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.     

The competence of criminal defendants: A theoretical reformulation

“Competence” of criminal defendants is best viewed not as an open-textured single construct but rather as two related but separable constructs-a foundational concept of competence to assist counsel, and a contextualized concept of decisional competence. This approach has several advantages. First, it provides a useful explanatory framework for the settled features of existing law. Second, it helps to clarify the issues in areas where the law is unsettled or controversial, such as the circumstances under which incompetence bars adjudication and the abilities required for decisional competence. Third, it exposes the similarities between competencies in criminal defense and competencies in other legal contexts, and thereby helps to link what have been discrete literatures in both law and behavioral science. Fourth, because this approach is derived from a theoretical analysis of the purposes of the pertinent legal rules, it provides a framework for defining the “psycho-legal abilities” that are encompassed by each of the two competence constructs. In this respect, a relatively simple reconceptualization has surprisingly concrete implications for designing a program of empirical research and, eventually, for improving the scientific basis of competence assessments in criminal cases.     

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.     

Adjudicative competence and comprehension of Miranda rights in adolescent defendants: a comparison of legal standards

Currently, there is considerable variability and ambiguity in legal standards pertaining to juveniles' comprehension of Miranda rights and their adjudicative competence. This study investigated rates of impairment under various proposed legal standards. One hundred and fifty-two young defendants aged 11-17 were assessed with Grisso's Miranda Instruments and the Fitness Interview Test-Revised. While over half of defendants aged 15 and under were classified as impaired in adjudicative capacities when adult norms were applied, significantly fewer adolescents were classified as impaired when adolescent norms were applied or a standard of "basic understanding and communication." Also, while over half of defendants aged 15 and under were classified as impaired in their comprehension of Miranda rights when both understanding and appreciation of Miranda rights were required, significantly fewer youth were classified as being impaired when only understanding was required. The implications of these findings are discussed.     

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.     

Five-year research update (1986-1990): Evaluations for competence to stand trial

This article reviews and evaluates publications during 1986–1990 with relevance for assessments of competence to stand trial. The review focuses specifically on articles that provide new concepts or data supported by research or case studies. The studies are reviewed under the following headings; (a) the systemic context of competence to stand trial (CST) evaluations, (b) conceptual definitions of competence and models for CST assessment, (c) research on CST assessment methods, (d) characteristics of incompetent defendants, (e) interpretation of CST evaluation data, (f) issues in CST assessment of special populations, and (g) treatment to restore competence. Suggestions are offered for further research to advance the quality of clinical evaluations for competence to stand trial.     

Five year research update (1996-2000): evaluations for competence to stand trial (adjudicative competence)

This article reviews and evaluates publications during 1996-2000 with relevance for assessments of competence to stand trial (also known as adjudicative competence). The review focuses specifically on articles that provide new concepts or data supported by research or case analyses. The studies are reviewed under the following headings: (i) the systemic context of evaluations of adjudicative competence (AC); (ii) conceptual guidelines for AC evaluations; (iii) research on AC assessment methods; (iv) empirical correlates of AC judgments and psycholegal abilities; (v) quality of AC evaluations and reports; (vi) interpretation of AC evaluation data; (vii) issues in AC assessment of special populations (e.g., juveniles, persons with mental retardation, and women); and (viii) treatment to restore competence. Suggestions are offered for further research to advance the quality of clinical evaluations of adjudicative competence.     

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.     

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.     

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.     

Issues and considerations regarding the use of assessment instruments in the evaluation of competency to stand trial

Since the early 1960s, a number of instruments, reflecting a broad range of assessment methods, have been developed to assist in the evaluation of competency to stand trial. These instruments have taken various forms including checklists, self-report questionnaires, sentence-completion tasks, and interview-based instruments with and without criterion-based scoring. This article reviews these assessment instruments with a specific focus on their contribution to the competency evaluation process. Furthermore, relevant issues and considerations regarding the use of these instruments are outlined, including a comparison of screening versus assessment applications of these instruments, balancing standardized approaches with individualized assessments, the integration of instrumentally derived data with other components of a competency evaluation, and the communication of results to the fact finder. Each of these issues is discussed in relation to specific competency assessment instruments. Overall, we argue that each of the competency assessment instruments developed to date can make a contribution to the competency evaluation process and this article serves to delineate those areas in which these contributions are made.     

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).     

Testing a self-determination theory intervention for motivating tobacco cessation: supporting autonomy and competence in a clinical trial.

A longitudinal randomized trial tested the self-determination theory (SDT) intervention and process model of health behavior change for tobacco cessation (N = 1006). Adult smokers were recruited for a study of smokers' health and were assigned to intensive treatment or community care. Participants were relatively poor and undereducated. Intervention patients perceived greater autonomy support and reported greater autonomous and competence motivations than did control patients. They also reported greater medication use and significantly greater abstinence. Structural equation modeling analyses confirmed the SDT process model in which perceived autonomy support led to increases in autonomous and competence motivations, which in turn led to greater cessation. The causal role of autonomy support in the internalization of autonomous motivation, perceived competence, and smoking cessation was supported.     

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.     

Neuroimaging techniques for memory detection: scientific, ethical, and legal issues

There is considerable interest in the use of neuroimaging techniques for forensic purposes. Memory detection techniques, including the well-publicized Brain Fingerprinting technique (Brain Fingerprinting Laboratories, Inc., Seattle WA), exploit the fact that the brain responds differently to sensory stimuli to which it has been exposed before. When a stimulus is specifically associated with a crime, the resulting brain activity should differentiate between someone who was present at the crime and someone who was not. This article reviews the scientific literature on three such techniques: priming, old/new, and P300 effects. The forensic potential of these techniques is evaluated based on four criteria: specificity, automaticity, encoding flexibility, and longevity. This article concludes that none of the techniques are devoid of forensic potential, although much research is yet to be done. Ethical issues, including rights to privacy and against self-incrimination, are discussed. A discussion of legal issues concludes that current memory detection techniques do not yet meet United States standards of legal admissibility.     

Psychopathic traits in adolescent offenders: an evaluation of criminal history, clinical, and psychosocial correlates

Although a large body of research has established the relevance of psychopathy to adult offenders, its relevance to adolescent offenders is far less clear. The current study evaluated the clinical, psychosocial and criminal correlates of psychopathic traits in a sample of 226 male and female incarcerated adolescent offenders. According to an 18-item version of the Psychopathy Checklist-Youth Version (PCL-YV; Forth, Kosson, & Hare, 2003), only 9.4% exhibited a high level of psychopathic traits (PCL-YV>/=25). Consistent with past research, higher PCL-YV scores were positively associated with self-reported delinquency and aggressive behavior and were unrelated to emotional difficulties. Although higher PCL-YV scores were associated with the experience of physical abuse, the only psychosocial factor to predict PCL-YV scores was a history of non-parental living arrangements (e.g. foster care). In terms of criminality, a violent/versatile criminal history was positively associated with psychopathic traits. However, PCL-YV scores were unrelated to participants' official criminal records for total, non-violent, violent, and technical violation convictions. In conclusion, the data partially support the construct validity of psychopathy with adolescent offenders, but some inconsistencies with prior adult and adolescent psychopathy research were evident. These issues are discussed.     

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.     

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.