The Competency The Competency AssessmentAssessment

Brian P. Skop, M.D.Brian P. Skop, M.D.Forensic Psychiatric Consultant to Forensic Psychiatric Consultant to

University Health SystemUniversity Health SystemAssociate Clinical Professor of Associate Clinical Professor of

PsychiatryPsychiatryUniversity of Texas Health Science University of Texas Health Science

CenterCenterSan AntonioSan Antonio

Learning ObjectivesLearning Objectives

• Conduct of the Conduct of the examinationexamination

• Impact of illness on Impact of illness on competencycompetency

• RestorabilityRestorability

• Placement Placement recommendationsrecommendations

• How to get the How to get the best examinationbest examination

Conduct of the ExaminationConduct of the Examination

– The competency assessment is a The competency assessment is a modified psychiatric evaluation. Shared modified psychiatric evaluation. Shared elements with a clinical psychiatric elements with a clinical psychiatric examination include assessment ofexamination include assessment of

• Current symptomsCurrent symptoms• Prior treatmentPrior treatment• Medical historyMedical history• Relevant family historyRelevant family history• Developmental historyDevelopmental history• Educational historyEducational history• Work historyWork history• Military historyMilitary history

Conduct of the ExaminationConduct of the Examination

• Legal historyLegal history• Relationship historyRelationship history• Current medicationsCurrent medications• Review of collateral recordsReview of collateral records• Mental status examinationMental status examination• Diagnostic formulationDiagnostic formulation• Determination of appropriate treatment Determination of appropriate treatment

settingsetting• Determination of prognosisDetermination of prognosis

Conduct of the ExaminationConduct of the Examination

– Key differences between a general Key differences between a general psychiatric examination and a psychiatric examination and a competency examinationcompetency examination•Clear demarcation of nature and purpose of Clear demarcation of nature and purpose of

examinationexamination– No doctor-patient relationshipNo doctor-patient relationship– It is not therapeuticIt is not therapeutic– There is no confidentialityThere is no confidentiality– The results of the examination may not help the The results of the examination may not help the

individualindividual

Conduct of the ExaminationConduct of the Examination

– Key differences Key differences •Competency assessmentCompetency assessment

– Understanding of the charge and potential Understanding of the charge and potential consequences of the proceedingsconsequences of the proceedings

– Ability to disclose pertinent facts, events, and states Ability to disclose pertinent facts, events, and states of mindof mind

– Capacity to engage in a reasoned choice of legal Capacity to engage in a reasoned choice of legal optionsoptions

– Capacity to understand the adversarial nature of the Capacity to understand the adversarial nature of the proceedingsproceedings

– Capacity to exhibit appropriate courtroom behaviorCapacity to exhibit appropriate courtroom behavior– Capacity to testify relevantlyCapacity to testify relevantly

Conduct of the ExaminationConduct of the Examination

– Key differences Key differences •High suspicion for malingered mental illnessHigh suspicion for malingered mental illness

•Determination of impact of illness or defect Determination of impact of illness or defect on competencyon competency

•Determination of the impact of medications Determination of the impact of medications on competencyon competency

•Determination of restorabilityDetermination of restorability

Impact of Mental Illness on Impact of Mental Illness on CompetencyCompetency• Mental illness does not equate with Mental illness does not equate with

incompetencyincompetency

• Conditions with a higher likelihood of Conditions with a higher likelihood of incompetence:incompetence:– Untreated schizophrenia or Untreated schizophrenia or

schizoaffective disorderschizoaffective disorder– Manic state of bipolar disorderManic state of bipolar disorder– Severe head injury, dementiasSevere head injury, dementias– Mental retardationMental retardation

Impact of Mental Illness on Impact of Mental Illness on CompetencyCompetency• The competency evaluation is a The competency evaluation is a

current state examinationcurrent state examination

• Mental illnesses fluctuate in intensityMental illnesses fluctuate in intensity– Natural course of the illnessNatural course of the illness– Variable compliance with medicationsVariable compliance with medications– Impact of incarceration on the course of Impact of incarceration on the course of

the illnessthe illness

RestorabilityRestorability

• Factors consideredFactors considered– Outcome of prior efforts at treatmentOutcome of prior efforts at treatment– Outcome of prior efforts to restoreOutcome of prior efforts to restore– Responsiveness of underlying condition Responsiveness of underlying condition

to treatmentto treatment– Capacity to learn new materialCapacity to learn new material

Considerations in Placement Considerations in Placement RecommendationsRecommendations

– InpatientInpatient•Safety concerns-suicidal or potential for Safety concerns-suicidal or potential for

violenceviolence

•Severe degree of psychotic symptomsSevere degree of psychotic symptoms

•Need for court ordered medicationsNeed for court ordered medications

•Poor outcome of prior efforts at treatmentPoor outcome of prior efforts at treatment

•Severe degree of complicating issues such Severe degree of complicating issues such as substance abuse or other medical as substance abuse or other medical conditionsconditions

•Poor support system to help with Poor support system to help with compliance and activities of daily livingcompliance and activities of daily living

Considerations in Placement Considerations in Placement RecommendationsRecommendations

– OutpatientOutpatient•No significant safety concernsNo significant safety concerns

•Relatively stable living situationRelatively stable living situation

•Willingness to comply with medicationsWillingness to comply with medications

•Lack of complicating medical conditions that Lack of complicating medical conditions that require nursing supervisionrequire nursing supervision

•Lack of substance abuse that is significantly Lack of substance abuse that is significantly impeding treatment responseimpeding treatment response

How to get the best How to get the best examinationexamination

• Include important information in the Include important information in the motion for examinationmotion for examination– What specific problems are you What specific problems are you

observingobserving– Relevant information from friends and Relevant information from friends and

familyfamily– Attach psychiatric and medical recordsAttach psychiatric and medical records

How to get the best How to get the best examinationexamination• Remember the examiners are not Remember the examiners are not

private investigators, mind readers, or private investigators, mind readers, or fortune tellersfortune tellers– Sometimes paranoid individuals may Sometimes paranoid individuals may

withhold information from examiners that withhold information from examiners that they may convey to their attorney or familythey may convey to their attorney or family

– There is a time limit to the orders that There is a time limit to the orders that often prevents obtaining medical records often prevents obtaining medical records prior to the due date for the reportprior to the due date for the report

How to get the best How to get the best examinationexamination• Feel free to attend the examinationFeel free to attend the examination

• Feel free to contact the examiner with Feel free to contact the examiner with specific concerns or questions after you specific concerns or questions after you receive the report. Addendums can be receive the report. Addendums can be made if warranted.made if warranted.

• Some defendants are adept at Some defendants are adept at malingering and the examiner can malingering and the examiner can explain the basis for concluding this is explain the basis for concluding this is present.present.

ConclusionConclusion