Assessing Competence to Stand Trial

Educational Objectives

The goal of this program is to improve assessment of competence to stand trial. After hearing and assimilating this program, the clinician will be better able to:

1. Define the legal standard for competence to stand trial.
2. Explain the key components of an assessment for competence to stand trial.
3. Consider potential ethical issues when assessing competence to stand trial.

Summary

Competence to stand trial: different from competence to represent oneself and is moment specific, ie, patients can have waxing and waning presentations or fluctuating mental status, or intellectual disability that can be more pervasive; the required task is for the person to be competent throughout the length of the trial; a diagnosis (eg, schizophrenia, dementia) does not define incompetence; some diagnoses may lead to functional impairment; individuals are presumed competent to stand trial until proven otherwise; the designation is an opinion, not a judicial determination; the threshold for incompetence varies depending on the task, eg, threshold of competence is higher for a complex murder case than for a minor charge

History: prior to the 17th century, peine forte et dure was in place and meant that defendants were required to enter a plea of guilty or not guilty; if they did not enter a plea, rocks were placed on their chest; if they were mute by malice (ie, malingering), they would eventually enter a plea; if they were mute by “visitation from God,” they may succumb to the rocks; the Sixth Amendment gives the defendant the rights to receive effective counsel, present evidence, and confront accusers; the 14th Amendment gives the right to due process; ideally, trial processes must be fair and accurate and have integrity and dignity; the goal of determining competence to stand trial is to achieve a fair process

Dusky v United States: defined the standard; Mr. Dusky was accused of abduction and unlawful transport of a 15-yr-old girl; during the trial, psychiatric testimony stated that he had a schizophrenia reaction but was oriented; the court ruled him competent to stand trial; Mr. Dusky was convicted but later appealed the verdict, arguing that he should not have been considered competent (ie, orientation was insufficient); the US Supreme Court agreed and overturned the conviction; they made a determination that to find somebody competent to stand trial, specific standards (known as the Dusky criteria) must be met

Dusky criteria: each state has its own version; evaluate whether the defendant has sufficient present ability to consult with their lawyer with a reasonable degree of rational understanding and whether they have a rational and factual understanding of the proceedings against them; “sufficient” is a judicial determination after psychiatrists render opinions on the defendant’s capacity to stand trial; “ability” is different from willingness; if a defendant refuses to participate in the evaluation, the psychiatrist must determine the reason, ie, malingering or paranoia; the defendant must have a reasonable degree of rational understanding

Elements of the Dusky standard: functional component — refers to the functional capacity to stand trial; causal component — refers to the reason a defendant lacks the functional capacity to stand trial, eg, psychiatric diagnosis (or immaturity for juvenile defendants); this interactional aspect interplays with the task demand on the defendant

Amnesia: Wilson v United States (1968) involved a man who developed retrograde amnesia after a robbery; the issue was whether this memory loss violated his right to a fair trial because he could not remember the events to defend himself; the court ruled that amnesia is not a ”per se bar” to competence; amnesia is not incompetence if knowledge of the events can be reconstructed (eg, video evidence, witnesses) and the defendant can currently follow the proceedings; after the ruling, the court may need to assess whether anything was unfairly decided because of the defendant’s amnesia (prejudicial ruling); some people are moved from the criminal system to the civil system for treatment of mental illness; this is not possible for people with traumatic brain (TBI) injury and amnesia with no concomitant mental illness; the practical solution is to proceed with the trial and ensure that the process was fair

Evaluation: the clinician must assess the validity of amnesia and whether the defendant has any other current deficits, eg, attention issues or irritability from TBI that may impede competence to stand trial; the clinician cannot state that the defendant is not competent to stand trial solely because they are amnestic to the events surrounding the crime

Focused psychiatric evaluation: obtain the relevant history, including the symptom pattern; for juvenile defendants, consider developmental factors, decision-making processes, and the ability to think about the future; assess the functional abilities; Dusky criteria — the defendant must factually and rationally understand the charges, verdicts, and potential consequences; they must understand the trial participants and the process; they must be able to assist their counsel (eg, recreating the event, weighing evidence); decision-making ability, including, eg, whether to waive certain rights and make a plea bargain, is often challenging to assess; several instruments are available to determine competency; because this is a pre-trial report, omit any self-incriminating information, eg, a defendant’s confession to a crime

