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.     

Preliminary support for a competency-based model of depression in children

The relation of child depression to competency feedback was explored in five domains: academic, social, physical attractiveness, conduct, and sports. Self-reports of depression and peer nominations of competency were obtained from 1,422 elementary school children. Findings supported 4 hypotheses from a competency-based model of child depression. Peer nominations of competency in various domains were negatively related to depression. Being nominated as relatively incompetent in multiple domains corresponded with higher levels of self-reported depression. Being nominated as competent in one or more domains corresponded with lower levels of depression. Individual differences in incompetency were more strongly related to depression than were those in competency, especially for girls. Early intervention in child depression is discussed. Longitudinal and experimental designs are recommended for testing further the competency-based model.     

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.     

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.     

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.     

Beyond Mental Competence

Justification for psychiatric paternalism is most easily established where mental illness renders the person mentally incompetent, depriving him of the capacity for rational agency and for autonomy, hence undermining the basis for liberal rights against paternalism. But some philosophers, and no doubt some doctors, have been deeply concerned by the inadequacy of the concept of mental incompetence to encapsulate some apparently appealing cases for psychiatric paternalism. We ought to view mental incompetence as just one subset of a broader justification for psychiatric paternalism. The very basis of liberal limitations on psychiatric paternalism, whether described in terms of rights to autonomy or as respect for differences in values and lifestyles, presupposes a sense of moral persistence, and hence some sufficiently persistent self. Paternalistic intervention is warranted when we are unable to govern our lives in a manner consistent with the goals and values that comprise that ‘self’. One way that can occur is when we lack the mental capacities required for autonomy, such that we are unable to interpret and interact with our environment in order to meaningfully pursue our goals, i.e. mental incompetence. But it can also occur when we are subject to impositions that alter our goals without altering our capacity to pursue them — i.e. when it is our ‘self’ that is impaired rather than our competence.     

Human figure drawings of adjudicated and nonadjudicated adolescents

We investigated differences between human figure drawings of adjudicated and nonadjudicated adolescents. In addition, the relationship between human figure drawings and crime category (person, property, other, none) was examined for the adjudicated adolescents. Subjects consisted of four groups of adolescents (n = 25 each): adjudicated males, adjudicated females, nonadjudicated males, and nonadjudicated females. Human figure drawings were obtained from all subjects; they were scored using a system that was developed for use with adolescents. Kruskal-Wallis one-way analyses of variance (ANOVAs) were used to assess the effects of adjudication status and gender. There were 11 significant differences between adjudicated and nonadjudicated adolescents and 11 differences among the four groups. Results of Kruskal-Wallis ANOVAs also showed two significant differences among crime categories.     

The right to refuse treatment in Oregon: A two-year statewide experience

The right to refuse treatment seems well established for psychiatric patients. Individual states, however, have very different procedures for managing this right and for overriding the refusal. Oregon's administrative procedure for override depends on an evaluation by an independent examining psychiatrist. This article empirically examines the 432 refusals leading to override requests in three Oregon psychiatric institutions in 1983 and 1984. Treatment refusal was found to be a common occurrence in all age groups. Those who refused treatment were seriously ill, unemployed, single individuals with previous psychiatric hospitalizations. Most refused treatment because of denial of their illness or delusional thinking about medication. Most refusals were overridden following the independent psychiatrist's examination. Because of the significant cost of the override procedure to the patient and the mental health system, the authors propose a new procedure which combines parts of the current procedure with a requirement that, at the time of the civil commitment hearing, the judge makes a separate decision as to the patient's competency to make treatment decisions.     

Influences upon willingness to participate in schizophrenia research: an analysis of narrative data from 63 people with schizophrenia

Schizophrenia affects more than 1% of the world's population, causing great personal suffering and socioeconomic burden. These costs associated with schizophrenia necessitate inquiry into the causes and treatment of the illness but generate ethical challenges related to the specific nature and deficits of the illness itself. In this article, we present a systematic analysis of narrative data from 63 people living with the illness of schizophrenia collected through semistructured interviews about their attitudes, beliefs, and experiences related to psychiatric research. In the comments of these individuals, half of whom had had prior personal experience in research protocols, we identified factors influencing openness toward research involvement as well as deterrents that appear to lessen interest in participation. Clear response pattern differences emerged between those with prior research experience and those without such experience. In the discussion, we explore the key findings and outline the implications for safeguards in mental illness research.     

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.     

Psycholegal Abilities and Restoration of Competence to Stand Trial

Criminal defendants adjudicated incompetent to stand trial are typically hospitalized for competence restoration in state institutions. Prolonged restoration hospitalizations involve civil rights concerns and increasing financial costs, and there remains interest in determining which individuals are likely to be successfully restored. We retrospectively reviewed hospital records of 455 male defendants admitted to a forensic treatment center for competence restoration in an effort to determine whether psychiatric diagnoses, demographic factors, or psycholegal abilities were predictive of successful or failed restoration. At varying stages of restoration efforts, psychotic disorder, mental retardation, and previous state hospitalization predicted unsuccessful restoration, while substance use and personality disorders were predictive of successful restoration. Psycholegal abilities were predictive of successful restoration and appeared to form a continuum, with basic behavior and outlook, factual legal understanding, and rational attorney assistance factors demonstrating progressively increased importance in successful restoration. Copyright © 2012 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.     

