The MacCAT-CA and the ECST-R in Competency to Stand Trial Evaluations: A Critical Review and Practical Implications.

There is debate regarding the utility of standardized instruments in the assessment of competence to stand trial (CST). Though the field generally has a positive view of the second-generation nomothetic instruments available, the frequency of use falls far behind this favorable impression. The current paper reviewed two standardized instruments used in CST evaluations, the Evaluation of Competency to Stand Trial - Revised (ECST-R) and the MacArthur Competence Assessment Tool-Criminal Adjudication (MacCAT-CA). We first review the psychometric properties of both instruments, including a review of limitations. Next, we discuss the legal standing of both instruments, including a review of past admissibility challenges and a discussion of potential issues in cross-examination. Finally, we end with practical guidance for clinicians; namely, that these instruments are generally valid indicators of competence to stand trial and are likely to be particularly useful in cases where competence is ambiguous and the clinician would benefit from additional standardized data to make a clear clinical decision.

Competence to stand trial and criminalization: an overview of the research.

Beginning in the 1960s, a steady decline in the number of inpatient psychiatric beds has occurred across the United States, primarily as a result of stricter civil commitment criteria and a societal movement toward deinstitutionalization. Concomitant with this decrease in psychiatric beds has been a steady increase in the number of mentally ill individuals who are arrested and processed through the criminal justice system as defendants. One consequence of this has been an explosion in the number of defendants referred for evaluations of their present mental state-adjudicative competence-and subsequently found incompetent and ordered to complete a period of competency restoration. This has resulted in forensic mental health systems that are overwhelmed by the demand for services and that are unable to meet the needs of these defendants in a timely manner. In many states, lawsuits have been brought by defendants who have had their liberties restricted as a result of lengthy confinements in jail awaiting forensic services. The stress on state-wide forensic systems has become so widespread that this has reached the level of a near-national crisis. Many states and national organizations are currently attempting to study these issues and develop creative strategies for relieving this overburdening of forensic mental health systems nationwide. The purpose of this article is to review the current state of the research on competence to stand trial and to highlight those issues that might be relevant to the issue of criminalization of individuals with mental illness in the United States.

Using the Internet for collateral information in forensic mental health evaluations.

There is a burgeoning literature regarding using Internet-based data in employment, university admissions, and healthcare settings, but such pertaining to forensic mental health assessment (FMHA) contexts is only beginning to develop and professional ethics codes have yet to address these issues in depth. We present the first empirical investigation of mental health and related professionals' (n = 139) attitudes and practices regarding using Internet data in forensic and therapeutic contexts. Respondents reported their experiences and levels of agreement with items measuring beliefs and attitudes toward using Internet-based data in various professional situations (e.g., 23% have searched the Internet for information about a therapy client, 39% for a forensic examinee, and only 26% opposed the practice for forensic evaluators). They also reported high levels of collective agreement, including feeling that there is a lack of guidance available from professional resources regarding Internet-related issues. Implications for forensic practice and research are presented.

Fetal Alcohol Spectrum Disorders (FASD) and competency to stand trial (CST): Suggestions for a 'best practices' approach to forensic evaluation.

Fetal Alcohol Spectrum Disorders (FASD), an umbrella term for neurodevelopmental conditions caused by prenatal alcohol exposure, is overrepresented in the U.S. juvenile and adult criminal justice systems. The brain damage in FASD manifests in a combination of cognitive and adaptive impairments that potentially reduce ability to function adequately during the criminal justice process, including capacity to stand trial (CST). Despite the high risk of arrest and conviction in this population, relatively little research guides CST assessment for defendants who have or may have FASD. Therefore, the purpose of this article is to describe how FASD may affect CST and suggest ways forensic professionals might modify assessment protocols to address possible effects of FASD-associated impairments on adjudicative capacity.

Psychiatric patients' comprehension of Miranda rights.

Seventy-five psychiatric inpatients were evaluated with respect to their Miranda-related abilities using Grisso's (1998, Instruments for assessing understanding and appreciation of Miranda rights. Sarasota, FL: Professional Resource Press) instruments and Goldstein's (2002, Revised instruments for assessing understanding and appreciation of Miranda rights) revision to determine: whether different versions of Miranda warnings translate into differences in understanding; the influence of psychiatric symptoms, diagnostic categories, and IQ upon Miranda comprehension; and the relative performance of persons with psychiatric impairment on Miranda-relevant abilities. Results indicated that although the Miranda language used in Goldstein's revision generally showed lower grade reading levels and higher reading ease scores than Grisso's original instruments, this did not translate into improved understanding. In addition, psychiatric symptoms were negatively correlated with Miranda comprehension, even after controlling for IQ. Finally, results revealed that psychiatric patients' understanding and appreciation was substantially impaired compared to Grisso's adult validation samples, and was roughly comparable to Grisso's juvenile validation sample. Implications of these results for policy reform are discussed.

