This article reviews and evaluates publications during 1986–1990 with relevance for assessments o... more This article reviews and evaluates publications during 1986–1990 with relevance for assessments of competence to stand trial. The review focuses specifically on articles that provide new concepts or data supported by research or case studies. The studies are reviewed under the following headings; (a) the systemic context of competence to stand trial (CST) evaluations, (b) conceptual definitions of competence and models for CST assessment, (c) research on CST assessment methods, (d) characteristics of incompetent defendants, (e) interpretation of CST evaluation data, (f) issues in CST assessment of special populations, and (g) treatment to restore competence. Suggestions are offered for further research to advance the quality of clinical evaluations for competence to stand trial.
... In recent years many attempts have been made to raise the consciousness and conscience of men... more ... In recent years many attempts have been made to raise the consciousness and conscience of mental health professionals regarding the rights of minors ... determi-nation, we are beginning to take seriously the idea that minors are entitled to have some form of consent or dissent ...
Examines theoretical and empirical challenges to a national trend toward increasingly punitive de... more Examines theoretical and empirical challenges to a national trend toward increasingly punitive determinate sentences in juvenile court, and “automatic transfer” of juveniles to criminal court, for homicides and other serious violent offenses. Theory and research in developmental psychology, criminology, and child clinical psychology and psychiatry are examined, with special attention to (a) decision-making by adolescents; (b) characteristics of adolescents who commit homicide; and (c) adolescents' recidivism and potential for rehabilitation. Theoretical support is found for promoting legal responses to adolescent violent offenders that are different from those for adult violent offenders, arguing against determinate sentences based on the offense alone. Empirical support, however, is limited by the lack of relevant systematic research, for which specific recommendations are offered.
Studies repeatedly have shown that clinical research subjects have trouble appreciating the impli... more Studies repeatedly have shown that clinical research subjects have trouble appreciating the implications for their clinical care of participating in a clinical trial. When this failure is based on a lack of appreciation of the impact on individualized clinical care of elements of the research design, it has been called the "therapeutic misconception". Failure to distinguish the consequences of research participation from receiving ordinary treatment may seriously undermine the informed consent of research subjects. This article reports results concerning appreciation of the risks of trial participation from intensive interviews with 155 subjects from 40 different clinical trials at two different medical centers in the USA. Working from transcripts of the interviews, every statement of a risk or disadvantage of trial participation was identified and coded into one of 5 different categories. Totally, 23.9% of subjects reported no risks or disadvantages in spite of being explicitly asked about them. Another 2.6% reported only incidental disadvantages such as having to drive a long way to get to the experimental site. In all 14.2% reported only disadvantages associated with the standard treatment (usually side effects). Another 45.8% told the interviewer about disadvantages and risks associated with the experimental intervention (usually side effects). Only 13.5% could report any risks or disadvantages resulting from the research design itself, such as randomization, placebos, double-blind designs and restrictive protocols. The results of this research suggest that subjects often sign consents to participate in clinical trials with only the most modest appreciation of the risks and disadvantages of participation.
... CR format adapted easily to the relevant content for informed consent in this particular clin... more ... CR format adapted easily to the relevant content for informed consent in this particular clinical study. Questions about the stability of MacCAT-CR ratings over time could not be answered because of the overall high level of performance of the subjects in this study group. ...
Three instruments assessing abilities related to legal standards for competence to consent to tre... more Three instruments assessing abilities related to legal standards for competence to consent to treatment were administered to 6 groups: patients recently hospitalized for schizophrenia, major depression, and ischemic heart disease, as well as three groups of non-ill persons in the community who were matched with the hospitalized patients on age, gender, race, and socioeconomic status. Significant impairments in decisional abilities were found for only a minority of persons in all groups. Both the schizophrenia and depression groups manifested poorer understanding of treatment disclosures, poorer reasoning in decision making regarding treatment, and a greater likelihood of failing to appreciate their illness or the potential benefits of treatment. Deficits were more pronounced, however, among patients with schizophrenia. Implications are discussed for policy designed to protect the rights and welfare of patients with mental illness who are at risk of incompetent refusal or consent when making treatment decisions.
