Hello and welcome. I'm Dr. Benjamin Dress, Professor and Rosalind Carter Chair in Mental Health at the Rollins School of Public Health at Emory University and health systems expert for FMI Advisor. I'm pleased that you'll be joining us for today's FMI Advisor webinar, Competence to Stand Trial and Competence Restoration, The Basics. FMI Advisor, also known as the Clinical Support System for Serious Mental Illness, is an APA and SAMHSA initiative devoted to helping clinicians implement evidence-based care for those living with serious mental illness. Working with experts from across the FMI clinician community, our interdisciplinary effort has been designed to help you get the answers you need to care for your patient. Today's webinar has been designated for one AMA PRA category one credit for physicians, one continuing education credit for psychologists, one continuing education credit for social workers. Credit for participating in today's webinar will be available until May 8th. Slides from the presentation today are available in the handouts area found in the lower portion of your control panel. Select the link to download the PDF. Please feel free to submit your questions throughout the presentation by typing them into the question area found in the lower portion of your control panel. We'll reserve 10 to 15 minutes at the end of the presentation for Q&A. Now, I'd like to introduce you to the faculty for today's webinar, Dr. Debra Pinals. Dr. Debra A. Pinals is an adjunct clinical professor at the University of Michigan Law School. She also serves as the director of the program in psychiatry, law, and ethics, and as a clinical professor of psychiatry at the University of Michigan Medical School. Dr. Pinals is also the medical director of behavioral health and forensic programs for the Michigan Department of Health and Human Services. She's board certified in psychiatry and forensic psychiatry, and is a diplomat of the American Board of Addiction Medicine. Thank you so much, Dr. Pinals, for leading today's webinar. Well, thank you, Dr. Drost. Really appreciate the kind introduction, and it's always a pleasure to be here with SMI Advisor and talk about issues that are of national relevance and helpful for practitioners and others. Let me start by just letting people know that I have no relationships or conflicts of interest related to the subject matter of this presentation. I consult to multiple jurisdictions, and I teach various disciplines related to the topics in this presentation. The positions and views expressed in this presentation are my own and do not represent the views or positions of any organizations, agencies, or other entities with whom I am affiliated. And with that, let me begin by reviewing what we're hoping to accomplish today by having your participation. It is my hope that at the end of participating in this webinar, that you will be able to describe competence to stand trial and why it is important in our society and our system of jurisprudence in the United States. I'm also the goal, the objective for today is to be able to develop a pathway for individuals with serious mental illness through the competence system and beyond, and have you all as listeners help in that endeavor. And then finally, participants should be able to review competence restoration services and associated system dynamics that are happening across the United States today. And with that, let me begin with the very first objective, describing competence to stand trial and why it is important. So competence to stand trial is the concept that a criminal defendant, anyone charged with a crime in the United States should be able to face the charges competently. And this is grounded in constitutional rights. And when we think about the rights in our society, our constitution is that fundamental document that upholds the basic tenets of our society. Rights are things that are not earned. These are things that are absolute established fundamentals for anyone in the United States. And the two constitutional rights that are represented in competence to stand trial or thought to be significant are the sixth amendment right. The right to face one's accusers and have the ability to really, when one is charged with a crime, be able to appropriately do so and face the accusations against one. And then 14th amendment rights, which are both substantive and due process rights that show that we have a right to be treated fairly, that there should be some process as well as the substantive issues at hand should be dealt with in a criminal process in a fair way. And what we know is that this has been tested over and over and brought up to the US Supreme court in many, many cases. I won't go through all of them, but the very first case that looked at this issue was the case of Dusky versus United States in 1960. And essentially this was the story of a man who had been accused of a crime and had been at trial, seemingly having some type of mental health issue. And the question was, was he really competent to stand trial? He was oriented to person, place, and time, but he was having other symptoms of mental illness. And the US Supreme court established that there'd be a standard to determine whether a defendant is competent to stand trial. And the standard that was established in 1960 was whether this defendant had sufficient present ability to consult with his lawyer with a reasonable degree of rational understanding, as well as a rational and factual understanding of the proceedings against him. And this again, set the floor for the United States for what should be expected in competence to stand trial. And we look at this very carefully when we're doing competence to stand trial evaluations. For example, each word within this standard has meaning. What is sufficient present ability? Means that there has to be enough ability for the individual to be able to go through the trial process in a way that's going to be fair and dignified and accurate. And we'll get determined by a judge who ultimately determines a defendant's competence to stand trial, even if clinicians are doing evaluations to recommend what they think about that. Present ability means that ability is here and now, and ability means capacity. It doesn't mean willingness. A person might not be willing to stand trial or not want to stand trial and might even feign symptoms to try and not stand trial. However, the Dusty standard requires that that individual have the ability to consult with their lawyer with what's considered a reasonable degree of rational understanding and a rational, as well as factual, understanding of the proceedings