Assessing Radical Effects on Adjudicative Competence

Assessing Radical Effects on Adjudicative Competence

Featured Article

Featured Article | The Journal of the American Academy of Psychiatry and the Law | Volume 51, Number 4, 2023, 542-550 

Article Title

Assessing Racial Effects on Adjudicative Competence


Kelsey S. Hobart, MD, Shilpa Krishnan, PhD, Sean D. Cleary, PhD, MPH, and Philip J. Candilis, MD


As racial influences on forensic outcomes are identified in every aspect of practice, scholars are exploring methods to disentangle race from its historical, economic, and attitudinal antecedents. Because jurisdictions vary in these influences, definitions and data may differ among them, creating inconsistencies in analysis and policy. This retrospective database review compared differences in racial outcomes among 200 pretrial defendants, 160 Black and 40 White, exploring a wide range of socioeconomic, clinical, and forensic influences before, during, and after hospitalization. Because of the tight relationship of socioeconomic factors and race, investigators hypothesized that it would be difficult to distinguish racial influences alone. Using a confirmatory approach to data collection and a statistical analysis based inlogistic regression, only differences in referral for psychological testing were identified. Application of this method based on local demographics and culture may prove useful for institutions interested in evaluating racial influences on forensic outcomes.


competency to stand trial; forensic hospital psychiatry; institutional racism; racial determinants

Summary of Research

Research Focus: The research explores the racial determinants influencing the forensic mental health system, mainly focusing on treating justice-involved individuals. It addresses disparities in mental health care access, forced interventions, and diagnosis of psychotic disorders among marginalized groups. The study aims to disentangle the various influences affecting racial differences in forensic outcomes, emphasizing the significance of understanding the complex associations of race in the context of social structures.

Methodology: Conducted at Saint Elizabeth's Hospital in Washington D.C., the retrospective review included 200 defendants court-ordered for inpatient evaluation for competence to stand trial (CST) between January 2017 and December 2019. The study analyzes demographic, clinical, and forensic variables, considering socioeconomic factors and disparities in the forensic mental health system.

Key Findings: Contrary to expectations, the research found no significant racial differences in charges, diagnosis of thought disorder, restraint or seclusion, time to attain competence, competence decisions, or disposition to jail. Although Black defendants took slightly longer on average to attain competence, this difference was not statistically significant. Notably, access to psychological testing was more likely for Black defendants, challenging assumptions about potential disparities in resource utilization.

“The results suggest that circulating extremist ideologies in our society are inspiring idioms of distress and behaviors in a sub-group of patients with mental health disorders, and that this constitutes a challenging presentation which clinicians may have to address…The extremist ideologies of patients are aligned with violent extremism sociopolitical trends in the last decade…The relatively large group of patients referred for what proved to be non-ideological forms of violence reflects the growing attraction to mass killers and school shooters by youth…Finally, more recently, the referral of individuals for extremist behaviors (threats and violent acts) related to conspiratorial and anti-system beliefs may be related to the effects of the pandemic on violence…Our findings converge with a study of active shooters in the US [United States], with and without ideological motives…in which the most frequent diagnosis encountered were mood disorders, followed by stress related disorders. The high number of ASD [autism spectrum disorder] diagnoses among clients is also noteworthy and has been reported in the violent extremism literature (Faccini & Allely, 2017)…Overall, the clientele served by the team is clearly a psychiatric population in need of mental health services and cannot be characterized only as a forensic population. Notably, for many of our patients, distress was often increased by the involvement of security forces that infrequently recognized the severity of patient mental health problems (except in cases of psychosis)…” (p. 229).

“Results show that patients referred for violent extremism report multiple social grievances…Issues related to social isolation and family conflict, which affect half of our patients, are frequently found among extremists…The low community engagement and the high internet use complete the picture of individuals who are generally in the margins of society and may project onto this society (and too often onto their family) the responsibility for the perceived injustices they suffer. The internet plays a well-recognized role of echo chamber which confirms the legitimacy of these grievances largely shared by a resentful community…These grievances are, however, also common in psychiatric patients, and it is not possible to determine if social grievances have a causal role for our patient population, or if violent extremism rather constitute[s] a new way to express distress for patients who would have channeled their despair and rage differently in the past…” (p. 229).

Translating Research into Practice

Implications for Forensic Practitioners:

1. Addressing Racial Disparities: The study underscores the importance of recognizing and addressing racial disparities in the forensic mental health system. Forensic practitioners should address racial inequality by implementing policies and procedures ensuring equitable treatment. For instance, regular training sessions could be organized to sensitize practitioners to potential biases and encourage culturally competent assessments.

2. Resource Allocation: Acknowledging that Black defendants were more likely to be referred for psychological testing, practitioners should ensure that access to such resources is consistent across racial groups. This might involve reassessing protocols for referral and ensuring that testing services are readily available to all individuals.

3. Organizational Self-Reflection: Institutions can adopt methods similar to those used in the study to evaluate their forensic outcomes. By conducting comprehensive reviews that include demographic, clinical, and forensic variables, organizations can identify areas of improvement and tailor interventions based on the specific needs of their community.

4. Interagency Coordination: Collaboration between mental health and legal systems is vital. Establishing regular communication channels between professionals in these fields can lead to a more holistic understanding of individuals' needs. This might involve joint training sessions, case reviews, and shared decision-making processes.

Policy Implications:

1. Policy Reform: Policymakers should consider the study's findings when evaluating existing policies related to forensic mental health. If disparities are identified, policies can be reformed to promote equity. For instance, policies might be revised to ensure that access to mental health resources is consistent across racial groups.

2. Training and Education: Training programs for mental health and legal professionals can incorporate modules specifically focused on recognizing and mitigating racial biases. Practical examples and case studies from the study can be used to illustrate potential pitfalls and best practices in maintaining cultural sensitivity during evaluations.

3. Data-Driven Decision-Making: Institutions should adopt a data-driven approach to identify and rectify disparities. Regular data reviews, incorporating demographic, clinical, and forensic variables, can guide decision-making. For instance, if disparities are identified, institutions can implement targeted interventions to address specific areas of concern.

Other Interesting Tidbits for Researchers and Clinicians

Insights and Considerations: 

1. Complexity of Race: Researchers should consider the complexity of race as a social construct. For instance, studies exploring racial influences should account for historical legacies, economic factors, and the intersectionality of race with other variables. This awareness can lead to more nuanced and accurate interpretations of research findings. 

2. Local Variables: Researchers should consider local variables and confirmatory data when designing studies. For instance, when investigating racial influences, understanding a specific community's unique socioeconomic and demographic characteristics can enhance the validity of the study's outcomes. 

3. Power of Demographic Adjustments: The study revealed that adjusting for demographic variables played a crucial role in uncovering the nuanced impact of race on forensic outcomes. This emphasizes the importance of demographic considerations in research design and analysis to provide a more accurate understanding of the relationships between variables. 

4. Protective Factors: The presence of a diverse group of psychiatrists and a progressive jurisdiction served as protective factors against potential biases. Institutions in less diverse settings might consider strategies to promote diversity among their staff to ensure a more balanced and culturally sensitive approach to forensic evaluations. In summary, practitioners and policymakers can use the stud's findings and examples to implement concrete measures that address racial disparities, allocate resources equitably, and promote data-driven decision-making in the forensic mental health context. These practices can lead to fairer outcomes and create a more just and inclusive forensic system.