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.     

Competency to stand trial evaluations: A state-wide review of court-ordered reports

Competence to stand trial (CST) evaluations are a critical part of certain criminal proceedings, and competence-related evaluation and treatment are an increasing part of public mental health services. Whereas more research describes the defendants undergoing competence evaluations, less research has examined the actual reports detailing those competence evaluations. This study reviewed 3,644 court-ordered CST evaluation reports submitted by 126 evaluators in Virginia since Virginia initiated an oversight system allowing for comprehensive review. The base rate of incompetence opinions was 38.8%, but these rates varied significantly across evaluation type (initial versus post-restoration efforts) and evaluators (ranging from 9.1% to 76.8% incompetence rate). Results suggest generally strong compliance with state statutes guiding CST evaluations, but also highlight marked variability in forensic conclusions and reveal a few areas in which some reports fell short of statutory requirements and practice guidelines.     

Competency to stand trial: rationalism, "contextualism" and other modest theories

Determinations of competency to stand trial in criminal cases are complicated and rendered unpredictable by two sub-surface issues that are rarely articulated: (i) the place of the defendant's rationality in the substantive standard(s) for competency and (ii) the level or degree of incompetency required to stop the criminal process. The rare references to these issues, mostly indirect, that are made in the cases, commentary, and competency testing instruments devised (including those civil as well as criminal) are examined. The conclusion that emerges is that the level of capacity and rationality required of the defendant depends much on context-the type of case, its relative complexity, and the values and stakes implicated in the outcome.     

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.     

Development and exploratory cluster-randomised opportunistic trial of a theory-based intervention to enhance physical activity among adolescents

This article reports the development and exploratory testing of a school-based intervention programme designed to enhance levels of physical activity in adolescents. The intervention is based on social cognitive theory (SCT), self-regulation theory (SRT) and planning as evidence-based mediators of physical activity changes. Two classes, paired on socio-economic variables, were selected from each of eight Portuguese schools and randomly assigned to an intervention or control group (N = 291). Primary outcome was ‘moderate to vigorous physical activity’ (International Physical Activity Questionnaire) measured pre and post intervention and at three and nine months follow-up. SCT, SRT and planning variables were secondary outcomes measured pre and post intervention. At post test, participants in the intervention group reported 18 min per week more physical activity (PA), adjusted for pre-intervention, age and sex, than those in the control group (95% confidence interval ?10 to 46; p = 0.249). This difference increased to 33 min (95% CI–4 to 71; p = 0.082) at three months and to 57 min (95% CI 13 to 101, p = 0.008) at nine month follow-up. Moreover, the intervention resulted in changes of some of the theoretical target variables, including outcome expectancies and coping planning. However, no evidence was found for the changes in theoretical moderators to mediate the intervention effects on behaviour. Implications for theory and for future research are discussed.     

The role of competency to stand trial in mental health courts

Concerns have been raised in the literature about the competency to stand trial and competency to make treatment decisions of defendants referred to mental health courts. However, there is little information reported about the evaluation and prevalence of incompetence, characteristics of incompetent mental health court defendants, and disposition of mentally ill defendants too disturbed to be diverted from the criminal justice system through mental health courts. This study reports on the 85 potential mental health court defendants referred for trial competency evaluations during the first three years of operation of the Akron Ohio Mental Health Court. Of the 80 defendants who could be located for evaluation, 77.5% were found incompetent, and 53% of the incompetent defendants were not restored to competence even after an average of 49 days of treatment in a state psychiatric hospital. The implications of these findings in terms of the diversion potential of mental health courts for the severely mentally ill are discussed.     

Abortion among adolescents

In most countries, adolescents' access to abortion is limited by restrictions on legal abortion. Abortion is legal in the United States, but many states require parental consent or notification. Legislation mandating parental consent has been justified by several assumptions, including high risk of psychological harm from abortion, adolescents' inability to make an adequately informed decision, and benefits of parental involvement. Empirical data raise questions about the first 2 assumptions: Studies suggest a relatively low risk associated with abortion, and adolescents seeking abortion appear to make an informed choice. Less is known about effects of parental involvement. The authors review available research and discuss policy debates over parental consent in the United States and the international context.     

Assessing dimensions of competency to stand trial: construct validation of the ECST-R

Four decades of forensic research have left unanswered a fundamental issue regarding the best conceptualization of competency to stand trial vis-à-vis the Dusky standard. The current study investigated three competing models (discrete abilities, domains, and cognitive complexity) on combined data (N = 411) from six forensic and correctional samples. Using the Evaluation of Competency to Stand Trial-Revised (ECST-R), items representative of the Dusky prongs were used to test the three models via maximum-likelihood confirmatory factor analyses (CFA). Of the three, only the discrete abilities model evidenced a good fit, indicating that competency to stand trial should consider separately each defendant's factual understanding of the proceedings, rational understanding of the proceedings, and ability to consult with counsel. ECST-R competency scales, based on the current CFA, have excellent alphas (.83 to .89) and interrater reliabilities (.97 to .98).     