against him. That means that the defendant need not have a lawyer's level of knowledge of what goes on at a trial, but they have to have a reasonable degree of rational understanding, as well as a rational and factual understanding of the proceedings against them. And so generally, we break this down into different domains of abilities that an evaluator would be examining and a judge would be looking for to establish whether the defendant meets those Dusty criteria. Now, each state may have their own somewhat modified language about competence to stand trial because there will be state-by-state variation, but essentially the fundamental elements of the Dusty standard will be incorporated in those state-by-state variations. And those would include the following four elements and domains. First, does the defendant have an understanding, again, not just a factual understanding, but a rational understanding of the charges, verdicts, and potential consequences? So do they know what they were charged with? Do they know what the potential verdicts might be and the potential consequences of each of those verdicts? For example, that a guilty finding could result in a period of incarceration or a criminal sentence, that a not guilty by reason of insanity verdict would potentially end in a hospitalization that could last longer than had they been found guilty of the charges. So do they really understand those charges, verdicts, and potential consequences? Do they have a factual as well as rational understanding of the trial participants and process? And here we might say, does the individual understand, for example, what the role of the judge is? What the role of the prosecutor is? What the role of the defense attorney is? And they may have, again, a factual understanding of this, but it may be impacted by delusional beliefs. For example, an individual may think that a judge is part of a conspiracy from the mafia who's implanting ideas into their gold fillings. And that would be part of a delusional belief that would make them not be able to see that the judge's role is one of a neutral decider in the case. And so they might have a general understanding of what a judge does in other cases, but for their case, they may be impacted by ideas of reference or delusional thinking. Similarly, they may be impacted by those ideas around trial processes. And again, a defendant is not required to know about trial process the way a lawyer would know or somebody who's gone through law school would know, but they are entitled to, from a constitutional perspective, have a basic factual and rational understanding to a sufficient degree as determined by the judge. Also, we're going to look at their ability to assist counsel. Are they able to assist counsel in a rational and meaningful way to get the best defense available to them? And are they able to make decisions rationally and also factually? So for this, we often look at decisions. For example, the most common decision that a criminal defendant makes is the decision to enter a plea bargain. They have to understand what a plea bargain is, that a bargain, a plea bargain means that they are accepting a guilty plea, often for a lesser sentence. And this, because this is one of the most common decisions as an evaluator, we often spend time helping to ascertain whether the defendant really understands what a plea bargain is or whether they understand what it means to testify, what, how they would look at their own testimony as being helpful or not helpful in a particular case. Another common decision that defendants have to make is whether to have a judge or a jury make the determination if they choose to go to trial instead of accepting a plea bargain. And all of those things would be looked at in competence to stand trial evaluations, examining the defendant's present abilities and how their serious mental illness, if they have serious mental illness, might impact upon those abilities. So this is the competence, you know, what competence to stand trial is. And again, the importance of that competence to stand trial is to ensure that the court processes are fair and accurate and even dignified. And so this becomes highly relevant for courts to ensure that defendants, and based on constitutional rights, that defendants are competent to stand trial. So our second objective is to look at a pathway for individuals with serious mental illness and understand how that pathway operates through the competence system and beyond. So we start with understanding what if someone presents in court with a criminal charge, but they have a serious mental illness and they're exhibiting acute symptoms in court. Well, in the criminal pathway, it is up to the individual's defense attorney or anyone else in court, because it is such a matter of high importance, to request an evaluation of their competence to stand trial so that there is no risk that we would be trying an incompetent defendant. And again, this is a very important constitutional issue so that anyone in the court process is obligated to raise a defendant's competence if their competence is in question. This can be raised at any time in the court proceedings. And as you'll see in the pathway that I'll be describing, an individual can be found competent, can proceed down what we call sometimes the trial highway or the trial pathway, but they might have an exacerbation of their symptoms and the competence issue can be raised again. Competence to stand trial also is not the same as competence to consent to treatment or competence to write a will or competence to waive Miranda rights at the beginning of when they're originally in custody or arrested. Those are different competencies that are raised at different parts of the trial pathway. We're only talking about the part where the defendant is arrested and then brought into court where competence to stand trial is raised. Once that happens, there's often an evaluation that will be ordered to take place. And I'll talk a little bit more about that. And then there are findings and we'll talk a little bit more about this, but just to lay out the general pathway, the findings from a judge would be that the defendant is competent to stand trial. They may be found incompetent, but restorable or incompetent and found to be unrestorable. And then there's going to be a disposition that's going to be required, meaning a next step in the pathway for that individual. And what this means is that individuals for whom competency is raised often become known as forensically involved individuals. And I always view this as a population that crosses over many different systems. They