Persistent, poor quality competency to stand trial reports: Does training matter?

Consistent with nationwide trends, the number of defendants judicially ordered to the California Department of State Hospitals (DSH) for competency restoration has nearly doubled in recent years. Previous research has shown that the majority of the time, judicial rulings on competency reflect forensic evaluators' opinions. Thus, the quality of competency to stand trial (CST) reports is critical. We examined 388 CST reports from defendants who were ultimately found incompetent to stand trial and admitted to a state hospital for restoration in 2012-2013. We evaluated the reports for adherence to both professional guidelines and current literature on the appropriate conduct of CST evaluations. Consistent with previous studies, our results showed that the reports evidenced overall poor quality and evaluators were largely unable to accurately describe the nature of the mental illness or explain how clinical factors (i.e., diagnoses or symptoms) impacted CST abilities. Notably, we found that experts board certified in psychiatry or psychology produced reports of higher quality. These findings demonstrate the continued poor quality of CST reports and highlight the importance of training. As in previous similar studies, we recommend mandatory training for experts conducting CST evaluations. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Gender and Malingering in Defendants Deemed Incompetent to Stand Trial.

The relationships between gender and malingering have received little attention in the literature. Our study examined data from 1,748 patients committed as incompetent to stand trial between 2008 and 2017, of whom 397 were women. Scores on a structured assessment of feigned psychiatric symptoms were only slightly higher for men than for women. Yet evaluators believed that over 23 percent of men but less than 15 percent of women were malingering. Our data suggest that these gender differences in rates of malingering may be attributable to symptom constellations and extent of criminal arrest history.

Role of Mandated Community Treatment for Justice-Involved Individuals With Serious Mental Illness.

OBJECTIVE: Research has suggested that increased length of mandated community treatment for individuals with a serious mental disorder leads to better outcomes, but few studies have described whether these outcomes are maintained after treatment ends. The goal of this study was to evaluate the impact of court-mandated treatment on outcomes for individuals found not guilty by reason of insanity (NGRI) and released to the community. METHODS: Ninety-three patients who were found to be NGRI participated in this study. Rearrest rates were compared for three groups: patients released to the community with court-mandated treatment (conditional release), patients who were conditionally released but later "restored to sanity" with no further court supervision, and patients released from the hospital to the community by the court with no court-imposed conditions. Patients were followed for an average of 4.83 years after discharge. RESULTS: Nearly half (43.8%) of the patients released to the community without court-mandated supervision were arrested for another offense in the study period, compared with 8.2% of patients released under the supervision of the conditional release program. In contrast, those who were restored to sanity and ultimately released unconditionally had higher arrest rates (25%). CONCLUSIONS: This study suggests that court oversight on an ongoing basis may be necessary to help justice-involved individuals with a serious mental disorder avoid the criminal justice system and remain engaged in community treatment. More research is needed to determine whether these findings can be extrapolated to civil commitment procedures.

A survey of national trends in psychiatric patients found incompetent to stand trial: reasons for the reinstitutionalization of people with serious mental illness in the United States.

OBJECTIVE: Recent information indicates that the number of forensic patients in state hospitals has been increasing, largely driven by an increase in patients referred to state hospitals as incompetent to stand trial (IST). This survey was intended to broaden the understanding of IST population trends on a national level. METHODS: The authors developed a 30-question survey to gather specific information on IST commitments in each state and the District of Columbia. The survey was administered to all 50 states and the District of Columbia via email. Specific individuals identified as primary administrators responsible for the care and evaluation of IST admissions in each state were contacted. RESULTS: A total of 50 out of the 51 jurisdictions contacted completed the survey. Fully 82% of states indicated that referrals for competency evaluation were increasing. Additionally, 78% of respondents thought referrals for competency restoration were increasing. When asked to rank factors that led to an increase, the highest ranked response was inadequate general mental health services in the community. Inadequate crisis services were the second ranked reason. Inadequate number of inpatient psychiatric beds in the community was the third highest, with inadequate assertive community treatment services ranking fourth. CONCLUSIONS: Understanding the national trend and causes behind the recent surge in referrals for IST admissions will benefit states searching for ways to remedy this crisis. Our survey indicates most states are facing this issue, and that it is largely related to insufficient services in the community.

A longitudinal description of incompetent to stand trial admissions to a state hospital.