Cooper v Oklahoma: at the time, Oklahoma law presumed defendants to be competent unless proven incompetent by clear and convincing evidence; the Supreme Court emphasized the importance of not trying incompetent defendants; requiring “clear and convincing evidence” is a high standard and risks putting people on trial who are likely incompetent; it is reasonable to require defendants to prove their incompetence only by a preponderance of the evidence

Jackson v Indiana: Theon Jackson, a man with a severe intellectual disability (mute and deaf), was charged with robberies totaling $9; he was found incompetent to stand trial and committed to a state mental hospital; Jackson's attorney argued a violation of his 14th Amendment rights (denying equal protection and due process); due process was violated by this forensic commitment because he was not dangerous and therefore only qualified to be held for the time necessary to determine “restorability”; the Eighth Amendment was violated by administering cruel and unusual punishment by keeping the defendant indefinitely committed as incompetent and unrestorable; the Supreme Court ruled that the nature and length of commitment must reasonably resemble the purpose of the commitment and not exceed the time needed to assess a reasonable likelihood of restoration

Issue of restoration: psychotic and mood disorders, eg, bipolar disorder, are the most common reason defendants are deemed incompetent to stand trial; rehabilitation plays a role, but medication is crucial for reducing symptoms that cause problems with daily functioning; Sell v United States is a landmark case in which the Supreme Court ruled that medication can be used in rare situations to restore competence but only after trying alternative methods; use of community- or jail-based restoration programs has increased to accommodate the increased pressure for timely competency evaluations and treatment; the juvenile justice system has similar challenges

Competence to enter a guilty plea: when someone pleads guilty and agrees to a plea bargain, they must understand the nature of the charges and penalties; a guilty plea involves waiving important rights and must be done knowingly, intelligently, and voluntarily; Godinez v Moran — established that the Dusky standard applies to waiving the right to counsel (ie, it is not a separate competency standard); however, competence to waive counsel is different from competence to represent oneself; in Indiana v Edwards, the Supreme Court ruled that a defendant can be competent to stand trial with an attorney but still be deemed incompetent to represent themself due to mental limitations; no legal standard exists for competence to self-represent; the trial judge must decide in the moment

Waiving Miranda rights: in Colorado v Connolly, Francis Connelly claimed God instructed him to confess to a crime; the confession was initially suppressed as involuntary and not the product of free and rational choice; the question was what constitutes a voluntary (ie, admissible) confession; the Supreme Court ruled that a confession under these circumstances is not a due process (14th Amendment) violation; limited situations, generally involving police coercion, would make a confession inadmissible

Panetti v Quarterman: the Supreme Court ruled that courts must consider a defendant's ability to rationally understand the reason for their execution when evaluating their competency if competence to be executed is raised as an issue

Readings

Adjorlolo S, Chan HCO. Determination of competency to stand trial (fitness to plead): an exploratory study in Hong Kong. Psychiatr Psychol Law. 2016;24(2):205-222. Published 2016 Nov 30. doi:10.1080/13218719.2016.1247417; Bourget D, Whitehurst L. Amnesia and crime. J Am Acad Psychiatry Law. 2007;35(4):469-480; Buchanan A. Competency to stand trial and the seriousness of the charge. J Am Acad Psychiatry Law. 2006;34(4):458-465; Hoge SK. Competence to stand trial: An overview. Indian J Psychiatry. 2016;58(Suppl 2):S187-S190. doi:10.4103/0019-5545.196830; Marcus DK, Poythress NG, Edens JF, et al. Adjudicative competence: evidence that impairment in "rational understanding" is taxonic. Psychol Assess. 2010;22(3):716-722. doi:10.1037/a0020131; Murrie DC, Gardner BO, Torres AN. Competency to stand trial evaluations: A state-wide review of court-ordered reports. Behav Sci Law. 2020;38(1):32-50. doi:10.1002/bsl.2436; Viljoen JL, Roesch R, Zapf PA. An examination of the relationship between competency to stand trial, competency to waive interrogation rights, and psychopathology. Law Hum Behav. 2002;26(5):481-506. doi:10.1023/a:1020299804821.

Disclosures

For this program, members of the faculty and planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. Pinals was recorded at the 2023 Forensic Psychiatry Review Course, held October 16-18, 2023, in Chicago, IL, and presented by the American Academy of Psychiatry and the Law. For more information about upcoming CME activities from this presenter, please visit aapl.org. Audio Digest thanks the speakers and the American Academy of Psychiatry and the Law for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 1.00 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 1.00 CE contact hours.

Lecture ID:

PS531301

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.