Cognitive Abilities and Expert Assessment Practices in Fitness to Stand Trial Evaluations

234 Pages·2015·1.14 MB·English

Cognitive Abilities and Expert Assessment Practices in Fitness to Stand
Trial Evaluations: An Australian Study based on the Legal Standard of
Presser

Amanda J. White
Bachelor of Psychology (Hons I)
Master of Psychology (Forensic)

Department of Psychology, Faculty of Human Sciences
Macquarie University, NSW, Australia

July 2015

Empirical thesis submitted in partial fulfilment of the requirements of the degree of
Combined Masters of Psychology (Clinical Neuropsychology)/ Doctor of Philosophy
Table of Contents
Thesis Abstract........................................................................................................... vii
Statement of Candidate............................................................................................... ix
Acknowledgements..................................................................................................... x
Thesis format ............................................................................................................. xi
Publications and Conference Presentations ............................................................... xiii
List of Tables.............................................................................................................. xiv
List of Figures............................................................................................................. xv
Key Terminology........................................................................................................ xvi
Chapter 1: Introduction 20
1.1 Opening Statement................................................................................................ 21
1.2 Fitness to Stand Trial: The Legal Standards and Associated Cognitive Abilities 22
1.2.1 New South Wales.................................................................................... 22
1.2.2 Other Australian Legal Jurisdictions....................................................... 27
1.2.3 United States of America......................................................................... 28
1.2.4 Canada..................................................................................................... 30
1.2.5 England and Wales.................................................................................. 31
1.2.6 Applying the Legal Standard................................................................... 32
Chapter 2: Psychology and Fitness to Stand Trial 35
2.1 Theoretical Models............................................................................................... 36
2.2 Psychological Research in Fitness to Stand Trial................................................. 38
2.2.1 Demographic Variables and Psychiatric Disorders............................... 39
2.2.2 Fitness to Stand Trial - Assessment Instruments (FST- AIs)......... 40
2.2.3 Generalisability of FST- AIs to Different Legal Jurisdictions................ 42
2.2.4 Quality of Forensic Reports.................................................................... 43
2.3 The Role of Forensic Neuropsychology............................................................... 45
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2.3.1 Non-credible Performance....................................................................... 49
2.4 Fitness to Stand Trial in Australia........................................................................ 52
2.5 Study Rationale..................................................................................................... 54
2.6 Aims...................................................................................................................... 54
2.7 Hypotheses............................................................................................................ 55
Chapter 3: The Role of Cognition in Fitness to Stand Trial: A Systematic 57
Review
3.1 Abstract................................................................................................................. 58
3.2 Introduction........................................................................................................... 59
3.3 Method.................................................................................................................. 61
3.3.1 Search Procedure..................................................................................... 61
3.3.2 Data Extraction and Analysis.................................................................. 62
3.3.3 Methodological Quality and Design........................................................ 62
3.3.4 Cognitive Domains.................................................................................. 66
3.4 Results................................................................................................................... 68
3.4.1 Included Studies....................................................................................... 68
3.4.2 Study Quality and Design....................................................................... 68
3.4.3 Cognitive Domains Assessed................................................................... 74
3.4.3.1 Working memory........................................................................ 78
3.4.3.2 Processing speed......................................................................... 78
3.4.3.3 Memory....................................................................................... 79
3.4.3.4 Visuoperceptual skills................................................................. 79
3.4.3.5 Academic abilities....................................................................... 79
3.4.3.6 Executive functioning................................................................. 80
3.4.3.7 Intelligence.................................................................................. 80
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3.5 Discussion............................................................................................................. 81
3.5.1 Strengths and Limitations of the Systematic Review Procedure............. 81
3.5.2 Methodological Limitations of Included Studies..................................... 82
3.5.3 Limitations Related to Cognitive Predictors............................................ 83
3.5.4 Cognition and Fitness to Stand Trial....................................................... 83
3.5.5 Recommendations for Future Research................................................... 84
3.6 Conclusion............................................................................................................ 85
3.7 Literature Update.................................................................................................. 85
