Competency to stand trial: Legal and clinical issues

A fundamental principle of criminal law is the right of defendants to a fair trial. Courts have long recognized that an essential component of this fairness doctrine is the ability, or competency, of defendants to participate in their defense. Mental health professionals have been extensively involved in assisting the courts in the evaluation of competency to stand trial. Three aspects of competency to stand trial in criminal cases are reviewed: the legal criteria defining competency to stand trial, the clinical assessment of competency, and the treatment of defendants found incompetent to stand trial.     

The question of sanity restoration in jail

Severe mental illness, especially psychotic disorders that are worsening, acute or complicated, normally require intensive psychiatric care and treatment that is most appropriately provided in a mental hospital. For criminal defendants, transfer to a forensic security hospital has traditionally been the means of achieving hospital care for mentally disordered defendants who have been found incompetent to stand trial or not guilty by reason of insanity. In recent years, with the shortage of intermediate and long-term hospital beds in the United States, including forensic security hospital beds, jail-based competency restoration programs are being established, seemingly obviating hospital transfer. Potential advantages of and concerns about jail-based, as opposed to hospital-based, competency restoration programs are discussed in the literature. If defendants with severe mental illness traditionally treated in a forensic security hospital for competency restoration are now treated for competency restoration in jail, it is not inconceivable that insanity acquittees could one day be treated in jail for sanity restoration. With the premise that it is better to consider the potential consequences before this becomes a serious proposal and is implemented, this analysis examine the advantages and concerns that have been put forth for jail-based competence restoration programs as they may or may not apply to jail-based sanity restoration programs. Substantial commonality is recognized, but also some differences, as well as reason for skepticism of the purported virtues of either alternative to care and treatment in forensic security hospitals.     

Representation by counsel: Right or obligation?

Since the Supreme Court's decision in Faretta v. California (1975), courts have generally permitted defendants to represent themselves, as long as they are competent to do so. The problem lies in the definition of competency to waive counsel, which has been vaguely defined by the courts. Little is known about the frequency of, or reasons for, attempts to waive counsel, about the process of forensic evaluation of such competency, and about the success of such attempts. The authors briefly review the case law on competency to waive representation, report on a longitudinal prospective study of these issues in a population of defendants referred to an inpatient forensic facility for evaluation of all types of competency related to their criminal prosecutions, and discuss the significance of the issue for forensic clinicians. A key question for courts, lawyers, and clinicians is whether a competency evaluation can be invoked to overcome a defendant's constitutional rights to self-representation and bail.     

Itemmetric and scale analysis of a new computer-assisted competency assessment instrument (CADCOMP)

Male defendants (n = 99) who had been court ordered to a forensic treatment facility as incompetent to stand trial were tested using the Computer-Assisted Determination of Competency to Proceed (CADCOMP) instrument soon after admission (median days = 15). Shortly thereafter, competency was assessed by a forensic psychiatrist and by a majority decision of three mental health professionals who viewed a videotape of the forensic psychiatrist's interview. From the CADCOMP item pool, 18 scales were constructed on conceptual grounds. Internal consistency analyses revealed that most scales had reasonable item homogeneity and scale reliability. In addition, item and scale analyses, with few exceptions, followed predicted patterns of intercorrelation and association with competency as determined by both criteria. Scales and items measuring serious psychopathology, psycholegal ability, and criminal history demonstrated the strongest associations with competency. These findings suggest that additional research on CADCOMP is warranted. The instrument shows promise for use in forensic research and assessment.     

Integrating the criminal justice system into mental health service delivery: the worcester diversion experience

The substantial number of persons with mental illness encountered in many sectors of the criminal justice system has spurred actors from various agencies within that system to take actions aimed at reducing the growth of this population. These actions have included the development of specialty police units, jail diversion programs, and other mechanisms for channeling persons with mental illness out of the criminal justice system and into mental health treatment. The courts, too, have become involved in this effort with the recent development of the "mental health court," the latest of the "specialty" or "problem solving courts." These courts have not been without their critics, however, nor are they the only feasible approach to court-based diversion. This paper identifies and explores a range of options for structuring the relationship between criminal courts and local mental health systems. Beginning with a discussion of the rationale motivating the development of mental health courts, two alternatives to this specialty court model are discussed. One involves judges dealing with defendants having mental illness and substance abuse on a case-by-case basis. The other takes advantages of linkages that may already exist between most courts and the mental health providers who conduct their forensic assessments, expanding the role of these providers to serve as boundary spanners between courts and the components of local mental health systems. Regardless of the model adopted, however, appropriate linkages must exist between the courts and relevant providers. A case study is provided that demonstrates how the status of a locale's linkages can be evaluated and how the information derived from such evaluation can be used to improve the linkages between police, courts, and health and human services agencies.     