This is the first of three papers reporting the results of the MacArthur Treatment Competence Stu... more This is the first of three papers reporting the results of the MacArthur Treatment Competence Study, a project designed to develop reliable and valid information with which to address clinical and policy questions regarding the abilities of persons with mental illness to make decisions about psychiatric treatment. Four commonly applied legal standards for determining decision-making competence are described: abilities to communicate a choice, understand relevant information, appreciate the nature of the situation and its likely consequences, and rationally manipulate information. Previous research related to the capacities of persons with mental illness in relation to these standards is reviewed and critiqued. The principles underlying the design of the MacArthur Treatment Competence Study are described.
A new actuarial method for violence risk assessment--the Iterative Classification Tree (ICT)--has... more A new actuarial method for violence risk assessment--the Iterative Classification Tree (ICT)--has become available. It has a high degree of accuracy but can be time and resource intensive to administer. To increase the clinical utility of the ICT method by restricting the risk factors used to generate the actuarial tool to those commonly available in hospital records or capable of being routinely assessed in clinical practice. A total of 939 male and female civil psychiatric patients between 18 and 40 years old were assessed on 106 risk factors in the hospital and monitored for violence to others during the first 20 weeks after discharge. The ICT classified 72.6% of the sample as either low risk (less than half of the sample's base rate of violence) or high risk (more than twice the sample's base rate of violence). A clinically useful actuarial method exists to assist in violence risk assessment.
This article reports the development and psychometric properties of three standardized and object... more This article reports the development and psychometric properties of three standardized and objectively scored measures, the MacArthur Treatment Competence Research Instruments. They were designed to assess abilities related conceptually to four legal standards for competence to consent to treatment: understanding, appreciation, rational manipulation (reasoning), and expressing a choice. Scoring reliability, internal consistency, intertest correlations, and test-retest correlations were examined with data from samples of hospitalized patients with schizophrenia, major depression, and ischemic heart disease, as well as matched non-ill community samples. The results indicate very good interscorer reliability and provide guidance for the use of the instruments and interpretation of their results in future research on patients' decisional abilities in treatment contexts.
The perormance of two groups of hospitalized mentally ill patients (schizophrenia and major depre... more The perormance of two groups of hospitalized mentally ill patients (schizophrenia and major depression) and two groups of non-mentally-ill patients (patients hospitalized for ischemic heart disease and non-ill primary care patients) was compared on a standardized, objective instrument for assessing patients' understanding of information relevant for patient decision making (consent) about treatment with medication. Generally, hospitalized schizophrenic patients manifested significantly poorer understanding of “informed consent” disclosures about potential medication than did the other groups. Considerable variance, however, was apparent within the schizophrenic group and was related to a number of clinical and demographic variables. The results are interpreted with reference to issues of compatence to consent to or refuse treatment.
The public perception that mental disorder is strongly associated with violence drives both legal... more The public perception that mental disorder is strongly associated with violence drives both legal policy (eg, civil commitment) and social practice (eg, stigma) toward people with mental disorders. This study describes and characterizes the prevalence of community violence in a sample of people discharged from acute psychiatric facilities at 3 sites. At one site, a comparison group of other residents in the same neighborhoods was also assessed.
An examination of the nature, foundation, and consequences of predictive testimony about future v... more An examination of the nature, foundation, and consequences of predictive testimony about future violence does not support the assertion, sometimes heard, that such testimony is necessarily unethical. Certain types of predictive testimony about future violence may have adequate scientific support. Moreover, society does not require certainty about future violence in order to restrict various liberties. Proper performance of an evaluation related to certain types of predictive testimony can provide an adequate foundation for the testimony. Finally, a consideration of the consequences of legal proceedings that restrict liberty does not support the conclusion that predictive testimony is necessarily ethically improper merely because it uses probabilities that create the potential for a significant number of false-positive legal decisions. Therefore, we would not advise psychology, psychiatry, or the courts to conclude that “predictions of dangerousness” as a class are unethical.
