Into the Thick of It: Cognitive Behavioral Therapy for Psychosis (CBT-p) as an Adjunct for Competency Restoration Treatment

Into the Thick of It: Cognitive Behavioral Therapy for Psychosis (CBT-p) as an Adjunct for Competency Restoration Treatment

Adjudicative competence evaluations are the most common forensic evaluation to occur in the United States. Below is a summary of the research and findings as well as a translation of this research into practice.

Featured Article | Journal of Forensic Psychology Research and Practice | 2021, Vol. 21 No. 4, 317-337

Cognitive Behavior Therapy for Psychosis (CBT-p) as an Adjunct to Competency Restoration


Laura M. Grossi; Department of Psychology, Eastern State Hospital, Williamsburg, VA

Mollimichelle Cabeldue; Department of Psychiatry and Behavioral Sciences, Tulane University School of Medicine, New Orleans, LA

Alexandra Brereton; Fairleigh Dickinson University, School of Psychology, Teaneck, NJ


Adjudicative competence evaluations are the most common forensic evaluation to occur in the United States. As a result of these evaluations, pretrial defendants are often found to be incompetent to stand trial and ordered for competency restoration, with psychotic symptoms as a major barrier to competency. Traditional competency restoration services are sometimes insufficient for restoring such defendants to competency within a reasonable period of time. This can lead to a finding that a defendant is unrestorably incompetent to stand trial and potentially a dismissal of charges. However, if not all available interventions are attempted during the course of competency restoration, this may be perceived as a miscarriage of justice for victims. In other cases, defendants with psychotic symptoms may lack insight into their mental illness, and after being successfully restored to competency, become non-adherent with their prescribed medication regimens and decompensate before their cases are resolved. The authors contend that use of Cognitive Behavior Therapy for psychosis (CBT-p) as an adjunct to traditional competency restoration services may be a means of restoring more defendants to competency, and also strengthening the durability of restored competency, when psychotic symptoms are identified as a barrier to adjudicative competence. This makes use of the skill sets of many clinically trained treatment providers working in forensic settings, and is consistent with recent trends of applying empirically-based interventions designed for use with non-forensic patients in forensic contexts. A case example is included to demonstrate the potential application of CBT-p to competency restoration during the course of individualized intervention.


Cognitive behavior therapy; psychosis; CBT-p; forensic treatment; treatment adaptations; competency restoration

Summary of the Research

“…In this article, the authors discuss one way in which mental health professionals can incorporate their clinical training in the forensic interventions they provide, with focus on the application of CBT [cognitive behavioral therapy] for psychosis (CBT-p) as an adjunct to competency restoration…Restoration of adjudicative competence or competency restoration is the process by which defendants are prepared to move forward with their pending legal case(s) knowledgably and reasonably, and without their due process rights being violated…Several resources exist for clinicians seeking to competently and ethically administer competency restoration services…However, there is no standardized treatment protocol for competency restoration in the United States…When severe mental illness is a barrier to adjudicative competence, psychiatric treatment with medication is a central component of competency restoration…Group-based interventions may be another core aspect of competency restoration…particularly in institutional settings…One-on-one restoration sessions provide the opportunity to discuss case-specific issues with a defendant, and provide more targeted interventions” (p.318-322).

“CBT-p is an empirically supported treatment designed to specifically target symptoms of psychosis…CBT-p follows the same general structure of cognitive therapy for emotional disorders…The goal of traditional CBT-p is to reduce distress and improve quality of life…It is sometimes the case that individuals who experience symptoms of psychosis are eventually found to be incompetent to stand trial specifically because psychotic symptoms pose a barrier to their adjudicative competence…Defendants with active symptoms of mental illness, including psychosis, can of course still demonstrate adequate adjudicative competence…these treatment-refractory symptoms may continue to impair the defendant’s ability to talk about their case in a reasonable manner and engage in a reality-based discussion about possible evidence that could be introduced in their case, legal strategy, etc…” (p. 322-324).

Translating Research into Practice

“CBT-p can be administered as an adjunct to competency restoration in a group format, as a one-on-one intervention, or in a mixed format…As is true of standalone CBT-p, CBT-p as an adjunctive treatment for competency restoration may be most promising when used in conjunction with psychotropic medications; the defendant may experience more benefit, and be able to participate in more challenging aspects of the intervention, as their symptoms alleviate as a result of medication adherence…The clinician may wish to use a manualized CBT-p treatment protocol to guide treatment…In addition to considering specific barriers to competency, the clinician should assess the defendant’s beliefs about mental illness and need for mental health treatment, treatment history, and cultural considerations” (p. 326).

“During this stage, it may be helpful to introduce and review basic skills for coping with stress, and to check in with the defendant about their use of coping skills; this may be something that a clinician returns to throughout the course of the intervention…the ability to cope with…stressors is particularly important, particularly as stress can exacerbate psychotic symptoms…As much as possible, a clinician should attempt to normalize the stress that a defendant is going through…It may be helpful to engage the defendant in discussion about what helped them in the past when they were feeling stressed…and to draw their attention to those techniques that can be utilized in the legal context (i.e., in court, with an attorney, or while in jail)…” (p. 326-327).

“The clinician should gradually move from these general interventions to more individualized and specific interventions. A next step may include education about their diagnosis, symptoms, and treatment. As much as possible, this process should be collaborative. When education is eventually provided, it can help to use printed handouts that include references. This helps to illustrate to the defendant that the information provided is legitimate and reliable, and may help the clinician to earn trust…when discussing specific symptoms, it is important to make sure that the clinician and defendant are speaking the same language. This helps to meet defendants at their comfort level, build rapport, reduce the adversarial feeling of the interaction…Once these foundational steps are established, a clinician can engage in more modality-specific CBT-p interventions, including cognitive therapy for voices and cognitive therapy for delusions…” (p. 327).

“At some point during each CBT-p session, the clinician should check in about the defendant’s legal case, including any recent contact with their attorney…this also helps to orient the defendant back to their legal case, and prime them to make connections between their symptoms and alleged offense on their own time. In cases where the defendant was experiencing psychosis at the time of the alleged offense, there eventually will be a time when the defendant is ready to challenge their experience of the alleged offense head-on in session. The clinician should use their best professional judgment to identify when this is…The function of discussing the defendant’s thoughts, behaviors, and symptoms at the time leading up to their arrest is in part to facilitate the defendant’s insight into their mental illness. Such discussion, as a kind of exposure exercise, also helps to reduce some of the emotionality associated with the incident in question…Once treatment goals are met, maintenance CBT-p sessions may be beneficial…During the maintenance phase in particular, engagement in more formal reality-testing may be indicated…” (p. 328-329).

Other Interesting Tidbits for Researchers and Clinician

“…at times, interventions designed for use with non-forensic populations have been adapted for use with forensic patients. At times, these interventions are used as adjunctive treatment, to pair with more traditional competency restoration services. Supportive interventions, motivational interviewing, cognitive remediation, and DBT [dialectical behavioral therapy] are among such interventions….” (p. 322).

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