OBJECTIVE: Evidence is clear that the nation is experiencing an increasing number of incompetent to stand trial (IST) admissions to state hospitals. As a result, defendants in need of treatment can wait in jail for weeks for admission for restoration. This study was conducted to better understand this growing population and to inform hospital administration about the characteristics of IST admissions. METHODS: The study was conducted at the Department of State Hospitals (DSH) facility in Napa (DSH-Napa), a 1200-bed primarily forensic inpatient psychiatric facility located in northern California. The records of patients found IST and admitted to DSH-Napa for restoration of competence between the dates of 1/1/2009 and 12/31/2016 were eligible for inclusion in the study. RESULTS: There were a total of 3158 unduplicated IST admissions available during the specified time period. Our data indicate that the number of admissions with more than 15 prior arrests increased significantly, from 17.7% in 2009 to 46.4% in 2016. In contrast, the percent of patients reporting prior inpatient psychiatric hospitalization evidenced a consistent decrease over time from over 76% in 2009 to less than 50% in 2016. CONCLUSION: Our data add to the body of literature on the potential causes of the nationwide increase in competency referrals. The literature is clear that jails and prisons are now the primary provider of the nation's mental health care. Our data suggest that another system has assumed this role: state hospitals and other providers charged with restoring individuals to competence.

Network analysis of psychopathy in forensic patients.

The question of which features represent the most central components of psychopathy remains unresolved and is the subject of considerable debate. Network analysis, which is a relatively new way to conceptualize mental disorders that emphasizes complex causal systems, provides a means to graphically and quantitatively describe the centrality of the various symptoms of a disorder. We applied association and adaptive LASSO networks on two samples of forensic patients. The first sample included forensic inpatients (N = 277) who were administered the Psychopathy Checklist-Revised (Hare, 2003), and the second sample included patients who previously had been civilly committed (N = 1136), who were administered the Psychopathy Checklist: Screening Version (Hart, Cox, & Hare, 1995). The models indicated the items on the affective facet are highly central across both samples and methods, and the item "lack of remorse" was especially central to the networks. Conversely, interpersonal, lifestyle, and antisocial facets generally resulted in low centrality in the models of both samples. Thus, the models lend support to the importance of affective deficits as the primary feature of psychopathy when psychopathy is assessed using the Hare Psychopathy Checklist measures. (PsycINFO Database Record

Insane Sex Offenders: Psychiatric and Legal Characteristics of Sexual Offenders Found Not Guilty by Reason of Insanity.

There is little known about sexual offenders hospitalized under forensic commitment statutes such as not guilty by reason of insanity (NGRI). We conducted a chart review to delineate the demographic, clinical, and legal characteristics of NGRI sexual offenders (n = 68) committed to the California Department of State Hospitals-Napa, including 41 found NGRI for a sexual offense and 27 found NGRI for a nonsexual offense. The two groups did not differ significantly in their demographics, psychiatric diagnoses, victim characteristics, or recidivism risk as measured by the Static-99R. Those found NGRI for a sexual offense were older at the time of their first criminal and first violent offense, younger at the time of their committing offense, and had fewer prior total convictions and sexual offense convictions. These findings may indicate that sexual offenders found NGRI for a sexual offense are less antisocial than those found NGRI for a nonsexual offense.

Examining the psychometric properties of the Barratt Impulsiveness Scale-Brief Form in justice-involved samples.

Impulsivity is an important component of many forms of psychopathology. Though widely used as an index of this construct, the 30-item Barratt Impulsiveness Scale-11 (BIS-11) has demonstrated questionable psychometric properties in several research reports. An 8-item shortened version has recently been proposed, the Barratt Impulsiveness Scale-Brief (BIS-Brief) form, which was designed to overcome some of the limitations of the longer scale. In this report, we examine the internal structure and theoretically relevant external correlates of this new short form in large archival samples of individuals involved in the criminal justice system (prison inmates, substance abusers in mandatory treatment, and forensic inpatients). Confirmatory factor analysis of the BIS-Brief indicates adequate fit following a relatively minor modification. Correlations between the BIS-Brief and an array of criterion measures-other self-report scales, interview-based measures, and behavioral outcomes-are consistent with predictions and show relatively little or no decrement in predictive validity when compared with the 30-item BIS-11. Our results suggest that the BIS-Brief is a promising brief measure of impulsivity that evinces good psychometric properties across a range of offender samples.

Assessment of aggression in inpatient settings.

