Competency and Community – A Radical Alternative?

Competency and Community – A Radical Alternative?

Article Title: Evaluating an Expedited Process to Assess Fitness to Stand Trial | 2023, Vol. 22, No. 1, 69-79


David Hill; Clinical Health Psychology, Max Rady College of Medicine, University of Manitoba, Winnipeg, Canada

Sabrina Demetrioff; Clinical Health Psychology, Max Rady College of Medicine, University of Manitoba, Winnipeg, Canada


In this study, we investigated the potential benefits of using an alternative approach for completing court ordered fitness to stand trial assessments in a Canadian forensic mental health service. Using file information, court databases, and an economic analysis, we compared a hospital-based model of evaluation to a court clinic model in a sample of 96 accused persons from 2013 to 2017. Results revealed a significantly shorter time period for forensic report completion in the court clinic group, but no difference in criminal case processing time between groups. There was a higher rate of accused persons opined to be unfit to stand trial in the court clinic group (25.9%) compared to the hospital-based model (7.7%). Report quality varied somewhat between groups, with forensic assessment reports citing mental disorder and relevant case law more often in the court clinic model. Economic analyses indicated there was a marked cost savings associated with completing assessments at court instead of hospital. Our findings suggest there are several benefits for forensic mental health systems in utilizing community-based models of forensic evaluation.


Fitness to stand trial; Forensic mental health assessment; Forensic mental health systems

Summary of the Research

“In Canada, fitness to stand trial assessments (i.e., competency) are one type of psycholegal evaluation that can be requested by lawyers or judges in criminal cases…In Canada, it remains largely unknown whether the supply of resources for forensic mental health services meets demands from the criminal justice system…In this study, we conducted an initial investigation into one provincial forensic mental health system’s approach to meeting increasing demands for fitness to stand trial evaluations…The present study had several primary objectives. Our first goal was to evaluate the effectiveness of a new model for conducting fitness to stand trial assessments at the provincial court. We also wanted to investigate the cost effectiveness of this new program compared to the previous hospital-based approach. In addition, another objective was to assess examinee satisfaction and gather information and suggestions for improving the new model. A related goal was to identify ways to improve the operation and efficiency of a forensic mental health system. Finally, we aimed to gather data on the characteristics of individuals referred for fitness to stand trial assessments and obtain information about the quality of fitness to stand trial assessment reports, as both of these topics are understudied in the literature base on Canadian forensic mental health assessments. Participants were 96 accused persons referred for 108 fitness to stand trial assessments from July 2013 to July 2017. They included 76 males (79.2%) and 20 females (20.8%)…Participants were placed into one of two groups based on the start date of the new fitness assessment process at the courthouse (June 2015)…” (p. 69-72).

“Related to our goal of examining the efficiency of a new fitness to stand trial assessment process, our findings generally support the use of a court clinic model. Not surprisingly, the court clinic approach produced shorter timeframes for completion of assessment reports. In forensic mental health systems where hospital beds are scarce, this approach is one way to provide better service to the courts…As demonstrated in the cost analysis completed in this study, the court clinic model was associated with reduced expenses for both hospitals and correctional agencies…In terms of criminal case processing, our results raise significant concerns about the amount of time accused persons with mental health issues spend in the justice system. Although we did not identify group differences in the total amount of time between first court appearance and disposition of charges, the average number of days for this process appears much higher than data published by our provincial justice system…In our sample, the overall mean case time for this period was 361.78 days (421.3 days for the hospital group vs. 297.9 days for the court clinic)…From a mental health treatment perspective…it is quite alarming that this subgroup of offenders spends this much time waiting for disposition of their charges…” (p. 75-76).

“Compared to the previous hospital-based approach, the court clinic model was associated with significantly less time to complete fitness assessments…The median amount of time for report completion was 7 days, which was a significant improvement from the hospital-based approach (median of 14 days) and corresponded nicely with the legislated period for fitness assessments in the Criminal Code…In addition, an important question about the court clinic model is whether it results in any difference in the ability of evaluators to accurately provide an opinion about fitness to stand trial. In our sample, psychiatrists more often opined that an accused was Unfit to Stand Trial in the court clinic group (25.9%) compared to the hospital-based group (7.7%)…In [the] hospital, accused persons may receive psychiatric medication and treatment during the assessment process…even though this is not a mandated aspect of the fitness evaluation. This intervention may improve their mental status and decrease the severity of psychiatric symptoms that could interfere with fitness to stand trial, thus resulting in less individuals being deemed Unfit to proceed…” (p. 76).

“In general, our results indicated that assessment reports addressed the key components of the Canadian legal standard for fitness to stand trial…There were some interesting group differences in our study, such as an increased mention of mental disorder and reference to a landmark court decision (R. v. Taylor, 1992) in the court clinic group (87.0%) versus the hospital-based group (16.7%)…Compared to research findings from other jurisdictions, the rate of individuals opined to be Unfit to stand trial (16.7%) in our sample falls roughly in the middle…Our findings indicated that examinees were generally satisfied with the fitness assessment process. Although the sample size was low (n = 14), our results offer some information about how examinees view the court ordered assessment process…” (p. 76-77).

Translating Research into Practice

“…The other implication of this finding, however, is that 50% of fitness assessment reports take longer than 7 days to complete. This raises the question of whether the suggested time frame is a realistic target for forensic mental health services to achieve, especially in smaller provinces where there may be few forensic psychiatrists available to the courts. Even with a court clinic approach, forensic mental health professionals may not have enough time to complete reports in an efficient manner…it may be difficult for the justice system to tolerate delays in forensic mental health assessments…The findings of this study appear to support utilization of alternative models for court ordered assessments of fitness to stand trial. The benefits of a court clinic approach may have financial implications for both healthcare and justice systems, although more Canadian research is needed to examine larger forensic mental health systems in other provinces. Further investigation into the economic impacts of community-based service provision may assist healthcare organizations in allocating resources for justice-involved individuals with mental health problems” (p. 76-78).

“…It would be great to see more research looking at the court ordered assessment process for both fitness and criminal responsibility evaluations in Canadian jurisdictions, in order to measure the quality and efficacy of report completion in these areas…In addition, gathering data on court ordered assessments across provinces may provide researchers and system administrators with performance indicators for this area of forensic mental health practice. Finally, one other aspect of the fitness assessment process may be an interesting topic for future research. Little is known about the outcomes and trajectories of accused persons who take part in fitness assessments and are then fount fit to stand trial. These individuals may have mental health, substance use, and other social service needs that are not addressed by a brief forensic assessment. One idea that has been proposed in our province is to connect this group with mental health resources during their involvement in the court process, through a mental health clinician who is based in the courtroom. Examining this type of boundary spanning intervention…may assist mental health and criminal justice systems in identifying best practices for serving this population” (p. 78).  

Other Interesting Tidbits for Researchers and Clinicians

“…In Canadian law, only medical practitioners are included in legislation about court ordered assessment reports for fitness to stand trial and criminal responsibility (Criminal Code, 1992). Unfortunately, this has historically prevented psychologists from contributing to fitness assessments, and may impact the quality and comprehensiveness of assessment reports. When there are concerns about malingering or cognitive functioning during a fitness assessment, psychological testing could be quite helpful to assist the psychiatrist in providing an evidence-informed opinion. Psychologists have consistently made significant contributions to the research literature on competency to stand trial (e.g., Pirelli et al., 2011; Zapf & Roesch, 2009), but continue to be restricted from making regular contributions to clinical assessments of fitness in provincial forensic mental health systems” (p. 77).

Additional Resources