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CBTp for Competency Restoration: A Long Overdue Application

Updated: Feb 10

By Victoria Shepard, BS and Sarah L. Kopelovich, PhD.


CBTp has over three decades of evidence supporting its efficacy and effectiveness in reducing distress associated with psychotic and mood symptoms. Despite this robust evidence base and numerous endorsements in national and international treatment guidelines, CBTp remains widely inaccessible, with recent reports suggesting that fewer than 1% of practitioners in the U.S. and Canadian behavioral health workforces trained to administer this evidence-based intervention.

The need to integrate empirically-supported treatments like CBTp within forensic and correctional settings is of particular consequence. Forensic settings are disproportionately populated by individuals with serious mental illness (SMI), and roughly  15-25% of individuals housed in U.S. prisons or jails exhibit psychotic symptoms, outnumbering those in hospitals by a ratio of three to one. This issue is reflected further up the criminal justice system stream, where individuals with SMI are more likely to interact with law enforcement, be arrested, and for questions to be raised related to their competency to stand trial for an alleged offense. Once a defendant is found to be not competent to participate in their own defense, the state has an obligation to provide treatment with the goal of competency restoration. Jackson v. Indiana (1972) held that people can only be held for a “reasonable period of time” to determine whether there is a substantial probability that they may be restored to competency, yet the court did not establish a maximum time period, or did they prescribe what constitutes competency restoration activities. As a result, practices vary across states.

The presence of psychotic symptoms constitutes a significant obstacle to achieving competency restoration, which requires that a defendant possesses “sufficient present ability to consult with his lawyer with reasonable degree of rational understanding" and "rational as well as factual understanding of the proceedings against him” [Dusky v. U.S. (1960)]. CBTp has potential to facilitate competency restoration by enhancing mental flexibility, problem-solving skills, distress tolerance, and interpersonal and communication skills and by diminishing the effects of attention, reasoning, or information processing biases. Furthermore, CBTp may be able to improve medication adherence, which cannot only facilitate competency restoration but can enhance the likelihood of sustained symptom stability when the defendant is returned to jail or community. Unfortunately, CBTp is an under-utilized treatment in competency restoration settings, and little research has been devoted to investigating whether population, treatment-target, or setting-responsive adaptations are indicated, much less to evaluating the effect of a CBTp for Competency Restoration protocol on competency outcomes. Given the exigent need to restore individuals’ civil liberties, this must change.

It is clear that additional research is needed to uncover the potential role that CBTp could play as an adjunct to traditional care models in forensic and correctional settings. This work is vital to improve psychiatric well-being and the restoration of civil liberties for this population. 

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