Competency

Having led a legal competency group since my first week at St. Elizabeth's, I'm only now getting a clear picture of some of the intricacies involved in "competency." These issues came up today in placement in a number of different circumstances.

H. is a client who is highly intelligent (a former college professor) who has been diagnosed with schizophrenia. Her prominent symptoms include persecutory delusions, which cloud her judgment. Her case highlights the two different kinds of competency. Her legal competency evaluation hinged on her rationality, as her factual understanding was intact. She rightfully pointed out the subjectivity involved in an assessment of rationality. Indeed, her medical competency was evaluated by two different committees who arrived at two different conclusions. She learned that the second committee found that she was not medically competent to refuse medications. She reacted violently to this news and created a pretty intense situation on the ward.

The relevant point here is that a person can be legally incompetent to stand trial yet be medically competent to refuse medications. Oddly, a mentally ill person is usually assumed to be legally incompetent; whereas, they are assumed to be medically competent. Since legal competency usually implies psychiatric medication, H's legal competency was entangled to an even greater degree with her medical decisions.

The other patient L is an example of when competency cannot be restored. L's schizophrenia symptoms cause her thoughts to be disorganized and her cognition about her case to be impaired. Since she had been to court for hearings three times, she is going to be civilly committed if she does not pass this competency evaluation. Our hospital is now trying to give some empirical evidence of incompetency, so she will be the first patient I've had who will be completing a formal battery/assessment of competency (a written test). However, these tests are not able or less able (according to the administrators on my ward) to assess the rationality of a person. For many of the clients, the rational part of competency is the problem, as the thought disorder impairs a full-enough level of rational thought.

The happier part of today was learning that two of my clients had passed their competency assessments, and seeing the progress they had made over the past few months. Makes that whole self-efficacy piece for me that much more evident.