      in     the     civil
    commitment context, we analyze “‘the importance of the private
    interest and the harm to this interest occasioned by delay; the
    justification      offered     by    the     Government       for     delay     and    its
    relation     to   the    underlying        governmental        interest;        and     the
    likelihood that the interim decision may have been mistaken.’”
    Timms, 
    664 F.3d at 451
     (quoting FDIC v. Mallen, 
    486 U.S. 230
    ,
    242    (1988).       This     test        “evaluate[s]       the      sufficiency       of
    particular procedures, while also avoiding the establishment of
    rigid rules due to the recognition that the requirements of due
    process are flexible and cal[l] for such procedural protections
    as    the   particular     situation        demands.”         
    Id.
         (citations        and
    internal quotation marks omitted).
    Without question, Bolander possesses a substantial private
    interest     affected    by    the   certification           under    §     4248.       His
    interest in liberty and freedom from physical restraint are at
    stake.      Thus, the private liberty interest factor weighs in his
    favor.      Id. (“The statute also places no express outer limit on
    how long that stay may remain in force or when the court must
    conduct     the   commitment     hearing.      During    that        period    of     time,
    however short or long it may be, an individual’s liberty is
    - 37 -
    restrained;       thus,        the      statute     implicates         a      substantial
    interest.”).       Moreover, the likelihood that the interim decision
    may    have    been    mistaken      factor    favors       Bolander.         Id.   at     452
    (noting that the interim decision factor weighed in favor of the
    respondent because § 4248 requires no specific steps prior to
    certifying      someone,       other    than    that    signatory’s        determination
    that the person meets the criteria for being sexually dangerous,
    § 4248 requires no pre-certification hearing or other initial
    adversarial review, and the risk of improper certification was
    “apparent       from     the     parties’       representation          that        of    the
    approximately         130    individuals        certified       under      § 4248,        the
    Government         subsequently           dismissed           almost         two         dozen
    certifications because it subsequently determined the individual
    did not satisfy the criteria”).
    However,       like   the     respondent        in   Timms,     Bolander’s         due
    process claim fails because the last inquiry, the government’s
    interest and the justification offered by the government for the
    delay, weighs decidedly in the government’s favor.                             To resolve
    this    last    inquiry,        we     must    first    turn    to     the     convoluted
    procedural history of the case.
    Following       the   implementation        of   the    Act,     the    government
    began to certify individuals as sexually dangerous under the
    Act.    Such action led to a host of constitutional challenges in
    the United States District Court for the Eastern District of
    - 38 -
    North Carolina, the district in which nearly all § 4248 actions
    were filed.
    On February 9, 2007, the government filed a certificate in
    the United States District Court for the Eastern District of
    North       Carolina      seeking      to     commit      Bolander         as     a    sexually
    dangerous person under § 4248.                   At the time, Bolander was about
    to be released from BOP custody, but his release was stayed
    because of the government’s § 4248 certification.                                On the same
    day,    Judge       Britt,      the     senior      district        judge       assigned       to
    Bolander’s        case,    appointed          the    Federal       Public       Defender        to
    represent Bolander and set a hearing date of September 4, 2007.
    On August 15, 2007, Bolander filed a motion to continue the
    hearing, which the district court granted.
    On    September     7,       2007,   Judge    Britt        issued    his       ruling   in
    United States v. Comstock, 
    507 F. Supp. 2d 522
     (E.D.N.C. 2007).
    In that case, the government certified five respondents in its
    custody      as    sexually         dangerous       under    §     4248     and       requested
    evidentiary hearings.               Id. at 526-27.           However, no evidentiary
    hearings      were     held.         Id.    at   559-60.          Instead,      Judge      Britt
    granted the respondents’ motions to dismiss as a matter of law,
    on   the     ground    that     §    4248    exceeded       the    scope    of        Congress’s
    authority         under    the       United      States      Constitution             to   enact
    legislation        and,   in     the   alternative,         on     the   ground        that    the
    statute facially violated the respondents’ due process rights.
    - 39 -
    Id. at 526, 559.          However, Judge Britt stayed the release of the
    respondents from custody pending an appeal from his decision.
    Id. at 560.