3.8 References............................................................................................................. 88
Chapter 4: The Role of Cognitive Assessment in Determining Fitness to Stand 95
Trial
4.1 Abstract................................................................................................................. 96
4.2 Introduction........................................................................................................... 97
4.3 Method.................................................................................................................. 100
4.4 Results................................................................................................................... 103
4.5 Discussion............................................................................................................. 107
4.6 Conclusion............................................................................................................ 112
4.7 Further Investigation............................................................................................. 113
4.8 References............................................................................................................. 114
Chapter 5: Fitness to Stand Trial in One Australian Jurisdiction: The Role of 117
Cognitive Abilities, Neurological Dysfunction and Psychiatric Disorders in Fit
and Unfit Defendants
5.1 Abstract................................................................................................................. 118
5.2 Introduction........................................................................................................... 119
5.3 Method.................................................................................................................. 123
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5.4 Results................................................................................................................... 126
5.4.1 Demographic Factors, Psychiatric Disorders and Neurological
126
Dysfunction.....................................................................................................
5.4.2 Cognitive Assessment.............................................................................. 128
5.4.3 Cognition and Fitness to Stand Trial....................................................... 130
5.4.4 Expert Referrals and the Legal (Presser) Criteria.................................... 130
5.5 Discussion............................................................................................................. 133
5.6 References............................................................................................................. 138
5.7 Footnotes............................................................................................................... 143
Chapter 6: Fitness to Stand Trial: Views of Criminal Lawyers and Forensic 144
Mental Health Experts Regarding the Role of Neuropsychological Assessment
6.1 Abstract................................................................................................................. 145
6.2 Introduction........................................................................................................... 146
6.3 Method.................................................................................................................. 148
6.3.1 Participants............................................................................................... 148
6.3.2 Sampling Procedures............................................................................... 148
6.3.3 Research Design...................................................................................... 149
6.3.4 Data Analysis........................................................................................... 150
6.4 Results................................................................................................................... 150
6.4.1 Understanding and Experience with Neuropsychology........................... 150
6.4.2 Assessment of FST and the Role of Cognition........................................ 151
6.4.3 Neuropsychological Reports.................................................................... 155
6.4.4 Problems and Obstacles to Assessment................................................... 158
6.5 Discussion............................................................................................................. 158
6.5.1 Recommendations.................................................................................... 159
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6.5.2 Limitations............................................................................................... 160
6.5.3 Future Research....................................................................................... 160
6.6 References............................................................................................................. 161
Chapter 7: Discussion 164
7.1 General Summary and Contribution to the Literature.......................................... 165
7.2 Converging the Evidence: The Current State of Affairs....................................... 167
7.3 Research Limitations............................................................................................ 170
7.4 Future Research Directions................................................................................... 170
7.5 Conclusion............................................................................................................ 171
Chapter 8: References 172
Appendices 197
198
Appendix A: Search Strategy.....................................................................................
199
Appendix B: Questionnaires.......................................................................................
Appendix C: Semi-structured Interview Questions for Forensic Mental Health 204
Experts, Lawyers and Judges..................................................................................
Appendix D: Additional Comments and Responses from Criminal Lawyers and 209
Forensic Mental Health Experts.................................................................................
Appendix E: Publication 1: The Role of Cognition in Fitness to Stand Trial: A 232
Systematic Review......................................................................................................
Appendix F: Publication 2: The Role of Cognitive Assessment in Determining 233
Fitness to Stand Trial..................................................................................................
Appendix G: Macquarie University Human Research Ethics Committee Approval 234
letter; Mental Health Review Tribunal Approval Letter; and Office of Director of
Public Prosecution Approval Letter............................................................................

