Fitness/Competency to Stand Trial: A Conceptual Overview, Review of Existing Instruments, and Cross-Validation of the Nussbaum Fitness Questionnaire

Abstract

Competency to Stand Trial or Fitness to Stand Trial (FST) is the most frequent referral issue facing forensic mental health professionals (FMHPs) and consumes considerable scarce resources in the process. This article summarizes minimalist and expanded legal approaches to FST and briefly describes three instruments developed by FMHPs to structure FST assessments. We then present evidence supporting the validity of the Nussbaum Fitness Questionnaire for efficiently screening individuals for fitness and blatant or subtle malingering. The paper ends with a number of suggestions to optimize use of these instruments within the current set of forensic mental health practices. Specifically, it is suggested that use of the screening instrument could reliably eliminate up to 70% of current referrals for complete assessments while the more in-depth semistructured interviews be utilized to confirm unfitness, especially when the mental health professional has more than trivial doubt regarding an individual's FST. [Brief Treatment and Crisis Intervention 8:43-72 (2008)]

Forensic psychiatry in Pakistan

“…One of the fundamental gatekeeping roles of the criminal justice system is assessing the accused's Competency to Stand Trial (US), or Fitness to Stand Trial (Canada and UK) (Nussbaum, Hancock, Turner, Arrowood, & Melodick, 2008). In Pakistani law this is defined as the 'capacity to defend'.…”

Screening and assessment of crime victimization and its effects

“…Clinical assessments differ from forensic evaluations that are conducted to determine whether crime-related symptoms warrant some type of compensation or disability, to detect malingering (Vitacco et al, 2008), to guide sentencing in criminal cases, and to assess fitness or competency to stand trial (Nussbaum, Hancock, Turner, Arrowood, & Melodick;. (For information about forensic assessment, see O'Donohue & Levensky, 2004;Springer & Roberts, 2007).…”

Adjudicative competence

“…The latter are generally construed in terms of the individual’s capacity to understand the relevant information, to appreciate its significance for his or her situation or condition, and reason with that information (such as consider possible consequences of the various alternatives), as well as to express a clear choice [7,8]. Although Bonnie’s model has been widely discussed, its legal status from subsequent case law remains murky [9]. In 1993 the Supreme Court rendered a decision in the case of Godinez v. Moran , which some have read as indicating that decisional capacity is not necessary, but others have interpreted it as indicating that decision making capacity is already inherent within the Dusky criteria [2,10].…”

“…Recently published guidelines from the American Academy of Psychiatry and the Law (AAPL) endorse the latter interpretation [11]. The preceding is just one many potential example of how the precise interpretation and application of the Dusky standards, and subsequent court decisions, as well as integration with state law, remain a complex endeavor [9]. …”

“…But the MacCAT-CA is just one of several available instruments, all of which have their strengths and limitations. Detailed comparisons of these instruments are available in several excellent critical reviews [2,9,11,29], but the strengths and limitations of some of the most common instruments are listed in Table 1. It is important to keep in mind the that, as noted in the AAPL guidelines [11], “Designers of these instruments intend that they be used in concert with, rather than as a substitute for, a more comprehensive clinical examination” (p. S43).…”