The present study evaluated whether specific aspects of psychopathological constructs assessed by the Minnesota Multiphasic Personality Inventory-2 Restructured Form (MMPI-2-RF) and specific cognitive abilities assessed by the Wechsler Abbreviated Scale of Intelligence (WASI/WASI-II), were associated with length of competency restoration of a sample of male pretrial defendants in a maximum security forensic psychiatric hospital. No MMPI-2-RF or WASI/WASI-II scales predicted restoration status at 180 days when controlling for age. Overall, the results suggested that externalizing behaviors are among factors that may play a role in predicting restoration status at certain time points. This is the bottom line of a recently published article in the International Journal of Forensic Mental Health. Below is a summary of the research and findings as well as a translation of this research into practice.
Featured Article | The International Journal of Forensic Mental Health | 2018, Vol. 17, No. 2, 167-180
Personality, Psychiatric, and Cognitive Predictors of Length of Time for Competency to Stand Trial Restoration
Laura M. Grossi, MA, Fairleigh Dickinson University
Debbie Green, PhD, Fairleigh Dickinson University
Melanie Schneider, MA, Fairleigh Dickinson University
Brian Belfi, PsyD, Kirby Forensic Psychiatric Center
Shanah Segal, PsyD, Kirby Forensic Psychiatric Center
Certain defendant characteristics, including psychiatric diagnosis, externalizing problems, and cognitive deficits, are associated with longer periods of restoration of competency to stand trial and general lack of treatment success. Prior research has called for a more detailed examination of symptom-level differences between defendants rapidly restored to competency and those who require lengthier treatment for competency restoration. The present study evaluated whether specific aspects of psychopathological constructs assessed by the Minnesota Multiphasic Personality Inventory-2 Restructured Form (MMPI-2-RF), and specific cognitive abilities assessed by the Wechsler Abbreviated Scale of Intelligence (WASI/WASI-II), were associated with length of competency restoration among 344 male pretrial defendants hospitalized at a maximum security forensic psychiatric hospital. Higher Juvenile Conduct Problems (JCP) scores were associated with restoration within 90 days, and Antisocial Behavior (RC4) predicted restoration status at 90 days; no MMPI-2-RF or WASI/WASI-II scales predicted restoration status at 180 days when controlling for age. Overall, results suggested that externalizing behaviors are among factors that may play a role in predicting restoration status at select time points.
Competency to stand trial, competency restoration, symptoms, MMPI-2-RF, WASI-II
Summary of the Research
“The psychological treatment of incompetent (IST) defendants as preparation for adjudication, termed, competency restoration, is largely educational and aimed at helping defendants gain a factual and rational understanding of the legal system. In addition, symptom and behavior management of those deemed IST plays an important role in various aspects of the restoration process…Although there is no standard competency restoration treatment protocol, treatment typically involves psychotropic medication, group therapy focused on psychoeducation, and when resources are available, individual therapy…Approximately two-thirds of IST defendants are deemed CST within 6 months of competency restoration treatment and more than 80% are restored to competency within one year…” (p.167-168).
“A relatively small literature has identified factors that are predictive of restoration/restorability, or length of time for competency restoration more generally…Even so, several demographic, historical, and clinical factors appear associated with restoration of competency or restorability…diagnoses of non-psychotic disorders, a criminal history, younger age, and/or female gender are typically associated with a determination that a defendant is restorable. In contrast, diagnoses of psychotic disorders and irremediable/organic cognitive disorders, greater number of days previously hospitalized, lack of prior convictions, current violent charge, older age, and male gender are frequently associated with a determination that a defendant is IST and/or unrestorable…The present study examined the extent to which specific psychological measures assessing personality, psychopathology, and intelligence may assist forensic evaluators in estimating the requisite length of treatment for competency restoration, in a sample of male IST pretrial defendants. Specifically, we examined the utility of the Minnesota Multiphasic Personality Inventory-2 Restructured Form…and Wechsler Abbreviated Scale of Intelligence…for informing predictions of competency restoration” (p.168).
