Reforming Competence Restoration Statutes: An Outpatient Model

Defendants who suffer from mental illness and are found incompetent to stand trial are often ordered committed to an inpatient mental health facility to restore their competence, even if outpatient care may be the better treatment option. Inpatient facilities are overcrowded and place the defendants on long waiting lists. Some defendants then spend weeks, months, or even years in their jail cell, waiting for a transfer to a hospital bed.Outpatient competence restoration programs promise to relieve this pressure. But even if every state suddenly opened a robust outpatient competence restoration program, an obstacle looms: the statutes governing competence restoration, which default to the inpatient treatment model. Several states mandate inpatient restoration in their statutory scheme. The rest allow for outpatient restoration, but the language of these laws often preserves the inpatient default by requiring defendants to meet a series of nebulous criteria before allowing them to participate in outpatient treatment. This Article is the first to examine how the language of competence restoration statutes, even those that allow for outpatient treatment, defaults to commitment to an inpatient facility. I do so by examining the wide latitude these statutes give to judges to place defendants in inpatient care and show how that discretion, paired with widespread false presumptions about the mentally ill, leads to overcommitment of incompetent defendants in state mental health facilities.I propose amendments to these statutes that will encourage judges to place defendants in outpatient care. Statutes must flip from inpatient-required or inpatient-unless to outpatient-unless, defaulting to outpatient treatment unless some specific criteria justify committing the defendant to an inpatient facility. Such a change would relieve pressure on inpatient facilities, opening up space for those who truly need inpatient treatment for competence to be restored. It would also ensure that specific criteria—not misunderstandings or fears about the mentally ill—inform the decision to commit the defendant to inpatient care

It Doesn\u27t Pass the \u3ci\u3eSell\u3c/i\u3e Test: Focusing on The Facts of the Individual Case in Involuntary Medication Inquiries

Criminal defendants who are incompetent to stand trial have a significant liberty interest in refusing the antipsychotic medication that could restore their competency. The Supreme Court cautioned that instances of intrusion upon that right “may be rare,” and, in Sell v. United States, it laid out what it believed to be stringent criteria for when a defendant could be medicated against his will. Yet, since Sell, trial courts have ordered over sixty-three percent of defendants involuntarily medicated. These individuals did not pose a danger to themselves or others, and they were rarely accused of crimes that involved damage to individuals or property. But the medication of these defendants, once predicted to be “rare,” has instead become routine. In this article, I argue that the overmedication of non-dangerous defendants is a result of the structure of the Sell test and its tilt in favor of the government. The use of a checklist of four threshold elements favors the issuance of medication orders because the court need not balance the defendant’s liberty interest in avoiding medication against the government’s interest in administering it. In addition, three of the four boxes on the checklist concern medical questions about the efficacy and side effects of antipsychotic medication that will fall in the government’s favor in the vast majority of cases. However, while the Sell test contains the seeds of the overmedication problem, it also contains the solution. The first factor of the test requires courts to consider whether the government interest at stake is “important,” and it mandates that courts assess the “facts of the individual case” to determine if the government interest crosses that bar. While few courts have delved deeply into this factor, some have looked to the nonviolent nature of the crime or the government’s minimal likelihood of success on the underlying criminal charge in concluding that the government interest in prosecuting the defendant was not important. I argue that more courts can and should follow this path. Such an approach would limit the involuntary medication of defendants to those exceptional cases where it is truly warranted

Analogical Reasoning

This chapter from our book Legal Writing in Context aims to demystify analogical reasoning for law students

Pandemic as Opportunity for Competence Restoration Decarceration

Before the pandemic, a defendant found incompetent to stand trial was often stranded in jail for weeks or months as she waited for an inpatient bed to open at a psychiatric facility. While there, she usually received no treatment, her mental health deteriorated, and she was astonishingly likely to be abused and neglected. She almost certainly came out of jail in a worse state than she was when she went in. The pandemic has made this desperate situation even worse. Now that wait in jail is both longer, as many psychiatric facilities stopped accepting new patients as they dealt with outbreaks or imposed social distancing measures, and more dangerous. Jails have been the sites of some of the worst virus outbreaks in the country. The solution to this problem is simple: release defendants. There is no inherent magic to inpatient treatment that renders it superior to community treatment. Even if community treatment is unavailable—a common problem in many jurisdictions—it is far worse to keep a person found incompetent in jail, where she will likely decompensate, suffer abuse or neglect, and, now, be exposed to a pandemic, than to release her. Pre-pandemic, judges rarely released defendants found incompetent to stand trial for two reasons. First, many competence restoration statutes default to the inpatient option; some even require it. Second, judges, like most people, harbor deep-seated fears of individuals with mental illness, and they are reluctant to release individuals who they suspect may be dangerous, even if that suspicion is founded on stigma instead of fact. But the pandemic has forced judges’ hands, and some are opting to release individuals who would have been slated for inpatient care and extended jail waits pre-COVID-19. In the District of Columbia, thirty-five people in competence proceedings were released. In Washington, a man charged with robbery was ordered to inpatient treatment; after he waited over three months in jail for a transfer, a judge dismissed the charge. While these are certainly small numbers, they indicate an opportunity to experiment with the decarceration of individuals found incompetent to stand trial. As the pandemic drags on, and defendants found incompetent remain stuck in limbo, pressure to decarcerate may continue to mount. Thus, while the pandemic has made the already egregious lag times for competence restoration treatment worse, it might also contain the seeds of a solution to this intractable problem. A crisis of this proportion might be the one thing that could shake the criminal justice system out of its assumption that defendants should be detained while they wait for an inpatient bed to open