may be individuals who are seen in the community mental health system or in community outpatient services, or they may not have come to the attention of mental health services. And unfortunately, we see people who have, for example, their first break of psychosis and exhibit symptoms and behaviors that come to the attention of law enforcement that then ultimately result in an arrest. And so the first time they present may be in a court setting or in a correctional setting. They may be sent to a forensic hospital along the way or have been in forensic hospitals before, either as defendants for other cases where competency was raised or individuals who were found not guilty by reason of insanity in the past. But there's this overlay of their symptoms and involvement in the criminal settings. And so we often see them crossing over across multiple settings. So this is looking at it from kind of a pathway perspective with a picture. Again, the competency evaluation would be ordered by a judge. There could be defense attorneys who may seek independent evaluations for their clients to see if they, what they think about competence to stand trial. But oftentimes what we're seeing is a judge ordering an evaluation and then that evaluation being conducted by a forensic evaluator that will either be a state certified forensic evaluator through state processes or through county-based processes or based on a list of certified evaluators that a local judge may keep. And so those evaluators can come from any number of places. And we'll talk again a little bit more about that evaluation process. And then the evaluation report is generated. A competency hearing will be held. There will be a finding by a judge. And again, the defendant will either be found incompetent to stand trial or competent to stand trial. If they're found competent to stand trial, they return to the usual criminal case process and competency might be raised down the road or they will be, their case will be dealt with as would any other criminal case. Now, let's talk a little bit more about evaluations and some state differences. And listeners, you may have questions about this for your own state. Every state is unique. We get into lots of questions about how long does an evaluation take or who can do the evaluation? And there's very different mechanics, often driven by state statutes and policy. For example, I've worked across multiple states. You can have state-operated forensic processes where your evaluators are all, for example, I work in one state now in Michigan, the court ordered evaluations are all handled through the Center for Forensic Psychiatry, which is a state-operated service. And people from all across the state will have that initial court-ordered evaluation done through those state-operated and state-certified examiners. There's also, for example, in Massachusetts where I worked, we had a combination of state-operated as well as contracted services that often worked side-by-side for that initial evaluation. There's going to be other models that are available. As I said, these might be county-run, county-funded. There might be a list of private practitioners that courts rely upon in the local jurisdiction. They may have two or three psychologists or psychiatrists on a list of go-to people to get evaluations done for that particular jurisdiction. The states also differ in terms of whether they require multiple evaluators. Some states say you need to have two opinions, three opinions, or a single opinion that will suffice for the competence determination. And so the number of evaluators that are required for the judge to be able to make the determination can differ across different states. Also, which disciplines can do these evaluations will differ depending on state rules and laws. In all states, psychiatrists are eligible to do these evaluations. In most states, psychologists are eligible to do these evaluations. And in some states, licensed independent clinical social workers are authorized to do these evaluations. And we're seeing in some states other disciplines coming on board doing these types of evaluations. For example, in Michigan, for a juvenile competence to stand trial evaluation, we have a much broader array of licensed practitioners who can do the evaluations as long as they've attended a particular training. So that can also differ in terms of the states, as well as the training that they're required to have or what it means to be qualified to do these evaluations. That can look very different across different states. Again, how much time does it take to do an evaluation or how much time is allowed to do the evaluation are two different questions. Different states will have different models. Again, just using my own experience in Massachusetts, we had court clinicians that were available to every court in the Commonwealth of Massachusetts for same-day evaluations. Sometimes we call those screening evaluations that would then determine whether a further evaluation was necessary. In other states, there can be a five-day requirement or even a 60-day requirement for evaluations to take place. And a lot of it depends, again, on how the system is set up, what it means to have the evaluation done, whether the expectation is that the records will be in for the evaluator to have available to them, for example, to review in order to conduct that evaluation and get that report written that would go back to the court. Again, evaluations can take place in different locations. It used to be that evaluations took place in state hospitals. More and more states, in fact, most states now do evaluations in community-based settings, and that can include at the courthouse, in an outpatient kind of clinic, or even in jails. Many evaluations do take place for defendants that are being held in jail, awaiting trial, and the evaluators work with the jails to go out to the jails or do the evaluations. Now, certainly from COVID, many of the evaluations have shifted to virtual types of evaluations across these different settings. And again, where they take place and the mechanics of those can look different. So what does the forensic evaluation process generally look like for competence to stand trial? It can look like speaking. Usually the evaluators will speak with the defense attorney to say, hey, what were the issues that you saw in court where you think that your defendant may have competence challenges, a review of records that are available to see if this is somebody with a history of known mental health issues or not. Maybe it's, again, a first time that they've appeared before some kind of mental health