Guidelines for determining restorability of competency to stand trial and recommendations for involuntary treatment

Over 50,000 defendants are referred for competency to stand trial evaluations each year in the United States (Psychological evaluations for the courts: A handbook for mental health professionals and lawyers, New York, NY: The Guildford Press; 2018). Approximately 20% of those individuals are found by courts to be incompetent and are referred for "restoration" or remediation (Psychological evaluations for the courts: A handbook for mental health professionals and lawyers, 4th edn. New York, NY: The Guildford Press; 2018; Bull Am Acad Psychiatry Law. 1991;19:63-9). The majority of those incompetent defendants meet criteria for psychotic illnesses (J Am Acad Psychiatry Law. 2007;35:34-43). Forensic mental health professionals frequently have such patients/defendants decline recommended treatment with psychotropic medication. For a significant minority of defendants diagnosed with psychotic disorders, treatment with medication is thought to be necessary to restore their competency to stand trial. Without psychiatric intervention to restore competency, defendants may be held for lengthy and costly hospitalizations while criminal proceedings are suspended. In these situations, clinicians are guided by the Supreme Court decision, Sell v. United States (2003). The Sell opinion describes several clinical issues courts must consider when determining whether a defendant can be treated involuntarily solely for the purpose of restoring his/her competency. This paper offers some guidance to clinicians and evaluators who are faced with making recommendations or decisions about involuntary treatment. Using a question and answer format, the authors discuss data that support a decision to request, or not request, court authorization for involuntary treatment. Specifically, eight questions are posed for forensic evaluators to consider in determining the prognosis or viability of successful treatment and restoration. Finally, a clinical vignette is also presented to highlight important factors to consider in Sell-related evaluations.