    On September 11, 2007, Bolander filed a motion to dismiss
    the    certification      on     the    basis     of   Judge    Britt’s       decision      in
    Comstock.          In response, on September 20, 2007, the government
    moved    to     stay    its    response      to    Bolander’s        motion       and     other
    similar motions pending in numerous certification cases in the
    Eastern District of North Carolina.                        On January 8, 2008, the
    district      court     granted       the   government’s       motion        to    stay    its
    response to Bolander’s motion and other similar motions pending.
    On January 8, 2009, we affirmed the dismissal of the § 4248
    certifications in United States v. Comstock, 
    551 F.3d 274
     (4th
    Cir. 2009), rev’d, 
    130 S. Ct. 1949
     (2010) (Comstock I), holding
    that    Congress       lacked     constitutional           authority     to       enact    the
    statute.        Id. at 276.            The following day, Bolander filed a
    motion    for      release     from    custody,      relying    on     our    decision      in
    Comstock      I.       While    this    motion       was    pending,    the       government
    petitioned for a writ of certiorari.                       The United States Supreme
    Court granted the petition on June 22, 2009.                          United States v.
    Comstock, 
    129 S. Ct. 2828
     (2009).                      Because the Supreme Court
    granted the petition, the district court declined to rule on
    Bolander’s motion for release.
    - 40 -
    In May 2010, the United States Supreme Court issued its
    opinion in United States v. Comstock, reversing our decision
    that    §    4248       was   unconstitutional,           and   holding       that   Congress
    properly         enacted      the    statute    pursuant        to    the     Necessary      and
    Proper Clause of the United States Constitution.                                
    130 S. Ct. 1949
    , 1954 (2010).             The Supreme Court remanded the case to this
    court       to    consider     the    additional         grounds     presented,       but    not
    decided, in Comstock I, and upon which the district court in
    that case had held that § 4248 was unconstitutional.                                      Id. at
    1955, 1965.
    Following the Supreme Court’s decision in Comstock, on June
    6,   2010,        the    district     court    denied,      under      the     authority      of
    Comstock, all pending motions for release in the § 4248 cases
    before      it     and   lifted      any    stay    or    abeyance      ordered      in    those
    cases.           The district court directed Bolander to proceed with
    additional constitutional challenges or an evidentiary hearing
    as he saw fit.
    On June 22, 2010, Bolander filed a motion to dismiss the
    certification,            relying      on     the     constitutional           claims       left
    unresolved by the Supreme Court’s decision in Comstock.                                   In the
    motion,          Bolander      stated       that    he     was       not     requesting       an
    evidentiary hearing “[a]t this time.”                      (J.A. 67).
    On August 4, 2010, the then-Chief Judge for the Eastern
    District         of   North    Carolina,       Chief      Judge      Louise    W.    Flanagan,
    - 41 -
    issued a standing order related to the processing of § 4248
    commitment actions in that district.        The order’s terms included
    the following provision regarding motions for hearings:
    Until such time as the final determination by an
    appellate court of “any claim that the statute or its
    application denies equal protection of the laws,
    procedural or substantive due process, or any other
    rights guaranteed by the Constitution[,]” if an
    individual respondent would like to proceed with the
    litigation of the government’s petition for his
    commitment, counsel for the respondent shall inform
    the court of the respondent’s desire to proceed with a
    hearing by filing a motion for a hearing. Such motion
    shall be filed . . . as soon as practicable after the
    respondent informs his counsel of his desire to
    litigate the commitment petition.
    Aug. 4, 2010 Standing Order of the Court, § 3(b).           On August 6,
    2010, Bolander’s case was reassigned to Chief Judge Flanagan.
    We heard oral argument in the remanded case in September
    2010.   In our December 10, 2010 decision in Comstock II, we
    reversed the district court’s judgment concerning the burden of
    proof under § 4248.     We held that the statute did not violate
    the Due Process Clause by requiring a court to find by clear and
    convincing   evidence   (rather    than    proof   beyond   a   reasonable
    doubt) that the individual has engaged or attempted to engage in
    sexual violence or child molestation and is sexually dangerous
    to others.    
    627 F.3d at 519-25
    .          Consequently, the case was
    remanded to the district court with instructions to proceed to
    the merits on the pending commitment actions.        