“We hypothesized that scores on the MMPI-2-RF scales assessing problems in thinking and externalizing problems would be positively associated with length of time for competency restoration, with the length of restoration variable defined (1) continuously, reflecting the number of days from hospital admission until a passed formal CST evaluation, and (2) dichotomously, representing restoration status at 90 days and 180 days. This was predicted as the constructs assessed by these MMPI-2-RF scales are negatively associated with treatment adherence and completion in other settings. Further, this hypothesis was developed with the assumption that traits assessed by the MMPI-2-RF scales may not be necessarily reflected in a defendant’s behavioral history…” (p. 170).
“We additionally hypothesized that composite scores (FSIQ-2) and subtest scores (Vocabulary and Matrix Reasoning) of the WASI/WASI-II would be negatively associated with length of time for restoration of competency to stand trial. Based on the limited literature described above, we anticipated that the strongest associations with length of competency restoration would include FSIQ-2 and Vocabulary, and that Matrix reasoning would be less strongly related. Overall, we expected that pathological traits and impaired abilities, assessed by MMPI-2-RF scales and WASI/WASI-II subtests, would contribute to impairment of examinee’s competency-related abilities (i.e., defendants’ factual understanding, rational understanding, and ability to consult with a defense attorney) and thus prolonged hospitalization for competency restoration. Finally, the present study explored whether reasons for MMPI-2-RF profile un-interpretability were predictive of time to achieve competency restoration” (p.170).
“As standard practice, all defendants were evaluated for diagnostic clarification and treatment planning within a few weeks of admission to the hospital. As part of that assessment, the Wide Range Achievement Test – 4th Edition (WRAT-4), MMPI-2-RF, and WASI/WASI-II were administered. For the purposes of the present study, the results of these measures, along with defendants’ demographic and legal information, were obtained from defendants’ hospital records…Analyses examining whether IST and CST defendants could be differentiated at 90 days based on MMPI-2-RF and WASI/WASI-II scores indicated that only JCP [Juvenile Conduct Problems] scores significantly differentiated those who were restored and those who were not, although RC4 [Antisocial Behavior] also approached significance. However, both the results of JCP and RC4 analyses were contrary to prediction, with those defendants who remained IST endorsing fewer conduct-related problems in childhood and adolescence, and fewer antisocial beliefs, than those who were CST at 90 days” (p.176).
“None of the MMPI-2-RF or WASI/WASI-II scores differentiated between IST and CST groups at 180 days, although Vocabulary approached significance. The scales in combination were predictive of restoration status at 180 days; however, age, which was entered as a covariate, was the only variable that uniquely contributed to the model. Thus, the hypothesis that MMPI-2-RF and WASI/WASI-II scales would be predictive of restoration status at 180 days was not supported. Instead, older age appeared to be a stronger indicator of continued incompetency at 180 days, consistent with the literature” (p.177).
Translating Research into Practice
“It is imperative for clinicians to be able to identify those defendants who are likely to require hospitalizations for restoration of competency to stand trial early in their treatment for several reasons. Such defendants might have treatment needs that are distinct from those of defendants who are on a more typical restoration trajectory. For example, such defendants may benefit from intensive or specialized treatment (e.g., cognitive remediation or individual therapy), among other resources that will help them move more rapidly through the restoration process…Further, identifying such individuals and intervening appropriately may pre-empt a potential standstill in the legal process, and help to ensure that defendants’ legal rights and liberty are protected. In particular, treatment providers and defendants may benefit from reliable early identification of those defendants who are not restorable, so that Jackson relief can be applied for appropriately and in a timely fashion” (p.176).
“As measures of behavioral instability and oppositionality…the JCP and RC4 scales likely have implications for management in the forensic psychiatric hospital, in terms of reflecting chronic behavior problems and lack of cooperation. We had presumed that the characteristics assessed by these scales, including antagonism, antisociality, and lack of responsibility, might persistently impair a defendant’s ability to work with a lawyer. Instead, the ability of JCP to differentiate IST and CST defendants at a time point as early as 90 days may indicate that forensic psychiatric hospitals are well-equipped to work with defendants with antisocial characteristics and to ensure that legal and hospital resources are allocated appropriately” (p.177).
