Chapter 1-6: Competence to Stand Trial (Introduction through Legal Context)

Competence to stand trial (CST) – overview

• A legal judgment about a defendant’s present ability to:
• understand the legal proceedings
• participate in their own defense (instruct, consult, and work with their attorney)
• This is a judge’s decision; clinicians inform via CST evaluations but do not decide.
• Focus is on present mental state, not past events or future predictions. It can be raised at any time during the trial.

Legal foundation and core concepts

• Sixth Amendment to the U.S. Constitution underpins CST: right to speedy and public trial, impartial jury, informed of charges, confrontation of witnesses, compulsory process, and most importantly, assistance of counsel for the defense.
• CST is tied to the defendant being present (in absentia trials are not permissible). CST concerns present mental capacity to participate, not insanity at the time of the offense.
• Dusky v. United States (1960) – the foundational standard used today (with minor variations across jurisdictions):

\text{Dusky standard: sufficient present ability to consult with one's attorney with a reasonable degree of rational understanding as well as factual understanding of the proceedings against them.}

• Distinction: CST (present abilities) vs insanity (retrospective view of mental state at the time of the crime).

Why CST matters

• A fair, dignified, accurate, and integrity-filled legal system depends on CST for defendants to exercise full rights and understand punishment.
• Mental illness does not automatically equal CST incompetence; there is a correlation, but one can be mentally ill and competent, or not mentally ill and incompetent.
• CST is about what a person can do now, not about a diagnosis per se.

Historical development and key cases

• Dusky v. United States (1960) establishes the modern CST standard.
• Godinez v. Moran (1993) – Supreme Court held that the standard for all criminal competencies (including pro se representation) is the same as CST; context does not justify a higher standard.
• Indiana v. Edwards (2008) – Supreme Court reversed Godinez for pro se competence: pro se right is qualified by the defendant’s ability to maintain courtroom decorum and effectively defend oneself; context matters for self-representation.
• Jackson v. Indiana (1972) – cannot hold a defendant indefinitely if permanently incompetent to stand trial; reasonable time limits apply, with states defining what is reasonable. If not restored, may transition out of the criminal process (e.g., civil commitment if dangerous).

Real-world example: Elizabeth Smart case (high-profile CST issues)

• Elizabeth Smart abducted in 2002; Mitchell and Barzee charged with kidnapping, aggravated sexual assault, burglary, conspiracy.
• Both were found incompetent to stand trial for years; Barzee later restored to competency with medication and pled guilty (2006). Mitchell was found malingering (2010) but also had a mental illness; later restored to competency and pled guilty.
• Video excerpt highlights: claims that Mitchell faked mental illness; illustrates complexities around malingering and restoration of competence.
• This case demonstrates how CST can be repeatedly raised and how restoration through treatment can lead to trial progress.

Frequency and real-world practice

• Neal & Grisso (2014) survey of 400 forensic psychologists with ~900 referrals shows CST is the most common CST-related referral (~18% of cases).
• Other referral types include violent risk assessments, juvenile-to-adult transfers, etc.
• Typical CST outcomes: about 70\%-80\% of referred individuals are found competent.
• Clinician opinion on CST is highly influential: judges rank clinicians’ CST opinions among the top three information sources; agreement between expert opinion and court decision exceeds 90\%\, (i.e., >90% agreement).
• These findings highlight the substantial role of clinicians in CST outcomes, and potential concerns about the legal boundary between clinical opinion and legal decision-making.

Malingering and its role in CST evaluations

• Malingering = production of false or exaggerated symptoms; individuals may be mentally ill and still malingering, or vice versa.
• For CST evaluations, identifying malingering is crucial because it can affect the evaluation outcome.
• There are strong, validated tools to detect malingering, though none are foolproof; they significantly improve detection when used properly.

The CST evaluation process

• No single standard approach; considerable flexibility exists across cases and jurisdictions.
• Descriptive data (Neal & Grisso, 2014) show:
• In >99% of cases, the evaluator interviewed the examinee (interview is essential; some cases refuse).
• Many experts rely on reviewing records (police reports, mental health records, etc.).
• Use of psychological testing is debated; most experts review records, but not all use tests.
• CST-focused evaluations: roughly 60% used a structured tool; average number of tools used ~3; average evaluation duration ~25\ \text{days}; typical report length ~13\ \text{pages}.
• Three broad instrument categories for forensic testing in CST contexts:
• Clinical assessment instruments (CAIs) – not specific to CST; e.g., ABAS (adaptive functioning) used when intellectual disability is suspected; require interpretive step to apply to legal questions.
• Forensically relevant instruments – have clinical and forensic validity; applicable to multiple forensic questions.
• Forensic assessment instruments – specific to the referral question (e.g., MacCAT-CA for CST).
• Two main CST-specific tools:
• MacCAT-CA (MacArthur Competence Assessment Tool for Clinicians – for CST):
  • 22-item test; vignette-based; presents a hypothetical scenario and asks 16 questions about reasoning and decision-making in a legal context.
  • Last 6 questions pertain to the examinee’s own case; can reveal discrepancies between general reasoning and case-specific reasoning.
  • Assesses general legal system understanding and reasoning about legal situations.
• ECST-R (Evaluation of Competence to Stand Trial – Revised):
  • Semi-structured interview developed from Dusky criteria; focuses on factual understanding, rational understanding, and ability to consult with counsel.
  • No hypothetical scenario; focuses on the defendant’s own case.
  • Includes a built-in malingering scale.
• Other commonly used instruments in CST contexts include WAIS/WISC (intelligence tests), TOMM and M-Fast (malingering scales), MMPI (personality/psychopathology), etc.