    Id. at 525
    .
    - 42 -
    On   December        15,     2010,        Bolander      filed    a    motion      for
    substitution of counsel, asserting that his relationship with
    his public defender had deteriorated to the point where he felt
    the   public     defender       could   not      adequately     represent       him.     On
    January    14,    2011,    the    Office        of   the    Federal   Public     Defender
    moved to withdraw and have new counsel appointed.                           On February
    16, 2011, the motion for substitution of counsel and the motion
    to withdraw were granted.
    On   January        28,     2011,     the      district       court    entered      a
    scheduling       order    directing       the    government      to   provide     initial
    disclosures.        The government’s initial disclosures were due by
    April 4, 2011, and Bolander’s were due by June 6, 2011.                                After
    the   exchange      of     initial      disclosures,          the     parties     had    an
    additional sixty days within which to conclude discovery.
    On March 25, 2011, the district court denied Bolander’s
    June 22, 2010 motion to dismiss the certification, finding no
    grounds in which to grant the motion.                      On May 31, 2011, Bolander
    moved for an extension of time until July 18, 2011 to provide
    his initial disclosure.             The motion was granted.                 On July 14,
    2011, Bolander sought to extend the deadline until September 16,
    2011, and the district court granted this request as well.
    On   September        16,     2011,        the       district    court     set     an
    evidentiary hearing date of November 28, 2011.                        On September 23,
    2011, Bolander requested a continuance of the hearing date until
    - 43 -
    the week of December 20, 2011.            The motion for continuance was
    granted, but the district court set the evidentiary hearing for
    January 12, 2012.
    In this case, the record reflects that the justification
    offered by the government for the delay in holding Bolander’s
    § 4248 hearing satisfies the requirements of due process.                       The
    initial date for Bolander’s evidentiary hearing was September 4,
    2007.    However, prior to the hearing date, Bolander moved for a
    continuance.     Before a new hearing date was set, the district
    court issued its ruling in Comstock.             From the time the district
    court   issued    this     decision,    the   government    cannot       be   held
    responsible for failing to push for an evidentiary hearing.                     As
    we noted in Timms, the government cannot be blamed “for agreeing
    to the abeyance in light of the heavy cost of pursuing hearings
    on the merits when § 4248 proceedings remained under a cloud of
    constitutional uncertainty.            There is simply no basis for the
    validity of the argument that the Government should have, at its
    own initiative, pressed for a commitment hearing under these
    circumstances.”    
    664 F.3d at 453
    .
    After the Supreme Court issued its decision in Comstock,
    the     constitutionality       of      § 4248     still    was         unsettled.
    Notwithstanding     this     uncertainty,     Bolander     did    not    seek   an
    evidentiary hearing.         Rather, in his June 22, 2010 motion, he
    specifically stated he was not requesting a hearing.                     His case
    - 44 -
    remained dormant, mainly because Comstock II was pending in this
    court, until the end of 2010 when he requested a substitution of
    counsel.      The    granting          of    this      request       further    delayed   the
    proceedings,       with    no     fault       attributable           to   the    government.
    After    substitute       counsel       was       appointed,         Bolander    sought   two
    extensions    of    time    in    which       to       file    initial      disclosures   and
    requested a continuance after the November 28, 2011 hearing date
    was set.      After this request for continuance was granted, the
    district court held the evidentiary hearing less than two months
    after the November 28 date.
    In sum, the government’s lawful exercise of its authority
    under § 4248 is not to blame for the delay in holding Bolander’s
    evidentiary       hearing        and        did       not     deny    him      due   process.
    Accordingly, the district court did not err when it concluded
    that Bolander’s due process rights were not violated in this
    case.
    C
    As noted above, Bolander participated in the SOTP at FCI-
    Butner     from    November       1997       until          April    1998.       During   his
    participation       in     the     program,            two     relevant        reports    were
    generated.        The first is titled “Psychosexual Evaluation” and
    dated January 29, 1998; the second is titled “Discharge Summary”
    and dated April 13, 1998.               (J.A. 518).            In preparing his expert
    report, Dr. North (as well as Dr. Warren) referred to these
    - 45 -
    reports.     Prior to the evidentiary hearing, on December 6, 2011,
    Bolander     moved     in    limine     to    exclude        any    and       all     evidence
    relating to the personal disclosures he made as part of the
    SOTP, contending they were privileged under a psychotherapist-
    patient privilege.           The district court denied the motion, and
    Bolander challenges this ruling before this court.