Competence-related abilities and psychiatric symptoms: an analysis of the underlying structure and correlates of the MacCAT-CA and the BPRS.

The current study used confirmatory factor analysis to examine the factor structures of two instruments commonly used in the assessment of competency to stand trial--the MacArthur Competence Assessment Tool--Criminal Adjudication (MacCAT-CA) and the Brief Psychiatric Rating Scale (BPRS). Results revealed support for the three-subscale factor structure of the MacCAT-CA defined by the authors of the instrument; for a slightly altered three-factor structure defined by Zapf, Skeem, and Golding (2005, Psychological Assessment, 17, 433-445); and for the four symptom clusters of the BPRS as defined by Hedlund and Vieweg (1980, Journal of Operational Psychiatry, 11, 48-63). In addition, exploratory factor analysis of all 24 items of the BPRS revealed a five-factor structure. Correlations between psychiatric symptoms, symptom clusters, and competence-related abilities were also examined using the previously identified and the newly identified factor structures of the MacCAT-CA and the BPRS. Significant relations between symptoms and psycholegal abilities are discussed.

Validation of an abbreviated version of the structured interview of reported symptoms in outpatient psychiatric and community settings.

This study examined the effectiveness of an abbreviated version of the Structured Interview of Reported Symptoms (SIRS-A) in identifying malingered mental illness. The SIRS-A is comprised of 69 items drawn from the SIRS (R. Rogers et al. 1992, SIRS: Structured Interview of Reported Symptoms: Professional Manual. Odessa, FL: Psychological Assessment Resources, Inc.), substantially reducing the administration time. A simulation design was used with three samples; 87 psychiatric outpatients who responded honestly were compared to 29 community-dwelling adults and 24 psychiatric patients instructed to malinger psychopathology. The SIRS-A generated sensitivity comparable to or exceeding that of the SIRS normative data, but specificity was poorer; many genuinely impaired patients were misclassified as malingering. Although these findings suggest the SIRS-A may be an effective means to assess malingering in psychiatric populations, further research assessing the reasons for the elevated false positive rates is necessary.

Adjudicative competence and comprehension of Miranda rights in adolescent defendants: a comparison of legal standards.

Currently, there is considerable variability and ambiguity in legal standards pertaining to juveniles' comprehension of Miranda rights and their adjudicative competence. This study investigated rates of impairment under various proposed legal standards. One hundred and fifty-two young defendants aged 11-17 were assessed with Grisso's Miranda Instruments and the Fitness Interview Test-Revised. While over half of defendants aged 15 and under were classified as impaired in adjudicative capacities when adult norms were applied, significantly fewer adolescents were classified as impaired when adolescent norms were applied or a standard of "basic understanding and communication." Also, while over half of defendants aged 15 and under were classified as impaired in their comprehension of Miranda rights when both understanding and appreciation of Miranda rights were required, significantly fewer youth were classified as being impaired when only understanding was required. The implications of these findings are discussed.

An investigation of the construct of competence: a comparison of the FIT, the MacCAT-CA, and the MacCAT-T.

The 1990s witnessed Supreme Court decisions in both Canada and the United States on issues of competence that went against longstanding case law, psychological research, and common sense. These decisions held that there is to be one standard for all types of criminal competencies. The present research attempts to investigate whether this is an appropriate assumption and thus tests whether there are one or more constructs that underlie different types of competence. Two divergent types of competence were examined, competence to stand trial (both Canadian and American conceptualizations) and competence to consent to treatment, to determine if these different types of competence share a common underlying construct. Confirmatory factor analysis was used to test this question and results indicate that there is a common construct that underlies different types of competence.

Factor structure and validity of the MacArthur Competence Assessment Tool-Criminal Adjudication.

Examination of the available literature regarding the development of the MacArthur Competence Assessment Tool-Criminal Adjudication (MacCAT-CA) reveals 2 theoretical factor structures on which the MacCAT-CA was based: one in which 3 lower-order constructs are proposed (understanding, reasoning, appreciation) and one in which 2 higher-order constructs are proposed (competence to assist counsel and decisional competence). Confirmatory factor analyses were conducted with the MacCAT-CA's original normative sample (N = 729) to test both the relative fit of these 2 theoretical factor structures and models that combine the 2 factor structures. Analyses were also completed to examine the convergent and discriminant validity of the MacCAT-CA. Results are discussed in terms of the strengths and weaknesses of the nomothetic nature of the MacCAT-CA.