Instrument categories in CST practice (summary)

• Clinical assessment instruments (CAIs): general clinical tools used in evaluating health or cognitive functioning; require translation to legal relevance.
• Forensically relevant instruments: bridge clinical findings to forensic questions; have both clinical and legal relevance.
• Forensic assessment instruments: specifically designed to answer the referral question (e.g., CST).

CST outcomes and post-evaluation pathways

• If deemed incompetent: CST restoration process starts, often involving medication, psychoeducation, and/or therapy.
• Restoration data:
• >75% of individuals deemed CST are restored to competency.
• Most restorations occur within roughly 6\ \text{months}.
• Hospitalizations for restoration tend to be relatively short; antipsychotic medications commonly help.
• After restoration, trials resume; defendants may plead guilty or proceed to trial.
• If restoration fails or is unlikely (e.g., severe intellectual disability with persistent incapacity): legal questions arise about continued detention, transfer to civil commitment, or other dispositions. Jackson v. Indiana established that indefinite detention without a trial is unconstitutional; states define what constitutes a reasonable period to restore CST.

If CST cannot be restored: legal and ethical questions arise

• Jackson v. Indiana (1972) established constitutional limits on indefinite confinement for CST-incompetent individuals.
• Depending on risk and other factors, individuals may be civilly committed if dangerous, or released from the criminal process but kept under civil or other supervision.

Reasons for CST incompetence – two main pathways

• Symptom-driven incompetence due to mental illness (e.g., psychosis) that interferes with trial participation; treat with medications and therapy.
• Foundational deficits in understanding of the trial process (rational understanding, ability to learn, etc.); addressed with psychoeducation and structured teaching about courtroom procedures, roles, and implications of legal choices.
• Some individuals may have both conditions, complicating treatment and restoration.

Educational and remedial approaches for foundational deficits

• Example from practice: group therapy “101 on how to be an effective defendant” by Dr. Tess Neal and colleagues – an in-hospital program using vignettes, courtroom drawings, and explanations of evidence, plea bargains, and courtroom layout to improve understanding and participation.
• Goal is to enhance the defendant’s ability to participate constructively in proceedings and to understand the consequences of legal choices.

Other competencies in the legal system (context and debates)

• Beyond CST, other competencies include waiving Miranda rights, representing oneself (pro se), etc.
• Core debate: should there be a single uniform standard for all criminal competencies or separate standards tailored to contexts (e.g., CST vs. waiving rights vs. self-representation)?
• Supreme Court stance: context is largely irrelevant for standard CST vs. other competencies in Godinez v. Moran (1993) – one standard across competencies (Dusky standard).
• However, subsequent case law has nuanced this: Indiana v. Edwards (2008) allows for higher standards for pro se competence than CST when necessary to preserve courtroom decorum and effective practice.
• Colin Ferguson case is discussed to illustrate the potential mismatch between CST and ability to represent oneself; this led to the Indiana v. Edwards decision.
• Direct quote from Indiana v. Edwards (2008):

"A right of self-representation at trial will not affirm the dignity of a defendant who lacks the mental capacity to conduct his defense without the assistance of counsel."

Takeaways for coursework and future study

• CST is a present-focused, legally defined construct bridging clinical assessment and judicial decision-making.
• It requires careful consideration of both clinical findings and legal standards, with attention to potential malingering and the accuracy of assessments.
• The CST process includes multiple data sources (interview, records, testing, functional observations) and varies by jurisdiction.
• Preparation for exams should cover: Dusky standard, major CST tools (MacCAT-CA, ECST-R), key cases (Dusky, Godinez, Indiana v. Edwards, Jackson v. Indiana), typical restoration outcomes, and the ongoing debates about contextual versus uniform competencies.

Summary notes on key numerical references and formulas

• CST referrals as a share of all forensic referrals: around 18\%.
• Proportion found competent: 70\%-80\%.
• Agreement between expert CST opinions and court decisions: >90\%\,.
• Use of structured tools in CST evaluations: approximately 60\%.
• Average number of tools used per CST evaluation: about 3.
• Average duration of a CST evaluation: about 25\ days.
• Average CST report length: about 13\ pages.
• Restoration rate after incompetence finding: >75\%.
• Typical restoration timeframe: most within 6\ months.
• Structure of typical CST tool usage:
• MacCAT-CA: 22 items; 16 questions on vignette; 6 questions about the defendant’s own case.
• ECST-R: semi-structured interview; derives from Dusky criteria; includes a malingering scale.

References to notable cases and sources in CST literature

• Dusky v. United States (1960) – foundational CST standard.
• Godinez v. Moran (1993) – uniform standard across competencies.
• Indiana v. Edwards (2008) – allows higher standard for pro se competency; contextual considerations.
• Jackson v. Indiana (1972) – limit on the duration of confinement for CST-incompetent defendants; possible civil commitment if dangerous.
• Elizabeth Smart case – high-profile CST discussions; illustrates multiple competency determinations over time.
• Tucson, AZ – Jared Loughner case demonstrates restoration and CST processes in high-profile cases.
• Neal & Grisso (2014) – descriptive chapter on CST evaluations and practice patterns; key statistics cited above.
• MacCAT-CA and ECST-R – CST-specific assessment tools; Madhukar and Dusky-derived frameworks.

Reminder about next steps and class activities

• Next week: assignment to teach classmates about one of several criminal or civil competencies (11 total topics); ~10-minute presentation per student; peer-teaching to cover diverse competencies.
• The instructor will provide readings and assign topics; expect to engage with both theory and case-based applications.

Quick references within this module

• CST is a shared domain across psychology and law; clinicians support judicial decisions, but do not replace them.
• The relationship between mental illness and CST is probabilistic, not deterministic; evaluations must assess current functional abilities and understanding of the proceedings.
• The legal framework recognizes that certain competencies may be context-dependent, especially for self-representation and other specialized duties in court.