Developing Court Competence Developing Court Competence Through MusicThrough MusicMarch 24, 2012March 24, 2012

WRAMTA Regional ConferenceWRAMTA Regional ConferenceSalt Lake City, UTSalt Lake City, UT

Mary E. Alvarado, MT-BCMary E. Alvarado, MT-BC

Yu-Chuan Chen, MTYu-Chuan Chen, MT

Atascadero State HospitalAtascadero State Hospital

Atascadero State Hospital – A Atascadero State Hospital – A Quick LookQuick Look

• Current Population +/- Current Population +/- 10001000

• All Adult Male Forensic All Adult Male Forensic • Mentally Disordered OffendersMentally Disordered Offenders• Not Guilty by Reason of Not Guilty by Reason of

InsanityInsanity• Referrals from CDCRReferrals from CDCR• Incompetent to Stand TrialIncompetent to Stand Trial

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”

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

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

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

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

Who Decides Incompetence?

• Hearing held after receipt of reports

• Jury trial if either side requests• Hearings can only occur in

Superior Court

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.

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

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

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

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

• Additional Treatment as Indicated• Medication Education• Substance Abuse• Depression Management• Neuro/Cognitive

Services• Compulsory Education• Anger Management• Leisure & Recreation• Social Skills• Medical/Physical

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!)

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

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

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.

Court Scenario Chant

• “The Court is the place that needs your face”

• ….so get there

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

Developing Court Cooperation Through Music

Mary Alvarado: Mary Alvarado: MALVARADO@ash.dmh.ca.govYu-Chuan Chen: Yu-Chuan Chen: YCHEN@ash.dmh.ca.gov