professional for an evaluation. Generally, we will meet with the defendant. The defendants will generally be willing participants in the evaluations, although there's certainly circumstances where an individual may not want to cooperate with the evaluation, and that could be for legal reasons. It could be for reasons related to symptoms. For example, somebody who's quite paranoid who might not want to engage in a conversation, in which case the evaluator has to pull from records and other information to make an opinion if they're able to make an opinion. But we will generally look at the current mental status in light of the past history, and then again, look at those elements about whether this individual is able to understand the trial participants and process, render competent decisions related to their case, their criminal case, as well as how they might comport themselves in court and whether their symptoms make that difficult for them to comport themselves in a positive manner in court. That could be another factor that could render them incompetent to stand trial. And then as evaluators, we will describe the background information, describe the data that was utilized to form the forensic opinion, and then render an opinion. Again, how the opinions are rendered will be dictated by the local state statutes about whether we think this individual defendant is competent to stand trial. Some states will use alternative language like whether the defendant has the capacities associated with competence to stand trial. And then if our opinion is that they don't and we opine them as being incompetent to stand trial, generally, there will be a statutory requirement to render an opinion about whether the defendant has a condition that is likely restorable, where their competence to stand trial is restorable, or whether they would be what we would consider unrestorable. Now, this is a really tricky area, and I think there's a lot of confusion clinically about this. When we say restorable, what we are only talking about is whether this defendant's capacities will be able to be returned or will be able to be lifted to the point where their functional capacities will be able to render them as a competent pretrial defendant. It does not mean that this person will be able to manage their own affairs, that they'll be able to live in their own apartment, that they'll be able to make treatment decisions for themselves. It really is restorability to the level of a competent pretrial defendant. It's not about general treatment capacity or hopefulness or their hope for the future. And very often, there's confusion, I would say, in the field about this definition of restorability, that we're really talking about a narrow issue of functional capacities. The other thing I want to point out is that since there are a not insignificant number of defendants in the competence to stand trial system who might have intellectual and developmental disabilities or youth, we usually don't use restorability as the language, because the idea of restorability is that you're restoring somebody to functioning that they previously had. So we might talk about attainment of capacity or competence to stand trial or remediation of competence to stand trial, but not restorability. We often think about restorability more for somebody who has symptoms of serious mental illness. They've had a recent exacerbation of those symptoms, but with treatment can have, can be restored to functioning that they, in that domain that they previously had. So there may be different language that you see for different populations. Again, if somebody is found competent to stand trial, whether that means that they have, they will go through a trial or enter a plea bargain as somebody competent to do so, they may be found guilty. And if they're found guilty, then there may be a criminal sentence. If they're found not guilty, obviously the case is over and the case may be dismissed. And if there's not enough evidence to prove guilt, but if there is, if they're found guilty, there may be a criminal sentence that would involve probation or time served leading to release with probation officer and conditions of probation. They may be placed in a mental health court. They may be sent to jail for less serious cases, or they may even be sentenced to prison for more serious cases. And then there are some States where there is obviously death penalty and those are very rare cases, but where these issues may arise. And so it is true that once a defendant is rendered competent to stand trial, there is the potential for a guilty finding and for the prosecution and for the judge to issue a sentence. And that's part of what we try and work with defendants in the evaluation. Do they really understand what the criminal charges are that they're facing and what the potential verdicts and consequences of those verdicts are. If a defendant is found incompetent to stand trial, I just want to drill down on this pathway a little bit further, which is if they're found incompetent to stand trial in most jurisdictions, they will be ordered for competency restoration. Now, the only requirement for being ordered for competence restoration, well, the primary requirement is that they be found incompetent to stand trial. Some jurisdictions will say that there's a least restrictive alternative for where that restoration should take place that should be considered. And then they will go through a period of restoration, which I'll be talking about. And then there will be reevaluations of whether their competence has been restored. And again, they may be found eventually unrestorable, or they may be found that they were restored and then sent back again to the trial, the criminal case pathway. If they're found unrestorable, then there may, or at some point not competent in time, the issue has been timed out. There is a possibility that they will be civilly committed either to inpatient commitment or to outpatient commitment. I'm not going to spend a lot of time on that, although there may be questions about that. Competency restoration itself is most commonly done in state hospitals. There are new models, which I'll be talking about related to community based restoration, and some states have jail based restoration. Restoration includes treatment, but mostly involves helping defendants overcome their deficits related to their role as criminal defendants. So again, when people are placed in programming, there is going to be programming that's going to focus on their role as a criminal defendant, not as much about how they're going to pay for their apartment, get their