1. The Competency Assessment Brian P. Skop, M.D. Forensic Psychiatric Consultant to University Health System Associate Clinical Professor of Psychiatry University of Texas Health Science Center San Antonio

2. Learning Objectives Conduct of the examination Conduct of the examination Impact of illness on competency Impact of illness on competency Restorability Restorability Placement recommendations Placement recommendations How to get the best examination How to get the best examination

3. Conduct of the Examination – The competency assessment is a modified psychiatric evaluation. Shared elements with a clinical psychiatric examination include assessment of Current symptoms Current symptoms Prior treatment Prior treatment Medical history Medical history Relevant family history Relevant family history Developmental history Developmental history Educational history Educational history Work history Work history Military history Military history

4. Conduct of the Examination Legal history Legal history Relationship history Relationship history Current medications Current medications Review of collateral records Review of collateral records Mental status examination Mental status examination Diagnostic formulation Diagnostic formulation Determination of appropriate treatment setting Determination of appropriate treatment setting Determination of prognosis Determination of prognosis

6. Conduct of the Examination – Key differences between a general psychiatric examination and a competency examination Clear demarcation of nature and purpose of examination Clear demarcation of nature and purpose of examination – No doctor-patient relationship – It is not therapeutic – There is no confidentiality – The results of the examination may not help the individual

7. Conduct of the Examination – Key differences Competency assessment Competency assessment – Understanding of the charge and potential consequences of the proceedings – Ability to disclose pertinent facts, events, and states of mind – Capacity to engage in a reasoned choice of legal options – Capacity to understand the adversarial nature of the proceedings – Capacity to exhibit appropriate courtroom behavior – Capacity to testify relevantly

8. Conduct of the Examination – Key differences High suspicion for malingered mental illness High suspicion for malingered mental illness Determination of impact of illness or defect on competency Determination of impact of illness or defect on competency Determination of the impact of medications on competency Determination of the impact of medications on competency Determination of restorability Determination of restorability

10. Impact of Mental Illness on Competency Mental illness does not equate with incompetency Mental illness does not equate with incompetency Conditions with a higher likelihood of incompetence: Conditions with a higher likelihood of incompetence: – Untreated schizophrenia or schizoaffective disorder – Manic state of bipolar disorder – Severe head injury, dementias – Mental retardation

12. Impact of Mental Illness on Competency The competency evaluation is a current state examination The competency evaluation is a current state examination Mental illnesses fluctuate in intensity Mental illnesses fluctuate in intensity – Natural course of the illness – Variable compliance with medications – Impact of incarceration on the course of the illness

13. Restorability Factors considered Factors considered – Outcome of prior efforts at treatment – Outcome of prior efforts to restore – Responsiveness of underlying condition to treatment – Capacity to learn new material

15. Considerations in Placement Recommendations – Inpatient Safety concerns-suicidal or potential for violence Safety concerns-suicidal or potential for violence Severe degree of psychotic symptoms Severe degree of psychotic symptoms Need for court ordered medications Need for court ordered medications Poor outcome of prior efforts at treatment Poor outcome of prior efforts at treatment Severe degree of complicating issues such as substance abuse or other medical conditions Severe degree of complicating issues such as substance abuse or other medical conditions Poor support system to help with compliance and activities of daily living Poor support system to help with compliance and activities of daily living

16. Considerations in Placement Recommendations – Outpatient No significant safety concerns No significant safety concerns Relatively stable living situation Relatively stable living situation Willingness to comply with medications Willingness to comply with medications Lack of complicating medical conditions that require nursing supervision Lack of complicating medical conditions that require nursing supervision Lack of substance abuse that is significantly impeding treatment response Lack of substance abuse that is significantly impeding treatment response

17. How to get the best examination Include important information in the motion for examination Include important information in the motion for examination – What specific problems are you observing – Relevant information from friends and family – Attach psychiatric and medical records

18. How to get the best examination Remember the examiners are not private investigators, mind readers, or fortune tellers Remember the examiners are not private investigators, mind readers, or fortune tellers – Sometimes paranoid individuals may withhold information from examiners that they may convey to their attorney or family – There is a time limit to the orders that often prevents obtaining medical records prior to the due date for the report

19. How to get the best examination Feel free to attend the examination Feel free to attend the examination Feel free to contact the examiner with specific concerns or questions after you receive the report. Addendums can be made if warranted. Feel free to contact the examiner with specific concerns or questions after you receive the report. Addendums can be made if warranted. Some defendants are adept at malingering and the examiner can explain the basis for concluding this is present. Some defendants are adept at malingering and the examiner can explain the basis for concluding this is present.

20. Conclusion