The right of patients to accept or refuse recommended treatment requires careful reassessment whe... more The right of patients to accept or refuse recommended treatment requires careful reassessment when their decision-making capacities are called into question. Patients must be informed appropriately about treatment decisions and be given an opportunity to demonstrate their highest level of mental functioning. The legal standards for competence include the four related skills of communicating a choice, understanding relevant information, appreciating the current situation and its consequences, and manipulating information rationally. Since competence is a legal concept and can be formally determined only in court, the clinical examiner's proper role is to gather relevant information and decide whether an adjudication of incompetence is required. Treatment for impairment of mental functioning can sometimes restore patients' capacities, making it unnecessary to deprive them of their decision-making powers.
OXFORD UNIVERSITY PRESS Oxford New York Athens Auckland Bangkok Bogota Buenos Aires Calcutta Cape... more OXFORD UNIVERSITY PRESS Oxford New York Athens Auckland Bangkok Bogota Buenos Aires Calcutta Cape Town Chennai Dar es Salaam Delhi Florence Hong Kong Istanbul Karachi Kuala Lumpur Madrid Melbourne Mexico City Mumbai Nairobi Paris Sao Paulo Shanghai ...
Since the 1970s, a wide body of research has suggested that the accuracy of clinical risk assessm... more Since the 1970s, a wide body of research has suggested that the accuracy of clinical risk assessments of violence might be increased if clinicians used actuarial tools. Despite considerable progress in recent years in the development of such tools for violence risk assessment, they remain primarily research instruments, largely ignored in daily clinical practice. We argue that because most existing actuarial tools are based on a main effects regression approach, they do not adequately reflect the contingent nature of the clinical assessment processes. To enhance the use of actuarial violence risk assessment tools, we propose a classification tree rather than a main effects regression approach. In addition, we suggest that by employing two decision thresholds for identifying high- and low-risk cases--instead of the standard single threshold--the use of actuarial tools to make dichotomous risk classification decisions may be further enhanced. These claims are supported with empirical data from the MacArthur Violence Risk Assessment Study.
Journal of The American Academy of Child and Adolescent Psychiatry, 2001
This report describes the development of the Massachusetts Youth Screening Instrument-Second Vers... more This report describes the development of the Massachusetts Youth Screening Instrument-Second Version (MAYSI-2), a brief screening measure to identify youths with potential mental, emotional, or behavioral problems at entry points in the juvenile justice system. This 52-item self-report measure, with content relevant to common mental health problems in delinquent populations, was administered to 1,279 male and female youths, aged 12 to 17, in Massachusetts juvenile justice facilities. A subsample of youths also received the Millon Adolescent Clinical Inventory (MACI) and the Youth Self-Report (YSR). The instrument was subsequently administered to 3,804 male and female youths in California Youth Authority custody. Factor analyses of the 52 items identified seven scales that were conceptually associated with various mental, emotional, and behavioral problems of youths, which were generally confirmed by separate factor analyses with the California sample. The scales manifested adequate internal consistency and test-retest reliability. Most scales were substantially correlated with conceptually similar scales in the MACI and YSR, and they identified most youths who scored at clinically significant levels on those instruments. The MAYSI-2 shows promise as a reliable and valid screening tool to assist juvenile justice staff in identifying youths who may need an immediate response to mental or emotional problems.
Abilities associated with adjudicative competence were assessed among 927 adolescents in juvenile... more Abilities associated with adjudicative competence were assessed among 927 adolescents in juvenile detention facilities and community settings. Adolescents' abilities were compared to those of 466 young adults in jails and in the community. Participants at four locations across the United States completed a standardized measure of abilities relevant for competence to stand trial (the MacArthur Competence Assessment Tool-Criminal Adjudication) as well as a new procedure for assessing psychosocial influences on legal decisions often required of defendants (MacArthur Judgment Evaluation). Youths aged 15 and younger performed more poorly than did young adults, with a greater proportion manifesting a level of impairment consistent with that of persons found incompetent to stand trial. Adolescents also tended more often than young adults to make choices (e.g., about plea agreements) that reflected compliance with authority, as well as influences of psychosocial immaturity. Implications of these results for policy and practice are discussed, with an emphasis on the development of legal standards that recognize immaturity as a potential predicate of incompetence to stand trial.
