Incorporating combined competency to stand trial (CST) and mental state at the time of the offense (MSTO) evaluations into CST and MSTO research is an important methodological consideration not to be overlooked. This is the bottom line of a recently published article in Law and Human Behavior. Below is a summary of the research and findings as well as a translation of this research into practice.
Featured Article | Law and Human Behavior | 2017, Vol. 41, No. 3, 217-229
Combined Evaluations of Competency to Stand Trial and Mental State at the Time of the Offense: An Overlooked Methodological Consideration?
Lauren Kois, John Jay College and the Graduate Center, City University of New York
Preeti Chauhan, John Jay College and the Graduate Center, City University of New York
James M. Wellbeloved-Stone, University of Virginia
Janet I. Warren, University of Virginia
Combined evaluations of competency to stand trial (CST; competency) and mental state at the time of the offense (MSO; sanity) frequently co-occur. However, most research examines the 2 as discrete constructs without considering 4 potential combined evaluation outcomes: competent-sane, incompetent-sane, competent-insane, and incompetent-insane. External validity can be improved if research more closely mirrored practice. It may be incorrect to assume incompetent defendants are similar across CST-only and combined evaluations, and insane defendants are similar across MSO-only and combined evaluations. Using a sample of 2,751 combined evaluations, we examined demographic, clinical, offense, evaluation, and psycholegal characteristics associated with evaluators’ combined evaluation opinions. Multinomial regression analyses revealed older defendants were more likely to be opined incompetent-insane. Defendants with psychotic disorders were more often opined insane, regardless of competency status. Affective diagnoses predicted competent-insane opinions. Developmental disorders were closely related to incompetence, regardless of sanity status. Defendants with organic disorders tended to have global psycholegal impairment, in that they were more often opined incompetent-insane, incompetent-sane, or competent-insane, relative to competent-sane. Prior hospitalization predicted competent-insane relative to competent-sane opinions. Defendants not under the influence of a substance during the offense or with no prior convictions were more likely to be opined insane, regardless of competency status. We interpret these findings in light of psycholegal theory and provide recommendations for research and practice. Collectively, results suggest incorporation of combined evaluations into CST and MSO research is an important methodological consideration not to be overlooked.
forensic assessment, competency to stand trial, mental state at the time of the offense, insanity, combined evaluation
Summary of the Research
“Evaluators regularly conduct combined evaluations of competency to stand trial (CST, competency) and mental state at the time of the offense (MSO, sanity). In their survey of U.S. pretrial forensic services, Grisso, Cocozza, Steadman, Fisher, and Greer (1994) found referral and evaluation processes for CST and MSO were similar and evaluators frequently conducted evaluations of both referral questions simultaneously in most states. Researchers have documented the frequency of these combined evaluations, with estimates occurring up to 100% of the time in study samples. However, the research literature most often examines correlates of CST and MSO independently, instead of examining them in the context of the four potential combined evaluation opinions or outcomes—competent-sane, incompetent-sane, competent-insane, and incompetent-insane. This brings to question the external validity and generalizability of this body of research, in that research thus far does not usually mirror clinical practice” (p. 217).
“We make two implicit assumptions when neglecting to identify this frequent pairing of referral questions, relative to CST-only or MSO-only evaluations. First, we assume defendants opined competent-sane in combined evaluations resemble those who are opined competent or sane in solitary CST or MSO evaluations, with the same pattern continuing for those opined incompetent-sane, competent-insane, or incompetent-insane. The second assumption is when combined evaluations are conducted in one assessment process, there are no differences between defendants opined competent-sane and competent-insane and no differences between defendants opined incompetent-sane and incompetent-insane. Stated differently, those found competent, regardless of their sanity status, are assumed to resemble each other; those found incompetent, regardless of their sanity status, are also assumed to resemble each other, and so on” (p. 217-218).
“Given CST and MSO embody different psycholegal concepts requiring different types of clinical inquiry, it may be inappropriate to consider singular and combined evaluations as mirrored reflections of one another, devoid of differences associated with referral or clinical processes” (p. 218).
“While they may be evaluated simultaneously, CST and MSO are distinct psycholegal constructs. CST evaluations focus on current functioning and assess two primary abilities: whether defendants understand the legal proceedings against them and whether they can work with their attorney in developing a defense” (p. 218).
“Whereas CST evaluations are present focused, MSO evaluations are retrospective inquiries. In order to be acquitted insane in most jurisdictions, defendants must demonstrate a major mental disease or defect substantially impaired their ability to understand the nature or consequences of the illegal act, their ability to distinguish right from wrong, or their ability to resist their illegal impulse” (p. 218).
