The competence-related abilities of women criminal defendants.

A new research instrument, the MacArthur Structured Assessment of Competencies of Criminal Defendants (MacSAC-CD), was administered to three groups of women defendants: those adjudicated incompetent and committed to forensic hospitals for treatment (n = 38), jail inmates receiving mental health treatment (n = 18) who had not been adjudicated incompetent, and randomly selected jail inmates (n = 50). Measures of the competence-related abilities of understanding and reasoning were found to have satisfactory indices of internal consistency (coefficient alpha), and all measures correlated in the expected direction with measures of global psychopathology, psychoticism, and verbal cognitive functioning. Between-group mean scores were all in the expected direction and were statistically significant for four of seven measures. No differences in MacSAC-CD performance were found in comparisons of male and female defendants who had been adjudicated incompetent, nor were differences found in the performance of male and female jail inmates.

The MacArthur Adjudicative Competence Study: diagnosis, psychopathology, and competence-related abilities.

A set of measures assessing abilities related to legal standards for competence in the adjudicative process were administered to mentally-disordered criminal defendants with diagnoses of schizophrenia, affective disorder, other psychiatric disorders, and to criminal defendants without diagnosed mental disorder. Mentally-disordered defendants were recruited from two groups: those who had been committed for restoration of competence and those who had been identified by jail personnel as mentally ill. Significant impairments in competence-related abilities were found for approximately half of the defendants with schizophrenia. Defendants with schizophrenia scored lower on measures of understanding, reasoning, and appreciation related to the adjudication process. The association between symptoms and competence-related abilities was explored within diagnostic groups. Conceptual disorganization was found to be inversely correlated with performance on all measures in both defendants with schizophrenia and those with affective disorders. For other psychotic symptoms, differing patterns of correlations were found in the two major diagnostic groups. The implications for policy designed to safeguard the rights of defendants to be tried while competent are discussed.

Prospective study of patients' refusal of antipsychotic medication under a physician discretion review procedure.

OBJECTIVE: The authors examined the refusal of antipsychotic medications and associated outcomes prospectively in a group of 348 psychiatric patients admitted to three acute inpatient units in a state-operated mental health facility in Virginia where psychiatrists have the discretionary power to administer treatment over patients' objections. METHODS: Newly admitted patients were administered both a questionnaire to ascertain their attitudes toward admission and the Brief Psychiatric Rating Scale (BPRS). Patients who refused antipsychotic medication were identified, and data were collected on the length of refusal and whether the refusal episode was terminated voluntarily or involuntarily. A group of patients compliant with antipsychotic medication was selected for comparison on outcome measures, including the rate of seclusion and restraint and length of hospitalization. RESULTS: Patients who refused treatment were found to have significantly higher BPRS scores than were patients who complied with antipsychotic treatment and more negative attitudes toward hospitalization and past, present, and future treatment. Refusal episodes were brief, on average 2.8 days, and all patients, who refused treatment were treated. When compared with the compliant patients, patients who refused treatment were more likely to be assaultive, were more likely to require seclusion and restraint, and had longer hospitalizations. CONCLUSIONS: Psychiatrists exercised their discretion to promptly treat all patients who refused treatment. Nonetheless, these patients suffered more morbidity than compliant patients. This study suggests that the negative sequelae of in-hospital treatment refusal cannot be eliminated by rapid treatment. The policy implications are discussed.

The MacArthur adjudicative competence study: development and validation of a research instrument.

Assessment of competence to stand trial is a common evaluation that can have substantial consequences for defendants and the criminal justice system. Despite a voluminous literature, much remains unknown. An obstacle to progress in understanding what is better termed "adjudicative competence" is the absence of structured, standardized research measures for assessment of defendants. This article presents the legal framework, assessment strategy, instrument description, psychometric properties, and construct validation of the MacArthur Structured Assessment of the Competencies of Criminal Defendants (MacSAC-CD). The measures meet or exceed accepted indices of internal consistency, and interscorer agreement. Observed patterns of correlations among measures support the underlying theoretical structure of competence-related abilities. Moreover, the MacSAC-CD distinguishes groups of competent and incompetent defendants; reflects changes in competence status; and correlates positively with clinical judgments, negatively with psychopathology and impaired cognitive functioning, and negligibly with cynicism toward the justice system.

The MacArthur Adjudicative Competence Study: a comparison of criteria for assessing the competence of criminal defendants.

A set of measures assessing competence-related abilities was administered to three groups of criminal defendants: a group committed for restoration of competence, a group identified by jail personnel as mentally ill but not incompetent, and a group without identified mental disorder. Data from this study were used to test key assumptions bearing on the legal criteria for adjudicative competence. The data show that among defendants able to understand the nature and purpose of the criminal proceedings, a significant proportion have an impaired ability to appreciate their situations as criminal defendants or to communicate relevant information to counsel; among defendants able to understand the proceedings and to assist counsel, a significant proportion have impaired decision-making abilities; and among defendants able to understand the nature and consequences of decisions to plead guilty or waive a jury, a significant proportion have impaired abilities to appreciate the significance of these decisions or to rationally manipulate information pertinent to making them. These findings highlight the importance of disaggregating the components of adjudicative competence.

Mentally ill and non-mentally ill defendants' abilities to understand information relevant to adjudication: a preliminary study.

The legal construct of competence to stand trial, or "adjudicative competence," is based on the premise that some mentally disordered defendants have impaired abilities when compared with most defendants and that adjudication should be barred if these competence-related abilities are significantly impaired. Where the line is drawn between sufficient and insufficient abilities has important consequences: as a result of being adjudicated incompetent, defendants may be detained and treated involuntarily and their trials will be delayed. However, no studies have systematically compared the capacities of relevant groups of defendants. In this study, 84 criminal defendants--42 of whom were hospitalized as incompetent and 42 of whom were regarded as unquestionably competent--were administered three instruments measuring capacity to understand legally relevant information. Incompetent defendants performed more poorly on all measures of understanding. Twenty-eight incompetent defendants were administered the measures a second time, after restoration to competence. Restored defendants improved their performance on all measures of understanding and their performance was similar to that of normal, competent defendants.

Long-term, assenting psychiatric patients: decisional capacity and the quality of care.

The objectives of this study were (1) to investigate whether the relationship between functional decisional capacity and the resulting quality of treatment posited by the informed consent theory is found in clinical practice; and (2) to describe the range of decisional impairments found in long-term psychiatric inpatients who comply with prescribed treatment. Eighty-eight long-term, compliant, psychiatric inpatients, in two public hospitals, who were prescribed antipsychotic medications were assessed. Following a formal assessment of decisional capacity, subjects were categorized according to level of impairment, using a hierarchical scheme. All subjects were evaluated for the presence of abnormal involuntary movements. The appropriateness of treatment with antipsychotic medications was determined using accepted clinical guidelines. Patients with more serious impairments of decisional capacity were more likely to receive inappropriate treatment with antipsychotic medication; and serious impairments of decisional capacity were common. The study lends empirical support to one of the bases of the doctrine of informed consent: the notion that capable patient involvement in decisionmaking plays an important role in checking the judgments of treating physicians. Remedial measures are needed to protect long-term psychiatric inpatients with impaired decisional capacity from receiving inappropriate treatment.