This article reviews and evaluates publications during 1986–1990 with relevance for assessments o... more This article reviews and evaluates publications during 1986–1990 with relevance for assessments of competence to stand trial. The review focuses specifically on articles that provide new concepts or data supported by research or case studies. The studies are reviewed under the following headings; (a) the systemic context of competence to stand trial (CST) evaluations, (b) conceptual definitions of competence and models for CST assessment, (c) research on CST assessment methods, (d) characteristics of incompetent defendants, (e) interpretation of CST evaluation data, (f) issues in CST assessment of special populations, and (g) treatment to restore competence. Suggestions are offered for further research to advance the quality of clinical evaluations for competence to stand trial.
... In recent years many attempts have been made to raise the consciousness and conscience of men... more ... In recent years many attempts have been made to raise the consciousness and conscience of mental health professionals regarding the rights of minors ... determi-nation, we are beginning to take seriously the idea that minors are entitled to have some form of consent or dissent ...
Examines theoretical and empirical challenges to a national trend toward increasingly punitive de... more Examines theoretical and empirical challenges to a national trend toward increasingly punitive determinate sentences in juvenile court, and “automatic transfer” of juveniles to criminal court, for homicides and other serious violent offenses. Theory and research in developmental psychology, criminology, and child clinical psychology and psychiatry are examined, with special attention to (a) decision-making by adolescents; (b) characteristics of adolescents who commit homicide; and (c) adolescents' recidivism and potential for rehabilitation. Theoretical support is found for promoting legal responses to adolescent violent offenders that are different from those for adult violent offenders, arguing against determinate sentences based on the offense alone. Empirical support, however, is limited by the lack of relevant systematic research, for which specific recommendations are offered.
Studies repeatedly have shown that clinical research subjects have trouble appreciating the impli... more Studies repeatedly have shown that clinical research subjects have trouble appreciating the implications for their clinical care of participating in a clinical trial. When this failure is based on a lack of appreciation of the impact on individualized clinical care of elements of the research design, it has been called the "therapeutic misconception". Failure to distinguish the consequences of research participation from receiving ordinary treatment may seriously undermine the informed consent of research subjects. This article reports results concerning appreciation of the risks of trial participation from intensive interviews with 155 subjects from 40 different clinical trials at two different medical centers in the USA. Working from transcripts of the interviews, every statement of a risk or disadvantage of trial participation was identified and coded into one of 5 different categories. Totally, 23.9% of subjects reported no risks or disadvantages in spite of being explicitly asked about them. Another 2.6% reported only incidental disadvantages such as having to drive a long way to get to the experimental site. In all 14.2% reported only disadvantages associated with the standard treatment (usually side effects). Another 45.8% told the interviewer about disadvantages and risks associated with the experimental intervention (usually side effects). Only 13.5% could report any risks or disadvantages resulting from the research design itself, such as randomization, placebos, double-blind designs and restrictive protocols. The results of this research suggest that subjects often sign consents to participate in clinical trials with only the most modest appreciation of the risks and disadvantages of participation.
... CR format adapted easily to the relevant content for informed consent in this particular clin... more ... CR format adapted easily to the relevant content for informed consent in this particular clinical study. Questions about the stability of MacCAT-CR ratings over time could not be answered because of the overall high level of performance of the subjects in this study group. ...
Three instruments assessing abilities related to legal standards for competence to consent to tre... more Three instruments assessing abilities related to legal standards for competence to consent to treatment were administered to 6 groups: patients recently hospitalized for schizophrenia, major depression, and ischemic heart disease, as well as three groups of non-ill persons in the community who were matched with the hospitalized patients on age, gender, race, and socioeconomic status. Significant impairments in decisional abilities were found for only a minority of persons in all groups. Both the schizophrenia and depression groups manifested poorer understanding of treatment disclosures, poorer reasoning in decision making regarding treatment, and a greater likelihood of failing to appreciate their illness or the potential benefits of treatment. Deficits were more pronounced, however, among patients with schizophrenia. Implications are discussed for policy designed to protect the rights and welfare of patients with mental illness who are at risk of incompetent refusal or consent when making treatment decisions.