housing, make sure that they're able to get the therapy that they need when they get out of jail. It's not really about that. It's really much more about restoring their capacity as criminal defendants. Again, restoration these days can involve waiting in jail and being returned to jail once a determination is made that they have been restored. And so what we see with this, again, crossover population is that continuity of care can be very challenged because somebody can go to a restoration site like a state hospital and then receive certain treatment to get better to be returned to jail where they're not going to receive the same treatment, where their symptoms are exacerbated. They show up in court and the question is raised again about their competency. So we do see a revolving door and that is a big problem. In terms of the duration of commitment for restoration, states vary on this. However, there is a leading Supreme Court case, Jackson versus Indiana, which in 1972 said, due process requires that the nature and duration of confinement bear some reasonable relation to the purpose for which the individual is confined. So typically you will see time limits of restoration after which you say, okay, we have to call the question. If they're not going to be able to be restored, then they need to be held in an institution. It should be under other grounds to hold them or they should be released because otherwise, and this was this case revolved around a man who had stolen $9 worth of goods, had significant intellectual disability and was deaf and mute and was potentially going to be confined indefinitely as an incompetent defendant. And the case was brought to the Supreme Court and they said, hey, this isn't fair because his deficits made him incompetent to stand trial. So the door in, there was like a wide door to go into the institution, but there is no hope for him getting out because he'll never be restored. And the Supreme Court said, that's true. That's not fair. Due process requires that there be some reasonable relation for confinement to the purpose for which the individual is confined. And after that question has been determined, you need to find a different reason. Now, evaluation and restoration has systems across the United States have had many legal challenges, mostly related to waiting for evaluations, but the litigation has generally centered around getting people out of jail and into what's been considered quote restoration beds. And that's again, primarily because the system was built on using state hospitals for this. And so you have, this is now old data pre-COVID, but again, you see across the United States, many people, many States, most States talking about wait lists to get in to hospital level of restoration services and a change in how state hospitals are being utilized with from 1999 to 2014, most States reporting a dramatic increase in the population served in the state hospital found incompetent to stand trial sent in for restoration. So there's been a lot of culture shifts within state hospitals, readjusting to these populations for restoration services. So what do those restoration services look like in hospitals and other places? And let's talk about this. Remember that most defendants found incompetent to stand trial will have serious mental illness, psychosis, mania. That's the most common reason that an individual may be a significant depression with psychotic symptoms. But these are going to be the most common reasons defendants are found incompetent to stand trial. And then you have a not insignificant second group of people with intellectual and developmental disabilities. There may be people with co-occurring conditions, traumatic brain injury, and another population that is a growing population actually are people with neurocognitive conditions like the dementias who get arrested and then sent into the restoration system. And so we're talking about multiple different conditions that might lead a defendant to appear as incompetent to stand trial. The mainstay of restoration is typically psychotropic medications for those individuals with mental illness. If you can get the appropriate medications to diminish the psychotic symptoms or the manic symptoms or the depressive symptoms, generally speaking with doing nothing else, an individual will be quote restored because they will be less symptomatic and therefore more capable of meeting the criteria for competence to stand trial. There can be some challenges for people who are unwilling to take medications and there's different case law and different jurisdictions handle that issue differently in terms of voluntary versus involuntary medication of the pretrial incompetent to stand trial defendant. But it's really important to think about medications and people, the more we can engage people in positive choice towards medications to get better, the more that we can help people get out of this competency loop that people tend to be in. There's also the non-pharmacological approaches and that generally includes classes, legal education, teaching people what a lawyer is, helping people manage anxiety and what might be non-positive comportment in courtroom, anxiety management so that they don't have disruptive episodes if they're stressed in court. And this really is important, but it's important to realize that this doesn't include what we typically consider re-entry supports for people that include planning and treatment supports for how somebody, when they return back to their community, are going to get housing access or going to get entitlements to food subsidies or whatever else they might need or even outpatient care. It's really focused on helping people stand trial and lots of thoughts about that people may have. So again, restoration goals are legally to help defendant get back to court with sufficient capacity to stand trial, but does not generally include long-term support services and continuity of care planning. Incompetent defendants very often will have housing needs, family needs, they will have sub-co-occurring substance use issues, but these are not generally connected to restoration services. There may be some light touch to these issues, but not generally the deep services that people need. And so there's a lot of efforts right now to try and enhance that, but realize that that goes beyond what the restoration orders require. And so the order for restoration that typically does not have to meet the same legal standard as for civil commitment and you're not committing somebody for general treatment, you're committing someone for restoration when the judge orders that commitment. There's