1. Developing Court Competence Through Music March 24, 2012 WRAMTA Regional Conference Salt Lake City, UT Mary E. Alvarado, MT-BC Yu-Chuan Chen, MT Atascadero State Hospital

2. Atascadero State Hospital – A Quick Look Current Population +/- 1000 All Adult Male Forensic Mentally Disordered Offenders Not Guilty by Reason of Insanity Referrals from CDCR Incompetent to Stand Trial

4. Incompetence to Stand Trial Most countries don’t have competency to stand trial laws U.S. states have fairly consistent laws from state to state Theory is that it is improper to try someone in abstentia Mental illness could constitute “mental abstentia”

5. Incompetence to Stand Trial Law distinguishes those who have free choice to be present versus those who do not (mentally ill) Competency to stand trial standard two pronged Rational understanding of charges and procedures Ability to rationally assist attorney in presenting defense

6. Incompetent to Stand Trial Dusky v US: Defendant must have a “present ability to consult with his lawyer with a reasonable degree of rational understanding” and “factual and rational understanding of the proceedings” Jackson v Indiana: Placed time limits on length of confinement as incompetent to stand trial Reasonable period to determine there is substantial probability of regaining competency in foreseeable future

7. Incompetent to Stand Trial Sell v. U.S. 2003 Involuntary forced medications is balance between government interests and individual rights Non-dangerous defendants can be forced medicated only under certain conditions Treatment is medically appropriate Side effects won’t undermine fairness of trial Less intrusive methods unlikely to work

8. Who Decides Incompetence??? Court officer (DA, PD, judge) can raise doubt Judge determines “official doubt” based on substantial evidence Court appoints 2-3 evaluators Speedy trial clock stops Bail revoked, if on OR and taken into custody

9. Who Decides Incompetence? Hearing held after receipt of reports Jury trial if either side requests Hearings can only occur in Superior Court

10. Competency Program in ASH Admission Unit From 1st day to two months or so Goal: Become competent to stand trial by attaining mental stability, familiarity with the treatment program at ASH and participation in the competency tests Treatment Unit Currently ASH has 2 treatment units. Goal: Essentially the same as on admissions however treatment units also clarify diagnoses, refine medication regimens and enhance resources as necessary to assist with attaining competency.

11. Competency Tests R-CAI (Revised-Competency Assessment Instrument) or other instruments as indicated by the needs of the patient Mock Trial Clinical Staffing Forensic Staffing Outcome: 1) Competent to stand trial, 2)Malingering, and 3) Non restorable to competency

12. The Clinical Picture Mentally Ill Upon admission typically psychotic, unstable Poor self care Possibly aggressive Responds well to medication Once in stabilization mode is willing to participate in treatment to attain competency May have behavioral issues/delusions that will impact upon competency May have learning or cognitive deficits that slow progress towards competency Malingering Upon admission appears non psychotic, easily able to make needs known Often excellent self care Becomes the “king pin” on the unit Shows no response to medication or atypical response Unwilling to comply with testing and treatment Often has multiple physical concerns needing staff attention Can be aggressive if needs are not met to satisfaction or as a means of intimidation

13. 2011 Statistics Total IST admitted to ASH – 268 Total returned to court (all reasons) – 381 Average length of stay – 139 days Total passing all tests – 356 (average 126 days) Discharged with Malingering Dx – 19 Discharged as “non restorable” – 21 7 completed the 3 year statute

14. Competency Treatment Groups Trial Competency Has demonstrated ability to concentrate for extended period Goal: To improve knowledge of court information Competency through Activities Typically more challenged patient with poor ability to concentrate and needs repetitive information Goal: To improve knowledge of court information A dditional Treatment as Indicated Medication Education Substance Abuse Depression Management Neuro/Cognitive Services Compulsory Education Anger Management Leisure & Recreation Social Skills Medical/Physical

15. Music Therapy at ASH Currently 18 Music Therapists and 1 intern Groups provided both in a centralized music center and throughout the hospital Groups range from insight oriented lyric analysis to emotive improvisation to social expression and just good old bands. (which provide all of the above!)

16. Developing Court Competence Through Music All Functioning Levels Goals: Address ambivalence about returning to court Identify problematic behaviors contributing to barriers to competency Provide “safe space” emotional expression for feelings related to being arrested, charged and committed for treatment Reinforce court information Increase attention span

17. Characters of the Court Improvisation Judge District Attorney Public Defender Bailiff Defendant Witness Jury Member Friend Family Member Court Reporter Objectives: Reinforce knowledge of key roles in the court room Warm up and ground the group Encourage focus and attention Interpret non verbal communication

18. Court Scenario Process Objectives Non verbal expression of feelings related to returning to court Clarification of concerns related to IST issues Pre problem solving of potential situations IST patients could encounter upon return to court Resolution of ambivalence for those attempting to avoid return to court due to fears of long sentence, “injustice of the system”, etc.

19. Court Scenario Chant “The Court is the place that needs your face” ….so get there

20. Structured Songwriting Objectives: Expression of concerns about being found Incompetent to Stand Trial Group Identity/Group Cohesion as a distinct population at ASH Instillation of hope during a time of great uncertainty Humor

21. Developing Court Cooperation Through Music Mary Alvarado: MALVARADO@ash.dmh.ca.gov MALVARADO@ash.dmh.ca.gov Yu-Chuan Chen: YCHEN@ash.dmh.ca.gov YCHEN@ash.dmh.ca.gov