This is the first of three papers reporting the results of the MacArthur Treatment Competence Stu... more This is the first of three papers reporting the results of the MacArthur Treatment Competence Study, a project designed to develop reliable and valid information with which to address clinical and policy questions regarding the abilities of persons with mental illness to make decisions about psychiatric treatment. Four commonly applied legal standards for determining decision-making competence are described: abilities to communicate a choice, understand relevant information, appreciate the nature of the situation and its likely consequences, and rationally manipulate information. Previous research related to the capacities of persons with mental illness in relation to these standards is reviewed and critiqued. The principles underlying the design of the MacArthur Treatment Competence Study are described.
A new actuarial method for violence risk assessment--the Iterative Classification Tree (ICT)--has... more A new actuarial method for violence risk assessment--the Iterative Classification Tree (ICT)--has become available. It has a high degree of accuracy but can be time and resource intensive to administer. To increase the clinical utility of the ICT method by restricting the risk factors used to generate the actuarial tool to those commonly available in hospital records or capable of being routinely assessed in clinical practice. A total of 939 male and female civil psychiatric patients between 18 and 40 years old were assessed on 106 risk factors in the hospital and monitored for violence to others during the first 20 weeks after discharge. The ICT classified 72.6% of the sample as either low risk (less than half of the sample's base rate of violence) or high risk (more than twice the sample's base rate of violence). A clinically useful actuarial method exists to assist in violence risk assessment.
This article reports the development and psychometric properties of three standardized and object... more This article reports the development and psychometric properties of three standardized and objectively scored measures, the MacArthur Treatment Competence Research Instruments. They were designed to assess abilities related conceptually to four legal standards for competence to consent to treatment: understanding, appreciation, rational manipulation (reasoning), and expressing a choice. Scoring reliability, internal consistency, intertest correlations, and test-retest correlations were examined with data from samples of hospitalized patients with schizophrenia, major depression, and ischemic heart disease, as well as matched non-ill community samples. The results indicate very good interscorer reliability and provide guidance for the use of the instruments and interpretation of their results in future research on patients' decisional abilities in treatment contexts.
The perormance of two groups of hospitalized mentally ill patients (schizophrenia and major depre... more The perormance of two groups of hospitalized mentally ill patients (schizophrenia and major depression) and two groups of non-mentally-ill patients (patients hospitalized for ischemic heart disease and non-ill primary care patients) was compared on a standardized, objective instrument for assessing patients' understanding of information relevant for patient decision making (consent) about treatment with medication. Generally, hospitalized schizophrenic patients manifested significantly poorer understanding of “informed consent” disclosures about potential medication than did the other groups. Considerable variance, however, was apparent within the schizophrenic group and was related to a number of clinical and demographic variables. The results are interpreted with reference to issues of compatence to consent to or refuse treatment.
The public perception that mental disorder is strongly associated with violence drives both legal... more The public perception that mental disorder is strongly associated with violence drives both legal policy (eg, civil commitment) and social practice (eg, stigma) toward people with mental disorders. This study describes and characterizes the prevalence of community violence in a sample of people discharged from acute psychiatric facilities at 3 sites. At one site, a comparison group of other residents in the same neighborhoods was also assessed.
An examination of the nature, foundation, and consequences of predictive testimony about future v... more An examination of the nature, foundation, and consequences of predictive testimony about future violence does not support the assertion, sometimes heard, that such testimony is necessarily unethical. Certain types of predictive testimony about future violence may have adequate scientific support. Moreover, society does not require certainty about future violence in order to restrict various liberties. Proper performance of an evaluation related to certain types of predictive testimony can provide an adequate foundation for the testimony. Finally, a consideration of the consequences of legal proceedings that restrict liberty does not support the conclusion that predictive testimony is necessarily ethically improper merely because it uses probabilities that create the potential for a significant number of false-positive legal decisions. Therefore, we would not advise psychology, psychiatry, or the courts to conclude that “predictions of dangerousness” as a class are unethical.