The threat of violence is a major concern for all individuals working or receiving treatment in an inpatient psychiatric setting. One major focus in forensic psychology and psychiatry over the past several decades has been the development of risk assessments to aid in the identification of those individuals most at risk of exhibiting violent behavior. So-called second- and third-generation risk assessments were developed to improve the accuracy of decision making. While these instruments were developed for use in the community, many have proven to be effective in identifying patients more likely to exhibit institutional aggression. Because the purpose of risk assessment is the reduction of violence, dynamic factors were included in third-generation risk instruments to provide opportunities for intervention and methods for measuring change. Research with these instruments indicates that both static factors (second-generation) and dynamic factors (third-generation) are important in identifying those patients most likely to engage in institutional aggression, especially when the aggression is categorized by type (impulsive/reactive, organized/predatory/instrumental, psychotic). Recent research has indicated that developing a typology of aggressive incidents may provide insight both into precipitants to assaults as well as appropriate interventions to reduce such aggression. The extant literature suggests that both static and dynamic risk factors are important, but may be differentially related to the type of aggression exhibited and the characteristics of the individuals exhibiting the aggression.

Characteristics of female homicide offenders found not guilty by reason of insanity.

Until recently, there has been little information regarding female offenders who commit homicides that are motivated by psychosis. We investigated gender differences in the characteristics of psychosis and crime variables in psychotically motivated homicide. In the study, conducted at a large U.S. forensic facility, we reviewed the records of women (n = 47) found not guilty by reason of insanity (NGRI) who were hospitalized between January 1991 and August 2005 for a homicide offense. A random sample of 47 men who were committed during the same period for the same offenses was selected for comparison. Religious delusions were found more often in women who killed infants (0-1 year of age) and children between the ages of 2 and 18. Women were more likely to have a diagnosis of an affective problem and borderline personality disorder. The results indicate gender-specific areas to focus on during clinical and forensic assessments of the risk of violence in women with psychosis.

Malingering in the correctional system: does incentive affect prevalence?

Incentives to malinger vary greatly dependent on the context, as does the prevalence. Malingering in the medico-legal context of the criminal courts is generally for one of two purposes: to present as incompetent to stand trial or to successfully plead not guilty by reason of insanity. Estimates of the prevalence of malingering in these contexts vary between 8 and 21%. The prevalence of malingering increases dramatically in a general offender sample, where the external incentive is likely to be substantially different. Malingering in this context can be as high as 56% and generally occurs to obtain a more desirable housing situation or desired medications. Our study examined data from two distinct samples to evaluate incentives to malinger: patients found incompetent to stand trial (IST) and sent to a state hospital for restoration and jail inmates seeking psychiatric services (JPS). Our results indicate that the rate of malingering in the IST sample was consistent with rates published in comparable samples (17.5%) and the rate for the JPS sample was substantially higher (64.5%). Only in the IST sample was rate of malingering associated with offense severity: patients found IST for murder and robbery evidenced malingering rates more than double the sample as a whole. Offense severity bore no relationship to malingering in the JPS sample.

Psychological testing and the assessment of malingering.

This article discusses the prevalence of feigning in both criminal and civil settings and various psychological assessments useful in detecting feigning. The focus of this information is on the various psychological assessments available to assist clinicians in making a determination of whether or not an individual is feigning and concludes with the recommendations that multiple assessments are necessary to improve the sensitivity of detection methods.

The predictive ability of the Classification of Violence Risk (COVR) in a forensic psychiatric hospital.

OBJECTIVE: Aggression is a common problem in psychiatric and correctional facilities. An actuarial instrument, the Classification of Violence Risk (COVR), has demonstrated utility in predicting community aggression among civilly committed psychiatric patients and, more recently, an ability to predict institutional aggression in a forensic facility. This prospective study aimed to extend validation of the use of the COVR in a forensic facility. METHODS: The study, conducted at a large U.S. forensic facility, used nursing records to document incidents of physical aggression by 146 patients for 20 weeks after COVR administration. Correlational and chi square analyses were conducted to evaluate the efficacy of the COVR in predicting aggression. RESULTS: The COVR showed modest predictive ability for institutional aggression, with a correlation of .331 and an area under the curve of .725. CONCLUSIONS: Results support use of the COVR in a forensic facility; its ability to predict institutional aggression is similar to that found for community aggression.

