CURRENT STATUS OF THE FIELD

Research Directions

Functional Component

As noted earlier in this chapter, the cognitive and volitional func­tional capacities delineated in the two major insanity standards cannot reasonably be assessed with the same type of instrumentation and strate­gies devised for other legal competencies such as competency to stand trial (Chapter 4) or competency to waive rights to silence and counsel (Chapter 5).

Only two forensic assessments instruments have been designed for use in clinical assessments of insanity. Both of them—the MSE and the R-CRAS—structure the analysis of data in forming a clinical opinion about the defendant's mental state at the time of the offense. Rather than focusing on specific cognitive of volitional capacities, which cannot rea­sonably be retrospectively assessed, both instruments focus on symptoms of psychopathology.

Further research might determine whether the content categories used in these instruments adequately cover the range of data that experts generally collect or find to be relevant in insanity assessments. Absent this research, the opinions of experienced forensic examiners regarding important types of data needed for insanity assessment reports (Borum & Grisso, 1996) suggest that the MSE and R-CRAS call for an adequate range and type of information.

Causal Component

In clinical assessments of insanity, the presence of a substantial mental disorder (disease or defect) at the time of the offense is a predicate condition. Unless such a condition existed, any inquiry or data concern­ing cognitive, affective, and volitional capacities is essentially moot. In most legal competency assessments, the examiner first assesses and notes functional deficits in relevant capacities, then determines the most likely cause.

Neither of the two FAIs reviewed here provide much specific guid­ance regarding how the examiner should establish a causal connection or verify the causal element. The MSE focuses primarily on screening for the existence of a predicate mental condition, with very little attention to the causal dimension. The R-CRAS addresses the causal requirements in the rated items and in the decision model, but it does not specify or sug­gest how to establish whether the requirement was met. For example, the R-CRAS calls for a rating of the examiner's estimate of "patient's self­control" at the time of the offense (Item 24), based on the examiner's "integration of other data and clinical judgment" (Rogers, 1984, p. 31). Item 25 calls for a rating concerning whether loss of control was "a result of a psychosis": for example, whether a "direct relationship" existed between delusions and the alleged offense (Rogers, 1984, p. 31). The data and the decision in these instances are relatively clear, but how the infer­ences are to be made is not. Nevertheless, there is value in having instru­ments that guide the collection and organization of assessment data and specify the sequential decisions that must be made.

Whether and how these inferences could be structured and specified is an open question. What kinds of data would inform efforts to develop structured decision guidelines? One approach would be to investigate the decisional processes of expert and/or legal decision makers and to identify and weigh the factors that influence causal inference decisions. This has been done for other psycholegal issues (e.g., Grisso, Tomkins, & Casey, 1984).

Research efforts of this type may lead to structured guidelines for the causal inferences underlying these various clinical judgments. This might increase the expert's ability not only to engage in the process more reli­ably, but also to describe to courts more clearly how the inferential con­clusions are reached. The development of similar research efforts focused on clinical reasoning in arriving at opinions about elements of the insanity standards could be of considerable benefit to this most difficult area of assessment and clinical judgment.

Interactive Component

As explained in the first section, the legal concept of insanity does not call for an evaluation of the examinee's capacities relative to the demands of the environmental context in which the alleged offense occurred. Environmental circumstances may be important for understanding how the event occurred, for checking the reality testing of the defendant at that time, for questioning the accuracy of the examinee's report, and for recon­structing the nature of the defendant's pathology. Yet the insanity stan­dard does not ask whether the defendant could conform his or her conduct "under the totality of circumstances," and courts do not seem to perceive this as an underlying question in insanity cases. For example, whether or not a victim had threatened a male insanity defendant (and thereby given him cause to believe that there was a plot against him by the victim) generally will not be an important argument for an insanity defense. What is important is how the defendant's mental disorder might have contributed to this belief. Thus there would seem to be little reason to pursue research on insanity assessment methods employing an interac­tive perspective.

Judgmental and Dispositional Components

In the first section of this chapter we described the professional and legal debate about whether is it appropriate for mental health professionals to offer opinions on the "ultimate issue" of a defendant's sanity.

Clinical Application

Description

The strength and promise of both the MSE and the R-CRAS lies in their potential to guide the collection and analysis of data in insanity assessments. Accordingly, in many ways they are more appropriately viewed as "guides" rather than tests. An additional function of fAIs is to provide (normative) data on individuals who have been evaluated or adjudicated for a particular legal competency to serve as a point of comparison for subsequent assessments. The potential to describe exami­nees in relation to other insanity defendants is somewhat better for the R- CRAS than for the MSE.

Although preliminary evidence suggests that both instruments can facilitate high rates of inter-examiner agreement on the final conclusion (sane vs. insane), the judgments themselves depend greatly on the general clinical skills of the examiner. In addition, the instruments are dependent on other assessment methods for the collection of reliable data. These may include interviews, psychological and neuropsychological tests, and a considerable range of secondary sources of information reviewed in the first section of this chapter.

Explanation

Chief among the potential causal conditions for insanity are inferred relations of the defendant's mental disorder (at the time of the offense) to specific cognitive, affective and volitional capacities noted in insanity standards. For example, one may be required to explain causal links between diagnoses, more specific features of thought disorder, and their relation to capacity to have appreciated the wrongfulness of the act.

The two insanity instruments guide these inferential processes only to the extent of highlighting certain data to be used and the types of infer­ences to be made. Just as they rely on clinical expertise to determine how data are to be collected, they also depend on the examiner's judgment to determine how the causal inferences and explanations are to be achieved.

Postdiction

One of the unique challenges in insanity assessments is that it requires an appraisal of the defendant's precise mental state at a particu­lar point in time. There can be no objective empirical data to determine that decision. Indeed, there are not even any existing studies demonstrat­ing the ability of mental health professionals to judge—through a postdic- tive investigation—the nature and degree of a person's particular mental condition or symptom pattern at a given point in the past with any degree of reliability or accuracy. Although this would not address directly the MSO question in insanity cases, it would at least provide some indication of the feasibility of postdictive assessments. The two insanity instruments and their existing research base do not alter this state of affairs.

Conclusions

The first section of this chapter discussed in some detail the argument that threshold decisions (e.g., sane/insane, "lacks substantial capacity") actually require moral not scientific judgments. Neither instrument directly addresses this issue, nor do they alter the boundaries of a mental health professional's expertise. As noted above, however, either instru­ment can be used without reaching or offering conclusions on the ulti­mate legal issue. For example, the R-CRAS asks the examiner to rate the defendant's degree of awareness of the act's criminality (Item 19). An expert might wish to provide the court with a rating of the defendant on this dimension, and to offer explanations for that opinion without necessarily going further to infer that the defendant did or did not "lack substantial capacity."

This page intentionally left blank