The relationship between criminal charges, diagnoses, and psycholegal opinions among federal pretrial defendants

This study analyzed data from 1710 criminal defendants referred by federal courts throughout the United States. We examined 12 categories of criminal charges with respect to diagnosed psychopathology and opinions related to competence to stand trial (CST) and criminal responsibility (CR) at the time of the alleged offense. Overall, 18% of the present sample were found to be incompetent to stand trial, while 12% were found to be not criminally responsible or 'insane.' In this study, crimes were associated with rates of psychopathology and rates of opinions regarding CST and CR. The findings of this study suggest that individuals who are charged with different crimes have different mental states and psychopathology and are therefore found to have differential rates of competence and sanity.     

The competency of criminal defendants to refuse,for delusional reasons,a viable insanity defense recommended by counsel

This article addresses the issues of whether mentally ill defendants charged with serious crimes who refuse to plead a viable and counsel-recommended insanity defense for delusional reasons (but who are otherwise competent to stand trial) should be considered to be competent, or incompetent, to stand trial; whether such defendants should be allowed to represent themselves with a delusional defense; and whether an insanity defense may properly be imposed upon such defendants. Based on an analysis of relevant Supreme Court decisions and other relevant cases, it is concluded that such defendants should not be allowed to go forward with a delusional defense (at least until reasonable efforts to treat the defendants' delusions are made). It is also argued, however, that unless an insanity defense would be viable (as well as recommended by counsel) delusional defendants who are otherwise competent to stand trial should be permitted to go forward, and represent themselves, with the defense of their choosing.     

Deaf murderers: clinical and forensic issues

Data are reported on 28 deaf individuals who were convicted, pled guilty, or have been charged and awaiting trial for murder. The unique forensic issues raised by these cases are discussed, and their clinical picture presented. A significant percentage of these deaf murderers and defendants had such severely limited communication skills in both English and American Sign Language that they lacked the linguistic ability to understand the charges against them and/or to participate in their own defense. As such, they were incompetent to stand trial, due not to mental illness or mental retardation, but to linguistic deficits. This form of incompetence poses a dilemma to the courts that remains unresolved. This same linguistic disability makes it impossible for some deaf suspects to be administered Miranda Warnings in a way comprehensible to them. This paper identifies the reasons for the communication problems many deaf persons face in court and offers remedial steps to help assure fair trials and police interrogations for deaf defendants. The roles and responsibilities of psychiatric and psychological experts in these cases are discussed. Data are provided on the etiology of the 28 individuals' hearing losses, psychiatric/psychological histories, IQs, communication characteristics, educational levels, and victim characteristics.     

Fixing forensic patients: Psychiatric recommendations for treatment in pretrial settings

This article is concerned with psychiatric recommendations for treatment at the Metropolitan Toronto Forensic Service (METFORS), a clinical assessment agency providing both 1-day and 30-day evaluations of criminal defendants in Toronto, Canada. Analysis of both psychiatric reports and quantitative research instruments demonstrated the saliency of treatment as a central forensic issue at METFORS. Among a sample of 592 defendants, 134 were considered in need of outpatient care. Persons recommended for hospitalization were most likely to exhibit histories of mental health rather than criminal justice contacts; to be arrested for nonviolent offenses; to manifest psychotic behavior while at METFORS; to be found unfit for bail, incompetent to stand trial, in need of further assessment and dangerous to self; and to experience higher rates of hospitalization, but lower levels of criminalization during the two years following their initial forensic assessment. Psychiatric reports at METFORS tended to merge recommendations for treatment and assessment; to suggest prison or probation as means for securing clinical treatment; and to provide little written support for judgments about the need for intervention. Along with competency and dangerousness, treatment is a key issue in forensic practice, and warrants further attention in the psycholegal literature.     