“Furthermore, these scales may be indicators of familiarity with the legal system, and thus better response to educational aspects of competency restoration. Alternatively, these scales may serve to differentiate patients whose traits are more criminogenic, and less psychiatric in nature, and thus require a lesser degree of pharmacological intervention than their peers. Regardless, JCP (and potentially RC4) may be clinically useful for the early identification of those defendants who will be successfully restored to competence with treatment as usual…Overall, exploratory findings suggest that estimated general intelligence and level of education may be more robust predictors of requisite time for competency restoration, such that low intelligence is associated with greater time until competency is restored. Further, these findings are applicable to the entire sample of defendants…These findings raise important implications for clinicians, who can quickly assess estimated general intelligence, gaining information regarding a defendant’s relative time for competency restoration, without the administration of more extensive cognitive tests or other additional measures” (p.176-177).
“Ensuring that defendants who have the potential to gain competency do so as quickly as possible is also important for economic reasons…the minority of IST defendants hospitalized for competency restoration for more than six months received a disproportionate amount of state mental health resources, when compared with those restored within six months…institutional and political pressures (e.g., to make room for new admissions, and to prosecute a violent offender, respectively) may influence determinations of competency status, particularly in cases of long-term hospitalization for competency restoration. As biases deriving from such pressures may impact decision-making about competency status and restorability, it is particularly important for evaluators to pay attention to relevant historical and empirical test data in forming empirically supported opinions” (p. 176).
Other Interesting Tidbits for Researchers and Clinicians
“These findings were somewhat consistent with prior research indicating that a lengthy criminal history is associated with restoration. However, findings are inconsistent with literature indicating that elevated RC4 and JCP scores (i.e., scores above the manual-recommended T-score cut-off) predict treatment failure in non-forensic contexts. The achievement of competency is not necessarily comparable to treatment success in other therapeutic contexts, and this finding may be interpreted in a straightforward manner, to mean that different personality characteristics have different predictive utility in different contexts. Notable tendencies toward antisocial or criminogenic behaviors (i.e., captured by psychological testing data including RC4 and JCP) may lead evaluators to believe that a defendant in this context (i.e., a maximum security forensic hospital) is more likely to possess competency-related abilities (e.g., due to familiarity with the legal system and prior experiences successfully completing the trial process) which would not be typically perceived as beneficial in non-forensic clinical contexts (e.g., civil hospital)” (p.176).
“Given the exclusion rate, future research might examine the ability of tests of personality and intelligence to predict time until competency restoration using a much larger sample. Larger samples might include female participants, as the present findings are not necessarily generalizable to the broader population of incompetent pretrial defendants. With a much larger sample, future research might examine whether elevations on specific scales (i.e., scores above the manual-recommended cut score) are predictive of time for competency restoration, as opposed to relatively high or low scores. Such an approach would be more informative for clinicians, who could then interpret scores above or below a particular threshold as indicative of alternative treatment…” (p.178).
“Further research might also examine the ability of self-report personality inventory scores to predict restoration status or restorability using less conservative exclusion criteria, as well as with alternative measures of personality and psychopathology (e.g., the Personality Assessment Inventory). Given the rate of exclusion and limited significant results related to personality and psychopathology in the present study, the MMPI-2-RF scales demonstrated little clinical usefulness in predicting length of competency restoration. This is important, as the administration of measures such as the MMPI-2-RF can take precious time and resources that could otherwise be allocated. It may be more efficient to obtain information relevant to behavioral instability and antisociality through brief clinical interviews and archival review of RAP sheets or hospital records” (p.178).
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Authored by Amber Lin
Amber Lin is a volunteer in Dr. Zapf’s research lab at John Jay College of Criminal Justice. She graduated from New York University in 2013 with a B.A. (honors) and hopes to obtain her PhD in forensic clinical psychology. Her research interests include forensic assessment, competency to stand trial, and the refinement of instruments used to assess the psychological states of criminal defendants.