also an important thing to realize that as we see people crossing between the criminal system and the mental health system, that the criminal system looks at risks differently and public safety issues are different. There's been lots of things written about trying not to overemphasize the risk of individuals with serious mental illness or caught in this system, but nonetheless, once they are in the criminal system, it's very often that people then say, well, they need locked settings and we need to have them try locked settings before they reintegrate into community-based settings. And if they've been held in jail, sometimes they're going to have worsened symptoms and worse, they may look more risky than they would be had they not had periods without medications when they were in jail. So it gets very complicated in terms of understanding really what risks do they really pose. Hospital restoration at state hospitals typically takes place on restoration units with group and individual sessions with periodic re-evaluations of competence. And again, how long an individual stays in restoration in a hospital generally is tied directly to the severity of the crime. And it's also important to realize that while they're in a locked setting of a hospital, this can count as time served, which means that many defendants go back to court. And because they've now had, let's say a year, two years time served, when they go back to court, oftentimes their charges are dismissed. And so in essence, there was a lot of effort put into restoring them so that they can stand trial. But because during that period of time, the clock of incarceration or detention has been ticking by the time they go back, there is no trial. And so many people are starting to look at, well, are we really using this resource in a way that makes sense? And so how do we make sure that people are in the right resource for the right reason? Again, the restoration services often include treatment planning around teaching people about their charges, understanding their possible consequences, how to work with their lawyers, how to think about courtroom procedures, and integrate this knowledge to make legal decisions. Now, again, because there had been this reliance on inpatient services, but clinically not everybody needs an inpatient level of care who's in the competency system, there has been this build out of what we call, it goes by two different names usually, Community-Based Competency Restoration, CBCR, or Outpatient Competency Restoration Programs, OCRP, or Community Restoration, CRP, so you'll see different acronyms being used in different states. This, again, is data pre-COVID, where states are trying to build out community-based options. Elements that include different things, although it's not always clearly defined in state programs, but generally the availability of treatment or habilitation supports at the proper level of care, whether it's outpatient services or ACT teams supporting them, and then linkage to what's going on with their criminal case, and then, of course, these restoration elements like legal education that's going to be part of what they would receive in an outpatient program. The Slater Method was promulgated in 2003, before 2003, but written up in 2003, looking at particular nuanced version of competency restoration for defendants specifically with intellectual disability, and they have both inpatient and outpatient versions that help, you know, educate the defendants, help them diminish their anxiety, and the outpatient version helps avoid confinement that could foster further regressive behavior and make things look worse. One study that examined a number of different outpatient community restoration programs that they had been developed over the last, I'd say, decade, decade and a half now, the size of the programs can include just a few participants to over 100 across the state. The supervision from courts, most of them operate as kind of pretrial programs under a court supervision. Most states will only consider people charged with misdemeanors or nonviolent felonies for community-based restoration. We see, just like we see demographics with criminal cases, more men than women, more minorities, more often in urban areas, and again, the majority of people are people with mental illness. Some will have intellectual and developmental disabilities, and usually the people in outpatient community restoration, competency restoration programs are going to be taking medications voluntarily with stable mental status. They may have substance use needs, but that may not be a specific component. People might be getting various levels of supports while they're in competency restoration in the community, like outpatient level ACT teams, forensic ACT teams. They might be in residential treatment centers, like in getting more supports from a residential support perspective, or even inpatient level of care in an acute setting rather than in a state hospital. And there's complex data looking at outcomes of these programs that can include looking at rates of restoration. I just put a caveat out there about what are rates of restoration actually mean. The data is quite variable to talk about what are the rates of restoration, 35 to 95%, which is obviously a wide variability, with the average being about 70% restorable. You can really look at it as a parallel to how likely are people to get a diminution in symptoms that allows them to regain that functional cognitive capacity to be able to meet those criteria of the DUSCIE standard. And so it's not surprising that you're going to see a significant number of people with serious mental illness, especially get better with medications. Some will be what's considered unrestorable where they have ongoing cognitive deficits or ongoing symptoms that just continue to interfere with their trial related capacities. And we sometimes see people with more chronic conditions and low level charges. So there may be more people who are deemed unrestorable in outpatient programs, probably because of a selection bias for who's eligible for outpatient restoration anyway. The timeframe for restoration, again, very complicated, fraught data because it can depend on when the court adjudicates the case and how quickly the evaluations are done. So it may have nothing to do with, or it may not just have to do with symptom diminution. It may have to do more with system complexity. But we do see in general that restoration, if it's going to happen, is going to happen within the average, some say would be 149 days in community-based settings. I think, again, that's really