Doctor of Philosophy

dissertationThis study examines the efficiency of resource reallocation within multisegment firms. A defining feature of multisegment firms is management's ability to transfer resources across divisions. Although the option to use the proceeds or cash flows from one division of the firm to finance operations in another division is valuable to a firm, a large stream of literature documents potentially value-destroying consequences when agency conflicts interfere with investment decisions. Research to date provides mixed results as to whether multisegment firms reallocate resources efficiently. The extent that managers' resource reallocation decisions reflect improvements in efficiency is relevant to firms' existing and potential stakeholders. The reallocation of resources within firms provides new information about factors that underlie firm value, such as growth opportunities and risk exposure. To assess the efficiency of firms' resource allocation decisions, I create two unique, composite measures of efficiency that combine the performance of each segment relative to a firm's other segments and the segment's industry lifecycle stage. I examine the association between these measures and changes in the assets allocated to each of the firm's segments. I also investigate the influence of corporate governance factors. When financing occurs in-house, the firm has greater incentives to monitor the use of funds. Therefore, the ability of a firm's corporate governance structure to alleviate agency problems should be related to the efficiency of management's resource allocation decisions. Additionally, the greater complexity inherent in operating in multiple segments increases demands on firms' governance systems, making the efficiency of resource reallocation and the influence of related governance mechanisms important empirical questions. Using segment data provided under SFAS No. 131, I find that firms reallocate resources to segments with the best comparative advantages within the firm, suggesting that multisegment firms, on average, reallocate resources efficiently. Additionally, I find that firms with more independent boards more quickly reallocate resources away from segments with lower within-firm comparative advantages than do firms with more affiliated or dependent boards

Genome-wide association study identifies common and low-frequency variants at the AMHgene locus that strongly predict serum AMH levels in males

Anti-Müllerian hormone (AMH) is an essential messenger of sexual differentiation in the foetus and is an emerging biomarker of postnatal reproductive function in females. Due to a paucity of adequately sized studies, the genetic determinants of circulating AMH levels are poorly characterized. In samples from 2815 adolescents aged 15 from the ALSPAC study, we performed the first genome-wide association study of serum AMH levels across a set of ∼9 M ‘1000 Genomes Reference Panel’ imputed genetic variants. Genetic variants at the AMH protein-coding gene showed considerable allelic heterogeneity, with both common variants [rs4807216 (PMale = 2 × 10−49, Beta: ∼0.9 SDs per allele), rs8112524 (PMale = 3 × 10−8, Beta: ∼0.25)] and low-frequency variants [rs2385821 (PMale = 6 × 10−31, Beta: ∼1.2, frequency 3.6%)] independently associated with apparently large effect sizes in males, but not females. For all three SNPs, we highlight mechanistic links to AMH gene function and demonstrate highly significant sex interactions (PHet 0.0003–6.3 × 10−12), culminating in contrasting estimates of trait variance explained (24.5% in males versus 0.8% in females). Using these SNPs as a genetic proxy for AMH levels, we found no evidence in additional datasets to support a biological role for AMH in complex traits and diseases in men

The power of the teacher: Integrating Latino-themed literature in the K-12 classroom

High quality books with culturally specific themes offer wonderful opportunities to access the background knowledge and personal connections of students with similar cultural heritage. However, the simple addition of the “right” multicultural books in the classroom is not enough to ensure that students engage in deep level responses involving culture. The teacher’s role in such conversations is critical and the focus of this session. Presenters will share examples from their work with students of Mexican origin and Mexican American-themed books published in the U.S. Participants will also have opportunities to take part in Book Clubs using Latino-themed children’s literature, respond to these texts in multiple formats, and examine notable Latino-themed texts

Effectiveness of simulation on promoting student nurses management skills

The purpose of this study was to explore the effectiveness of simulation on promoting student nurses management skills. A review of the literature suggests that newly qualified nurses are not adequately prepared for their role as staff nurse. Deficits in management skills are the main areas of concern for both newly qualified staff and hospital employers. Consequently, all involved in students’ clinical learning environment are charged with the responsibility to devise sound innovative and effective teaching methodologies to prepare students for their role as staff nurse upon registration. A simulation exercise was conducted in Dublin City University by the Clinical Education Centre project team for fourth year general undergraduate student nurses. The main focus of the simulation was to promote consolidation of knowledge in the areas of organisation and management of patient caseload, clinical practice, and communication, legal, ethical and professional issues. A qualitative and quantitative approach was used for this study. Ninety students participated in the simulation exercise and 68 completed the questionnaire. Six focus group interviews were conducted with 15 students in each group. Results identified that simulation is a realistic and enjoyable way of learning and helped prepare students for their clinical role as staff nurse. Students indicated that they felt the exercise had helped them to consolidate their previous knowledge, felt more confident and were able to determine their own learning needs. However, participating in the simulation exercise was also seen as a stressful experience for some students. In conclusion, simulation used as an educational strategy running parallel and closely linked with clinical experience, is a powerful tool to prepare students for their role as staff nurse. It allows students to reflect on and learn from their strengths and weakness promoting improvement on their management skills and enhancing nursing services