Predictor variables in competency to stand trial decisions.

Clinicians possess significant discretion in competency to stand trial assessment. Therefore, it is paramount to explore the contribution of individual variables to ensure that the decision-making process is devoid of bias and solely relates to the legal criterion. To test for the possibility of bias in clinical decision-making, we examined the predictive efficiency of clinical, criminological, and sociodemographic variables in a sample of 468 criminal defendants referred for competency evaluations. Only clinical diagnostic variables and employment status were significant predictors. This finding supports the idea that examiner decisions of competency appear to be unbiased and relate primarily to a defendant's functional ability.

Issues and considerations regarding the use of assessment instruments in the evaluation of competency to stand trial.

Since the early 1960s, a number of instruments, reflecting a broad range of assessment methods, have been developed to assist in the evaluation of competency to stand trial. These instruments have taken various forms including checklists, self-report questionnaires, sentence-completion tasks, and interview-based instruments with and without criterion-based scoring. This article reviews these assessment instruments with a specific focus on their contribution to the competency evaluation process. Furthermore, relevant issues and considerations regarding the use of these instruments are outlined, including a comparison of screening versus assessment applications of these instruments, balancing standardized approaches with individualized assessments, the integration of instrumentally derived data with other components of a competency evaluation, and the communication of results to the fact finder. Each of these issues is discussed in relation to specific competency assessment instruments. Overall, we argue that each of the competency assessment instruments developed to date can make a contribution to the competency evaluation process and this article serves to delineate those areas in which these contributions are made.

Competency restoration: an examination of the differences between defendants predicted restorable and not restorable to competency.

According to the U.S. Supreme Court's decision in Jackson v. Indiana (1972), examiners must determine if a defendant has "substantial" probability of regaining competency through treatment "in the foreseeable future." Previous research has indicated that, given the low base rate of defendants unable to be restored to competency, examiners are relatively poor at predicting which defendants will regain competency. Determining the characteristics of not restorable incompetent defendants and restorable incompetent defendants is a necessary first step toward improving examiners' ability to predict a defendant's likelihood of regaining competency. This study examined the competency evaluation reports of 468 defendants evaluated for competency to stand trial. Incompetent defendants significantly differed from competent defendants with regard to age, employment status, ethnicity, criminal charges, and psychiatric diagnosis. Few significant differences existed between defendants predicted restorable and those predicted not restorable by mental health examiners--the differences that did exist were related mainly to nonpsychiatric variables.

Assessment of competency for execution: professional guidelines and an evaluation checklist.

The issue of whether mental health professionals should be involved in conducting evaluations of competency for execution is a topic that has elicited controversy and heated debate. This article picks up at a point beyond the controversy and addresses issues of professionalism and the objective assessment of competency for execution. Specifically, this article identifies professional standards for conducting competence for execution (CFE) evaluations, describes current practices in this area, and provides an interview checklist that can be used as an evaluation guide by involved professionals.

An examination of the relationship between competency to stand trial, competency to waive interrogation rights, and psychopathology.

This study compared the legal abilities of defendants (N = 212) with current primary psychotic disorders (n = 44), affective disorders (n = 42), substance abuse disorders (n = 54), and no diagnosed major mental illness (n = 72). Defendants with primary psychotic disorders demonstrated more impairment than did other defendants in their understanding of interrogation rights, the nature and object of the proceedings, the possible consequences of proceedings, and their ability to communicate with counsel. Psychosis was of limited value as a predictor however, and high rates of legal impairment were found even in defendants with no diagnosed major mental illness. Sources of within-group variance were examined to further explain this finding. Policy and clinical implications of these results are discussed.

Interrater reliability of the Fitness Interview Test across 4 professional groups.

OBJECTIVE: This study investigated the interrater reliability of the Fitness Interview Test (FIT), revised edition, a semistructured interview that assesses fitness to stand trial. METHOD: Physicians, forensic psychologists, nurses, and graduate students in psychology were trained in the FIT, and they subsequently viewed 2 videotaped interviews of actual fitness assessments. Using the FIT, they rated the fitness of each defendant portrayed in the videotapes. RESULTS: For overall judgment of fitness, the average intraclass correlation based on the full samples of raters was found to be 0.98, and for most items on the FIT, intraclass correlations fell within the 0.80 s and 0.90 s. Reliability estimates were high across professional groups. CONCLUSIONS: Overall, this study provides further support for the psychometric properties of the FIT, as well as for the ability of various professionals to conduct reliable fitness assessments using the FIT.