complicated data because of how long it takes to do the evaluations and to do those assessments. Negative outcomes, what would be considered in the research, quote, a negative outcome, which I'm not always thinking is negative, obviously it would be a negative outcome for somebody to be arrested or to leave a program that you don't want to leave a program. A decompensation with serious chronic relapse and conditions I don't like to see as a, quote, negative outcome. It may be that we need to do better with illness management and engagement strategies. And rule violations may also be seen as a negative outcome, at least as the courts were concerned. If you identify somebody who's having symptoms who needs a higher level of care, that that is part of illness management and we don't want to stigmatize what that means. But from a court's perspective, that might be viewed as a, quote, negative outcome. Hospitalization, reconsideration of a treatment plan, or convening of stakeholders to reassess the needs of the individual can help with that. In terms of outpatient competency restoration, there's no one right way to operationalize these programs. There's no one model that's been shown empirically to yield better outcomes than others. Since they're relatively new, the programs have little outcome data suitable for true analysis for comparisons, and there's a lot of work being done to expand data on this. But what we really have to understand is for a person to be considered for outpatient restoration, would they be considered appropriate for an outpatient level of care or do they need a hospital level of care? Whether they need a locked setting or not, and like a jail setting is a different question. And again, sometimes we see courts and prosecution and defense kind of answering the question from a different angle. From a treatment angle, we look at what level of care do they need? What would risk or failure to appear look like from a community-based alternative? So how do we address that? If that happens, are individuals going to adhere to the treatment that's recommended and who's going to provide the services are all questions that need to be addressed as somebody who's looking at outpatient restoration. Medication management is another question that needs to be looked at. And so we want to think about, again, does this person need medication that's managed on an inpatient setting? If we can manage the symptoms in an outpatient system, we want to make sure that we're using thoughtful psychopharmacology with appropriate treatments to help that individual, again, have a diminution in symptoms in a safe manner. Again, there is jail-based restoration that this is data, again, pre-COVID. I think these programs, several states have been looking at these programs with interest and these focus on a select group of people who are on jail wait lists. And there are lots of different views about these jail-based restoration programs with people raising concerns about really, are jails the right environment to do these types of programs? And others saying, well, since there are wait lists, there should be programs within jails that look to get treatment to people sooner. My position is that jails should provide care for individuals regardless of their competency status. And if care is provided across the board, then perhaps some of this revolving door can start shifting. And then regardless of where restoration takes place, we have to think from a sequential intercept standpoint of making sure that transitions in care, while people are on community supervision, that are going to be really important that we think of the whole person and making sure people with SMI have the care that they need. And so you see many things happening, cases get dismissed, there may be adjudications. And so this re-entry support for reducing the revolving door is really critical. Some states are trying to develop these navigators where there's somewhat like enhanced case managers who are supporting individuals as they move out of the competency system and back into treatment as usual. And so there's lots of things to consider in this continuity of care, maintaining restoration once it's been established, making sure medications are available across sites, making sure systems are using services efficiently, and re-evaluating competency appropriately so people aren't languishing in systems without that evaluation. And of course, with the workforce challenges that we have, we really need to be mindful of trying to maximize efficiencies, and of course, utilize peers and transitional supports to help people stay out of these systems, if at all possible, by avoiding arrest, diverting people from the criminal system, building out cross-training so people are aware, like trainings like this, so people are aware about what competence to stand trial is and what restoration is. And remembering that times of transition, like community restoration, they need more than just restoration, getting restoration done, we really need to help people and support them over the long run with coordination, collaboration, and system transformation and partnership so that the front and back door that may be related to clinical, forensic, judicial, political, and public safety influences to services and systems are well-coordinated so that the people involved in these systems and the person served get the best care across the sequential intercept model as we look at opportunities to divert people from the competency system, and again, into programming. So just to conclude, competence to stand trial systems are complex, they're multidimensional. Individuals for whom competence to stand trial is raised can benefit from having more community and hospital providers understanding what that legal status means and what it means for treatment planning. So I really appreciate people signing on to a webinar to learn about this, and we really want to continue to divert individuals with SMI from the criminal legal system. And whether they're competent or incompetent shouldn't mean that they aren't eligible for diversion programs, and so we really want to make sure that regardless of where they sit in the system, that they have the options for diversion programs. And there are references that we provided on the slide deck, and with that, I will say thank you for your attention. Thanks. Thanks so much, Dr. Pinal, it's really informative and fascinating presentation. Thank you. We're going to shift into Q&A in a minute, but before we do, I just want to take a moment to let you know that SMI Advisor is accessible from your mobile device. Use the SMI Advisor