Question for the Forensic Psychiatrists or Psychologists: Comp Evals

[SomeDoc]

(Comp meaning competency)

How much time on average do you spend completing one? 3 hours? 8 hours? More than 8 hours? (Include collateral record review and time spent with the individual, minus travel time).

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[whopper]

Well in all honesty sometimes in less than 5 minutes I have enough information to come to a decision but I always spend at the very least about 30 minutes, sometimes a few hours depending on the case.

On a few occasions I had to see the patient serially over the course of days.

A patient showing a presentation of psychosis and is clearly not malingering could literally be correctly ascertained quickly but in fairness and respect to the court system you must do a thorough evaluation, meaning do a mental status exam, get a good history, collateral, ask the questions, and consider a malingering test.

Do you specifically mean competency to to stand trial in court or another area?

 

[Therapist4Chnge]

Do you specifically mean competency to to stand trial in court or another area?

Also, to add on to whopper's inquiry...do you mean competency or capacity?

 

[SomeDoc]

Sorry, yes by comp I mean competency to stand trial in court. Are you planning on being at aapls conference this October whopper?

 

[SomeDoc]

Well in all honesty sometimes in less than 5 minutes I have enough information to come to a decision but I always spend at the very least about 30 minutes, sometimes a few hours depending on the case.

On a few occasions I had to see the patient serially over the course of days.

A patient showing a presentation of psychosis and is clearly not malingering could literally be correctly ascertained quickly but in fairness and respect to the court system you must do a thorough evaluation, meaning do a mental status exam, get a good history, collateral, ask the questions, and consider a malingering test.

Do you specifically mean competency to to stand trial in court or another area?

Do you administer the TOMMS, etc. yourself or refer this aspect of the eval to a psychologist?

 

[notdeadyet]

60-90 minutes doing the eval. Maybe 2 hours to do the full write up.

 

[Therapist4Chnge]

To clarify. Multiple measures should be utilized to look at validity, not just one.

 

[whopper]

I will not be at AAPL. It's a combination of reasons. Alan Felthouse-one of the top guys in forensic psychiatry is in my department and he absolutely has to be there to give leadership. We just got a new forensic psychiatrist that IMHO could be a leader in the field and he's an AAPL officer. The way the department is if too many doctors take off at once the ship sinks because we don't have a big department so guess who's the guy that's forced to stay home? Me.

I don't mind cause my kids are at that age where leaving them just for a few days is very sad for me. Maybe I'll go to mid-west AAPL.

As for competency to stand trial evals, AAPL I believe has a manual on doing these.
My recommendations: read the manual (if it exists I haven't checked my manual recently), consider doing a Georgia Court Competency Test or one of the other tests.

I've done around 150 of these evaluations.

Do you administer the TOMMS, etc. yourself or refer this aspect of the eval to a psychologist?

I'd do the TOMMs myself (if malingered memory is a suspicion but you have to be careful with psychological testing. First some of these test really are for the psychologists because we don't get enough training to understand them such as the MMPI. Another thing is some tests could be done by a psychiatrist where our training is enough but the author of the test will add a rule saying something to the effect of -this test should only be done by a licensed psychologist.- You need to know these things before administering these types of tests.

Also bear in mind that if memory is a problem the Supreme Court ruled that defendants that have memory problems could still be competent to stand trial but if they do not recall the events that led to their charge and arrest they must be afforded to use hypothetical defensive theories that could've happened that the defendant wasn't aware happened due to poor memory. This is a reason why forensic psychiatry may be best done by forensic psychiatrists. You just can't read a manual and do a competency eval in all cases. Little things like this creep up and if you don't have the training you don't know these things.

 

[PSYCHEVAL3]

In my area judges frequently ask for competency and sanity. I spend on average 4 hours. This includes the interview, psych testing, reviewing the criminal complaint, reading hospital records, school records, interviewing others, and writing the report. I evaluate about 5 people a week.

 

[shan564]

Also, to add on to whopper's inquiry...do you mean competency or capacity?

Why would a forensic psychiatrist be called in to do a capacity evaluation?

 

[Therapist4Chnge]

Why would a forensic psychiatrist be called in to do a capacity evaluation?

...because many people confuse the difference between capacity v. competency.

 

[EatSleepForensics]

Why would a forensic psychiatrist be called in to do a capacity evaluation?

Depending upon the place of forensic psychiatry within the infrastructure of an academic hospital system, this can occur more frequently. In our system, forensics provides consultation to the hospital psychiatry and med/surg services on complex capacity cases. A few years ago, I developed guidelines for the C/L service about capacity assessments and addressing particularly difficult issues in reports to the court. This cut down on the need for forensics quite a bit. Now I only get involved in the most difficult cases, where the office of clinical affairs, the ethics committee and the office of general counsel are often also involved. These cases usually deal with extreme personality disorders and repeated problems with poor judgment in managing health care decisions leading to significant complications and repeated hospitalizations.

 

[EatSleepForensics]

(Comp meaning competency)

How much time on average do you spend completing one? 3 hours? 8 hours? More than 8 hours? (Include collateral record review and time spent with the individual, minus travel time).

