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.     

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).     

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.     

Examining the effectiveness of an intervention designed for the restoration of competency to stand trial

This study examined the effectiveness of the Fitness Game, an intervention created for the restoration of competency to stand trial. Of 28 participants who completed either the experimental or control intervention at Hawai'i State Hospital (HSH), it was found that both groups had significant pretest to posttest improvements on Understanding and Appreciation subsets of the MacArthur Competence Assessment Tool-Criminal Adjudication (MacCAT-CA). However, there was no statistically significant difference between the groups on competency measures, indicating that the Fitness Game was not significantly more effective at restoring competency than non-legal programming. In other words, individuals committed to a psychiatric hospital for care and treatment were as likely to improve as those receiving additional specialized competency restoration treatment.     

An analysis of competency to stand trial: an integration of case law and clinical knowledge

In the past three decades competency to stand trial has emerged as a central issue in mental health law and forensic psychology. This article combines legal and clinical frameworks for a more integrated understanding of competency to stand trial. The legal framework focuses on Supreme Court decisions beginning with Dusky and reviews several legal theories of competence. The empirical framework is investigated within Grisso's (1986) conceptualization of legal competencies. In addition, the efficacy of specialized forensic assessments is evaluated, including the newly developed MacArthur Structured Assessment of the Competencies of Criminal Defendants (MacSAC-CD). The article concludes with observations of competency as a construct and their implications for forensic practice. © 1998 John Wiley & Sons, Ltd.     

Recent interview-based measures of competency to stand trial: a critical review augmented with research data

Forensic experts are frequently asked to conduct competency-to-stand trial evaluations and address the substantive prongs propounded in Dusky v. United States (1960). In understanding its application to competency evaluations, alternative conceptualizations of Dusky are critically examined. With Dusky providing the conceptual framework, three interview-based competency measures are reviewed: the Georgia Court Competency Test (GCCT), the MacArthur Competence Assessment Tool-Criminal Adjudication (Mac-CAT-CA), and the Evaluation of Competency to Stand Trial-Revised (ECST-R). This review has a twin focus on reliability of each measure and its correspondence to Dusky prongs. The current review is augmented by new factor analytic data on the MacCAT-CA and ECST-R. The article concludes with specific recommendations for competency evaluations.     

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.     

Ethical considerations in the use of computers in psychological testing and assessment

Ethical considerations in the use of computers in psychological testing and assessment are discussed. Particular attention is given to existing ethics and standards that provide guidance to users of computerized test interpretation and report-writing programs. Issues covering professional accountability and confidentiality are also discussed as they relate to computer-assisted assessment. Areas of appropriate use of computers in testing and assessment are suggested, including test scoring, the analysis of scores, and generating remedial recommendations. Findings are summarized and several guidelines are suggested for users of computers in testing and assessment.     

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.     

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.     

Issues relating to the use of forgiveness in counselling and psychotherapy

This paper explores forgiveness, which is a key component of spiritual pastoral care. Encouraging forgiveness is also one of the spiritual interventions most frequently used by psychotherapists. However, although forgiveness has been explored as an element in psychotherapy, the models generated have had little impact on research and practice. Recent research into forgiveness in therapy is considered, including several models put forward for its use. Some of the implications of the use of forgiveness in therapeutic practice are examined and guidelines for the use of forgiveness in psychotherapy are put forward based on the work of the Forgiveness Project at the University of Manchester.     

Hospitalization of criminal defendants for evaluation of competence to stand trial or for restoration of competence: clinical and legal issues

The clinical and legal literature abounds with articles dealing with competence to stand trial; while most agree that criminal defendants must be capable of defending themselves before the state can bring them to trial, a number of articles are quite critical of the procedures by which these concepts are operationalized, some even going so far as to suggest abolishing the requirement for competence altogether. One of the major problems leading to the criticisms is the unnecessary loss of liberty involved. Although the length of incarceration has decreased significantly since the 1970s, the majority of states still permit, or require, hospitalization for evaluation of competence, and even more so for treatment to restore competence.The author reviews case law and presents data from his survey of current state statutes and responses from state forensic mental health program directors, to demonstrate the rarity of outpatient treatment to restore competence. He argues that outpatient treatment for defendants who do not require hospitalization on clinical or public safety grounds should be available, on both clinical and legal grounds, and provides recommendations for establishing such programs in the community.     

Electrical safety in the use of biofeedback instruments

Electrical hazards associated with the use of medical apparatus are described with emphasis on biofeedback instruments. Safety standards specify safe current levels for instruments in normal operation; however, the user can take steps to provide back-up protection against hazards caused by component malfunction or breakdown. Measures for protection of patient and operator are outlined, including instrument design considerations and guidelines for the user to follow in order to provide a margin of safety.     

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.     

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.