app to access resources, education, and upcoming events, complete mental health rating scales, and even submit questions directly to our team of SMI experts. Download the app now at smiadvisor.org forward slash app. So there are a lot of questions, I'm going to try to lump a few of them together. The first couple are around ethical issues, so I wonder if you could reflect a bit on the ethical issues of competency restoration for people for whom that may mean incarceration, and then relatedly, how you think about the privacy of information that is shared about potential guilt or innocence during the restoration process. Yeah, great question. So first of all, there's been a lot written about the ethical issues of clinicians providing restoration services, and I think state hospitals have grown comfortable with that role, but providers are still kind of digesting it. One ethical argument in favor of it is that we want to help people kind of restore our treatment role is to help people get back to their best level of functioning. And even if that means at the end of the day, they have to face the consequences of some of their actions that resulted in a criminal charge. But our job is to get them to their best level of functioning, otherwise, we risk further stigmatizing people with mental illness and leaving them to languish in this uncertain space of being incompetent. So getting people to capacity is part of the work that we do every day. And it's just that when this happens, then they're facing their charges, but they're better able to face their charges because of that. So I think that's one of the ethical arguments. There's many more things to say about that. In terms of the information sharing, there are ethical standards for forensic evaluators to not provide self-incriminating information in a competence to stand trial evaluation. That's generally the rule of thumb that we don't say, you know, Johnny said that he, you know, committed that robbery on Monday at 8 p.m. and was, you know, so we don't put that in. That's not relevant. What's relevant is their capacity to understand the charges. Do they understand they were charged with robbery? Do they understand what the criminal complaint says about them so that they can weigh evidence and that kind of thing so that they can get the fairest trial? The competence to stand trial evaluation isn't there to be used for guilty findings. Great, thank you. That was very helpful. Thank you. We also have a few questions about kind of the, you know, the proliferation of persons who are in state hospitals awaiting restoration. So a few questions both about, you know, why this is the case and then perhaps if you have any thoughts about at a policy level about ways of remediating that. Yeah, I mean, we are working at many policy levels trying to figure out why and how to remediate. So this, that's a very complex question. I would say that states that some states have attempted to address this, these issues through legislation. For example, we know that many of the people coming in through the competency system are charged with misdemeanor crimes, low level offenses for often nuisance issues who would not be going to trial anyway. So spending a lot of resources on restoring them to be able to go to trial doesn't really make a lot of sense. There's challenges with that too, because, you know, from a prosecution standpoint, a low level misdemeanor might present another type of risk for somebody later becoming a higher, you know, charged with higher crimes. And so there's different competing views about that. But we do know that people with serious mental illness are arrested more often for lower level charges and more of those individuals are going to be found incompetent to stand trial. And so we, there's legislation people have proposed. That's just one example of a strategy. Many states were developing ways to get ahead of this when COVID hit, some of the numbers went down. The numbers of people in jails went down. There has now been a kind of a resurgence. Jail numbers are going back up generally. And with that, the people with complex needs with, you know, co-occurring substance use and mental health concerns are also going up. Some people have speculated that some of the methamphetamine usage is creating more people going up in court, looking impaired. And so that their competency is being raised. So there's a number of hypotheses as to why the numbers are, seem to be going up. Great. I, it looks like we're at the hour, so there are a lot of other good questions in the chat. I believe there's a ability to participate in the discussion board around this that people may want to take advantage for those who have remaining questions. But it's wonderful to see so much interest around this important topic. So yes, it's the SMI Advisors Webinar Roundtable Topics Discussion Board, and it's a way to network and share ideas with other clinicians who participate in the webinar. If you have questions about this webinar or any other topic related to evidence-based care for SMI, you can get an answer within one business day from one of SMI Advisors National Experts on SMI, the services available to all mental health clinicians, peer support specialists, administrators, and anyone else in the mental health field who works with individuals who have SMI. It is a completely free and confidential service. SMI Advisor is just one of many SAMHSA initiatives that are designed to help clinicians implement evidence-based care. We'd encourage you to explore the resources available through the Homeless and Housing Resource Center, the Center of Excellence for Behavioral Health Disparities and Aging, the Suicide Prevention Resource Center, the Peer Recovery Center of Excellence, and the Mental Health Technology Transfer Centers. These initiatives cover a wide range of topics related to your practice. To claim credit for participating in today's webinar, you'll need to have met the requisite attendance threshold for your profession. Verification of attendance may take up to five minutes. You'll then be able to select Next to advance and complete the program evaluation before claiming your credit. Please join us on March 9th as Dr. Dawn Sugarman presents Digital Interventions for Co-Occurring Substance Use and Psychiatric Disorders. Again, this free webinar will be March 9th from 3 to 4 p.m. Thursday. Thank you for joining us. Until next time, take care.

Competence to Stand Trial

Competence Restoration

Legal System

Dusty Standard

Serious Mental Illness

Evaluation and Restoration Process

Psychotropic Medications

Ethical Issues

Privacy

Diversion Programs