    The    United        States    Supreme         Court        has        recognized        a
    psychotherapist-patient          privilege,          finding       that       psychotherapy
    serves “a public good of transcendent importance.”                                   Jaffee v.
    Redmond, 
    518 U.S. 1
    , 11 (1996).                In Jaffee, the Court held that
    confidential        communications      between       a     patient      and     a    licensed
    social worker, during the course of diagnosis or treatment, are
    privileged and protected from discovery.                     
    Id. at 15-16
    .
    The   Court     looked   to    Rule     501     of    the    Federal          Rules    of
    Evidence,      which       authorizes        federal       courts        to     define       new
    privileges by interpreting “principles of common law . . . in
    the light of reason and experience.”                   Fed. R. Evid. 501.                  Reason
    and experience, as well as the fact that all fifty states plus
    the     District       of     Columbia         had        some      version           of     the
    psychotherapist-patient          privilege,          led    the    Court       to     conclude
    that   the    psychotherapist-patient            privilege         exists       under       Rule
    501.    Jaffee, 
    518 U.S. at 10-12
    .
    In Jaffee, the first officer to respond to a call involving
    a   fight    shot    and    killed    Ricky    Allen.         
    Id. at 10
    .      Officer
    - 46 -
    Redmond shot Allen because she believed he was about to stab
    another man with a butcher knife.                  
    Id. at 4
    .           As a result of
    this   incident,       Officer    Redmond     participated         in    approximately
    fifty counseling sessions with a state-licensed social worker.
    
    Id. at 5
    .      Jaffee, the administrator of Allen’s estate, brought
    a § 1983 excessive force claim against the Officer Redmond.                           Id.
    Jaffee requested production of the social worker’s notes from
    her counseling sessions with Officer Redmond in order to use
    these notes in cross-examination.              Id.        Although Officer Redmond
    and    the    social    worker      asserted    the        psychotherapist-patient
    privilege and “vigorously resisted the discovery,” the district
    court ordered that the notes be disclosed.                       Id.     After Officer
    Redmond and the social worker refused discovery of the notes,
    the district court instructed the jury that they could presume
    the contents of the notes to be unfavorable to Officer Redmond.
    Id. at 5-6.       Jaffee was awarded a total judgment of $545,000
    against Officer Redmond.           Id. at 6.
    The Seventh Circuit reversed and remanded for a new trial,
    concluding       that     Rule      501      compelled          recognition      of     a
    psychotherapist-patient           privilege.         Id.         According      to    the
    Seventh      Circuit,    the     privilege    would       not    apply    if    “in   the
    interests of justice, the evidentiary need for the disclosure of
    the contents of a patient’s counseling sessions outweighs [the]
    patient’s     privacy    interests.”         Id.     at    7    (internal      quotation
    - 47 -
    marks omitted).           The Seventh Circuit determined that Officer
    Redmond’s privacy interest outweighed Jaffee’s evidentiary need
    for the notes.       Id.
    On   appeal    to    the   Supreme    Court,    the    Court    affirmed    the
    Seventh      Circuit,       holding        that      protecting        confidential
    communications between a psychotherapist and patient promotes a
    critical interest and outweighs the need for probative evidence.
    Id. at 16-18.       However, the Court rejected the Seventh Circuit’s
    balancing test.       Id. at 17.          The Court reasoned that “[m]aking
    the promise of confidentiality contingent upon a trial judge’s
    later evaluation of the relative importance of the patient’s
    interest    in    privacy     and   the    evidentiary      need    for   disclosure
    would eviscerate the effectiveness of the privilege.”                        Id. at
    17.   The Supreme Court feared that use of a balancing test would
    frustrate the aim of the privilege by making its application
    uncertain.       Id. at 18.
    The Court’s decision in Jaffee is premised on the notion
    that “[t]he mental health of our citizenry, no less than its
    physical health, is a public good of transcendent importance.”