Examining the construct validity of the Psychopathic Personality Inventory-Revised: preferential correlates of fearless dominance and self-centered impulsivity.

Although the construct of psychopathy is frequently construed as a unitary syndrome, the Psychopathic Personality Inventory (PPI; Lilienfeld & Andrews, 1996) and its revision, the PPI-R (Lilienfeld & Widows, 2005), are composed of 2 scales, termed Fearless Dominance (FD) and Self-Centered Impulsivity (SCI), which appear to reflect orthogonal dimensions. In this study, we examined the construct validity of the FD and SCI scales of the PPI-R as markers of these constructs with a range of theoretically relevant correlates assessed across multiple domains in a sample of 200 forensic psychiatric inpatients. Results were generally, though not uniformly, consistent with hypothesized relationships: The SCI scale positively and selectively predicted anger and hostility, impulsivity, total psychiatric symptoms, drug abuse or dependence, antisocial behavior, and violence risk, whereas FD predicted anger, depression, anxiety symptoms (negatively), and alcohol abuse or dependence (positively).

Malingering in a correctional setting: the use of the Structured Interview of Reported Symptoms in a jail sample.

The ability to detect malingering in the correctional setting is of paramount importance. The burgeoning jail and prison population combined with statutory requirements for the provision of mental health treatment require that only those most in need receive these services. Several structured assessments have been developed to assist in the identification of individuals more likely to be feigning psychiatric symptoms. Prior to the development of these specialized assessments, subscales of standard psychological tests were used as an indicator of assessment attitudes, for both malingering and other dissimulation. At the Sacramento County (CA) Jail, the Structured Interview of Reported Symptoms (SIRS) is routinely administered when clinicians feel there is a possibility that an inmate receiving psychiatric services may be feigning or exaggerating his/her symptoms. Our study examined data from these evaluations of inmates in conjunction with other clinical data (e.g., psychiatric diagnosis, educational level) to determine those factors most associated with malingering in jail inmates. Our results indicate that the prevalence of malingering in our sample was quite high: over 66% were found to be malingering based on the scoring criteria for the SIRS. Inmates diagnosed with Antisocial Personality Disorder were no more likely to feign symptoms than inmates without this diagnosis. Inmates designated as malingering in their charts were no more likely to be found malingering on the SIRS, suggesting that they may have adopted an effective strategy.

The accuracy of risk assessment instruments in the prediction of impulsive versus predatory aggression.

Actuarial violence risk assessments, many of which include the construct of psychopathy, have been shown to be superior to clinical judgment in the prediction of long-term risk of community violence and recidivism. While these instruments initially appeared to provide similarly accurate judgments of risk of institutional aggression, recent research has indicated that such assessments may be less robust in this setting. One explanation may lie in the types of aggression most frequently observed in each setting. Impulsive (or reactive/affective) is the type of physical aggression most commonly exhibited in psychiatric facilities. This research examines the relationship between risk assessments and aggression in an inpatient forensic setting, with such aggression categorized as impulsive, predatory or psychotic aggression. Consistent with previous research, impulsive aggression was the most frequent type observed (58%). Anger (as measured by the Novaco Anger Scale) and clinical issues (as measured by the HCR-20) were most associated with impulsive aggression, with AUC values of .73 and .71 respectively. In contrast, anger and psychopathy (as measured by the PCL-R) were more associated with predatory aggression, with AUC values of .95 and .84 respectively. Psychotic symptoms were highly associated with psychotically motivated aggression (AUC=.90). These results suggest that traditional violence risk assessments may have limited utility in predicting aggression in an institutional setting and that psychiatric symptoms and heightened affect are more relevant.

The conditional release of insanity acquittees: three decades of decision-making.

The problem with the practical application of decision-making regarding release of mentally ill defenders lies in the inherently ambiguous definitions of mental illness and dangerousness, both of which are necessary for the continued commitment of insanity acquittees. In this study, we examined how clinicians make release decisions in a forensic facility, with particular attention paid to how such decision-making may have changed over time. Records were reviewed to determine documented criteria indicating readiness for release. The results indicated that compliance and treatment response were the primary reasons that the patients were judged ready for release. In addition, increasing attention to the use of substances as a risk factor was evident in the records, with substantially more documentation found in the most recent decade. Our data suggest that clinicians view three concerns to be of primary import when making release decisions: responsiveness to and compliance with the treatment, substance use, and risk of violence.