Evaluation of the Performance of Experimenters as a Function of Their Sex and Competence1

A study was conducted to investigate evaluations of experimenters as a function of their sex and competency. It was hypothesized that (a) competent male and female experimenters would be evaluated as equal in competence, but that females acting incompetently would be judged as less competent than would males who were also acting incompetently and (b) competent females would be judged as less feminine relative to incompetent females; whereas incompetent females would be judged as extremely feminine. Undergraduate males and females viewed videotapes of male or female experimenters acting either competently or incompetently and then rated these experimenters on a 20-item semantic differential scale. It was found that when the female experimenters unambiguously displayed competence, they were judged as of equal competence to male experimenters acting in a similar manner; in the incompetent condition, however, female experimenters were judged as less competent than male experimenters. Competent females were perceived as less feminine than incompetent females; incompetent females were perceived as more feminine than females in any other experimenter condition. It was postulated that these findings were due to (a) subjects’expecting incompetency of women and (b) subjects’equating competence with the masculine role and incompetence with the feminine role.     

Differences in attributions of mental illness and social distance for portrayals of four mental disorders

For individuals with mental illness, others' perceptions of mental illness often limit integration into communities. Perceptions of mental illness manifest as social stigma in the form of social distance and may depend on individuals' attributions of the origins of mental illness. 180 university students completed a survey on attribution of mental illness and social distance across several disorders (psychiatric and physical). Participants indicated greater social distance for severe mental illness (i.e., schizophrenia) than less severe mental illness and physical illness. More desire for social distance may be related to unfamiliarity with severe mental illness rather than less severe mental and physical illnesses. Greater understanding of how individuals perceive mental illness can inform efforts to educate the public.     

Systematic Monitoring of the Implementation of a Case Management Model

A systematic approach for monitoring case management service provision and the results obtained when this approach was applied to a program for community-dwelling elders with severe mental illness are presented. A detailed, closed-ended, daily service log was used to collect data on 713 client-contact days. Participants (N = 24) were predominantly female (71%), were White (63%) or African American (37%), and tended to have diagnoses of either schizophrenia (42%) or major depression (21%). Services were delivered most frequently in the client's home (47%), the program office (35%), or by phone (27%); most frequent activities were monitoring psychiatric symptoms/medications (62 %), and monitoring physical symptoms or medications or both (54%). Service characteristics did not differ with regard to demographics but did vary with living situation and psychiatric diagnosis. The findings point to the need for flexible programs capable of meeting diverse service needs as well as the utility of a daily service log in studying case management.     

A Little Goes a Long Way: The Impact of Distal Social Support on Community Integration and Recovery of Individuals with Psychiatric Disabilities

Although an extensive body of literature highlights the important role of social support for individuals with psychiatric disabilities, definitions of support tend to be restricted—focusing on intimate relationships such as friend and family networks and ignoring the role of casual relationships existing naturally in the community. This mixed-methods study of 300 consumers of mental health services in the Southeastern US aims to better understand the impact of community supports, termed distal supports, on community integration and recovery from mental illness. Qualitative content analysis, tests of group mean differences, and hierarchical linear regression analyses revealed the following: (1) participants primarily reported receiving tangible support (e.g., free medication/discounted goods) from distal supports rather than emotional support (e.g., displays of warmth/affection) or informational support (e.g., provision of advice); (2) women and older participants reported more distal supports than men or younger participants; and (3) distal supports played a unique role in predicting community integration and recovery even after accounting for the influence of traditional support networks. Results highlight the importance of considering diverse types of social support in naturally occurring settings when designing treatment plans and interventions aimed at encouraging community participation and adaptive functioning for individuals with psychiatric disabilities.     

Mental Health Screening of Female Juvenile Offenders: Replication of a Subtyping Strategy

Recent research indicates that adjudicated female youth have higher rates of mental health problems and histories of trauma exposure and abuse relative to adjudicated male youth. These differences are important for gender-specific assessment, intervention, and management strategies. We replicated a subtyping strategy for adjudicated female youth based on mental health screening data from the Massachusetts Youth Screening Instrument-2 (MAYSI-2) by investigating subtype differences on trauma symptoms, abuse history, and other background variables. Cluster analysis of the standard MAYSI-2 scales revealed a three cluster solution replicating results from a prior study. Additionally, results indicated expected differences between female youth with mental health problems compared to those without mental health problems with co-occurring female youth (i.e., self-reported mental health and substance abuse problems) having have greater mental health problems and more extensive abuse histories compared to other subtypes.     

Changing self-perception: success in independent living for individuals with chronic mental illness

Rates of rehospitalization of individuals with serious and persistent mental illness were compared prior to and after they were moved into 4-bed corporate foster homes. Results showed a significant drop in the number of rehospitalizations and in the total number of days hospitalized after moving into a 4-bed home. The data suggest that living in a 4-bed home-like environment may result in significantly fewer and shorter hospitalizations for these types of mentally ill individuals.     

Psychological distance reduces the effect of internalized stigma on mental health treatment decisions

Although stigma is a major barrier to treatment for those with mental health concerns, it is poorly understood when stigma is more or less influential in mental health treatment decisions. In the current work, we examined whether psychological distance—the removal of an event from direct experience—reduced the influence of internalized stigma on willingness to seek treatment. Specifically, we tested the hypothesis that psychological distance versus proximity (e.g., seeking treatment in three months vs. in two days, respectively) decreases the negative influence of stigma on willingness to seek treatment. We focused on a population for whom mental health treatment decisions are personally-relevant: individuals who had previously sought mental health treatment. Experiment 1 showed that the extent to which these individuals internalized (i.e., personally endorsed) stigma about mental illness predicted lower intentions to make an appointment with a mental health care provider for themselves (but not another person). Experiment 2 replicated this result using a different measure of psychological distance (temporal distance) and extended this finding to behavior (time spent reading mental health resources). Overall, this research demonstrated that internalized stigma disrupts mental health treatment-seeking intentions and behaviors when they are psychologically proximal, but not when they are distant. Potential applications of these results are discussed.     

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.