vi
Abstract
Background: Fitness to stand trial (FST) is a cornerstone of western legal systems. Mental
health experts play a crucial role in assisting the courts’ fit or unfit determinations.
Research has identified psychiatric variables and cognition as important for FST. However,
the specific cognitive abilities relevant to FST remains largely untested. Further, there is no
research examining these variables within the Australian legal context.
Aims: The aim of the current body of research was to examine the role of cognition in FST
assessments within an Australian context and in relation to the legal criteria of R v Presser.
Methods: The aim of the research reported in the present thesis was achieved by:
1) conducting a systematic literature review evaluating the evidence for specific cognitive
abilities in predicting FST;
2) evaluating FST reports produced in NSW (2005-2010) in order to determine the
evidence for specific cognitive abilities, psychiatric disorders and neurological dysfunction
impacting FST and to inform expert assessment practices;
3) conducting semi-structured interviews with lawyers and forensic mental health experts
in order to evaluate views regarding the role of neuropsychological assessment in FST
cases and the relevance of cognitive abilities.
Results: Findings suggested that cognitive abilities, specifically verbal memory, nonverbal
abilities and executive functioning, were relevant to the question of FST within the
Australian legal context. Neurological disorders were also important in predicting a
defendants' FST. Expert assessment techniques were highly variable. Reporting on the
legal criteria of Presser was also variable. Finally, lawyers and mental health practitioners
acknowledged an important role for neuropsychology within FST assessments; however
understanding about the discipline of neuropsychology and its application was limited.
Several key areas of improvement were identified and recommended.
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Implications: Further research exploring the relationship between specific cognitive
abilities and FST determinations is warranted as well as further education for both lawyers
and forensic mental health experts conducting FST assessments in order to improve the
quality and standard of FST reports.

viii
Statement of Candidate
I hereby certify that the work presented in this thesis entitled, "Cognitive Abilities and
Expert Assessment Practices in Fitness to Stand Trial Evaluations: An Australian Study
based on the Legal Standard of Presser" has not previously been submitted for a higher
degree to any other university or institution.
I also certify that this thesis is an original piece of research and that it has been
written by me. Where appropriate, I have acknowledged any assistance provided to me by
others in undertaking the research project and in preparing this thesis. I also certify that all
sources of information and literature used in the preparation of this thesis have been
indicated within the thesis and cited appropriately.
The research presented in this thesis was approved by the Macquarie University
Human Research Ethics Committee (Reference: HE29MAY2009-D06597; dated
03/09/2009) and also by the Mental Health Review Tribunal of New South Wales
(23/07/2010) and the Office of the Department of Public Prosecutions (10/06/2011). These
approval letters appear in Appendix G.

__________________________
Amanda J White
Student ID: 41139593

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Acknowledgments
I would like to thank Dr Jennifer Batchelor, my primary academic supervisor and a
constant source of support, for her ongoing understanding and guidance throughout my
candidature. I would like to express my gratitude to Dr Susanne Meares, for sharing her
expertise and pushing me to achieve a higher standard. I would also like to thank Dr
Naomi Sweller for her assistance with the planning and review of statistical analyses.
I would like to thank my external supervisors, Dr Susan Pulman, Clinical
Neuropsychologist and Forensic Psychologist, Private Practice and Associate Professor
Dan Howard SC, Wollongong University and President of the NSW Mental Health Review
Tribunal (MHRT). I would like to thank both of them most sincerely for their endless
encouragement and support throughout the project.
I wish to thank the MHRT of NSW and the Office of the Department of Public
Prosecutions (ODPP) as well as the participants from the legal and forensic mental health
community, who gave their time and shared their knowledge and experiences with me,
without whom this thesis would not have been possible.
Finally, thank you to my family for your unwavering support. I am extremely
grateful to my parents, John and Jan, and my Grandad, Bob, for their encouragement, love
and generosity throughout my studies. To my extended family and friends, especially
Dejan, Erin, Elian and Deepa, thank you for helping me through the really hard times and
for your belief in my ability. Finally, to Sandy and Ellie, my "study buddies" who have
never left my side and showered me with unconditional love. This thesis is dedicated to
you.

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