Charge Severity and Aggression during Competence Restoration.

Most competence restoration occurs in secure inpatient settings. As states struggle with strained resources and seek to best utilize restoration services, factors such as charge severity and violence risk remain key considerations in determining the appropriate setting for an individual's competence restoration. This study offers a quantitative analysis of aggressive behavior during inpatient restoration efforts and whether criminal charge severity correlates with inpatient aggression. Results of this study indicate that a substantial minority of defendants engaged in aggressive behavior and required restraint during the initial months of their hospitalizations. Most of those engaged in few episodes of aggression and required few episodes of restraint. Rates of aggression and restraint were higher in individuals with lower severity charges compared with those with higher severity charges. Courts and evaluators may have selected for a more disordered group of defendants with lower severity charges.

Long-term competence restoration.

While the United States Supreme Court's Jackson v. Indiana decision and most state statutes mandate determinations of incompetent defendants' restoration probabilities, courts and forensic clinicians continue to lack empirical evidence to guide these determinations and do not yet have a consensus regarding whether and under what circumstances incompetent defendants are restorable. The evidence base concerning the restoration likelihood of those defendants who fail initial restoration efforts is even further diminished and has largely gone unstudied. In this study, we examined the disposition of a cohort of defendants who underwent long-term competence restoration efforts (greater than six months) and identified factors related to whether these defendants were able to attain restoration and adjudicative success. Approximately two-thirds (n = 52) of the 81 individuals undergoing extended restoration efforts were eventually deemed restored to competence. Lengths of hospitalization until successful restoration are presented with implications for the reasonable length of time that restoration efforts should persist. Older individuals were less likely to be restored and successfully adjudicated, and individuals with more severe charges and greater factual legal understanding were more likely to be restored and adjudicated. The significance of these findings for courts and forensic clinicians is discussed.

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.

Indiana v. Davis: revisiting due process rights of permanently incompetent defendants.

With its landmark Jackson v. Indiana (406 U.S. 715 (1972)) decision, the United States Supreme Court ruled that states may not indefinitely confine criminal defendants solely on the basis of incompetence to stand trial. While this decision led to widespread state statutory and procedural changes, the Jackson court left unresolved whether states could indefinitely maintain criminal charges against incompetent defendants. Nearly four decades after the Jackson decision, the Indiana Supreme Court finally revisited this question in Indiana v. Davis (898 N.E.2d. 281 (Ind. 2008)), unanimously ruling that holding criminal charges over the head of a permanently incompetent defendant, when her pretrial confinement extended beyond the maximum period of any sentence the trial court could impose, violated the basic notions of fundamental fairness embodied in the Due Process Clause of the Fourteenth Amendment. In this analysis of Indiana v. Davis, the facts of the case and the court's rationale for its decision are discussed. This unique ruling is considered in light of the questions resolved and still unanswered since Jackson v. Indiana.

Effects of advanced age and dementia on restoration of competence to stand trial.

Elderly defendants (age 65+) and defendants with dementia adjudicated incompetent to stand trial and hospitalized for restoration to competence (RTC) often present unique challenges to clinicians charged with their restoration. In this study, we attempted to better identify predictors of successful RTC by building upon previous research correlating increased age with decreased likelihood of RTC. We identified elderly non-demented defendants (n=31) and defendants diagnosed with dementia (n=47) from a state database of 1380 individuals hospitalized for competence restoration from 1988-2004. Using regression analysis and correcting for demographic variables and common admission psychiatric diagnoses, we studied the relationship of age at hospital admission and dementia diagnosis on the likelihood of successful RTC. Both advanced age and dementia diagnosis were associated with decreased RTC. After correcting for dementia diagnosis, increased age retained its negative correlation with restoration success. Both elderly non-demented defendants and defendants diagnosed with dementia were significantly less likely to be restored to competence than all other RTC admissions (n=1302). However, a substantial percentage of both demented and elderly non-demented defendants were successfully restored to competence, potentially justifying restoration attempts for both of these groups of defendants.

Jackson's Indiana: state hospital competence restoration in Indiana.

Restoration to competence (RTC) of mentally disordered defendants has become increasingly important for state hospitals. In Indiana, most RTC admissions are sent to one primarily forensic state hospital, but many are admitted to other state hospitals. A state database of defendants admitted for RTC between 1988 and 2005 was analyzed for trends in annual admissions, length of stay (LOS), and success of restoration by hospital and by diagnostic category. Regression models were developed to identify factors associated with RTC success. Analysis of 1,475 RTC admissions showed increased annual admissions over the study period. While the forensic hospital restored a higher percentage of individuals than the other state hospitals, the percentage of RTC success decreased over time in all hospitals. Admission to the forensic hospital, female gender, and mood disorder diagnosis were associated with increased restoration success. Older age and psychotic disorder or mental retardation diagnoses were associated with decreased likelihood of restoration. Race was not significantly associated with RTC at six months, but white defendants were less likely to be restored within one year.

Pro se competence in the aftermath of Indiana v. Edwards.

The right to represent oneself at trial is well-established, but not absolute. Recently, in Indiana v. Edwards, the United States Supreme Court considered whether states may demand a higher standard of competence for criminal defendants seeking to represent themselves at trial than that necessary for standing trial with attorney representation. Ultimately, the Court ruled that the Constitution allows states to employ a higher competency standard for pro se defendants. In this analysis of the Court's decision, the authors describe the facts of this case, the legal precedents framing the issues facing the Court, and the Court's rationale for its opinion. The ruling is considered in light of available research involving pro se defendants and whether this ruling is consistent with professional guidelines related to forensic psychiatric practice. Implications of the decision for forensic clinicians and limitations of the decision are discussed.