“Our literature review suggests base rates and correlates of CST and MSO may vary according to a sample’s composition of singular and combined evaluations. This provides further evidence that, with combined evaluation samples, CST and MSO outcomes should be examined according to the four evaluation outcomes, rather than competent versus incompetent and sane versus insane. To shed light on this methodological consideration, we examined which demographic, clinical, offense, evaluation, and psycholegal characteristics are correlated with the four definitive outcomes of combined evaluations. Consistent with the literature, we hypothesized clinical and psycholegal impairment would demonstrate the most robust relationships with opinions of incompetent-sane, competent-insane, and incompetent-insane as compared to competent-sane” (p. 219).
“In line with our hypotheses, psychiatric diagnoses and psycholegal abilities were strongly associated with evaluators’ CST and MSO opinions. Furthermore, we found predictors of incompetency and insanity vary when considering all four combined evaluation outcomes. We can conclude those found competent, regardless of their sanity status, do not always resemble each other; those found incompetent, regardless of their sanity status, do not always resemble each other, and so on. As a result, our findings shed light on the complexity of opinions associated with combined evaluations” (p. 223).
Translating Research into Practice
“Along with Bush, Connell, and Denney (2006), we recommend that when evaluating both psycholegal questions, evaluators submit two separate reports to the court, accompanied by a message explaining the reports are kept separate so as not to violate defendants’ rights from self-incrimination. Combined evaluation reports may create important ethical and legal issues currently under addressed in the literature. For instance, is it incriminating for an evaluator to note, in a CST report, whether or not defendants were also evaluated for MSO? At present, there is no consensus or standard protocol for opining combined evaluation outcomes, and we are unsure of how evaluators typically proceed in combined evaluations when they believe a defendant is incompetent” (p. 227).
“According to the American Bar Association, ‘Existing professional ethics boards and committees should develop specific criteria and special review procedures designed to address the ethical questions that may arise when mental health professionals participate in the criminal process.’ Combined evaluation issues require further contemplation by our field” (p. 227).
Other Interesting Tidbits for Researchers and Clinicians
“Our findings indicate we cannot assume (1) defendants opined competent-sane in combined evaluations resemble those who are opined competent or sane in solitary CST or MSO evaluations (or similar patterns), and (2) there is no difference between defendants opined competent-sane and competent-insane, and no difference between defendants opined incompetent-sane and incompetent-insane. Assuming ‘pure’ CST or MSO samples may set the stage for methodological confounds (e.g., evaluation type) that cloud the true nature of CST and MSO research findings. These findings highlight the need for further research to attend to the complexity of combined evaluations and the impact they may have on evaluation outcomes and the related research” (p. 227).
“We encourage researchers to replicate our study across jurisdictions. We cannot assume our results are typical or if they will generalize to other forensic systems. Although Grisso et al. (1994) found more similarities than differences among individual states’ pretrial forensic services, divergence in referral base rates, legal criteria, and evaluator and defendant characteristics will likely influence evaluation outcomes. Past research that incorporated a subset of our data identified both inter- and intrastate differences in these domains” (p. 227).
“Our base rate of incompetency was much lower than that of Pirelli, Gottdiener, and Zapf (2011), but similar to research incorporating combined evaluations. It may be that, in general, base rates of incompetence are much higher when the only psycholegal question is a defendant’s CST. We suggest researchers begin to clearly state the source of their data (i.e., CST-only, MSO-only, or combined evaluations). In doing so, research will better mirror practice and enhance external validity” (p. 227).
“Like Crocker et al. (2002), we had small portions of evaluators provide no opinion for CST or MSO in our study. Pirelli, Zapf, and Gottdiener (2011) proposed that exploring the ‘gray areas’ (i.e., deferred opinions) of CST is an important pursuit. This is an important endeavor in MSO research as well. Deferred evaluation opinions could limit due process by stalling legal proceedings. Unfortunately, our sample sizes were too small to analyze ‘no opinions.’ While it may be difficult to locate a significant number of deferred opinions given their low base rates, researchers may oversample this group in future analyses” (p. 227).
“As it stands, the nature of these evaluations is largely overlooked in the literature, and there are still many questions to pursue in order to develop a comprehensive understanding of the intricacies of CST and MSO research and practice. On a broader level, this study encourages researchers to carefully consider external validity (meaning, true practice) when conceptualizing clinical study designs. Moving forward, we hope researchers and practitioners consider the methodological implications of combined evaluation structures in their work” (p.228).
Join the Discussion
As always, please join the discussion below if you have thoughts or comments to add!
About the Author
Amanda Beltrani is a current graduate student in the Forensic Psychology Masters program at John Jay College of Criminal Justice in New York. Her professional interests include forensic assessments, specifically, criminal matter evaluations. Amanda plans to continue her studies in a doctoral program after completion of her Masters degree.