Empirically based assessment of competence to stand trial: Instrument development and preliminary findings

An instrument was designed to assist mental health professionals in objectively assessing competence to stand trial. Items were empirically derived based on input from multidisciplinary teams of mental health professionals experienced in working with forensic patients in a state hospital. Procedures were adapted from Goldfried and D'Zurella's five-stage behavioral-analytic model for the assessment of social competence. The resulting 15-item audiotaped scale assessed both legal and social competence based on reported responding in jail, in interactions with lawyers, and in the courtroom. Interrater reliability on scoring of responses ranged from .68–.96. High correlations between social and legal competence (.56–.82) demonstrated the likelihood of overlap of these constructs and the importance of directly addressing both. A pilot intervention program was designed from the instrument and implemented with three forensic patients. Failure to demonstrate change in these subjects is briefly discussed, and recommendations for future efforts in this area are made.     

Amnesia and competency to stand trial: A review of legal and clinical issues

Recent case law is discussed regarding the role of amnesia in determining competency to stand trial. Clinical issues are examined for a range of amnestic conditions on a spectrum of organic and functional disorders. Clinical methods are explored for establishing the extent of amnesia and its relevance to competency.     

An examination of the ECST-R as a screen for feigned incompetency to stand trial

Psychological assessments of competency-to-stand-trial (CST) referrals must consider whether the defendants' impairment is genuine or feigned. This study addressed feigning on the Evaluation of Competency to Stand Trial--Revised (ECST-R), a standardized interview designed for assessing dimensions of CST and screening for feigned CST. In particular, this study examined the effectiveness of the ECST-R's Atypical Presentation (ATP) scales as screens for feigned incompetency. It examined ATP scales for (a) jail detainees (n=96) in simulation and control conditions and (b) inpatient competency cases (n=56) in clinical comparison and probable malingering groups. Comparisons of ATP scales yielded very large effect sizes for feigners when compared with jail controls (mean d=2.50) and genuine inpatient competency cases (mean d=1.83). Several cut scores were established with very few false negatives and robust sensitivity estimates. In summary, the ECST-R ATP scales appear to be homogenous scales with established clinical use as feigning screens in CST evaluations.     

Loneliness among late adolescents

The extent of loneliness among late adolescents was assessed by means of the Revised UCLA Loneliness Scale. Findings suggest that although moderate loneliness was reported by most participants, a number of young people evidenced a high degree of loneliness. A comparison of lonely and nonlonely adolescents yielded relatively few significant differences. Of particular interest, however, was the finding that lonely and nonlonely adolescents use different strategies to deal with feelings of loneliness. Implications for working with lonely adolescents are offered.     

Wellness factors among adolescents

This study was directed toward the identification of components of wellness in adolescents ages 12-17. Content for wellness-learning games aimed at youth was derived from the professional judgment of an advisory panel composed of experts in preventive medicine, health education, and adolescent development. The panel was polled by mail in a Delphi-like series of structured inquiries to gather information about the physical, social, and emotional characteristics of healthy adolescents and to identify the knowledge, attitudes, and behaviors appropriate to the promotion or support of those characteristics. The study resulted in a consensus of 39 attributes considered important in the development of healthy adolescents.     

Dispositional forgiveness among adolescents

The study examined whether the four constructs of forgivingness found in adults—propensity to lasting resentment, sensitivity to circumstances, willingness to forgive, and willingness to avenge—were already in place among adolescents. It also examined the differences in propensity to forgive and related constructs between young adolescents and older adolescents. More than 500 adolescents (124 sixth graders, 170 seventh graders, 135 eighth graders, and 78 ninth graders) were presented with a slightly modified version of the Forgivingness Scale (Mullet, Barros, Frongia, Usai, Neto, & Rivière-Shafighi, 2003 Mullet, E., Barros, J., Frongia, L., Usai, V., Neto, F. and Rivière-Shafighi, S. 2003. Religious involvement and the forgiving personality. Journal of Personality, 71: 1–19. [Crossref], [PubMed], [Web of Science ®] , [Google Scholar]). The same four-factor structure that was found among adults was also found among adolescents. Scores regarding sensitivity to circumstances and willingness to forgive were lower among older adolescents than among younger adolescents. Scores regarding lasting resentment and willingness to avenge were higher among older adolescents than among younger adolescents.     

Locus of control and attitudes to authority among adolescents

This study investigated the relationship between locus of control and attitudes toward authority among a sample of Australian adolescents. Results showed, firstly, that internals have positive attitudes toward those in positions of authority (Police, Teachers, Army) and, secondly, that attitudes to various authorities are generally interrelated. These findings are discussed in the light of the personality correlates of internality and externality.     

Suicidal ideation among adolescents in relation to recalled exposure to violence

The relationship between exposure to violence and vulnerability to suicide among adolescents was examined. The topic was initiated by the rapid increase in adolescent's exposure to violence and the sparse systematic research available on its relationship to attitudes about life and death. The study's main hypothesis is that high levels of exposure to violence are associated with high suicide risk according to two conceptual paradigms-Fear of Death and Attraction and Repulsion to Life. Eighty-five adolescents were administered three self report questionnaires. The questionnaires assessed levels of exposure to violence, fear of death, and attitudes towards life and death. Those who had been exposed to a high level of violence reported attitudes synonymous with the profile of an individual at risk for suicide (low fear of death, low repulsion to death, and low attraction to life; high repulsion to life and high attraction to death).