The time for competency assessments and reports is highly variable, from 60-90 minutes total on the light end to several hours on the heavy end. I'd say there are a few rate-limiting variables:

• the quality of the referral question: if you have to do the case blind without any idea why the attorney referred the defendant, it takes longer because you have to be more thorough to ensure you don't miss something subtle. I often try to avoid this by making myself as available as possible to attorneys when I try to contact them - I give my cell phone for return call or text -at any hour -and also give my email, which is often helpful in getting return communication before the examination.
• the domain of competency impaired: if it is the capacity to understand the basics of their legal situation, their options and how court works, you are likely dealing either with acute mania or thought disorder, or intellectual impairment. If it's the former, it can be a quick examination due to the obvious level of impairment and validity of the presentation. If it's the latter, the examination can be much more tedious and will also require psychometrics with interpretation, and possibly a second examination. If the defendant's impairment appears to be in their capacity to assist their attorney, the examination can be very involved, usually depending upon how subtle vs. overt the defendant's psychosis is and the extent to which it influences their decision-making. Malingering is not a significant issue in the majority of cases, and especially not to the level where exaggerated symptoms would actually impact competency if they were taken at face value. Testing to get at malingering is really only needed for a sliver of competency examinees.
• the nature of the case and how much you know about the defendant's legal jeopardy and options: again, this makes communication with the attorney critical. There are many cases where the options are quite limited and the outcome is very easy to anticipate. This makes discussion with defendant about their plan and expectations straightforward, and in turn the competency assessment is much more linear.

In some places (including fellowships), psychiatrists and fellows aren't necessarily in the general examiner pool but instead have some latitude in choosing cases - these are disproportionately "interesting cases" that tend to be more complex and take longer.

 

[SomeDoc]

Thanks all, for the valuable feedback. I was trying to figure out where on the spectrum of efficiency I was based on the time I was taking to complete mine; sounds like I'm not too far off the norm which is a relief.

 

[shan564]

...because many people confuse the difference between capacity v. competency.

It's a bit condescending to assume that the person was making a mistake about a very fundamental part of the job, especially when the original post was very clearly describing a competency evaluation rather than a capacity evaluation.

 

[Therapist4Chnge]

Yes, because I obviously meant it in a condescending way since these things are NEVER confused and/or conflated, even by healthcare professionals and lawyers.

 

[honsano]

In fellowship I spent about 2hr average with some taking less and some a bit more. Rarely did I have to revisit the situation later but that up to the complexity of the case. I always spent way more time writing the reports though.

This stuff is pretty variable. I was in talks with a community mental health program to do their evals. They wanted me to complete 3per day with reports in hand. rhats a bit too fast for me but they had a person doing it before.

 

[whopper]

I've unofficially grouped competency evaluations to stand trial in two categories.
1-The evaluator does a standard job. Such an evaluation takes a handful of hours. You see the evaluee, you try to get as much collateral in a small amount of time, and you write the report and give it.
Some courts have psychologists and psychiatrist that do these rather quickly because literally on-the-spot they're faced with a defendant that shows signs of mental illness and need a quick evaluation.
Cincinnati's courts utilized a private firm literally across the street from the courts that was made of mostly psychologists but a few psychiatrists that saw defendants literally the same day the court requested and had an evaluation done sometimes the same day.
They could afford to be quick because if they were wrong-and the patient was found incompetent to stand trial, the people in the hospital did a more thorough job and had the time to get it right while the people at private firm across the street needed to be more expedient, and not surprisingly for that reason erred on the side of saying the defendant was not competent and recommended they be sent to the hospital.

2-The evaluator does the job needed. This could range from a very short duration even several days. Short? Here's an example: the evaluee has a severe TBI to the degree where he cannot even feed, dress, or bathe himself and is not expected to recover. Long? The person is suspected to be malingering and the person is a very good malingerer. In such a case it'll be slowed down by the malingering evaluation that will need to be done.

Sometimes , I would find an evaluee competent that the private firm doctor did not find competent. In such cases it turned out the evaluee was malingering or very very careful evaluation did show he/she was truly competent.

What I found very frustrating with this was there was a particular doctor at the private firm where if I ever disagreed with her, she'd start huffing and puffing that I was a right-wing conservative that was hell-bent on getting everyone on trial. This is a doctor that literally spent less than an hour evaluating someone while I spent literally at times 15 hours evaluating that same person. Of course I am going to do a more thorough job when I am given 1 month to do the evaluation and she was given about an hour. Just as when I admit someone from the ER I wouldn't be surprised if the inpatient doctor after a few days found out stuff I didn't from my initial evaluation in the ER.

One time I tried to extend an olive branch and talk to her about a case where she disagreed and aside from her being pretty much stone-walled into her position, her voice was high-pitched and pretty much just irritating to listen. After about 10 minutes of talking to her, realizing I was going to get nowhere and just plain getting a headache hearing her talk I just gave up on her. Besides all the judges, lawyers and doctors I knew pretty much agreed with my opinion on what was really going on with her.

If you are a doctor working in a state hospital with a forensic unit such an evaluation can be done in a manner that is compatible with your job. That is you can drop by the evaluee's unit daily and do serial checks. The court and the hospital should make sure that the doctor doing the evaluation is not treating the person (e.g. they'll get the psychiatrist on the neighboring unit to do the competency evaluation). I've seen cases where psychologists did a large battery of tests, literally several because the case was complicated. Those types of cases can take days.

 

[shan564]

Yes, because I obviously meant it in a condescending way since these things are NEVER confused and/or conflated, even by healthcare professionals and lawyers.

Sorry, I shouldn't have accused you of intentional condescension, but it's quite presumptuous to think that a forensic psychiatrist would know so little about forensic psychiatry as to be unable to distinguish competency from capacity - I wouldn't even think to suspect that unless he said "competency eval" and then went on to describe a capacity eval, which he wasn't doing. In the brief one line that was mentioned in the original post, it was obvious that the OP knew that he/she was referring to a competency eval - a capacity eval never involves forensic consultation, 8 hours of evaluation, and travel time.

 

[Ceke2002]

...ventage nvm.