The right of patients to accept or refuse recommended treatment requires careful reassessment whe... more The right of patients to accept or refuse recommended treatment requires careful reassessment when their decision-making capacities are called into question. Patients must be informed appropriately about treatment decisions and be given an opportunity to demonstrate their highest level of mental functioning. The legal standards for competence include the four related skills of communicating a choice, understanding relevant information, appreciating the current situation and its consequences, and manipulating information rationally. Since competence is a legal concept and can be formally determined only in court, the clinical examiner's proper role is to gather relevant information and decide whether an adjudication of incompetence is required. Treatment for impairment of mental functioning can sometimes restore patients' capacities, making it unnecessary to deprive them of their decision-making powers.
OXFORD UNIVERSITY PRESS Oxford New York Athens Auckland Bangkok Bogota Buenos Aires Calcutta Cape... more OXFORD UNIVERSITY PRESS Oxford New York Athens Auckland Bangkok Bogota Buenos Aires Calcutta Cape Town Chennai Dar es Salaam Delhi Florence Hong Kong Istanbul Karachi Kuala Lumpur Madrid Melbourne Mexico City Mumbai Nairobi Paris Sao Paulo Shanghai ...
Since the 1970s, a wide body of research has suggested that the accuracy of clinical risk assessm... more Since the 1970s, a wide body of research has suggested that the accuracy of clinical risk assessments of violence might be increased if clinicians used actuarial tools. Despite considerable progress in recent years in the development of such tools for violence risk assessment, they remain primarily research instruments, largely ignored in daily clinical practice. We argue that because most existing actuarial tools are based on a main effects regression approach, they do not adequately reflect the contingent nature of the clinical assessment processes. To enhance the use of actuarial violence risk assessment tools, we propose a classification tree rather than a main effects regression approach. In addition, we suggest that by employing two decision thresholds for identifying high- and low-risk cases--instead of the standard single threshold--the use of actuarial tools to make dichotomous risk classification decisions may be further enhanced. These claims are supported with empirical data from the MacArthur Violence Risk Assessment Study.
Journal of The American Academy of Child and Adolescent Psychiatry, 2001
This report describes the development of the Massachusetts Youth Screening Instrument-Second Vers... more This report describes the development of the Massachusetts Youth Screening Instrument-Second Version (MAYSI-2), a brief screening measure to identify youths with potential mental, emotional, or behavioral problems at entry points in the juvenile justice system. This 52-item self-report measure, with content relevant to common mental health problems in delinquent populations, was administered to 1,279 male and female youths, aged 12 to 17, in Massachusetts juvenile justice facilities. A subsample of youths also received the Millon Adolescent Clinical Inventory (MACI) and the Youth Self-Report (YSR). The instrument was subsequently administered to 3,804 male and female youths in California Youth Authority custody. Factor analyses of the 52 items identified seven scales that were conceptually associated with various mental, emotional, and behavioral problems of youths, which were generally confirmed by separate factor analyses with the California sample. The scales manifested adequate internal consistency and test-retest reliability. Most scales were substantially correlated with conceptually similar scales in the MACI and YSR, and they identified most youths who scored at clinically significant levels on those instruments. The MAYSI-2 shows promise as a reliable and valid screening tool to assist juvenile justice staff in identifying youths who may need an immediate response to mental or emotional problems.
Abilities associated with adjudicative competence were assessed among 927 adolescents in juvenile... more Abilities associated with adjudicative competence were assessed among 927 adolescents in juvenile detention facilities and community settings. Adolescents' abilities were compared to those of 466 young adults in jails and in the community. Participants at four locations across the United States completed a standardized measure of abilities relevant for competence to stand trial (the MacArthur Competence Assessment Tool-Criminal Adjudication) as well as a new procedure for assessing psychosocial influences on legal decisions often required of defendants (MacArthur Judgment Evaluation). Youths aged 15 and younger performed more poorly than did young adults, with a greater proportion manifesting a level of impairment consistent with that of persons found incompetent to stand trial. Adolescents also tended more often than young adults to make choices (e.g., about plea agreements) that reflected compliance with authority, as well as influences of psychosocial immaturity. Implications of these results for policy and practice are discussed, with an emphasis on the development of legal standards that recognize immaturity as a potential predicate of incompetence to stand trial.
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Papers by Thomas Grisso