Outcome of hospitalization for defendants found incompetent to stand trial

This study assessed the outcome of hospitalization for incompetent criminal defendants admitted to the forensic unit of a state hospital for treatment during a 4-year period. Findings suggested that the overwhelming majority of the defendants were restored to competency. The defendants also showed significant improvement in overall severity of psychopathology during hospitalization. Further, the duration of hospitalization for these defendants was relatively short. Although these results are promising with regard to treatment of incompetent defendants, predicting the outcome of hospitalization for these defendants was problematic. Prediction of competency restoration was precluded because persistent incompetence was so infrequent. Moreover, multiple regression analyses suggested limited predictive ability with regard to defendants' discharge level of functioning or length of hospitalization. These findings are consistent with the view that examiners should exercise caution in making recommendations to the courts concerning treatability of incompetent defendants.     

Patient Characteristics and Outcomes Related to Successful Outpatient Competency Restoration

Criminal defendants have a fundamental right to a fair and speedy trial. However, individuals found incompetent to stand trial are unable to move forward in the adjudication process and are often mired in protracted legal proceedings. If competency restoration is statutorily permissible and can be conducted in the outpatient setting, we propose that it should be considered based on burgeoning empirical data. We present data from an outpatient forensic clinic in which individuals are conditionally released to receive competency restoration in the community. Results indicated that three variables, including being single/never married, having comorbid intellectual disability and mental illness, and having one's conditional release revoked, were negatively related to successful restoration. The final model explained approximately one‐third of the variance in restorability and correctly classified 75% of cases. Results demonstrate that individuals can be safely released to the community and successfully restored to competency in the outpatient setting. Utilizing outpatient competency restoration would not only reduce strain on inpatient facilities, but would also reduce the cost of treatment. Copyright © 2017 John Wiley & Sons, Ltd.     

Factors affecting jail detention of defendants adjudicated incompetent to proceed

The movement of defendants through the legal process who have been adjudicated incompetent to proceed is little studied, yet it is important. The purpose of this study was to provide empirical data regarding factors that affected the amount of time defendants adjudicated incompetent to proceed and ordered to undergo hospitalization remained in jail while awaiting transfer to a state hospital. Statewide data collected in Florida between July 2005 and June 2008 were used to determine the lengths of time incompetent defendants spent at certain stages in the legal process. The addition of forensic bed capacity following media attention and litigation resulted in a significant decrease in the amount of time defendants adjudicated incompetent to proceed waited in jail for transfer to a state hospital for treatment. The amount of time it took for completed commitment orders to be submitted to the state mental health authority by the Clerks of Court of each county accounted for a meaningful portion of days defendants spent in jail awaiting transfer to a state hospital, with considerable variation across counties with respect to waiting times. These findings reflect how various stakeholders can affect the amount of time defendants spend in jail while awaiting hospitalization. These issues are discussed in the context of controversy related to Florida's forensic mental health system, as well as issues related to the political process and funding of the state's mental health authority.     

Diagnostic Differences and Demographic Predictors of Respondents Adjudicated Civilly Incompetent Versus Competent

The purpose of this study was to determine if diagnostic and demographic variables predict civil competency adjudications, a topic that has received scant research attention. Respondents (i.e., individuals alleged to be incompetent) were evaluated by a licensed psychologist to assist the court in civil competency and possible guardianship determination. Prior research using some of the same participants demonstrated select differences on activities of daily living between these groups (Quickel & Demakis, 2013 ), but the current set of analyses was not conducted. The current study included 107 competency evaluations in Mecklenburg County North Carolina and, at conclusion of the case, the public record of the adjudication was obtained. Based on prior legal theorizing in related criminal areas—focused on discrimination of individuals with mental illness—we predicted that cases involving respondents with psychiatric diagnoses would be likely to be overrepresented in those referred for evaluation as well as those subsequently adjudicated incompetent. A series of analyses indicated no statistical differences between competency groups (psychiatric/substance abuse, neurological, both psychiatric and neurological, and intellectually disabled). In a series of exploratory logistic regression analyses, we found that respondents who were single versus in a relationship and those not living at home versus living at home were significantly more likely to be adjudicated incompetent, even after controlling for difference in activities of daily living. There were no differences in incompetency adjudication by age, education, gender, race, or relationship status. Results are discussed in terms of implications for individuals with mental illness in incompetency hearings, as well as specific issues for psychologists evaluating a broad range of respondents. Copyright © 2015 John Wiley & Sons, Ltd.     