    Id.   at   11.      The    Court    recognized      that    the    psychotherapist-
    patient    relationship       is    “rooted   in     the    imperative     need   for
    confidence and trust” wherein the patient willingly makes “frank
    and   complete      disclosure      of     facts,    emotions,       memories,     and
    fears.”     Id. at 10 (internal quotation marks omitted).                        Thus,
    - 48 -
    “the mere possibility of disclosure may impede development of
    the      confidential            relationship       necessary         for      successful
    treatment.”         Id.      Without the privilege, the Court observed,
    “confidential conversations between psychotherapists and their
    patients      would     surely      be    chilled,     particularly         when    it     is
    obvious that the circumstances that give rise to the need for
    treatment will probably result in litigation.”                     Id. at 11-12.
    The    Jaffee       Court    did   not    outline    the       contours      of    the
    psychotherapist-patient              privilege,       because     it     was       “neither
    necessary nor feasible to delineate its full contours in a way
    that   would    govern       all     conceivable      future     questions         in    this
    area.”        Id.     at    18     (citation    and    internal       quotation         marks
    omitted).      In a footnote, the Court noted that the patient may
    waive this privilege, like other testimonial privileges, but did
    not further address the issue of waiver.                   Id. at 15 n.14.
    The Court in Jaffee also noted that the privilege would
    yield under some circumstances.                 Id. at 18 n.19.         In a footnote,
    the Court stated “[w]e do not doubt that there are situations in
    which the privilege must give way, for example, if a serious
    threat of harm to the patient or to others can be averted only
    by means of a disclosure by the therapist.”                     Id.
    Like    all     testimonial         or    evidentiary          privileges,         the
    psychotherapist-patient             privilege      must   be    strictly       construed.
    United States v. Squillacote, 
    221 F.3d 542
    , 560 (4th Cir. 2000)
    - 49 -
    (spousal       privilege).            In    the    case       of     another      evidentiary
    privilege,        the    attorney-client          privilege,         we    have     recognized
    that the holder of it may waive the privilege either expressly
    or   impliedly          by    a    voluntary      disclosure         to    a   third      party.
    Hawkins      v.   Stables,         
    148 F.3d 379
    ,      384    n.4    (4th    Cir.     1998)
    (attorney-client             privilege).          An   implied        waiver      waives     the
    privilege not only as to the specific information disclosed, but
    also as to the subject matter of the disclosure.                                    
    Id.
          The
    burden rests on the person invoking the privilege to demonstrate
    its applicability, including the absence of any waiver of it.
    United States v. Jones, 
    696 F.2d 1069
    , 1072 (4th Cir. 1982).
    In this case, the government argues that a person subject
    to civil commitment does not have a constitutionally protected
    expectation       of     privacy      in   prison      treatment          records    when    the
    government has a legitimate interest in access to them.                                     This
    argument is premised on Footnote 19 in Jaffee, where the Court
    stated    that     the       psychotherapist-patient              privilege       would    “give
    way”    in     certain       situations.          Jaffee,      
    518 U.S. at
       18    n.19.
    Alternatively, the government argues that Bolander waived any
    psychotherapist-patient privilege he may have enjoyed.                                 Because
    we     agree      with       the    government         that        Bolander       waived     any
    psychotherapist-patient               privilege        he     may     have       enjoyed,     we
    decline      to    address         the     government’s           argument       premised    on
    Footnote 19 in Jaffee.                   Accordingly, we express no opinion on
    - 50 -
    whether   the      disclosures    made      by   Bolander     during    his
    participation in the SOTP are protected communications under the
    psychotherapist-patient privilege.
    A patient may waive the psychotherapist—patient privilege
    by knowingly and voluntarily relinquishing it.         United States v.
    Hayes, 
    227 F.3d 578
    , 586 (6th Cir. 2000).           A waiver may occur
    when the substance of therapy sessions is disclosed to unrelated
    third parties, see 
    id.
     (noting that “a patient can waive the
    protections      of   the    psychotherapist/patient        privilege    by
    disclosing the substance of therapy sessions to unrelated third
    parties”), or when the privilege is not properly asserted during
    testimony.      See Hawkins, 
    148 F.3d at 384
     (“By answering the
    question as [the defendant] did, [the defendant] both waived her
    [attorney-client] privilege and provided probative evidence [on
    the subject matter].”).
    In   this    case,     Bolander   willingly    provided    the     SOTP
    materials to his own expert, Dr. Warren.            In the report, Dr.
    Warren acknowledged that he received and reviewed the materials
    Bolander claims are privileged.            Bolander did not assert the
    psychotherapist—patient privilege prior to his disclosure to Dr.
    Warren.   Rather, he waited until approximately one month prior
    to the evidentiary hearing to do so, even though the case had
    been pending in the district court for quite some time.                   By
    failing to timely assert the psychotherapist—patient privilege,
    - 51 -
    Bolander waived whatever privilege he may have had.                   Put another
    way,    it   was      incumbent       upon     Bolander         to   assert     the
    psychotherapist—patient       privilege       in   a   timely    fashion,    rather
    than waiting until the eleventh hour to do so.                        See United
    States v. Ary, 
    518 F.3d 775
    , 784-85 (10th Cir. 2008) (holding
    that    failure     to     timely     assert       attorney-client      privilege
    constitutes waiver); United States v. White, 
    970 F.2d 328
    , 334–
    35 (7th Cir. 1992) (same).             Moreover, to the extent Bolander
    claims a privilege in his communications with Dr. Warren, we
    reject this argument as well.             Dr. Warren was not being sought
    for    treatment,    but     rather     to     evaluate    Bolander’s        mental
    condition.    And as the Supreme Court in Jaffee made clear, the
    privilege only extends to those psychotherapists who are being
    consulted    for     diagnosis      and      treatment,     not      under    other
    circumstances.      501 U.S. at 15.
    Bolander also failed to assert the psychotherapist—patient
    privilege during his October 4, 2011 deposition.                      During that
    deposition, Bolander was asked questions about his participation
    in the SOTP.       He did not assert any privilege with respect to
    the information he provided in the SOTP, including the documents
    generated by the program.             Instead, Bolander openly discussed
    his participation in the SOTP, including the numerous admissions
    he made during that program.              By answering questions without
    - 52 -
    asserting the psychotherapist—patient privilege, Bolander waived
    any privilege he may have enjoyed.            Hawkins, 
    148 F.3d at 384
    .
    Bolander suggests that a defendant in need of psychotherapy
    treatment      will    be   forced   to   make   the   unenviable    choice   of
    foregoing      treatment      altogether    or    receiving     treatment     and
    thereby     waiving     the   psychotherapist—patient         privilege.      We
    certainly are not insensitive to the Hobson’s choice faced by a
    person    in   Bolander’s     position.       However,   in   this   particular
    case, Bolander simply failed to properly assert any privilege he
    may have had.         Accordingly, the district court did not err when
    it denied Bolander’s motion in limine. 14
    14
    The government also argues that Bolander waived any
    psychotherapist/patient privilege he may have enjoyed when he
    executed    the   “INFORMED   CONSENT   FORM”   as   part   of  his
    participation in the SOTP.       (J.A. 168).     By executing this
    consent form, Bolander acknowledged that the information he
    provided in the program may be disclosed by the SOTP.           The
    consent form states: “I also understand that the staff of the
    SOTP and Federal Bureau of Prisons, Department of Justice, and
    United States Probation Office may share information regarding
    my case.”     (J.A. 168).   The meaning of this provision in the
    consent form is ambiguous because it is unclear whether the
    information disclosed by Bolander could be “share[d]” amongst
    only these federal agencies or “share[d]” by these agencies with
    third parties, such as an expert in a civil commitment
    proceeding.     Bolander says the ambiguity is resolved by the
    provision in the consent form that says his “confidentiality
    will be protected at all times.”      (J.A. 168).   Bolander posits
    that this provision means that the information he provided in
    the SOTP could not be disclosed to third parties; otherwise, his
    confidentiality would not be protected. We need not resolve the
    government’s waiver argument premised on the consent form
    because there are other bases in the record in which to find a
    (Continued)
    - 53 -
    IV
    For the reasons stated herein, the judgment of the district
    court is affirmed.
    AFFIRMED
    waiver of any   psychotherapist/patient   privilege   Bolander   may
    have enjoyed.
    - 54 -