Competent and incompetent criminal defendants: a quantitative review of comparative research

Thirty studies comparing competent and incompetent criminal defendants (N = 8,170) were quantitatively reviewed to identify variables associated with judgments about defendants' competency to stand trial. Effect sizes reflecting the magnitude of the relationship between competency status and defendant characteristics were derived and averaged across studies. The characteristics most strongly related to incompetency were (a) poor performance on psychological tests or interviews specifically designed to assess defendants' legally relevant functional abilities, (b) a psychotic diagnosis, and (c) psychiatric symptoms reflective of severe psychopathology. To a lesser degree, traditional psychological tests, previous psychiatric hospitalization, previous legal involvement, marital resources, and demographic characteristics were also related to competency status. Although these results are generally consistent with the legal standard for competency to stand trial, some of the correlates of competency may reflect potential biases in the decision-making process. Limitations of existing research and directions for future inquiry are discussed.     

Can defendants with mental retardation successfully fake their performance on a test of competence to stand trial?

The purpose of this study was to determine whether criminal defendants with mental retardation can feign poor performance on a test of competence to stand trial. Four groups of adjudicated criminal defendants were given a test of competence to stand trial. In the experimental condition, defendants with mental retardation (MR) and mentally typical defendants (non-MR) were given instructions to fake their performance on the test. In the control, MR defendants and non-MR defendants took the test under standard conditions. The results indicated that both the MR and non-MR fakers scored significantly lower than the MR and non-MR controls. There was no significant difference in the scores of the MR and non-MR fakers. The results suggest that defendants with mental retardation may be able to successfully fake their performance in certain circumstances. Implications of these findings are discussed.     

What Happens to Mental Health Court Noncompleters?

Mental health court (MHC) research consistently finds that defendants who successfully complete and graduate from the court are less likely to recidivate than those who do not. However, research has not assessed what happens to these noncompleters once they are sent back to traditional court. Using follow-up data on six years of noncompleters from pre-adjudication MHC, we examine what happens to these defendants in traditional court. Findings suggest that 63.7% of defendants' charges were dismissed, 21.0% received probation, and 15.3% were sentenced to incarceration. We examine the time to disposition and differences in defendant characteristics and disposition outcome as well as the relationship between disposition and subsequent recidivism. Results suggest that more severe punishments in traditional court are associated with recidivism. Logistic regression analysis shows that defendants whose charges were dismissed in traditional court were less likely to recidivate than those who were sentenced to probation or incarceration. Our findings highlight the need for future MHC evaluations to consider traditional court outcomes and support trends towards post-adjudication courts. Copyright © 2015 John Wiley & Sons, Ltd.     

Co‐Occurring Disorders in Treatment‐Based Courts: Results of a National Survey

Drug courts and mental health courts have expanded rapidly in the past several decades to provide more efficient coordination of treatment and supervision of offenders with behavioral health problems. A significant number of offenders in these court‐based programs have co‐occurring mental and substance use disorders, which predict early termination, relapse, rearrest, and other negative outcomes. A web‐based national survey examined programmatic adaptations for co‐occurring disorders (CODs) among 54 drug courts, mental health courts, and freestanding COD dockets. COD dockets were smaller and of longer duration, and provided more intensive services than programs situated in drug courts or in mental health courts. However, more similarities than differences were noted across the different types of court‐based program. Key adaptations for CODs included extended program duration, highly intensive and integrated treatment, smaller, less formal, and more frequent hearings, and use of specialized supervision teams and dually credentialed staff. Copyright © 2012 John Wiley & Sons, Ltd.     

Offense Characteristics of Incompetent to Stand Trial Defendants Charged With Violent Offenses

The current study compared offender and offense characteristics of pretrial defendants found incompetent to stand trial (IST) against those described as general offenders by victims in the 2008 Bureau of Justice Statistics (BJS) survey and evaluated factors that differentiated IST defendants who allegedly used weapons from those who did not during the course of a violent offense. IST defendants were older and used “weapons” more frequently than those reported in the BJS survey; however, other characteristics, including use of firearms, did not differ. No demographic, clinical, or legal factors differentiated pretrial defendants who used weapons from those who did not. Overall, pretrial defendants were frequently diagnosed with a comorbid substance use disorder, and were homeless, unemployed, and had an extensive history of psychiatric hospitalizations and prior arrests at the time of their alleged offenses. Such results indicate that models for comprehensive discharge planning may have utility in addressing the unique needs of this subgroup of mentally disordered offenders. The findings also raise questions about the federal and state prohibition of gun rights to all IST defendants. Copyright © 2015 John Wiley & Sons, Ltd.